IGNACIO, Richelle Angelika E. Dr.
Emma Guevara
2017-0116 Otorhinolaryngology
[November 25, 2019 8:00-10:00 AM]
IDENTIFYING DATA
Patient. M.O. is a 52-year-old female residing in Cubao, Quezon City.
Referral. SLMC-OPD.
Source & Reliability. Information acquired from the patient. She was consistent and reliable.
CHIEF COMPLAINT
Right anterior neck mass
HISTORY OF PRESENT ILLNESS
Three months prior to consult, M.O. noticed right anterior neck mass described as cartilage-like, movable,
and nontender. It is associated with difficulty of breathing and aggravated upon exertion. No weight loss,
sweating, palpitations, heat or cold intolerance noted. In the interim, patient just observed its growth and no
consult was sought.
Ten days prior to consult, patient sought consult and had undergone biopsy, which revealed it to be 2-cm
“thyroid mass”. Thyroid function test was also done but results has not yet been given.
On the day of consult, patient presented with the same symptoms stated above with no additional symptoms.
PAST MEDICAL HISTORY
Childhood Illnesses. Unrecalled.
Adult illnesses. Hypertensive; highest BP recorded was 160/100; usual BP is 140/90. Non-diabetic. No
kidney, heart, or liver diseases. No asthma or tuberculosis. No history of diagnosed thyroid problem.
Medical treatment and hospitalization. History of breast cancer stage 2B; managed with left breast
mastectomy; undergone chemotherapy from December 2010-May 2011.
Surgical.
OB/Gyn. G3P3 (3-0-0-3). Menarche at 12 years old; Early menopause at 44 years old due to chemotherapy.
History of OCP use for 9 years after having her 1st child; initially used injectables then switched to IUDs.
Allergies. Allergies triggered by perfume and other strong odors, smoke, and ingestion of certain food
(shrimp)
FAMILY HISTORY
History of hypertension from the maternal side and breast cancer from the paternal side. She has 8 siblings;
3 siblings
PERSONAL AND SOCIAL HISTORY
M.O. used to be a cashier at the mall but is now a housewife. She does not smoke and previously drinks
alcohol (San Miguel beer) occasionally. Patient claims there are no smokers at home and her house is far
from any sources of pollution i.e. factories, main road. She usually eats twice a day with her meal consisting
of 1 cup of rice, meat, and vegetables. She eats processed foods occasionally. Salt at home is iodized.
REVIEW OF SYSTEMS
General. Fever and easy fatigability reported. No weight gain and weakness.
Skin. No rashes, lumps, sores, itching, and dryness. No changes in color or changes in hair or nails.
HEENT. Head—No headache or dizziness. No head injury reported. Eyes—No dryness, redness, spots,
specks, and flashing lights. No sensitivity to light. No double vision or blurring. Ears—Fullness experienced
during episodes of colds. Nose & Sinuses—No nasal stuffiness, discharge, itching, hay fever, nosebleeds,
and sinus trouble. Throat—No sore tongue, dry mouth, sore throats, and hoarseness.
Neck. Check HPI.
Respiratory. Episodes of cough and colds lasted 3 weeks; no hemoptysis.
Cardiovascular. No chest pains and palpitations. No history of rheumatic fever. No heart murmurs and
paroxysmal nocturnal dyspnea. No edema.
Gastrointestinal. No change in appetite, trouble swallowing, and nausea. Regular bowel movement. No pain
with defecation, rectal bleeding or black or tarry stools. No hemorrhoids, constipation, diarrhea.
Urinary. No change in urination. No kidney or flank pain, kidney stones, ureteral colic, suprapubic pain and
incontinence.
Musculoskeletal. No joint pains. No arthritis, gout, stiffness of muscles, and backache.
Peripheral vascular. No edema, cramps or claudication.
Psychiatric. No nervousness, tension, depression, memory change, suicidal ideation, and suicide plans or
attempts. No history of counseling, psychotherapy, or psychiatric admissions.
