MEDINA, Miguel Andrei C.
2016-00448
ORL 260 Case Paper
Pertinent points in the history and physical exam alone
Detail
Chief complaint of an anterior neck mass in a
47/F
2 year history of gradually enlarging mass located
in the left side of the neck, now 2.5 x 2.1 x 1 cm
on PE
Firm mass, no skin changes
Non-tender, movable
(-) dyspnea, dysphagia, odynophagia, hoarseness
(-) fever, weight loss, palpitations, tremors, hair
loss, bowel movement changes
AD: Near total perforation with pale middle ear
mucosa
AS: Intact TM, no discharge
Fully mobile vocal cords
(-) cough, dizziness, BOV, headache, ear pain,
vertigo, diplopia
(-) palpable lymph nodes, oral cavity
masses/lesions, (-) nasal
masses/bleeding/deviation
No PMHx of HPN, DM, asthma, TB, allergies
FMHx of goiter in the mother
No vices, no exposure to radiation
Significance
This would already narrow down our approach as
certain pathologies would present in the anterior
neck. Women > 50 y/o are more at risk for
malignancy.
This would tell us of the time course of the
patient’s condition and also tell us where the
mass began
Classically, harder lesions and skin changes are
more associated with malignancy.
Non-tender masses are less likely to be caused by
reactive/inflammatory processes. The mass being
movable will also tell us about whether or not it
is invading deeper structures, which increases the
chances for malignancy.
It is important to rule out breathing and
swallowing difficulties due to mass effect from
the ANM.
These are symptoms of hyperthyroidism, which
must be considered if we are considering thyroid
pathologies
This would alert us to the possibility of the
patient having CSOM or other chronic ear
diseases
In the case we would need surgical management
for this patient’s mass, baseline documentation
of the patient’s vocal cord mobility is important.
We need to determine if there is recurrent
laryngeal nerve involvement. Involvement this
early on would raise suspicion for malignancy.
Review of systems pertinent to ORL.
Palpable lymph nodes adjacent to the anterior
neck mass are more suspicious for malignancy.
These comorbidities may affect management
Goiters may have a hereditary component, and
may also reflect iodine deficiencies in families
Smoking, alcoholism, and illegal drug intake may
affect our approach and management. Exposure
to radiation may increase the risk for malignancy.
 Smoking and alcoholism may reduce the risk for
thyroid malignancy.

Additional points to elicit in the history and physical exam

Detail
Weight gain, cold intolerance, constipation,
depression, lethargy
Is the mass movable with deglutition?
History of hearing loss and discharge, tinnitus,
respiratory tract infections, and ear infections,
Weber and Rinne Tests
Is the trachea midline? Is stridor present?
Significance
These are symptoms of hypothyroidism, which
along with the symptoms of hyperthyroidism,
needs to be assessed for as it will help us
formulate an impression
Movability on deglutition would localize the
lesion to the thyroid gland.
To further characterize the patient’s near totally
perforated PM on the right ear
This is important to assess for anterior neck
masses, as it may compromise the airway

Differentials and Diagnostics

It is prudent to first ask the patient to swallow and assess if the mass moves with deglutition, which
would localize the mass to the thyroid gland. Differentials for anterior neck masses localized to the
thyroid include benign causes like goiters, adenomas, or cysts. Otherwise, another consideration is
malignancy.
To differentiate benign from malignant processes, factors in the history which may suggest malignancy
include: vocal cord paralysis, hard and fixed masses, lymphadenopathy, rapid growth, childhood
radiation exposure, family history of cancer, and presence of syndromes associated with thyroid
malignancy. Notably, none of these are present in the patient, but there absence cannot rule out the
possibility of cancer, and ultimately, the history and physical examination are not sufficiently accurate in
the evaluation of thyroid masses. We will need to utilize diagnostic tests.
