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Cystic Neck Mass in a Middle-aged Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 44-year-old woman presented to the otolaryngology clinic with a 6-month history of a right neck mass with compressive symptoms. She first noticed swelling that progressed to pressure and dyspnea while supine. She reported fatigue but denied pain, voice change, weight loss, hemoptysis, and dysphagia. A physical examination revealed a visible and palpable fullness to the right neck without overlying cutaneous or sinus tract changes. Results of a complete blood cell count, a thyroid stimulating hormone test, triiodothyronine and levorotatory thyroxine testing, and a complete metabolic panel were normal. Ultrasonography showed a 7.9 × 6.3-cm septate cystic mass lateral to the right thyroid gland. A contrast-enhanced computed tomography scan of the neck demonstrated a large, nonenhancing cystic-appearing lesion abutting the lateral and posterior margins of the right thyroid lobe and extending from the level of the piriform sinus to the thoracic inlet (Figure). Ultrasound-guided fine-needle aspiration revealed clear fluid with a parathyroid hormone (PTH) level of 67 pg/mL (reference range, <100 pg/mL; to convert to ng/L multiply by 1.00). A barium swallow study showed no communication between the cyst and the piriform sinus. Excision in the operating room was performed, and right thyroid lobectomy was necessary because of the intimate association of the lesion to the thyroid lobe.

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A 44-year-old woman presented to the otolaryngology clinic with a 6-month history of a right neck mass with compressive symptoms. She first noticed swelling that progressed to pressure and dyspnea while supine. She reported fatigue but denied pain, voice change, weight loss, hemoptysis, and dysphagia. A physical examination revealed a visible and palpable fullness to the right neck without overlying cutaneous or sinus tract changes. Results of a complete blood cell count, a thyroid stimulating hormone test, triiodothyronine and levorotatory thyroxine testing, and a complete metabolic panel were normal. Ultrasonography showed a 7.9 × 6.3-cm septate cystic mass lateral to the right thyroid gland. A contrast-enhanced computed tomography scan of the neck demonstrated a large, nonenhancing cystic-appearing lesion abutting the lateral and posterior margins of the right thyroid lobe and extending from the level of the piriform sinus to the thoracic inlet (Figure). Ultrasound-guided fine-needle aspiration revealed clear fluid with a parathyroid hormone (PTH) level of 67 pg/mL (reference range, <100 pg/mL; to convert to ng/L multiply by 1.00). A barium swallow study showed no communication between the cyst and the piriform sinus. Excision in the operating room was performed, and right thyroid lobectomy was necessary because of the intimate association of the lesion to the thyroid lobe.

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Article Information

Corresponding Author: Daniel Gerges, MD, Division of Otolaryngology, University of Vermont Medical Center, 111 Colchester Ave, W Pavilion 4, Burlington, VT 05401 (dgerges779@gmail.com).

Published Online: September 16, 2021. doi:10.1001/jamaoto.2021.2400

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Papavramidis  TS , Chorti  A , Pliakos  I , Panidis  S , Michalopoulos  A .  Parathyroid cysts: a review of 359 patients reported in the international literature.   Medicine (Baltimore). 2018;97(28):e11399. doi:10.1097/MD.0000000000011399 PubMedGoogle Scholar
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Rossi  ED , Revelli  L , Giustozzi  E ,  et al.  Large non-functioning parathyroid cysts: our institutional experience of a rare entity and a possible pitfall in thyroid cytology.   Cytopathology. 2015;26(2):114-121. doi:10.1111/cyt.12153 PubMedGoogle ScholarCrossref
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McCoy  KL , Yim  JH , Zuckerbraun  BS , Ogilvie  JB , Peel  RL , Carty  SE .  Cystic parathyroid lesions: functional and nonfunctional parathyroid cysts.   Arch Surg. 2009;144(1):52-56. doi:10.1001/archsurg.2008.531 PubMedGoogle ScholarCrossref
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Coste  AH , Lofgren  DH , Shermetaro  C . Branchial cleft cyst. StatPearls Publishing; 2021. Accessed August 12, 2021. https://www.ncbi.nlm.nih.gov/books/NBK499914/
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Allard  RH .  The thyroglossal cyst.   Head Neck Surg. 1982;5(2):134-146. doi:10.1002/hed.2890050209 PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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