What’s the Mass in the Neck?
May 21, 2015
A 21 year old Japanese male is presenting with a mass in his neck he finds incidentally. The mass is best seen on the right side of his neck when he turns his head to the left. The picture denotes a change upon swallowing. What is his diagnosis and workup? (Scroll down to see answer)
The video can be seen here:
Diagnosis: Thyroid Nodule
We can confirm this patient has a thyroid nodule on exam for two reasons:
1) The mass is more easy to see when patient looks to the contra-lateral side of the mass.
2) Most importantly, the mass moves with swallowing.
Thyroid nodules are important not to miss on exam as the major concern is to rule out a thyroid cancer. The general management of a thyroid nodule, either found on exam or imaging (if non-palpable) is to measure the serum TSH level. If low, patients generally will get a radionuclide study to look for a functioning (i.e. producing thyroid hormone) nodule. If the radionuclide study shows a functioning nodule, the next step is to measure the thyroid hormones and treat hyperthyroidism is present. However, if the radionuclide study shows a non-functioning thyroid nodule or if the initial TSH level is normal or elevated, all patients should receive a thyroid fine needle aspiration to rule out cancer.
Also, don’t forget to look for other findings suggestive of hyperthyroidism such as postural tremor, lid lag, and a sweaty palm. Some of this is described in Dr. Verghese’s video on the examination of the hand.
This patient had a benign non-functioning thyroid nodule. He will get periodic ultrasound monitoring to ensure there isn’t sudden growth to suggest a malignancy, although malignancy is benign thyroid tumors are rare.
A 46-year-old Vietnamese female with history of Churg-Strauss syndrome was seen for a flare-up and had the above skin changes. Based on the characteristics pattern can you diagnose the cause of this skin rash?…
37 yr old male with a history of these lesions on his the back of his hands for the past two years. Notes no other medical issues. No weakness, fatigue, fevers or rashes anywhere else on his body. He works as a chiropractor and is concerned about his patients seeing his hands. Use of various over the counter treatments such as topical steroids and moisturizers did not improve the lesions.