Anterior Neck Mass 2 Group 2: Nuevo - Olegario

General Data  65 years old  Female Anterior Neck Mass

History of Present Illness  2x2 cm anterior neck mass  No other accompanying symptoms 5 yrs PTC  Progressive increase in size of the mass  She started to feel the presence of a “lump in the throat”  Consulted → L thyroxine 100 ug/tab 1 tab TID (1 month)  Easy fatigability, Palpitations, Weight loss  Consulted → Serum T3,T4, and TSH → advised to discontinue medication 4 yrs PTC Consulted at USTH

Physical Examination  VS: BP=120/80 PR=85/min RR=28/min  Eyes: Pink palpebral conjunctiva & Anicteric sclerae  Neck:  8 X 6 cm firm anterior neck mass  Well ‐ defined borders  Moves with deglutition  No palpable cervical adenopathies  Heart/Chest/Abdomen – Unremarkable

If you were the physician who initially saw the patient one year ago, what would you have done? 1

What do you think were the serum T3,T4, and TSH levels in the previous consult? What do you call this condition? 2

HYPOTHALAMUS PITUITARY THYROID TISSUE T4 T3 TRH TSH T3 T4 T3, T4, TSH levels during previous consult: HYPERTHYROIDISM T3 & T4 -  TSH - 

HYPERTHYROIDSIM  (+) Goiter or Nodule  Nervousness  Palpitations  Hyperactivity  Increased sweating  Heat Hypersensitivity  Fatigue  Increased appetite  Weight Loss  Insomnia  Frequent Bowel Movements (Diarrhea)  Hypomenorrhea  Warm, moist Skin  Tremor  Tachycardia Elderly patients may present: Atypically (Apathetic or Masked Hyperthyroidism) Most do not have exopthalmos & tremor Atrial fibrillation Syncope Altered sensorium Heart faliure Weakness

What is your diagnosis? Other considerations? 3

SUBJECTIVE Salient Features  65 y/o, F  Anterior neck mass  Progressive increase in size (1 year)  Felt a “lump in the throat”  L-Thyroxine 100 ug/tab 1 tab TID  Easy fatigability, Palpitations, Weight loss (Hyperthyroidism)  BP=120/80, PR=85/min, RR=28/min  Eyes:  Pink palpebral conjunctiva & Anicteric sclerae  Neck:  8 X 6 cm  Firm anterior neck mass  Well ‐ defined borders  Moves with deglutition  No palpable cervical adenopathies  Abdomen – Unremarkable OBJECTIVE

Impression CRITERIA SIMPLE NONTOXIC GOITER AGE & GENDERPuberty; Pregnancy; Menopause SIGNS & SYMPTOMS Asymptomatic Enlarged, Non-tender, Soft, Symmetric, Smooth RISK FACTORS Intrinsic Thyroid Hormone Production Defect Low Iodine Intake Ingestion of Goitrogens (Broccoli, Cauliflower, Cabbage) Drugs that inhibit thyroid hormone production TSH. T3.T4 Auto-Antibodies Iodine uptake Others Normal / Slight ↑ TSH, Slight ↓ T4 (-) Normal or High L-Thyroxine Contraindicated in older patients because goiters rarely shrink and are autonomous GIVEN IN EXCESS L-Thyroxine Contraindicated in older patients because goiters rarely shrink and are autonomous GIVEN IN EXCESS DRUG – INDUCED HYPERTHYROIDISM

DRUG INDUCED  Adult Initially mcg daily, adjusted every 4-6 wk by 50 mcg until normal metabolism is maintained.  May require doses of mcg daily.  Patient >50 yr Max: 50 mcg/day initially.  OTHER DRUGS: Amiodarone, Lithium, Interferon a, Interleukin-2 and Iodine

Differential Diagnosis CRITERIA GRAVES DISEASE (Toxic Diffuse Goiter) PLUMMER’S DISEASE (Toxic Solitary or Multinodular Goiter) AGE & GENDER Female (5:1) Peak: 40 – 60 y/o >50 y/o (multinodular) Young (solitary) SIGNS & SYMPTOMS Diffuse Goiter & Symmetric Exopthalmos (at onset or as late as 20 yrs) Dermopathy (pretibial myxedema) Mild hyperthyroidism Absent Extra-thyroidal manifestation RISK FACTORSStrong familial predispositionLong standing history of Goiter TSH. T3.T4 Auto-Antibodies Iodine uptake Others ↓ TSH, ↑ T3 & T4 + Autoantibodies Diffuse ↓ TSH, ↑ T3 & T4 (mild) - Autoantibodies Single or Multiple foci

SUBACUTE THYROIDITIS SILENT LYMPHOCYTIC THYROIDITIS PITUITARY TUMOR Female (Postpartum or Spontanoues) y/o Neck pain with radiation (jaws & ears) Asymmetric Firm& Tender Hyper to Hypo Resolves within months Absence of thyroid tenderness Hyper to Hypo to Eu Resolves within months Headache Visual Manifestations (bitemporal hemianopsia) Endocrinopathies Antecedent Viral URI Family history of autoimmune thyroid disease ↓ TSH, ↑ T3 & T4 + Autoantibodies No uptake ↑ ESR ↓ TSH, ↑ T3 & T4 + Autoantibodies No uptake ↓ ESR ↑ TSH, T3 & T4 ↑ a subunit of TSH ↑ Uptake Differential Diagnosis

How would you manage this patient now? 4

Treatment  Most euthyroid patients with small, diffuse goiters do not require treatment  If large goiters – use of exogenous thyroid hormone to decrease size and stabilize gland growth  Endemic goiter – iodine administration

When to consider surgery?  Continuous growth despite T4 suppression  (+) obstructive symptoms  (+) substernal extension  Suspected to be malignant or proven malignant by FNA biopsy  Cosmetically unacceptable **if there is a need for lifelong T4 therapy – treatment of choice is total lobectomy on dominant nodule and subtotal resection of the contralateral side

Prognosis  The prognosis for a patient with hyperthyroidism is good with appropriate treatment.  Postoperative recurrences: %  Risk of hypothyroidism is directly related to the extent of surgery and occurs in about ½ of patients  Myxedema coma can result in death.  Uncommon complications: vocal cord paralysis and hypoparathyroidism.

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