Cagayan Valley Medical Center

Department of ORL-NHS

CASE
PRESENTATION
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CSU JI BALMORES, JOANNA MAE

 General Data
Name: R.M.
Age: 46 y/o
Gender: Female
Nationality: Filipino
Birthdate: November 29, 1975
Address: Santa Maria, Lal-lo, Cagayan
Civil Status: Married
Occupation: Teacher
Religion: Roman Catholic
Informant: Patient
Reliability: 95%
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Date of Admission: July 9, 2022

 Chief Complaint
Neck Mass
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 History of Present Illness
9 years PTA
●Small mass on the anterior part
of the neck (size of a mung bean)
●Consulted at CVMC during a
medical mission
●Diagnosed with Goiter and
Thyroid lobectomy was done
● No complications noted
● Take home meds : Antibiotic
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3 years PTA
● Recurrence of mass on the anterior
part of the neck (about the same
size)
● No Associated Signs or Symptoms
● Sought consult at CVMC OPD;
Diagnostic tests were done (UTZ
and FNAB)
● Scheduled for another surgery
● Did not push through because of
the pandemic
 Thyroid Gland/Neck Ultrasound
Thyroid gland is surgically absent
There is a well defined isoechoic soft tissue mass with lobulated margin in the midanterior neck
area at the hyoid-suprahyoid region measuring 3.3 x 2.8 x 1.8 cm. Color Doppler study shows
minimal intralesional blood flow
There are several cervical prominent lymph nodes in both mid jugular and submental regions
with the largest measuring 0.9 cm and 0.7 cm respectively

Impression:
S/P Thyroidectomy
Midanterior Neck Mass, as described suggest biopsy correlation
Prominent Cervical Lymph nodes, bilateral mid jugular (Level III) and
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Submental (Level 1) regions

 Cytology Report

● Surgical Procedure: Fine Needle Aspiration Biopsy

● Specimen: Anterior Neck Mass Aspirate

Diagnosis:
Suspicious for Follicular Neoplasm
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 History of Present Illness
interim 1 month PTA

● persistence of the previously

● Gradual increase in size stated complaints
● Did not seek consult due to the ● went for check up at CVMC
pandemic ● CT SCAN of the NECK W/
● No associated signs and CONTRAST was done.
symptoms ● Patient was asked to go for her
scheduled surgery on July 9, 2022.
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 CT SCAN of NECK with CONTRAST MEDIA

Impression:
Hypoplastic right lobe of the thyroid
with an ectopic thyroid tissue in the upper
anterior neck
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 Past Medical History
● Patient was diagnosed with goiter last year 2013.
● No history of hypertension, diabetes, asthma, TB or
heart disease
● Patient was hospitalized previously when she gave
birth to three of her children. (NSD)
●No other surgeries done other than the one stated in
the history.
● No known allergies to food and medications
● Completed 2 doses of COVID vaccines.
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 Personal and Social History

● College Graduate
● Elementary School Teacher
● Married for 21 years with 3 children
● Lives with family in a bungalow house
● (-) smoker, (-) alcoholic beverage
drinker, (-) illicit drug use
● Prefers to eat vegetables but sometimes
eats meat and fish
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 Review of Systems

Constitu Skin Head Eyes Ears

tional (-) headache
(-) chills (-) itching (-) pain (-) hearing loss
(-) unintentional (-) dryness (-) dizziness (-) excessive (-) tinnitus
weight loss (-) lightheadedness tearing (-) pain
(-) double vision (-) vertigo
(-) blurry vision
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 Review of Systems

Nose Mouth Neck Breast Respirat

and
(-) nasal (-)Throat
bleeding gums (-) pain (-) pain
ory
(-) DOB
stuffiness (-) pain (-) stiffness (-) lumps (-) Shortness of
(-) pain (-) dysphagia breath
(-) itching (-) odynophagia
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 Review of Systems

Cardiov Gastroint Genito Extremi Hematol

ascular estinal
(-) chest pain (-) diarrhea
urinary
(-) pain during
ties
(-) leg cramps
ogic
(-) easy bleeding
(-) palpitations (-) constipation urination (-) swelling (-) easy bruising
(-) vomiting (-) itchiness (-) stiffness
(-) pain (-) joint
tenderness
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 Physical Examination

Anthropometrics: Vital Signs:

Body Temperature: 37.0 C

Pulse rate: 80 bpm
Weight: 47 kg Respiratory rate: 18 cpm
Height: 152.4 cm Blood Pressure: 140/90
BMI: 20.2 mmHg
sPO2: 97% at room air
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 Physical Examination
Awake, conscious and coherent, not in cardiorespiratory
General
distress

