Neck Swellings & goiter

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Neck Swellings goiter

• Dr.AbdulWAHID M Salih
• M.D. Surgery

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Neck Swellings

• Lymphadenopathy
• Thyroglossal cyst
• Dermoid cyst
• Branchial cyst
• Carotid artery aneurysm
• Carotid body tumour
• Laryngocele

• Pharyngeal pouch
• Cystic hygroma
• Pancoast's tumour
• Salivary glands
• Thyroid
• Lipoma
• Neurofibroma
• Sebaceous cyst (aka Epidermoid cyst)?

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Differentiate Neck Lumps

• ANTERIOR TRIANGLE
• Pulsatile
• Carotid aneurysm
• Carotid tumour
• Non-pulsatile
• Lymphadenopathy
• Thyroglossal cyst
• Dermoid cyst
• Branchial cyst
• Pharyngeal pouch
• Thyroid

• POSTERIORTRIANGLE
• Lymphadenopathy
• Cervical rib
• Cystic hygroma
• Pancoast's tumour
• Subclavian aneurysm

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BRANCHIAL CYST

• young adults
• Usually within upper 2/3rds of anterior border of
  sternocleidomast muscle
• soft and fluctuant
• may transilluminate

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PHARYNGEAL POUCH

• Older
• Pulsion Diverticulum
• Dysphagia
• ?size on swallowing
• Usually on the left
• Can be midline too!

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CAROTID BODY TUMOURSGlomus tumour/ Chemodectoma

• Benign at carotid bifurcation
• middle age
• PULSATILE, hard and elastic
• Classically moves from ? but not up ? and ?

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Midline Neck Swellings

• Thyroglossal cyst
• Hard with a clearly defined edge
• Moves up on protrusion of the tongue
• Goitre
• Less common causes
• Lymphadenopathy
• dermoid cyst
• plunging ranula
• pharyngeal pouch

Thyroglossal cyst
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Posterior Triangle Neck Swellings
CYSTIC HYGROMA (Cavernous lymphangioma)

• At birth or soon after
• Brilliant transillumination!

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ANATOMIC BONDARIES OF THYROID
Lying Over The 3rd-4th Tracheal Rings

• Cricoid cartilage
• Supraesternal notch
• Carotid arteries

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Sites of normal ectopic thyroid tissue
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• Invested in the pretracheal fascia of the neck
• Two lobes connected together by an isthmus
• A normal thyroid 10 grams
• Upper limit of 20 grams(2 to 4 teaspoons).

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Answer these questions

• Any enlargement of the thyroid gland?
• Diffuse or nodular?
• Physiological, inflammatory or toxic?
• Euothyroid, hyper or hyperthyroid?
• Benign or malignant?

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History

• How quickly has it developed
• Smooth or nodular
• Painful ?
• Lymph nodes
• Sudden changes
• Big symptoms
• (e.g. breathing problems)

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Goitre

• Hypo-, Hyper- Or Euthyroid?
• Weight loss/ gain
• Appetite
• Sweating and heat intolerance
• Tremor
• Palpitations
• Menorrhagia/ Oligomennorhoea

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Hyperthyroidism

• Symptoms
• Jittery, shaky, nervous
• Difficulty concentrating
• Emotional lability
• Insomnia
• Rapid HR, palpitations,
• Feeling Hot
• Weight Loss
• Diarrhea
• Fatigue
• Menses lighter flow,
• shorter duration

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Thyrotoxicosis

• Common
• Nervousness, Irritability
• hand tremor
• weight loss
• Fatigue
• Palpitations
• Heat Intolerance
• amenorrhea.

• Less common
• Dyspnea
• Gynecomastia
• Proptosis
• Burning sensation in eyes
• Muscle weakness
• Diarrhea
• Osteoporosis

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Hyperthyroidism

• Exam
• Goiter
• Eyes
• Thyroid bruit or thrill
• Cardiovascular abnormalities
• Musculoskeletal
• Hands
• Dermopathy
• Legs

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Physical Exam

• Patient upright - Examination of the goiter is
  best performed with the patient upright, sitting
  or standing. screening exam.
• The neck in a neutral or slightly extended
  position.
• Cross-lighting increases shadows
• Improving the detection of masses.

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swallow a sip of water Inspect upward
movement of the thyroid gland Palpate feeling
for the upward movement of the thyroid gland.

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• Both hands simultaneously symmetry.
• Palpation of the goiter is performed
• either facing the patient or from behind
• Followed by
• Systematic
• Examination

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Pseudogoiter

• a prominent thyroid seen in individuals who are
  thin.

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Palpation

• Each lobe is palpated for
• Size
• Consistency
• Nodules
• Tenderness
• -Diffuse thyroid tenderness subacute
  thyroiditis
• -local thyroid tenderness intranodal
  hemorrhage or necrosis.

