neck masses Flashcards
etiologies for neck mass
-squamous cell carcinoma (SCC) - >90%
-alcohol and tobacco- 75%
-HPV (16), betel quid, occupational wood dust, or asbestos, EBV
-pts can develop further associated (secondary) malignancies within following years - 9-23% -> very common
-complications after head/neck cancer: dysphagia, pharyngocutaneous fistula, injury to accessory, vagus, hypoglossal, mandibular nerves
-mocositis or xerostomia (dry mouth) from radiotherapy
diagnosing neck mass
-biopsy
-flexible nasendoscopy (FNE) for direct visualization
-if only presenting with lymphadenopathy -> U/S FNA
-MRI is the imaging of chocie
-CT of neck and chest to look for spreading -> Stages
-PET-CT- first line choice if primary tumor location is unknown
child neck mass
-more likely congenital, inflammatory, infectious
-adults- neck masses > 2cm have >80% malignant
thyroid cancer
-lumps are common- cancer is not
->4cm has increased risk
-lumps are more common in women -> if you find one in men its more chance of cancer
-family hx- 10x increased risk
-usually asymptomatic, compressive sx
-MEN2? past radiation?
-painful? -> most likely an infection
-papillary
-follicular
-medullary
-anaplastic
papillary thyroid cancer
-MC thyroid cancer 75%
-40-50 yo women > men
-multiple lesions
-spread via lymph (bilateral cervical)
-Psammona bodies
-Pupil nuclei - orphan annie eyes- cell
-good prognosis
-tx- total or near total thyroidectomy
follicular carcinoma
-40-60yo women>men
-2nd MC thyroid cancer
-focal encapsulated lesions
-usually hematogenous spread to bones and lungs
-iodine deficiency
-tx- lobectomy
-older pts with >4cm -> total thyroidectomy
-poor prognosis:
-age > 50
-size >4cm
-vascular invasion
-extrathyroidal invasion
-distant metastases
medullary carcinoma
-3% of thyroid cancer
-usually painful
-elevated calcitonin levels !!!
-20% are MEN 2A and 2B syndromes cases
-spread via lymph (cervical) and medullary routes
-monitor calcitonin post op
-distant metastatic ds -> liver, bone, lung
-screen for pheochromocytoma
-tx- total thyroidectomy -> its multicentric
anaplastic thyroid cancer
-rare
-undifferentiated
-painful, hoarse, dyspnea, cough
-skin is warm and discolored over
-older pts (>65) women >men
-very aggressive
-spread by time of presentation 90%
-do neck and chest CT at time of dx
-tx- resection or debulking, chemo
red flags of neck lump
-rapid growth or pain
-pressure symptoms- dysphagia
-cough, hoarse voice, stridor
-multiple enlarged cervical lymph nodes
-tether of lump surrounding structures
-cold nodule (can also be benign)
non-cancerous neck lumps
-benign thyroid adenoma or thyroid cyst
-toxic multi-nodular goiter - hyperthyroidism sx
-non-toxic multi-nodular goiter
-thyroglossal duct cyst*- will move superiorly as pts sticks out tongue
thyroid lump work up
-TFTs- TSH (normal in cancer) and thyroglobulin (used post op- should be undetectable after total)
-toxic/hot nodule- low TSH and high T3/T4 -> low chance of cancer
-high calcitonin- can be medullary carcinoma (use to monitor)
-1. U/S- microcalcifications, hypoechogenicity, irregular margins, increased vascularity -> Red flags
-2. FNA- >1cm, suspicious US, family hx
-radioiodine imaging- tells you if nodule is hot or cold
-bone scintigraphy to further look for metastasis
-1 year after surgery -> fu with serum thyroglobulin level and US
FNA-bethesda scaling
-bethesda scaling
-B1- non diganostic -> repeat in 4-6 weeks
-B2- benign
-B3-4- case by case basis
-B5- surgery
-B6- cancer -> surgery
thyroid cancer management
-chemo, radio, radio-iodine
