1. Case scenarios- Neck Swelling
M K ALAM

2. 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.

3. 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

4. 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

5. 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

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

7. 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

8. Differential diagnosis
Papillary carcinoma
Anaplastic carcinoma
MTC
Lymphoma

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

10. 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)

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

12. 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