Neck Masses

Question 0

how do you diagnose lateral neck masses that are suspected to be congenital?

Answer 0

CT scan: Will appear as a cystic mass medial to the sternocleidomastoid muscle at the level of the hyoid bone

Question 1

Differential diagnosis for a neck mass.

Answer 1

“CCoNSuLLTSS”

C - Congenital - TBD, Thyroglossal duct cyst, Branchial cleft, Dermoid
C - Carotid Anerysm, Carotid body tumor
o
N - Neuroma, Neurofibroma
S - Soft Tissue - ‘PALS’ 1 tumor, Abscess, Lipoma, Sebaceous cyst
u
L - Lymph node - ‘MIRL’’ Mets, inflammatory, reactive, lymphoma
L - Lipoma
T - Thyroid: ‘CCG’ Cyst, Cancer, Goiter
S - Salivary - submandibular or preauricular
S - Supraclavicular - Lymphoma or metastatic tumor

Question 2

What is the treatment for a congenital lateral neck mass?

Answer 2

(1) FNA to exclude cystic mets from squamous cell carcinoma or waldeyers tonsillar ring
(2) surgical excision is curative

Question 3

Diagnosis for a central congenital neck mass?

Answer 3

Clinical – thyroglossal duct cyst

Question 4

What is the treatment for a thyroglossal duct cyst?

Answer 4

Sistrunk procedure- excision with a segment of the hyoid bone

Question 5

Treatment for inflammatory conditions?

Answer 5

Observation plus/minus abx

Question 6

Infectious process in neck with HIV

Answer 6

FNA to rule out lymphoma

Question 7

What tests should you order for the workup of a thyroid nodule?

Answer 7

(1) TSH if abnormal risk of malignancy < 5%
(2) ultrasound – cystic or solid?
(3) FNA – If cystic send fluid for cytology

Question 8

Fine needle aspiration of thyroid nodule reveals cystic fluid. You send for cytology, what are the possible results and management?

Answer 8

Benign and cyst resolves -> f/u exam

Benign and solid component -> repeat FNA

Malignant-> treat as thyroid cancer, Partial or total thyroidectomy, lymph node dissection, radioactive iodine ablation

Question 9

A fine needle aspiration is performed on a thyroid nodule. The mass is solid. What is the next step?

Answer 9

Send cells for cytology:

Benign -> Levothyroxin suppression, repeat FNA in six months

Suspicious 4 categories of types of cells: PAM F papillary, atypical (medullary), malignant, follicular

Question 10

Fine needle aspiration is performed on a thyroid nodule. Cells are sent to pathology after a solid mass is found. Name the types of cells that would be suspicious, and the next steps and management?

Answer 10

Papillary – thyroid scan – if cold thyroid lobectomy
– If functioning, less than 1% risk for malignancy
Atypical – medullary cancer – calcitonin test
Malignant – treat as thyroid cancer
Follicular or hurthle cells – Thyroid lobectomy

Question 11

If salivary nodule is suspected how do you diagnose?

Answer 11

CT scan of the neck

Question 12

Treatment for salivary nodule?

Answer 12

FNA

Excise if malignant

Question 13

Management of a cervical lymph node?

Answer 13

If suspicious primary site is present: pan endoscopy with biopsy of primary site and screening for secondary sites

Treatment – resection of primary site, en block removal of lymph nodes, radiation, chemotherapy

If no suspicious site: fine needle aspiration

Question 14

Management of supraclavicular lymph node

Answer 14

Chest x-ray, bronchoscopy, Mammogram, upper G.I. series, CT of the abdomen looking for primary. If no primary, fine needle aspiration or excisional biopsy

Question 15

How do you diagnose a carotid body mass?

Answer 15

History of nonpainful pulsatile mass at carotid bifurcation. Lyre sign on carotid angiogram
Biopsy contraindicated due to vasculature

Question 16

Treatment for carotid body mass?

Answer 16

Excision

Preoperative embolization for masses greater than 3 cm

Question 17

Diagnosis of carotid body aneurysm?

Answer 17

Doppler ultrasound, angiogram or MRA

Question 18

What findings on CT of the neck with contrast would suggest a malignancy?

Answer 18

– Hypodense lucency to core
– Greater than 1.5 cm
– loss of edge sharpness

Question 19

Tx for medullary cancer?

Answer 19

Total thyroidectomy + LN dissection

Question 20

First diagnostic test for neck mass

Answer 20

CT with contrast of head and neck

Question 21

Enlarged lymph node is found in neck. Next step?

Answer 21

Excisional biopsy. Tx is based on primary tumor

Question 22

Gene for MEN1?

Answer 22

Menin gene, tumor suppressor gene, AD

Question 23

MEN1 syndrome

Answer 23

Hyperparathyrodiism >90%,
pancreatic neuroendocrine tumors PNETS 70%, gastrinoma
Pituitary tumors 30%

Question 24

Gene involved in MEN2A

Answer 24

RET, oncogene, AD

Question 25

MEN2A

Answer 25

Medullary thyroid cancer - 100%
Pheochromocytoma - 50%
Hyperparathyroidism - 50%

Question 26

Patient with hypercalcemia. First step?

Answer 26

Order PTH - fi high, primary hyperparathyroidism 99.9% of the time

Check urine calcium - normal or high in primary HPTHism.

Question 27

MEN2B

Answer 27

Thyroid medullary carcinoma
Pheochromocytoma
Mucosal neuromas - body habitus

Question 28

When should the parathyroid gland be removed?

Answer 28

Any symptomatic disease (stones, bones, psychic moans, GI groans)
Renal insufficiency, no matter how slight
Very elevated serum calcium >12.5
T score < -2.5 or fragility fracture

Question 29

Cushings disease

Answer 29

Any form of hyperadrenalism or hypercortisolism, no matter what the cause

Question 30

How do you diagnose the presence of Cushing’s syndrome

Answer 30

1 mg overnight dexamethasone suppression test

24-hour urine cortisol - adds specificity

Question 31

How do you diagnose the location or origin of Cushing’s syndrome?

Answer 31

ACTH Level

ACTH level high: Pituitary or ectopic source - scan chest for lung cancer or carcinoid.
ACTH low: Adrenal source