1. Anterior Neck Mass Case 1 Navarro – Ng 3-C

2. HISTORY OF PRESENT ILLNESS: – 7 Years Ago She noted an enlarging left anterior neck mass – 1 Year Ago Easy fatigability Palpitations Weight loss Consulted a physician and was prescribed medications that relieved her symptoms. – However, the mass continued to increase in size prompting her admission 36 Years Old Female Pampanga Anterior Neck Mass

3. Clinical Impression TOXIC MULTINODULAR GOITER PHYSICAL EXAMINATION: PR: 90 bpm RR: 20cpm Temp: 37C No exophthalmos Neck: 12x10cm Mutilobulated firm mass (Left) Moves with deglutition

4. Differential diagnosis

5. Anterior neck mass benign pathology malignant pathology Family history of Hashimoto’s thyroiditis; Past or family history of thyroid carcinoma Symptoms of hypo-or hyperthyroidismH/O external neck radiation during childhood or adolescence Pain or tenderness associated with the nodule Recent change in voice (hoarseness or dysphonia), difficulty in swallowing (dysphagia) Surface of nodule being soft, smooth, and mobile firm consistency of nodule Multinodular goitre without a dominant nodule irregular shape, its fixation to underlying or overlying tissues, and suspicious regional lymphadenopathy. Female sex Male sex; Young patients (< 20 years age) or old (> 70 years age)

6. PatientHashimoto’s thyroiditis Riedel's Thyroiditis Nontoxic goiter SexFemaleFemale > male Age3630- 5030-60 SymptomsEasy fatigue Palpitations Weight loss hypothyroidism, and 5% present with hyperthyroidism hypothyroidism and hypoparathyroidi sm asymptomatic PE12X10 cm mass No exopthalmos Multilobulated firm mass Mass moves with deglutition minimally or moderately enlarged firm gland Painless diffusely enlarged, firm gland, which is also lobulated painless, hard, "woody" thyroid gland anterior neck mass, Soft, diffusely enlarged gland (simple goiter) or nodules of various size and consistency in case of a multinodular goiter.

7. Hyperthyroidism PatientGrave's DiseaseToxic Multinodular Goiter Thyroid Adenoma Sex Female Female preponderance (5:1) F=MFemale Age 36 peak incidence between the ages of 40 to 60 years older patients>50 years old Symptoms Easy fatigue Palpitations Weight loss hyperthyroidism subclinical hyperthyroidi sm or mild thyrotoxicosis; large neck mass – airway obstruction, dysphagia hyperthyroidism PE 12X10 cm mass No exopthalmos Multilobulated firm mass Mass moves with deglutination Diffusely enlarged thyroid gland Exophthalmos; Dermopathy Multilobular, asymmetricall y enlarged gland solitary thyroid nodule without palpable thyroid tissue on the contralateral side

8. Toxic Multinodular Goiter “Plummer’s Syndrome” Long-standing simple goiter Recurrent episodes of hyperplasia & Involution –> irregular enlargement of thyroid Variations among follicular cells in response to external stimulus Mutations in proteins of TSH-signaling pathway

9. Diagnostic Studies  Suppressed TSH level  Elevated Free T3 or T4 levels  RAI uptake is increased (showing multiple nodules with increased uptake and suppression of the remaining gland)

10. Diagnostic Studies  FNA biopsy is recommended in patients who have a dominant nodule or one that is painful or enlarging, as carcinomas have been reported in 5 to 10% of multinodular goiters

11. Diagnostic Studies  CT scan is helpful to evaluate the extent of retrosternal extension and airway compression

12. What do you think were the medications given to this patient to control her symptoms of easy fatiguability, palpitations? Explain their mechanism of action.

13. Beta Blockers Drugs: Propranolol, Metoprolol, Atenolol MOA: – bind to beta-adrenoceptors and thereby block the binding of norepinephrine and epinephrine to these receptors. – Ameliorate many disturbing signs and symptoms of hyperthyroidism secondary to increased circulating catecholamines by blocking beta receptors

14. Thioamides Methimazole Propylthiouracil (PTU) MOA: – inhibit synthesis by acting against iodide organification and coupling of iodotyrosines – Blocks peripheral conversion of T4 to T3 (PTU)

15. How would you manage this patient?

16. Management: Surgical Excision Reserved for young individuals 1 or more large nodules or with obstructive symptoms Dominant nonfunctioning or suspicious nodules Pregnant Pharmacologic therapy has failed

17. Complications Injury to the recurrent and superior laryngeal nerve Hypothyroidism Hypoparathyroidism Vocal Cord Paralysis