1. Question No.1 If you were the physician who initially saw the patient four years ago, what would you have done?

2. General Considerations Age -Pediatric (0-15), young adult (16-40), and late adult (>40) -Neck masses in children and young adults -inflammatory > congenital or developmental congenital > neoplastic -Neck masses in late adult= neoplasia -The “rule of 80” = 80% of non-thyroid neck masses in adults are neoplastic and that 80% of these masses are malignant. -A neck mass in a child has a 90% probability of being benign.

3. Thorough evaluation of the patient and head and neck examination Developmental time course of the mass, associated symptoms, personal habits, and prior trauma, irradiation or surgery History of smoking and alcohol use, fever, pain, weight loss, night sweats. Symptoms of dysphagia, otalgia, and/or hoarseness with a smoking history most likely represent a neoplastic process.

4. Thorough evaluation of the patient and head and neck examination Emphasis on location, mobility and consistency of the neck mass can place the mass within etiologic grouping, such as vascular, salivary, nodal/inflammatory, congenital or neoplastic.

5. Diagnostic Tools Fine Needle Aspiration Biopsy (FNAB) – Standard of diagnosis for neck masses – indicated in any neck mass that is not an obvious abscess and persists following prescribed antibiotic therapies. – Differentiates inflammatory and reactive processes from neoplastic lesions, either benign or malignant. – In Thyroid, nodules can be categorized into: benign (65%), suspicious (20%), malignant (5%) and non- diagnostic (10%) – Helps to differentiate carcinoma from lymphoma, which can prevent unnecessary panendoscopy.

6. Diagnostic Tools Fine Needle Aspiration Biopsy (FNAB) – Indicated for solitary thyroid nodules, multinodular goiters with a new increasing nodule and with Hashimoto’s who develop a new nodule. – Very safe with no serious complications. – There are no contraindications to FNAB. – Less reliable in patients with a history of head and neck irradiation or positive history of thyroid CA, because of a higher likelihood of multifocal lesions

7. Diagnostic Tools TSH Assays – Enhanced sensitivity and specificity – TSH levels change dynamically in response to alterations of T4 and T3, a logical approach to thyroid testing is to first determine whether TSH is suppressed, normal, or elevated.

8. Diagnostic Tools Free or unbound Thyroid Hormone levels – An abnormal TSH level must be followed by measurements of circulating thyroid hormone levels to confirm the diagnosis of hyperthyroidism (suppressed TSH) or hypothyroidism (elevated TSH). – T4 and T3 are highly protein-bound, and numerous factors (illness, medications, genetic factors) can influence protein binding. It is useful, therefore, to measure the free, or unbound, hormone levels, which correspond to the biologically available hormone pool.

9. Diagnostic Tools Ultrasonography – sometimes useful in differentiating solid from cystic masses and congenital cysts from solid lymph nodes and glandular tumors. – Indicated in nodules which are difficult to palpate and for complex solid cystic nodules that recur. Computed Tomography (CT) – It can distinguish cystic from solid lesions, define the origin and full extent of deep, ill-defined masses – With contrast, can delineate vascularity or blood flow. – Helps obtained to detect an unknown primary lesion and to help with staging purposes.

10. Diagnostic Tools Magnetic Resonance Imaging – provides much of the same information as CT. – Ccurrently better for upper neck and skull base masses due to motion artifact on CT. – With contrast, good for vascular delineation and even substitute for arteriography in the pulsatile mass or mass with a bruit or thrill.

11. Diagnostic Tools Radionucleotide Scanning With 123 I or 99m Tc – differentiate a mass from within a gland from one outside a glandular structure – Evaluates patients for “hot” or autonomous nodules – can also indicate the functionality of the mass. – Currently recommended for assesing patients with follicular thyroid nodules on FNA biopsy and a suppressed TSH.

12. Factors suggesting malignancy History of head or neck irradiation Family history of medullary thyroid CA or MEN2 Age 70 Male predominance Hard and fixed nodule upon palpation Presence of cervical adenopathy Persistent hoarseness, dysphonia, dysphagia or dyspnea

13. Hyperthyroidism Clinical presentation Hypermetabolic state Increased adrenergic stimulation Heat intolerance and sweating Increased appetite and weight loss Tacchycardia Excitability Diarrhea Increased circulating active thyroid hormone