Ultrasound is a useful diagnostic test to order as it will reveal the depth, consistency, and precise
anatomy of the mass. It may also reveal additional masses which are not readily palpable in the physical
exam. It will also allow us to evaluate the mass for suspicious features and allow us to grade the mass
using the TI-RADS system. In this system, masses are classified from 1-5 with 5 being the classification
with the highest risk for malignancy. Grading the mass using the TI-RADS system will also inform us if the
mass can be followed-up or would require additional evaluation via a fine needle aspiration biopsy
(FNAB). Ultrasound will also reveal if there is lymph node involvement or extrathyroidal extension.
Ordering serum TSH, FT4, and FT3 is also important to determine the patient’s thyroid functional status.
Notably, higher serum TSH is an independent risk factor for predicting malignancy in a thyroid nodule.
Obtaining these labs will allow us to say if the patient is in a hyperthyroid, euthyroid, or hypothyroid
state and help direct further diagnostic work-up. If the TSH is normal or high, and ultrasound reveals
suspicious findings with a high TI-RADS classification, then an FNAB would be warranted if the mass is
large enough in size (specific size depends on the TI-RADS classification). In those such cases, the
primary consideration would be a malignancy. If TSH is low, then a thyroid scintigraphy may be ordered
next. Hyperfunctioning nodules are rarely cancer and do not require an FNAB, but it is still prudent to
order an FNAB if scintigraphy reveals nonfunctioning or indeterminate nodules that meet the
sonographic criteria for an FNAB as guided by the TI-RADS system.
An FNAB guided by the ultrasound would achieve greater diagnostic yield as opposed to doing it via
palpation alone. It should only be ordered if on ultrasound imaging, the thyroid masses meet the criteria
warranting an FNAB in the TI-RADS system.
Obtaining chest x-rays and performing a CT scan of the abdomen may also be prudent to rule out distant
metastasis.
For the patient’s near total tympanic membrane perforation on the right ear, common causes include
trauma and infection. In the PGH setting, this may be due to longstanding CSOM. However, as there was
no discharge noted on the otoscopy on the right, this may be an inactive CSOM. Further, there were no
details noted regarding cholesteatoma on otoscopy so it is not being highly considered at this time.
Regardless of its etiology, surgical repair of the ruptured tympanic membrane is warranted and will be
discussed further later. It is prudent to assess the patient’s preoperative hearing status via pure tone
audiometry and to assess the air-bone gap via tympanography, for comparison post-tympanoplasty.
Imaging tests are not usually required for tympanoplasty procedures, except if a cholesteatoma is being
considered, in which case the preferred imaging test is a CT scan of the temporal bone.
Interpretation of Test Results
Thyroid gland UTZ revealed multiple complex predominantly solid lesions (1.3 x 0.6 x 1.1 cm; 0.7 x 0.4 x
0.4 cm; and 0.4 x 0.3 cm) with peripheral color uptake in an unenlarged right lobe and a hypoechoic
mass (2.9 x 1.2 x 2.2 cm) with increased color uptake and an isoechoic nodule (0.9 x 0.4 x 0.7 cm) in an
enlarged left lobe. Unfortunately, no TI-RADS score was given. However, hypoechoic and solid masses
are associated with malignancy, and are assigned higher weights in the assessment of the TI-RADS score.
Other factors that could have been assessed in the ultrasound were if the masses were taller than wide
in the axial plane, had irregular/extrathyroidal borders, and if echogenic foci were present. All these
would be more associated with malignancy. Notably, there was no note of enlarged lymph nodes.
As it stands, the given features of the masses being hypoechoic and solid give the patient a TI-RADS
score of at least 4 (2 points each feature). For TI-RADS scores of 4 to 6 (moderately suspicious), an FNAB
is warranted if the mass is > 1.5cm, as in this patient’s case.
TFTs revealed normal levels indicating that the patient is biochemically euthyroid. A thyroid scintigraphy
is no longer needed as it is only indicated in the evaluation of patients with subnormal TSH levels.
