Case Presentation and Discussion

Neck Mass

Liborio I. Soledad, Jr., MD
Year I 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 his 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. Gemma Uy, another surgical resident.

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

Case Presentation

This is the case of M.S. , 36/F, from Cavite, admitted for the first time in Philippine General Hospital (PGH) for a neck mass.

15 years prior to admission (PTA), patient accidentally palpated a mass on the anterior neck area, described as non-hard, non-tender, and movable. No associated symptoms were observed. No consult was sought. No medications taken.

7 years PTA, there was note of persistence of the neck mass with slight enlargement. She consulted a private MD who prescribed Tapazole which she took every 8 hours for 4 months. No note of increase in mass size and patient was advised surgical intervention. Patient declined due to lack of finances.

1 year PTA, there was note of persistence of mass with further increase in size.

2 months PTA, patient consulted at PGH-Outpatient Department (OPD).

T4 = 109 (62-165 nmol/L)
TSH = 1.64 (0.1-4.5mIU/L)
Fine Needle Aspiration Biopsy = bloody smears

Patient was advised surgery.

Negative for fever, cough, easy fatigability, increasing appetite, dysphagia, diarrhea, difficulty in breathing, weight loss, hoarseness, vomiting, jaundice, tremors, palpitations, abnormal sweat patterns

Negative for hypertension, asthma, diabetes, TB

Negative for cancer, hypertension, diabetes, asthma, goiter

Menarche at 16 years of age; regular monthly intervals; no oral contraceptive use; last normal menstrual perior: 7/3/99 - 7/9/99; G9P9(7-0-2-7)

Nonsmoker, nonalcoholic beverage drinker, housewife

Fairly developed, fairly nourished, not in acute cardiorespiratory distress

BP = 120/70; HR = 84/min; RR = 18/min; T = afebrile

Pink conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy, no neck vein engorgement

(+)4x5 cm mass on anterior neck, non-hard, non-tender, non-erythematous, moves with deglutition

Equal chest expansion, clear breath sounds

Adynamic precordium, distinct heart sounds, regular rhythm, no murmurs

Abdomen soft, nontender, normoactive bowel sounds, no masses, no organomegaly

Full pulses, pink nailbeds, no edema

Case Discussion

In dealing with neck masses, one must first identify the exact location. History and PE would tell you that the mass is located in the anterior neck area. The next step is identify the tissue of origin. It may be any of the following: skin, thyroid gland, lymph node, soft tissue, or muscle.

Absence of skin changes or signs of skin invoolvement weakens the possibility that the lesion comes from the skin. Lymph node usually indicates secondary involvement. Further PE does not reveal any primary lesion from the face, head, or oral cavity. It is likely, therefore, that the lesion is not lymph node in origin. Investigating muscle as the probable source leads us to ask the patient to flex the different musculatures of the neck. The mass does not become prominent in any of these attempts, which lowers the likelihood of muscle as the source.

A particular finding in this patient is movement of mass upon swallowing. This is a strong indication that the mass is coming from the thyroid gland.

Having identified the source, we now determine whether the mass is malignant or not. Signs of malignancy would include hard, non-movable, single nodule, and presence of lymphadenopathies together with symptoms of compression. These are not found in the patient. It is highly likely that the mass is non-malignant.

Next, we need to look for signs of inflammation like tenderness, warmth, and redness of overlying skin. There are no such findings leading us to conclude that the mass is most likely not inflammatory.

Signs of benignity found in this patient include cystic consistency, non-hard, well-delineated borders, mobility, and history of gradual enlargement. Prevalence would also tell you that 70-80% of thyroid masses are benign. Other data in the history tells us that the patient is in the euthyroid state as evidenced by lack of signs of symptoms of tremors, tachycardia, palpitations, weight loss, easy fatigability, increased appetite, abnormal sweat patterns, and normal serum levels of T4 and TSH.

At this point, our primary clinical diagnosis is a thyroid mass, probably colloid adenomatous goiter.

Our secondary clinical diagnosis is a malignant thyroid tumor.

To confirm our primary diagnosis, we employ an additional diagnostic tool. Fine needle aspiration cytology is the most powerful tool available in the diagnosis of a thyroid nodule. It can differentiate a malignant lesion from a non-malignant one. Furthermore, one can identify if the mass is cystic or solid and if cystic, can be used to drain its contents. It is important to identify whether the mass is malignant or not as a malignant tumor warrants a surgical procedure for treatment.

Ultrasonography can also tell you if the mass is cystic or solid, but it could not differentiate a malignant from a benign lesion. Some malignant masses occasionally are cystic in consistency. This modality was not employed in our patient.

The most cost-effective treatment is to surgically remove the mass, without complications.

After having informed and explained to the patient and relatives the contemplated procedure, it is prudent to do the following: ask for consent, clear the patient of any medical condition that may affect outcome of operation, prescribe and prepared needed materials and equipment.

Plan the incision so as to have adequate exposure, with excellent cosmetic benefits. Create flaps that remain viable after the operation and with adequate extension to enable the surgeon to view and handle the mass. Once visualized, mass should be examined further to determine origin and whether mass is malignant or benign. Afterwards, one must decide on operative techniques to be employed.

The lone objective to satisfy here is to be able to remove the mass without sacrificing or compromising any anatomical structure such as nerve (recurrent laryngeal), or blood vessel, as the thyroid might be sharing nerves and blood with other anterior neck structures.

After removal of the tumor, several steps must be made prior to wound closure. One must check for bleeding and should employ hemostasis, either by suture ligation or electrocautery. A drain must also be kept in place to provide outlet for any unwanted fluid accumulation. Make sure to confirm instrument and sponge counts before closing.

Closure should be done in layers using absorbable material to lessen pain experienced in suture removal. Also be wary of the suturing technique in order to provide an acceptable cosmetic appearance after the scar has healed. This can be achieved through proper wound edge approximation.

Immediate postop care should focus on patient monitoring so as to detect any untoward incidents. In addition, one should also address basic needs regarding pain management, wound care, nutritional support, and patient comfort.

In the succeeding days postop, one should check for wound healing and anticipate possible complications. A complete physical examination should be made prior to sending patient home. Patient should be instructed regarding home instructions and proper wound care and future visits.

Questions and Comments from Readers

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rjoson@pacific.net.ph

Dr. Gemma Uy's Case Presentation and Discussion
Manuscript With Facilitator's Comments
GSI Case Presentation and Discussion
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