Soft Tissue Neck Mass -- Goiter

Thyromegaly, goiter

• Subtle soft tissue swelling is present along the left side of the patient's neck.
  • The trachea is deviated to the right.
  • Lung fields are clear.
  • There is no definite evidence of mediastinal or hilar adenopathy.
• CT scan of the neck demonstrates an enlarged thyroid with calcification.
  • The trachea is deviated to the right.

Radiography is consistent with a thyroid mass, subsequently demonstrated to represent an enlarged gland, otherwise known as a Goiter.

As in our previous cases of neck mass, radiographic findings are nonspecific and there is no way to make the diagnosis from the x-ray alone. The important point is to make the finding!

• Soft tissue mass in the neck is non-specific.
• Clinical history is important.
• The DDX includes:
  • Abscess
  • Hematoma
  • Lymphadenopathy
  • Vascular Masses
  • Congenital Abnormalities
  • Neoplasm
• CT scan
  • Can demonstrate the relationship of the mass to vessels and other structures.
  • Can help characterize the lesion.
  • Can serve as a guide for biopsy.
• It can be useful to view the radiograph and CT scan together.

• Thyroid disease is not uncommon.
  • An enlarged thyroid is a non-specific neck mass radiographically.
    • The thyroid is easy to visualize on CT scan because of its high iodine content.
      • In general, one cannot distinguish benign from malignant thyroid masses on CT.
        • The presence or absence of calcification is not helpful in this regard.
    • Nuclear medicine plays a key role.
      • "Hot" nodules on 123-Iodine studies are almost never malignant.
      • "Cold" nodules, especially in the setting of prior neck radiation, may represent malignancy and, therefore, are usually biopsied.
      • A mix of "hot" and "cold" nodules in an enlarged gland is usually a multinodular goiter, which is usually benign.
        • I recently returned from a meeting in which the speaker felt that the three largest nodules should be biopsied to exclude carcinoma.
      • 131-Iodine is used to treat hyperthyroidism and to ablate the thyroid after cancer surgery.
    • Laboratory tests are important in diagnosing thyroid disease.
      • Tests include, but are not limited to, T4, T3, TSH.
    • Ultrasound also plays a key role.
      • It can distinguish cystic from solid lesions.
      • It can guide biopsy.

Teaching Points:

• It is easy to overlook bone and soft tissue abnormalities on a chest exam.
• Look for asymmetries and deviation of midline structures.

Ref: Mancuso, A.A., Hanafee, W.N., Computed Tomography and Magnetic Resonance Imaging of the Head and Neck, 2nd ed, Williams & Willkins, Baltimore, MD, 1985. pp. 169-240.

Unknowns>

List of Cases>