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.