Neurologic. No changes in mood, attention, or speech; No changes in orientation, memory, insight, or
judgment. No episodes of fainting, blackouts, and seizures. No tinnitus.
PHYSICAL EXAMINATION
General Survey. Patient appears healthy and well-groomed. She is conscious, coherent, and cooperative.
No noted body or breath odors.
Vital Signs. Height and weight not taken. Blood pressure (right arm) 110/80 mmHg. Heart rate 70 bpm;
regular. Respiratory rate 22 bpm. Body temperature (temporal) 36.1°C.
Skin. No jaundice, lesions, redness, scalings, and swelling.
HEENT. Head—Normocephalic. Coarse gray hair. Face was symmetric. Eyes—Normal symmetry and
alignment of eyes and eyebrows. Ears— Ears symmetric. Mole noted on right ear lobe. No deformities, lumps,
or skin lesions. No ear pain, discharge; and tragal tenderness. On the left ear, non-hyperemic ear canal with
cerumen; opaque membrane was seen with a sclerotic plaque noted in the anterior part of the tympanum;
good cone of light. On the right ear, opaque tympanic membrane slightly retracted with distinct malleolar
folds; handle of malleolus more lateral. Non-lateralizing Weber ; Rinne positive for both ears (AC>BC).
Nose— No visible deformities. Nasal mucosa pink. Septum slightly deviated to the left, with septal spurs
toward the left side. Crusted mucus discharge seen in the right nasal cavity. Left nostril clear. No nasal
congestion, discharge, swelling, and obstruction. No sinus tenderness. Mouth & Throat— No dentures. Oral
mucosa pink. No lesions, exudates, inflammation of tonsils. Tongue midline. Dental cavities in the right and
left, upper and lower pre-molars and molars. Tonsils not inflamed; no exudates. No palpable mass on the
floor of the mouth.
Neck. Trachea midline; 2-cm right anterior neck mass, oval-shaped with well-defined borders, firm, and non-
tender, movable and moves with deglutition. Slight thickening on level III on the left neck was palpated. No
palpable lymph nodes.
SALIENT FEATURES
This is a case of a case of a middle-aged female presenting with a right anterior neck mass approximately 2
cm in size, cartilage-like, movable, non-tender, with well-demarcated borders, and is associated with difficulty
of breathing aggravated upon exertion. Biopsy revealed that it was a thyroid mass with thyroid function test
results still pending. On history, patient reported weakness and easy fatigability. Salt used at home is iodized
and eats processed foods occasionally. History of breast cancer noted but no history of thyroid diseases. No
fever, weight loss, sweating, palpations, heat and cold intolerance, and change in appetite or thirst. Upon
physical examination, patient appears well with stable vital signs. An oval-shaped mass was palpated at the
right anterior neck described to be firm, movable, non-tender, and moves with deglutition. A slight thickening
on level II on the left neck area was palpated. No hoarseness, dysphagia, or palpable lymph nodes.
WORKING IMPRESSION
Nontoxic goiter
DIFFERENTIAL DIAGNOSES
In any case of neck mass, malignancy should be immediately ruled out. In this case, given the age of the
patient and is a known case of breast cancer, in addition to eating processed food, thyroid cancer is a
possible diagnosis. The most common thyroid cancer is papillary thyroid carcinoma which accounts for 80%
of thyroid malignancies and is more common among females. It presents as an asymptomatic mass with
accompanying persistent cough, dyspnea, and dysphagia. Although the patient presents with an
asymptomatic mass and dyspnea, this is not likely the case because the characteristics of the mass has
benign features. However, further tests should be done to confirm the exclusion of this diagnosis. In the same
line, lymphoma can also be considered in this case as it presents with a lateral painless swelling and fatigue,
which are both seen in our patient. However, it is usually accompanied with fever, night sweats, and
unexplained weight loss, which the patient does not manifest. Hence, lymphoma is also an unlikely case.
