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Unilateral Progressively Growing Neck Mass in a Young Adult

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

An 18-year-old male presented to the primary care physician with a 4-month history of a slowly progressive painless lateral neck mass on the right side. The patient denied any history of dysphagia, dysphonia, drainage, previous neck surgery, trauma, or recent fever. There was no significant medical or family history of thyroid disease. On examination, the mass moved with swallowing. The patient had normal thyroid stimulating hormone and calcium levels and a parathyroid hormone (PTH) level of 63 pg/mL. Neck ultrasonography revealed a well-circumscribed anechoic lesion with a diameter of 5.9 cm in the right thyroid lobe without any internal solid nodularity or septation. A neck computed tomography (CT) scan revealed an intrathyroidal lesion extending inferiorly to 3 cm above the angle of Louis causing tracheal compression and displacement (Figure, A). The patient underwent right hemithyroidectomy to relieve tracheal compression. A near-infrared autofluorescence (NIRAF) camera yielded a homogenously dim lesion (Figure, B). Pathologic examination confirmed a normal right thyroid lobe, a normal right parathyroid gland, and a cystic lesion at the inferior pole with no evidence of malignant disease in the specimen. The tissue inside the lesion stained positive for PTH.

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An 18-year-old male presented to the primary care physician with a 4-month history of a slowly progressive painless lateral neck mass on the right side. The patient denied any history of dysphagia, dysphonia, drainage, previous neck surgery, trauma, or recent fever. There was no significant medical or family history of thyroid disease. On examination, the mass moved with swallowing. The patient had normal thyroid stimulating hormone and calcium levels and a parathyroid hormone (PTH) level of 63 pg/mL. Neck ultrasonography revealed a well-circumscribed anechoic lesion with a diameter of 5.9 cm in the right thyroid lobe without any internal solid nodularity or septation. A neck computed tomography (CT) scan revealed an intrathyroidal lesion extending inferiorly to 3 cm above the angle of Louis causing tracheal compression and displacement (Figure, A). The patient underwent right hemithyroidectomy to relieve tracheal compression. A near-infrared autofluorescence (NIRAF) camera yielded a homogenously dim lesion (Figure, B). Pathologic examination confirmed a normal right thyroid lobe, a normal right parathyroid gland, and a cystic lesion at the inferior pole with no evidence of malignant disease in the specimen. The tissue inside the lesion stained positive for PTH.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Amr H. Abdelhamid Ahmed, MBBCH, MMSc, Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114 (amr_ahmed@meei.harvard.edu).

Published Online: April 28, 2022. doi:10.1001/jamaoto.2022.0513

Conflict of Interest Disclosures: Dr Randolph reported grants from Eisai outside the submitted work; and Dr Randolph is the President of the International Thyroid Oncology Group (ITOG) and the World Congress on Thyroid Cancer (WCTC), is Chair of the Administrative Division of the American Head and Neck Society (AHNS), and is the American College of Surgeons (ACS) Otolaryngology Governor. No other disclosures were reported.

Additional Contributions: We thank the patient for granting us permission to share this case to support our educational efforts. Dr Randolph would like to acknowledge the ongoing support of Mike and Eliz Ruane and of John and Claire Bertucci for his research efforts.

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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