Case Presentation and Discussion

Neck Mass

Gemma Uy, MD
Year III Surgery Resident
GSI, Department of Surgery, Philippine General Hospital
1999

Notes from the Facilitator

Note 1: The surgical resident was asked to read the self-instructional program entitled "Management of a Surgical Patient" written by the undersigned and used it as a guide to present and discuss the case. This is her output.

Note 2: You are welcome to make comment and ask questions.

Note 3: You are invited to look at the manuscript containing my comments.

Note 4. You are invited to compare the case presentation and discussion of the same patient by Dr. Liborio Soledad, Jr., another surgical resident.

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Facilitator

Case Presentation

This is a case of a 36 year-old female with a chief complaint of neck mass. The mass was noted since 15years prior to consult and was gradually enlarging. No hoarseness, dysphagia, tremors, palpitations were noted.

On physical exam, pertinent findings were:

HR = 84/min (-) tremors

Case Discussion

With a chief complaint of a neck mass, considerations for the origin of the mass include:

1. skin
2. soft tissue
3. thyroid gland
4. parathyroid gland
5. lymph node
6. cartilage

On physical examination, the mass is unlikely to involve the skin since no break or skin lesions were noted. Also, it does not originate from the cartilage because of its consistency and mobility.

A mass in the neck of this relatively large size (4x5cm) with no other masses noted on the head and neck area has a low possibility of being a metastatic lymph node when no obvious primary focus is seen.

On the other hand, parathyroid masses are uncommonly seen, and by prevalence, this consideration is not highly entertained.

After taking into account those mentioned above, the considerations are narrowed down to either a soft tissue mass or a thyroid gland mass.

Furthermore, the characteristics of the mass, soft, moves with deglutition and location on the anterior neck below the thyroid cartilage plus the fact that a thyroid mass is more often seen than a soft tissue mass in the neck make the thyroid gland the most likely tissue of origin.

The next step is then to determine the nature of this thyroid mass - be it an inflammatory, benign or malignant type.

Because of its long duration (15 years) and no obvious signs of inflammation (redness, tenderness, etc) then its unlikely to be inflammatory.

Benign or Malignant?

Malignant masses in the neck are usually firm or hard, associated with cervical lymphadenopathy, and compressive symptoms- hoarseness, dysphagia.

In this patient, a 36-year-old female with 15-year duration of a soft mass with no other symptoms, then it can be said that the neck mass is of thyroid gland origin most probably benign by pattern recognition and prevalence.

Primary clinical diagnosis: colloid adenomatous goiter

Secondary clinical diagnosis: thyroid cancer

Options	Cost	Benefit	Risk	Availability
Fine needle aspiration biopsy	affordable	know nature of mass - cystic or solid, malignant or benign; may be therapeutic if mass is cystic - aspirate all fluid	low	available
Thyroid scan	expensive	know if hot or cold nodule (10% of cold nodules are malignant)	low	not always available
Ultrasound	relatively expensive	know if solid or cystic	low	not always available

Is a paraclinical diagnostic procedure needed for the patient?

Will the management of the patient differ if the mass is proven to be benign vs malignant?

Since the contemplated treatment plan for the patient is surgical regardless of whether it is benign or malignant, then a paraclinical diagnostic procedure will not alter the treatment plan.

The goal of treatment for a benign thyroid mass is to remove as much of the mass without any complication or harm to the patient. This is usually done for cosmetic purposes in patients who are asymptomatic.

Medical treatment may sometimes decrease the size of the mass but it does not eradicate this size and require continued therapy.

The options will be explained to the patient.

1. Explain the diagnosis to the patient and relatives, the treatment options, possible complications
2. Secure written consent
3. Optimize the medical and psychological condition of the patient
4. Prepare the materials needed for the operation

• Incision
  • must allow adequate visualization of vital structures and removal of mass
  • cosmetically acceptable
  • low collar incision over anterior neck is made
• Exposure
  • must facilitate accurate evaluation and removal of mass
  • superior and inferior subplatysmal flaps developed
• Intraoperative evaluation
  • determine exact diagnosis and extent of resection needed
  • if mass is limited to the left lobe, then a left lobectomy with isthmusectomy and pyramidalectomy is done.
• Operative procedure
  • remove all grossly abnormal thyroid tissue
  • care must be exercised not to injure the recurrent laryngeal nerve
  • careful ligation of vessels
  • preservation of the parathyroid glands
• Hemostasis
• Drain - Penrose drain is inserted
• Sponge and instrument count
• Wound closure
• cosmetically acceptable
  • fascia closed with absorbable suture
  • skin closed with absorbable suture
  • Penrose drain is brought out at the corner of the incision and anchored

• Adequate pain control
• Nutrition
• Wound care
• Monitoring for complications
  • hematoma formation
  • infection
  • hypocalcemia
  • check for hoarseness
• Removal of Penrose drain
• Advise on home care of wound
• Discharge plans

Questions and Comments from Readers

(You can use the text area below and then press the "submit" button or
you can email me your questions and comments.)

rjoson@pacific.net.ph

Dr. Liborio Soledad, Jr.'s Case Presentation and Discussion
Manuscript With Facilitator's Comments
GSI Case Presentation and Discussion
GSI Frontpage