What’s the Mass in the Neck?
May 21, 2015
A 21 year old Japanese male is presenting with a mass in his neck he finds incidentally. The mass is best seen on the right side of his neck when he turns his head to the left. The picture denotes a change upon swallowing. What is his diagnosis and workup? (Scroll down to see answer)
The video can be seen here:
Diagnosis: Thyroid Nodule
We can confirm this patient has a thyroid nodule on exam for two reasons:
1) The mass is more easy to see when patient looks to the contra-lateral side of the mass.
2) Most importantly, the mass moves with swallowing.
Thyroid nodules are important not to miss on exam as the major concern is to rule out a thyroid cancer. The general management of a thyroid nodule, either found on exam or imaging (if non-palpable) is to measure the serum TSH level. If low, patients generally will get a radionuclide study to look for a functioning (i.e. producing thyroid hormone) nodule. If the radionuclide study shows a functioning nodule, the next step is to measure the thyroid hormones and treat hyperthyroidism is present. However, if the radionuclide study shows a non-functioning thyroid nodule or if the initial TSH level is normal or elevated, all patients should receive a thyroid fine needle aspiration to rule out cancer.
Also, don’t forget to look for other findings suggestive of hyperthyroidism such as postural tremor, lid lag, and a sweaty palm. Some of this is described in Dr. Verghese’s video on the examination of the hand.
This patient had a benign non-functioning thyroid nodule. He will get periodic ultrasound monitoring to ensure there isn’t sudden growth to suggest a malignancy, although malignancy is benign thyroid tumors are rare.
Watch this video to get a first-person perspective of the Examination of the Hand with Abraham Verghese.
In this session, we shared our experiences with teaching the physical exam at the bedside. Our participants got into groups and came up with their own bedside teaching example to share with everyone.
It’s important to understand what diseases are associated with a given type (test) of tremor.