FNAB revealed the mass as having Bethesda class V and having findings suspicious of papillary thyroid
carcinoma. The Bethesda system is a standardized, category-based reporting system for thyroid fine-
needle aspiration specimens. It has 6 different classifications, from I to VI: (I) nondiagnostic or
unsatisfactory; (II) benign; (III) atypia of undetermined significance (AUS) or follicular lesion of
undetermined significance (FLUS); (IV) follicular neoplasm or suspicious for a follicular neoplasm; (V)
suspicious for malignancy; and (VI) malignant. For this patient, a Bethesda classification of V would imply
that the patient has a 50-75% chance of malignancy based on FNAB findings.
Assessment
Multinodular nontoxic goiter, t/c papillary thyroid carcinoma (Bethesda Class V)
Ruptured tympanic membrane, AS
Discussion
Epidemiology and Risk Factors
Thyroid neoplasms represent 95% of all endocrine tumors but represent only about 2.5% of all
malignancies. The incidence of thyroid cancer has been steadily increasing over the past two decades
and is regarded as the malignancy that has the fastest rate of increase in incidence. In the United States,
thyroid nodules are present in an estimated 4-7% of the population, with 5% of this subset having
malignant thyroid lesions. Papillary thyroid cancer represents about 85% of all thyroid follicular
epithelial-derived cancers.
Being female is a risk factor for the development of papillary thyroid carcinoma, with a female-to-male
ratio of 2.5-3:1. most of the female cases occur in the 4th to 5th decade of life. Both of these risk factors
are present in this 47/F patient. Other risk factors include radiation exposure during childhood and a
familial history of thyroid cancer or any of the thyroid cancer related syndromes (e.g., familial polyposis,
MEN2, etc.). Notably, the patient has a familial history of goiter. While there is no association between
goiters and papillary thyroid carcinoma, follicular and anaplastic thyroid carcinomas occur more
commonly in areas with endemic goiter. Other factors which are postulated (but not definitively proven)
to increase the risk of thyroid cancer include occupational and environmental exposures, hepatitis C
infection, increased parity, late age at first pregnancy, and obesity.
Pathophysiology
Mutations within the mitogen-activated protein kinase (MAPK) pathway are involved in the
development of papillary thyroid cancer. Rearrangements or activation of RET or BRAF protooncogenes,
which can also activate the MAPK pathway, are also often seen in papillary thyroid cancer. Other
mutations that may encode effectors that signal through the MAPK pathway include BRAF V600E and
RAS mutations. Mutations in BRAF V600E occur in almost 60% of papillary thyroid cancers. Gene
rearrangements in NTRK and ALK may also be implicated in papillary thyroid cancer.
Management Plan
Papillary Thyroid Carcinoma
The cornerstone of papillary thyroid cancer management is surgical. For this patient, as she has tumors
ranging in size from 1-4 cm, without extrathyroidal extension and lymph node involvement, and with
nodules in both thyroid lobes, total thyroidectomy is recommended. Intraoperatively, care must be
taken to preserve the recurrent laryngeal nerve (RLN) and as much of the parathyroid glands as possible
in order to avoid postoperative hoarseness/stridor and hypoparathyroidism, respectively. A neck node
dissection is not necessary as there is no sonographic or clinical evidence of lymph node involvement
and the patient’s masses are < 4 cm in size. Immediately after the operation, watch out for signs and
symptoms of hypocalcemia from hypoparathyroidism (circumoral paresthesia, Chvostek’s and
Trousseau’s sign). Watch out also for hoarseness/stridor which may reflect iatrogenic damage to the
RLN and for hematoma formation, both of which may compromise the patient’s airway.
