Case scenarios- Neck Swelling M K ALAM

Case scenario A 60- year old female presented with neck swelling for 4 months, dyspnea and hoarseness of voice for 1 month. She is in your clinic.

History History of neck swelling: How noticed? Often noticed by others Duration? Acute or chronic Painful- acute lymphadenitis, thyroiditis, bleeding in goitre, submandibular salivary gland stone Painless- chronic lymphadenopathy, goitre, branchial cyst Change in size: Rapid increase- infection, bleeding, malignant change. Slow increase in neoplasms Single or multiple? Multiple- lymph nodes

Other symptoms Voice change ( malignant invasion) Dysphagia ( pressure on esophagus) Dyspnea (pressure on trachea) Eye symptoms Throat pain , Oral ulcer , Nasal symptoms, Scalp lesion Systemic inquiry: GI, CVS, RS, Endocrine (hyper/hypothyroid) PMH- Nil significant, on neck radiation FH of neck /thyroid malignancies- NAD Medication/allergies- nil

Examination GE: Appearance, Eye, Hand tremors, tachycardia- NAD Local: Inspection- solitary mass, left anterior triangle, moving up on deglutition Palpation: 3x3 cm hard mass from left lobe, non-tender. Rt. Lobe- normal Multiple ipsilateral LAP, Trachea shifted Percussion & Auscultation- NAD

Differential Diagnosis Goitre, Thyroid mass Functional- ?Hyper, hypo, Normothyroid ? D/D Pathological MNG, Thyroiditis, Cyst Thyroid neoplasms ? Which type

Thyroid malignancy Papillary Follicular Hurthle cell MTC (sporadic / familial MEN 2 A (Sipple syndrome- MTC, pheo, HPT, lichen planus amyloidosis, Hirschsprung's dis.) MEN2B (MTC, pheo, marfanoid, mucosal neuromas, ganglioneuroma of GIT) Anaplastic Lymphoma

Differential diagnosis Papillary carcinoma Anaplastic carcinoma MTC Lymphoma

Investigations FNA- PC (malignant, non-diagnostic, benign) TFT CXR US CT Indirect laryngoscopy: Lt RL nerve palsy Surgery

Inconclusive FNA Non-diagnostic/ cellular – repeat Repeat FNA- inconclusive TSH level- normal/high- surgery TSH low- nuclear scan Low uptake- surgery, High uptake- FU or therapy)

Thyroidectomy Malignant nodule Progressively enlarging nodule Pressure symptoms Suspicious nodule (FNA failed to establish a benign nature) Thyrotoxic nodule

Total thyroidectomy Malignant tumours ? Neck lymph node dissection RIA (Radio iodine ablation)- large tumour, metastasis, local tumour extension Complications: Bleeding, hypoparathyroidism, recurrent laryngeal nerve injury