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Palpation Anterior Approach

• Attempt to locate the thyroid isthmus
• palpating between the cricoid cartilage and
  the suprasternal notch.
• The size of each lobe
• 2 dimensions.
• Rubbery
• sternomastoid muscle

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Examine TRACHEA

• Trachea Central, Deviated
• Retrosternal extension Percuss over the
  clavicle.
• Auscultation goiter (Listen for bruits) trachea
  and carotid artery.
• Congestion upper chest and neck veins.
• Hand raising Pemberton's Test
• (retrosternal extension , proximal myopathy)
• Raise arms above head for 1 minute looking
  for
• Pink colour
• Stridor
• Distention Of Neck Veins

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Lateral Approach

• Inspection better outline the thyroid profile.
• Estimate the smooth, straight contour from the
  cricoid cartilage to the suprasternal notch.
• Measure any prominence
• using a ruler placed in
• the area of prominence.

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Posterior Approach

• Behind or beside the patient
• Thyroid isthmus
• by palpating the cricoid cart
• And the suprasternal notch.
• Feel under the sternocleid.
• A sip of water
• Palpate, feeling for the upward Movement of
  the thyroid gland.

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Cervical lymph glands

• Signs of metastatic thyroid cancer.
• Submental, submandibular, cervical chain,
  supraclavicular, infraclavicular, posterior
  triangle, occipital and post auricular.

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Tongue

• Protrude
• Thyroglossal Cyst
• Tremor
• Voice changes
• (recurrent laryngeal nerve).
• The oropharynx
• lingular thyroid tissue.

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Clinical diagnosis of etiology ofcommon causes
of thyrotoxicosis
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Simplified Goiter Classification

• Degree 0 No goiter
• Degree 1 Goiter palpable but not visible
• Degree 2 Goiter palpable and visible. (2)
• Degree 3 thyroid visible at distance

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Thyrotoxicosis

• Transient
• Neonatal thyrotoxicosis
• Infectious Acute subacute thyroiditis
• Drug induced
• interferon
• 4.Iatrogenic

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Thyrotoxicosis

• Persistent
• Graves disease
• Diffuse Toxic Goiter
• 2.Toxic multinodular goiter
• 3.Toxic solitary adenoma
• Plummer disease
• 4.Central (pituitary origin)

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Graves ophthalmopathy
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Lid lag
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HANDS

• Warm, moist skin Sweaty
• Tachycardia
• Fine tremor
• Irregular heart beat
• (atrial fibrillation)
• large volume pulse
• Muscle weakness
• Palmar erythema
• Thyroid acropachy marked
• in the index and thumbs

thyroid acropachy
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Legs

• Thyroid Dermopathy
• Thickening and redness of the dermis
• Pre-tibial myxoedema

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Thyrotoxicosis

• Heart Tachycardia, Increase contractility and
  cardiac output, Atrial fibrillation, Flow murmur,
  Systolic hypertension
• Skeletal muscles Proximal myopathy, easy
  fatigability, slow-relaxing reflexes and muscle
  atrophy

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Neonatal hyperthyroidism born to mother with
Graves disease
A Color Atlas of Endocrinology p51
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Graves' disease

• The pyramidal lobe often is enlarged .
• Is diffuse, bilaterally enlarged, symmetrical,
  elastic, soft.
• Palpation a thrill
• Auscultation soft bruit.

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Subacute Thyroiditis

• Acute phase (2-6/52) hyperthyroidism
• Recovery phase (weeks-months) transient
  hypothyroidism
• then euthyroidism
• sore throat
• fever
• tender goiter
• cervical LN

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Multinodular Goitre

• Most common type
• One lobe or its
• part is affected
• Hypofunctional
• or euthyroid
• If tolerable then
• can be left alone

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Congenital Hypothyroidism

• Prolonged hyperbilirubinemia
• Dry yellow skin
• Macroglosia
• Poor feeding
• Hoarse cry
• Decreased activity
• Constipation
• Umbilical hernia
• large fontanelle
• Delayed skeletal maturation

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Hypothyroidism Symptoms

• General Slowing Down
• Lethargy/somnolence
• Depression
• Modest Weight Gain
• Cold Intolerance
• Hoarseness
• Dry skin
• Constipation
• General Aches/Pains
• Brittle Hair
• Menstrual irregularities
• ? Libido

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HypothyroidismExamination

• Dry, pale, course skin with yellowish tinge
• Periorbital edema, Puffy face and extremities
• Sinus Bradycardia, Diastolic HTN
• ? Body temperature
• Delayed relaxation of reflexes
• Megacolon (? peristaltic)
• Pericardial/ pleural effusions
• Congestive heart failure
• Non-pitting edema
• Hoarse voice
• Myopathy

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Nontoxic goiter

• Chronic lymphocytic thyroiditis (hashimoto
  disease)
• Early graves disease
• Endemic goiter
• Sporadic goiter
• Congenital goiter
• Physiologic goiter puberty

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Small diffuse goitre

• Bilaterally slightly enlarged
• Soft consistency
• Eufunctional
• Adolescence              

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Colloidal goitre

• Usually diffuse
• Symmetrical
• rigid consistency
• Adulthood
• Usually eufunctional

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 Hashimoto's goitre

• Auto-immune disease
• Usually more rigid consistency
• Rough surface
• Hypothyroidism

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Malignant goitre

• Markedly rigid
• sensitive to palpation
• Limitation of move.
• Often fixed to the base
• Rapidly progresses
• A hard thyroid gland
• malignancy or riedel struma.

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Retrosternal goitre

• Reaches behind the sternum
• Sometimes visible on the neck
• Its function may be normal
• cause mechanical problems

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Have A Nice Day