Following surgery, do not administer levothyroxine yet. Serum TSH and Tg should be measured at
approximately 4 to 6 weeks postoperatively in order to assess the patient for postoperative disease
persistence. Expected Tg values after total thyroidectomy are approximately <5 ng/mL. The patient will
be able to tolerate this initial 4-6 weeks post-op without levothyroxine intake as her body’s stores are
still high, but eventually, she will require thyroid hormone supplements at a dose of approximately 1.6
to 2 mcg/kg per day, with follow-up TSH measurements after 4-6 weeks to titrate the dose, with a goal
TSH of 0.1 and 0.5 mU/L for low-risk patients such as this case. She is deemed low risk for recurrence
because she has no distant metastases or invasion of locoregional tissue, does not have aggressive
histopathology (based on currently available information), no vascular or nodal metastases, and her
tumor is intrathyroidal.
Likewise, as this patient is deemed low risk for recurrence, prophylactic radioactive iodine (RAI) ablation
is not needed for this patient. However, once final histopathology results come out, should the patient’s
risk stratification change (e.g. if there is evidence of aggressive histopathology) then RAI would be
warranted, in which case levothyroxine supplementation should be withheld until the patient’s TSH is 30
mU/L. This is partly the reason why levothyroxine may be withheld for 4-6 weeks postoperatively, as it is
a viable strategy to prepare the residual thyroid/cancer for adequate uptake of radioiodine.
Ruptured tympanic membrane, AD
The management for a chronically ruptured tympanic membrane is tympanoplasty. This can be
combined with the thyroidectomy surgery of the patient. Baseline physical exam maneuvers such as the
Weber and Rinne hearing tests should also be done for the patient, and tests such as pure tone
audiometry and tympanography should also be done. After repair, the patient should be assessed for
improvement. As there seems to be no evidence of involvement of the ossicular chain, only type I
tympanoplasty will be carried out, which is synonymous with myringoplasty. Tympanoplasty is
successful in up to 93% of patients, but complications include failure of the graft, conductive hearing
loss, persistent perforation of the tympanic membrane, and the need for ventilation tube insertion if
there is a need to drain fluid in the middle ear.
Prognosis
As the patient is relatively young (< 55 y/o) and has no evidence of metastasis, her cancer is in Stage I.
With correct diagnosis and management, most patients with well-differentiated cancers such as
papillary thyroid carcinoma have an excellent prognosis. The 10-year disease-specific mortality rate is
less than 7% for papillary thyroid cancer. Based on 2011 to 2017 data, the 5-year relative survival rate
for papillary thyroid carcinomas is reassuring, at 98.3 percent.
As mentioned earlier, the patient has a low risk for recurrence based on the ATA risk stratification
system because she has no distant metastases or invasion of locoregional tissue, does not have
aggressive histopathology (based on currently available information), no vascular or nodal metastases,
and her tumor is intrathyroidal.
Lay person explanation of disease
Ma’am BA, ayon sa eksaminasyon namin at mga tests po na ginawa namin, mataas po ang tsansang
mayroon po kayong kanser sa thyroid. Alam ko po na medyo nakakatakot pong marinig ito, pero huwag
po kayong mag-aalala kasi mataas naman po ang tsansang malunasan ang kanser sa thyroid – halos 100
porsyento po ang tsansang mabuhay po rito, lalong-lalo na dahil sa tingin po namin “papillary thyroid
carcinoma” o yung hindi aggresibong tipo ng kanser ang mayroon kayo. Pero kailangan po namin ang
inyong kooperasyon: kailangan po ninyong sumailalim sa surgery kung saan tatanggalin po ang thyroid
ninyo, pero hindi naman po ito masakit dahil may anesthesia po ito. Sa pamamagitan nito, matatanggal
namin yung kanser. Pagkatapos po, kailangan din po ninyong uminom ng thyroid supplements habang
buhay. Napansin din po namin na butas ang eardrum ninyo sa kanan, isasabay na rin po namin ang
pagsasaayos nito sa surgery po ninyo sa thyroid. Mayroon pa po ba kayong tanong?
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