Skin (-) pallor, (-) cyanosis, (-) jaundice, good skin turgor

Face (-) facial asymmetry, (-) swelling, (-) paralysis

Symmetric, (-) gross deformities, (-) lesions, dry and

Head
evenly distributed hair, (-) tenderness
Anicteric sclerae, Pupils are round and equally reactive to light
Eyes and accommodation, extraocular muscles are intact, (-)
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discharges, pink palpebral conjunctiva

 Physical Examination
(-) lesions, (-) pain on manipulation, (-) erythema, (-)
Ears
swelling, (-) discharge
(-) gross deformities, septum is at midline, (-) erythema,
Nose non boggy turbinates, (-) hyperthrophy, (-) mass, (-)
polyps, (-) discharge
Moist lips, (-) dental carries, (-) gingival swelling, Tongue is at
Oral
midline, Pinkish buccal mucosa, uvula at midline, (-) tonsil
Cavity swelling
(-) lesions, (+) 3x3 cm mass on the anterior midline of the
Neck neck, nontender, soft, moves with deglutition, (+) scar from
previous surgery

Breast (-) Nipple retraction, (-) discharge, (-) mass, (-) tenderness
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 Physical Examination
Symmetrical chest expansion, (-) retractions, (-)
Chest and Lungs
grunting, (-) tenderness, clear breath sounds

Adynamic precordium, PMI at 5th ICS left

Heart
midclavicular line, (-) murmur, regular rhythm

Flat, (-) scars or bruises, (-) distention, soft,

Abdomen
(-) tenderness, normoactive bowel sounds

Genitalia Grossly female

Extremities (-) gross deformities, (-) swelling

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Neurologic No neurologic deficit

 Salient Features
● 46 y/o, Female
● (+) 3x3 cm mass on the anterior neck
slightly to the left from the midline,
nontender, soft, moves with deglutition
● increasing size of mass
● (+) family history of goiter
● Thyroid/Neck UTZ
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 ANTERIOR NECK MASS

CONGENITAL INFLAMMATOR NEOPLASM

Y / INFECTIOUS
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 DIFFERENTIAL
DIAGNOSIS
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 Metastatic Carcinoma
RULE IN RULE OUT
• (+) 3x3 cm mass on the anteromedial
part of the neck • (-) unintentional
• Euthymic weight loss
• Prominent Cervical Lymph nodes, • (-) pain
bilateral mid jugular (Level III) and • (-) unremarkable PE
Submental (Level 1) regions on the other areas
• minimal intralesional blood flow
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 Diffuse Non Toxic Goiter
RULE IN RULE OUT
• Solitary Neck Mass
• Does not live in areas with
• (+) 3x3 cm mass on the
endemic goiter
anteromedial part of the
• Prominent Cervical Lymph
neck, nontender, soft, moves
nodes, bilateral mid jugular
with deglutition
(Level III) and Submental
• (+) family history of goiter
(Level 1) regions
• euthymic
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 Follicular Thyroid Carcinoma

RULE IN RULE OUT

• 46 y/o, Female
• Solitary Neck Mass
• (+) 3x3 cm mass on the anteromedial part of the neck, nontender,
soft, moves with deglutition • iodine-deficient
• (+) family history of goiter regions
• Euthymic
• Prominent Cervical Lymph nodes, bilateral mid jugular (Level • Cannot totally rule
III) and Submental (Level 1) regions out
• minimal intralesional blood flow
• (-) large, clear nuclei with powdery chromatin with nuclear
grooves and prominent nucleoli
• Suspicious Follicular Neoplasm by FNAB
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 Follicular Adenoma
RULE IN RULE OUT
• 46 y/o, Female
• Solitary Neck Mass
• (+) 3x3 cm mass on the anteromedial part
of the neck, nontender, soft, moves with
deglutition
• (+) family history of goiter
• Euthymic
• Cannot totally rule out
• Prominent Cervical Lymph nodes,
bilateral mid jugular (Level III) and
Submental (Level 1) regions
• minimal intralesional blood flow
• Suspicious Follicular Neoplasm by FNAB
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 Admitting Diagnosis

Anteromedial neck tumor, Follicular

Neoplasm by FNAB S/P Lobectomy
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 CASE DISCUSSION
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 Thyroid Gland
● Right and left lobes connected by
a narrow Isthmus
● Pear shaped lobes
● About 20 grams
● Pyramidal lobe is often present
● Capsule – True fibrous capsule
and False fascial capsule
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 Blood Supply

● Superior thyroid artery

● Inferior thyroid artery
● Thyroid Ima Artery
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 Venous Drainage

● Superior Thyroid Vain

● Middle Thyroid Vein
● Inferior Thyroid Vein
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 Innervation

● Sympathetic – fibers from the

superior and middle cervical
sympathetic ganglia

● Parasympathetic – from the vagus

nerve via branches of the laryngeal
nerves
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 Follicular Neoplasm

● Represents a heterogeneous group of lesions including benign

follicular hyperplasia, follicular adenomas, follicular carcinomas,
and the follicular variant of papillary carcinoma.

