Midline Neck Lumps

Question 1

What are thyroid differentials for a midline neck lump

Answer 1

Physiological goitre (puberty, pregnancy_
Multinodular goitre
Graves disease
Hashimoto's thyroiditis 
Thyroglossal cyst
Thyroid cyst
Solitary adenoma
Carcinoma
Subacute thyroiditis (de Quervain's, Riedel's)

Question 2

What are non-thyroid differentials for a midline neck lump

Answer 2

Lipoma
Dermoid cyst
Epidermal cyst
Abscess
Lymphoma

Question 3

What questions should be asked about the lump

Answer 3

How long has it been there
Has the lump changed in size
Is the lump painful
Are there any other lumps

Question 4

What can the length of duration of a lump tell you

Answer 4

Sudden appearance - acute haemorrhage into a thyroid cyst, or fast-growing thyroid carcinoma/subacute thyroiditis

Question 5

What can the changes in size of a lump tell you

Answer 5

Rapid increase - haemorrhage or infection

Slow growing - thyroid neoplasm (except anaplastic)

Question 6

What information can you get from whether the lump is painful or not

Answer 6

Most are not painful
Subacute thyroiditis, infected thyroglossal cysts or acute haemorrhagic cysts are often painful
Hashimotos - discomfort, no pain

Question 7

What other symptoms should be asked about when regarding a midline lump

Answer 7

Any symptoms of hypo/hyperthyroiditis
Any symptoms suggestive of compression or invasion
Symptoms of infection

Question 8

What are the symptoms of compression

Answer 8

Stridor
Dyspnoea
Dysphagia or discomfort in swallowing

Question 9

What are the symptoms of invasion

Answer 9

Changes in the quality of voice due to Recurrent laryngeal nerve and/or vocal cords invasion (may also be seen in hypothyroidism due to oedema of the vocal cords)

Question 10

What aspects of the past medical history should be enquired about for midline neck lumps

Answer 10

Any autoimmune disorders e.g. T1DM, PA, vitiligo, Addison’s

Known risk factors for thyroid malignancy e.g. previous radiation for papillary thyroid carcinoma

Question 11

What aspects of the family history should be enquired about for the midline neck lump

Answer 11

Autoimmune diseases

Hereditary forms of thyroid carcinoma (medullary thyroid carcinoma)

Question 12

What can the location of a midline lump tell you

Answer 12

Superficial - lipoma, epidermal cyst, dermoid cyst or abscess
Deep - thyroid

Question 13

What does the midline lump’s relationship to other structures tell you

Answer 13

Moves on swallowing - thyroid gland
Moves on tongue protrusion - thyroglossal cyst
Tethered to neighbouring muscles - malignancy, Reidel’s

Question 14

What does the character of the midline lump tell you

Answer 14

Diffuse, smooth enlargement - physiological goitre, Graves’, Hashimoto’s, de Quervain’s thyroiditis
Solitary, solid - malignancy
Solitary, cystic - Thyroglossal, epidermal, dermoid, thyroid cysts
Multiple nodules - multinodular goitre (focal hyperplasia)

Question 15

What other features should be examined other than the midline lump itself

Answer 15

Any cervical lymphadenopathy - thyroid malignancy
Extent of thyroid swelling
Any signs of hyper, hypothyroidism

Question 16

What is Pemberton’s sign

Answer 16

elevate the arms above the head which results in facial venous congestion and plethora due to thoracic inlet obstruction by a retrosternal mass

Question 17

What would serum calcitonin be investigated for a thyroid disease

Answer 17

only there is family history of thyroid cancer.

MTC is a tumour of the calcitonin-secreting parafollicular C-cells, thus calcitonin can be used as a serum marker

Question 18

What investigations should be done for thyroid nodules

Answer 18

Fine needle aspiration (+ USS guidance if needed)

Question 19

What may present as an upper midline lump that grown sub-acutely, is not painful but mildly tender. It moves on swallowing and sticking out the tongue. It is not attached to muscles and has well-defined boundaries + smooth. Cystic and non-pulsailte.

Answer 19

Thyroglossal Cyst (attached to the hyoid bone)

Question 20

What nay cause a change in thyroglossal cyst size or sudden appearance

Answer 20

Thyroglossal cysts occur due to abnormal descent of the thyroid gland to the thyroid cartilage. Sudden increases may represent infection secondary to another infection.

Question 21

Diffuse midline swelling in the lower 1/3. Non-tender and moves when swallowing. Smooth and no palpable nodules. Has symptoms of hyperthyroidism + lid lag and exophthalmos

Answer 21

Graves disease

Question 22

What is the pathophysiology of Graves and Hashimotos

Answer 22

Graves - Anti-TSH that causes hyperthyroid

Hashimoto - Antithyroid Abs that causes hypothyroid

Question 23

What are the histological types of thyroid neoplasia

Answer 23

Papillary
Follicular
Medullary 
Lymphoma 
Anaplastic
Metastases

Question 24

How does tachycardia in hyperthyroidism differ from that of anxiety

Answer 24

Hyperthyroid - associated with AF and arrhythmias, persists when the patient is sleeping