-ultimately surgical resection
-hemi-thyroidectomy
-total thyroidectomy
-neck dissection- removes lymph nodes
neck surgery complications
-damage to parathyroid -> hypocalcium
-symptoms: paraesthesia or tetany
-check calcium levels after always
-thyroid storm
-hematoma -> airway obstruction
-reopen the wound
-drain and stop bleeding
-ARDS
-cervical sympathetic nerve damage -> horners syndrome - ptosis, miosis (constricted), anhidrosis
-cellulitis, infection
-hypothyroidism and recurrent hyperthyroidism
-ALWAYS HAVE A TRACHEOSTOMY KIT
neck surgery laryngeal nerve injury
-recurrent laryngeal nerve damage -> IPSILATERAL vocal cord paralysis
-unilateral- hoarse voice
-paramedian vocal cords- normal or weak voice
-abducted position- hoarse and ineffective cough
-bilateral- life threatening stridor -> tracheostomy may be needed
-inferior thyroid artery crosses the recurrent laryngeal nerve
-suspensory ligament (ligamentum berry) is near the tubercle of zuckerkandl (lateral part of thyroid gland) -> identifies where inferior thyroid artery feeds in -> and therefore where the recurrent laryngeal
-external laryngeal nerve -> NO hoarseness, difficulty projecting sound, problem for singers
-superior recurrent laryngeal
-2b is most common to cause injury
-nerve injurys can heal
thyroid lymph nodes
-malignant lymph nodes fixed and have tissue in them
cretinism
-failure of thyroid from birth
-intellectual disability
-short stature
-thickening of facial features
thyroid cancer: radioiodine therapy
-mainly used for papillary or follicular
-only effective after TOTAL thyroidectomy (4-6 weeks)
-used in cases of higher risk of occurrence
-ablates remnant thyroid tissue and distant metastases
-PO
-graves, hot nodules, cancers
thyroid: external beam radiotherapy
-primary or adjunctive therapy
-routine for anaplastic
-dont use if you can resect
hot nodules
-toxic nodules
-initial tx- thionamides to tx hyperthyroidism
-preferred tx- lobectomy
-beta blockers for symptomatic therapy
-toxic multinodular goiter- Plummer’s Disease -> total thyroidectomy
toxic multinodular goiter
-plummer’s disease
-T3 toxicosis
-can cause afib, CHF
-hyperthyroidism
-can be precipitated by iodide containing drugs (contrast media and antiarrhythmic agent amiodarone -> Jod-Basedow hyperthyroidism)
-tx- RAI, subtotal/total thyroidectomy
-PTU short term if urgent
toxic adenoma
-single hyperfunctioning nodule
-pts are younger
-hyperthyroidism once nodule reaches at least 3cm
-tx- RAI or thyroid meds
-lobectomy with isthmectomy for younger pts -> bc of cost
primary hyperparathyroidism
-usually benign adenoma secretes PTH
-high calcium as a result
-MEN1
-stones, bones, groans (PUD), psychiatric undertones
-can cause pancreatitis
-osteitis fibrosa cystica salt and pepper skull, brown tumors of long bones
-renal failure can happen
-24-hour urine calcium excretion -> used to rule out familial hypocalciuric hypercalcemia -> does NOT need resection
-Weakness
-Fatigue
-Polydipsia
-Polyuria
-Nocturia
-Bone and Joint Pain
-Constipation
-Decreased Appetite
-Nausea
-Heartburn
-Pruritus
-Depression
-Memory Loss
-DX:
-high vitamin D
-24 hours urine- calcium will be high
-dual energy x-ray absorptiometry (DEXA)
-bone scans, imaging for kidneys
-parathyroidectomy for everyone unless risks are prohibitive
secondary hyperparathyroidism
-due to low vitamin D
-PTH is high but Ca is low or normal
-osteomalacia
-osteitis fibrosa cystica
-tx- calcimimetic agents
-prevent with- vitamin D replacement and phosphorus binders
-if refractory -> surgery