● Usually diagnosed following fine-needle aspiration (FNA) biopsy of

a dominant thyroid nodule
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 Follicular Adenoma
●A benign encapsulated tumor of the
thyroid gland. It is a firm or rubbery,
homogeneous, round or oval tumor
that is surrounded by a thin fibrous
capsule. A follicular adenoma is a
common neoplasm of the thyroid
gland.
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Follicular Carcinoma
●tends to be more cellular with a thick
irregular capsule, and often with areas of
necrosis and more frequent mitoses
●distinguished based on capsular invasion,
vascular invasion, extrathyroidal tumor
extension, lymph node metastases, or
systemic metastases
 Epidemiology

• Follicular carcinoma accounts

for ∼10% of all cases of
thyroid malignancy
• Female-to-male ratios : 3:1
• Mean age : 50 years
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 Etiology

● Iodine Deficiency in areas with endemic goiter

● correlated with pregnancy
● human leukocyte antigen (HLA) subtypes (DR1,
DRw, and DR7).
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 Clinical Presentation

● Solitary Thyroid Nodule

● Asymptomatic / Euthyroid
● Larger Tumors
■ Dyspnea,
■ Coughing or Choking spells,
■ Hoarseness
■ dysphagia
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Diagnostics
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 Diagnostics
Radiology
•useful when determining whether:
•mass is more likely of inflammatory or
malignant origin
•surgery is likely to be indicated
•adjunct treatments may be necessary
•maintain a cost-effective approach
•should distinguish between anatomic and
functional imaging of the neck
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 Diagnostics
CT SCAN
• most frequently utilized modality
• discernment of close relationships of the soft tissues and vasculature of the
neck is facilitated using iodinated contrast studies
• can provide crucial information about:
• the relation of the mass to lymph nodes
• major blood vessels
• the airway
• bony structures
• not as ubiquitous in the pediatric population because:
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• risk of radiation exposure

• clinical likelihood of the type of neck mass present in this population
 Diagnostics
Ultrasonography
• can readily distinguish between a solid and a fluid-filled mass.
• useful in the pediatric population 
• can be performed easily without the need for sedation or
exposure to radiation
• mainstay imaging modality for thyroid nodules
• often used in conjunction with FNA to obtain cytologic
information
• larger sialoliths can be identified on ultrasonography
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 Diagnostics
MRI
• useful in both the pediatric and adult populations
• yields most detailed anatomic soft tissue information
• determine perineural disease extension by malignancies in adults
and children
• workup salivary gland masses which may not be easily
discernible on CT
• absence of radiation exposure beneficial for children and
pregnant patients
• much more expensive than CT scans, requires general anesthetic
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sedation in the newborn and toddler populations

 Diagnostics
Magnetic resonance arteriography (MRA) &
Computed tomographic arteriography (CTA)

• useful modalities when there is concern that a lesion is

vascular in origin
• provide excellent anatomic correlation and do not
carry the invasive risks of standard arteriography
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 Diagnostics
Fine Needle Aspiration (FNA)
• should be collected prior to any open procedures 
• performed with a 25-gauge needle
• If FNA is nondiagnostic → consider core needle biopsy
• If still nothing → consider excisional biopsy
• If SCC is identified → neck dissection may be
performed
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 Diagnostics
Bethesda System
● The Bethesda system for reporting thyroid
cytopathology: Implied risk of malignancy and
recommended clinical management
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 Management

Surgery Conservative
● Thyroid lobectomy with ● short-term observation with
isthmectomy follow-up ultrasound
● Total thyroidectomy is often
performed if carcinoma is identified
in a lymph node
● older patients with a nodule
greater than 4 cm in size
diagnosed by FNAC as
follicular neoplasm
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 Prognosis
● The recurrence rate after
initial management is
approximately 30%
● 5-year survival is 90%, and
it decreases to 84% at 10
years
● Presence of distant
metastasis diminishes 5-year
survival to 82%
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Factors that worsen prognosis
• age older than 50 years at
presentation
• tumors greater than 4 cm in
size
• higher tumor grade
• marked vascular invasion
• extrathyroid extension
• Distant metastasis at the time
of diagnosis
Thank you!
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