Approach to neck swelling in adults | Thyroid .pptx

Approach to neck swelling in adults | Thyroid

1. APPROACH TO NECK SWELLING IN ADULTS ASNA ZAHIDAH BINTI OMAR

2. Definition: an abnormal lesion that is visible, palpable or seen on imaging How to approach a neck swelling?? Anatomic classification Age based classification ( paeds vs adult) Level I: submental and submandibular triangles Level II, III, IV: upper, middle and lower internal jugular chain Level V: posterior triangle Level VI: anterior compartment. -same differential dx -relative position of dx infection most common cause in children neoplasm is most common cause in adult Differential diagnosis -Infectious -Inflammatory -Congenital -Neoplastic : benign vs malignant History - age,size,duration -acute symptom: fever, sorethroat,cough adenopathy from URTI sx -chronic symptom:dysphagia /change in voice quality/hoarseness of voice anatomic or functional alteration -recent trauma,travel , insect bite or exposure to pets or farm animals -history of smoking/alcohol/previous radiation treatment

3. Goal is to identify a neck mass that is at increased risk for malignancy

4. PHYSICAL EXAMINATION Inspection for cutaneous lesions O toscopy (unilateral middle ear effusion may indicate nasopharyngeal carcinoma) A nterior rhinoscopy O ral cavity inspection and palpation O ropharyngeal inspection (looking for masses, ulceration) T onsil enlargement or asymmetry F lexible nasopharyngolaryngoscopy . Suspicious physical examination ->1.5cm -firm -non tender -fixed -ulceration of overlying skin

5. HYPERTHYROIDISM

6. CAUSES OF THYROTOXICOSIS  Increased Synthesis & Secretion of Thyroid Hormone Graves disease Toxic adenoma Toxic multinodular goitre Malignancy (thyroid papillary carcinoma) Genetic mutation Marine-Lenhart syndrome (Graves disease + toxic adenoma)  Increased Released of Preformed Thyroid Hormone Autoimmune  Hashimoto’s thyroiditis Infection  viral, TB, cellulitis Physical insult  Anaplastic carcinoma/ primary thyroid lymphoma Extrathyroidal Thyroid Hormone (Endogenous Or Exogenous) Endogenous: Struma ovarii Metastatic thyroid carcinoma Exogenous Thyroid hormone supplements Cooked animals thyroid gland Excessive Stimulation By Trophic Factors Such As Thyrotropin-Stimulating Hormone (TSH) & Other Factors  TSHoma (pituitary gland thyrotrophs adenoma)  secondary hyperthyroidism Gestational trophoblastic disease  secretes b-HCG (partial molecular similarity with TSH) Iodine-induced hyperthyroidism ( Jod – Basedow thyrotoxicosis) Iodinated contrast materials Amiodarone

7. INVESTIGATION Thyroid function test Ultrasound of neck Colour flow doppler – thyroid vascularity & peak systolic velocity of inferior thyroid artery (to distinguish Graves’ disease & thyroiditis) TSH receptor antibodies ( TRAbs ) Thyroid scintigraphy -(assess thyroid regional function & nodule) Indications for Ultrasound Palpable neck swelling/ nodule/ lymph nodes Painful goitre Difficult physical examination of neck (obese/ thick neck) Suspected malignant properties of neck swelling/obstructive symptoms To screen first-degree family members of patients with familial thyroid cancer

8. GRAVES’ DISEASE FEATURES Triad Goitre + Thyrotoxicosis + Graves’ ophthalmopathy (GO) – exophthalmos, proptosis, diplopia Family history of thyroid disorder Association with other autoimmune disorders Vitiligo Rheumatoid arthritis Type 1 DM Autoimmune gastritis Positive TRAb Smoking increase likelihood and severity of hyperthyroidism & GO

9. BETA BLOCKER Consider giving to symptomatic patient ( esp elderly), resting PR > 90/min, coexistent cardiovascular disease Symptomatic control Reduce heart rate Lower blood pressure Improve muscle weakness & tremor Reduce irritation, emotional lability, exercise tolerance Propanolol , metoprolol, atenolol Alternative Calcium-channel blockers (verapamil / diltiazem) TREATMENT OPTIONS FOR HYPERTHYROIDISM Anti-thyroid drug (ATD) Radioactive iodine (RAI) Surgery

10. ATD Carbimazole (CMZ) Start with 10-30mg OD (10mg CMZ ≈ 6mg methimazole) Titrate down to 5-10mg OD maintenance (usually start 30mg OD for 2W follow by 20mg OD for 4W, then maintain 10-15mg OD) Propylthiouracil (PTU) 50-150mg TDS Adverse effect Minor – pruritus, rash Major – agranulocytosis, vasculitis, hepatic damage (more with PTU) Repeat TFT in 2-6 weeks after initiation of ATD Once euthyroid, decrease dose by 30%–50% and repeat TFT in 4–6 weeks Monitor TFT 2-3 monthly once achieve euthyroid with minimal maintenance dose (6-monthly if tx > 18 month) Consider check for fT3 if symptomatic despite normal TSH & fT4 Treat 12-18 months in Graves’ disease Remission = normal serum TSH, fT4 & fT3 for a year after discontinuation of ATD

11. Suitable for High likelihood of remission (women, mild disease, small goitres & negative or low- titre TRAb ) Pregnancy Elderly or with comorbidities or limited life expectancy Unable to follow radiation safety regulations Previously operated or irradiated necks Lack of access to a high-volume thyroid surgeon Moderate to–severe active Graves’ ophthalmopathy (GO) Need more rapid biochemical disease control Contraindication Previous known major adverse reactions to ATD

12.  Suitable for • Comorbidities increasing surgical risk • Previously operated or externally irradiated necks • Lack of access to a high-volume thyroid surgeon • Contraindications to ATD use or failure ATD treatment • Patients with periodic thyrotoxic hypokalaemic paralysis, right heart failure, pulmonary hypertension or congestive heart failure Contraindications • Pregnancy / Planning a pregnancy within 6 months • Lactation • Coexisting or suspicion of thyroid cancer • Unable to comply with radiation safety guidelines RAI (radioactive iodine)

13.  Suitable for : • Planning a pregnancy in less than 6 months • Symptomatic compression or large goitres (>80 g) • Relatively low uptake of RAI • Thyroid malignancy is documented or suspected • Large thyroid nodules (> 4 cm) or if non-functioning or hypo-functioning • Coexisting hyperparathyroidism requiring surgery • TRAb levels are particularly high • Patients with moderate-to– severe active GO Contraindications: • Substantial comorbidities • Lack of access to a high-volume thyroid surgeon • Pregnancy (relative contraindication) - surgery should only be used in circumstances wherein rapid control of hyperthyroidism is required and ATD is contraindicated SURGERY

14. SUBCLINICAL HYPERTHYROIDISM

15. Should we treat subclinical hyperthyroidism?