Branchial cleft cyst is also considered because the patient’s mass is situated literally, which is typical for
this condition. Branchial cleft cyst are congenital epithelial cysts that arise from the failure of obliteration of
the 2nd branchial cleft in embryonic development. However, considering its congenital etiology, this commonly
appears during early childhood and remains unrecognized until it becomes infected. Although the anatomic
location of the mass is similar with the patient’s case, this is not likely the case because of the patient being
a middle-aged female. Moreover, no history of infection was reported that could cause the cyst to appear.
Considering that we live in the Philippines, tuberculous (TB) adenitis should also be considered since a
neck mass is a common manifestation of extrapulmonary tuberculosis. Moreover, the patient had a 3-week
history of cough. However, no other systemic symptoms such as fever, malaise, or weight loss is present in
the patient that would typically manifest in a patient with tuberculosis. Hence, this is also unlikely.
Given the benign features of the patient’s mass with no symptoms of thyroid dysfunction, nontoxic goiter is
highly considered.
CASE DISCUSSION
A nontoxic goiter is a diffuse or nodular enlargement of the thyroid gland that is not associated with abnormal
thyroid function. It is usually an endemic case among iodine-deficient regions. In the patient’s setting, this
was not the case as the salt she uses at home is iodized. Some more possible etiologies of nontoxic goiter
would be radiation exposure and family history. However, no history of radiation exposure or thyroid diseases
were reported. Hence, the patient’s case is most likely a sporadic case. Development of sporadic goiter does
not usually occur before puberty and usually progresses with age.
Given the characteristics of the patient’s mass, it is highly unlikely that it is a malignancy considering its
benign features i.e. well-demarcated borders, movable, no change in size. Moreover, the patient did not
present with any symptoms that would indicate to a thyroid dysfunction. Hence, nontoxic goiter is highly
considered in this case. However, she presents with difficulty of breathing aggravated upon exertion. This
could be due to the mass compressing the trachea due its anatomical location anterior to the trachea. It is
generally asymptomatic until a critical narrowing has occurred and it presents with dyspnea especially upon
exertion, as seen in the patient’s case.
To confirm the impression, considering that the patient has already had biopsy and thyroid function test, a
neck ultrasound can be ordered in order to locate and estimate the number of nodules as well as their sizes.
Although, optional thyroid scintigraphy can also be ordered to evaluate the functioning of the thyroid—if it is
overactive or underactive. Given that lymphoma is being considered in this case, CBC should also be done
to rule out this condition. Chest x-ray may also be used to rule out possible infections since tuberculous
adenitis is considered a differential.
Given that the patient is complaining of difficulty of breathing, it is likely that the mass is obstructing the airway,
hence surgery is indicated. The procedure of choice is thyroidectomy or surgical decompression as it causes
rapid relief for obstructive symptoms. Bilateral subtotal thyroidectomy has been recommended to reduce the
risk of continued goiter growth. Afterwhich, patient must undergo thyroid hormone replacement therapy,
which starts immediately after surgery with TSH levels checked every 3-4 weeks in order to monitor signs of
overtreatment such as tachycardia, palpitations, atrial fibrillation, nervousness, tiredness, headache,
increased excitability, sleeplessness, tremors, and possible angina. Consultation with an endocrinologist
should be considered in complicated cases and if highly suspicious for malignancy within the nontoxic goiter.
Since the patient uses iodized salt at home, it is unlikely that the patient does not reach the adequate
requirement for iodine. Otherwise, supplementation through multivitamins must be implemented.
REFERENCES
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Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). New York, NY: McGraw Hill Professional.
2. Somasundar, P. (2018, September 16). Papillary Thyroid Carcinoma Treatment & Management:
Approach Considerations, Surgical Care, Radioiodine Therapy. Retrieved from
https://emedicine.medscape.com/article/282276-treatment
3. Haynes, J., Arnold, K., Aguirre-Oskinsi, C., & Chandra, S. (2015, May 15). Evaluation of Neck Masses in
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