Neck Mass/Thyroid Enlargement
Neck Mass/Thyroid Enlargement: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
Neck Mass
❑ Inflammatory lymphadenopathy
❑ Parotid swelling/tumor
❑ Laryngeal cancer
❑ Intramuscular hematoma
❑ Lymphoma
❑ Nasopharyngeal carcinoma
❑ Branchial cleft cyst
❑ Thyroglossal duct cyst
❑ Supraclavicular adenopathy
❑ Aortic aneurysm
❑ Carotid aneurysm
❑ Ludwig angina
❑ Pharyngeal pouch
❑ Carotid body tumor
Thyroid Enlargement
❑ Simple goiter
❑ Hashimoto thyroiditis
❑ Grave disease
❑ Drugs
❑ Subacute thyroiditis
❑ Thyroid cancer
❑ Infiltrative disease
Diagnostic Approach
Patients often present for evaluation of a “neck mass” that is a normal structure such as the hyoid, and they will insist that it is new or asymmetric.
With thyroid enlargement, the mass will be low in the neck and extend across the midline. Occasionally, a prominent thyroid nodule will mimic a lymph node but is in an atypical location. The thyroid gland rises and falls with swallowing. The only other structure to do this is a thyroglossal duct cyst.
In a multinodular goiter, a malignancy should be suspected when there is a dominant nodule or cervical adenopathy.
Clinical Findings
Inflammatory lymphadenopathy Bilateral, enlarged, tender anterior cervical nodes are seen in streptococcal pharyngitis and infectious mononucleosis. Concomitant posterior cervical nodes are found with the latter. Unilateral tender adenopathy is seen in dental, sinus, ear, and facial skin infections.
Parotid swelling/tumor The swelling will be present at the angle of the jaw. Bilateral swelling with fever, lacrimal gland inflammation, and uveitis occurs in patients with Hodgkin disease, tuberculosis, lupus, and sarcoidosis. Isolated swelling can occur with mumps, HIV, or bulimia. A tumor appears as a discrete rubbery mass. Unilateral swelling occurs with ductal obstruction caused by a stone.
Laryngeal cancer Glottic cancers present with persistent hoarseness, chronic cough, hemoptysis, referred ear pain, and in later stages dysphagia or stridor. Supraglottic cancers present late with airway obstruction or metastatic lymph nodes. Both occur in smokers.
Intramuscular hematoma Hematoma occurs with neck strain or trauma, as a rapidly appearing mass within a muscle body.
Lymphoma It presents with firm, large (.2 cm), rubbery, nontender nodes, often contiguous in a chain. Fever, night sweats, and weight loss are helpful signs.
Nasopharyngeal carcinoma The most common presenting sign is a neck mass, present in 90%. Consider in a patient of Asian origin with posterior epistaxis and idiopathic facial pain. Serous otitis with decreased hearing is a subtle early sign and abnormal function of CN II–VI is a late sign of invasive disease.
Branchial cleft cyst It is a lateral cystic structure that may enlarge suddenly as a result of trauma or infection.
Thyroglossal duct cyst It appears as a fluid-filled mass in the midline, which transilluminates and elevates when the tongue is protruded.
Supraclavicular adenopathy Right supraclavicular nodes are found in intrathoracic cancers. Left supraclavicular nodes are found in intra-abdominal cancers.
Aortic aneurysm A pulsatile mass will appear in the supraclavicular space.
Carotid aneurysm A pulsatile mass is palpated over the carotid.
Ludwig angina A consequence of a dental infection, the floor of the mouth and sublingual/submandibular space beneath the deep cervical fascia are swollen.
Pharyngeal pouch The swollen area feels uncomfortable when the patient swallows. Stagnating food causes halitosis.
Carotid body tumor It is present at the carotid bifurcation, with a transmitted pulse.
Simple goiter Goiter presents as diffuse or multinodular thyroid enlargement in a clinically euthyroid person, most commonly a woman (5 to 10:1). Diffuse goiter occurs in adolescence or pregnancy, and multinodular goiter occurs in middle age. Iodine deficiency, soybeans, and iodides (seaweed) are dietary causes.
Hashimoto thyroiditis Diffuse thyroid enlargement has a gradual onset. The gland is lobulated and rubbery and often has a prominent pyramidal lobe. The patient may be either euthyroid or hypothyroid on clinical evaluation. A family history of autoimmune endocrine disorders frequently exists.
Grave disease An autoimmune goiter has a finely nodular “cobblestone” feel and is vascular with a bruit and thrill. The patient is usually overtly hyperthyroid, with signs of hyperthyroidism and infiltrative ophthalmopathy.
Drugs Antithyroid drugs, iodides, lithium, sulfonamides, sulfonylureas, methylxanthines, and ethionamide can all cause thyroid enlargement.
Subacute thyroiditis The enlarged, tender gland has a bruit.
Thyroid cancer It begins as a hard focal nodule, often with firm regional lymphadenopathy. Local extension produces loss of movement of the thyroid with swallowing. The recurrent laryngeal nerve and carotid bundle may be involved early, but Horner syndrome is a late finding.
Infiltrative disease Riedel thyroiditis produces a firm goiter, often mistaken for cancer, and pressure symptoms disproportionate to the size of the gland. It may be associated with retroperitoneal fibrosis or sclerosing cholangitis. The recurrent laryngeal nerve is involved early. Sarcoidosis, amyloidosis, and lymphoma can also produce this.
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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