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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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B. Parathyroid cyst

The positive PTH staining of tissues inside the cyst combined with the homogenously dim image yielded by the NIRAF camera are clues for the parathyroid cyst diagnosis.

Benign thyroid nodules may be the first diagnosis that comes to mind in the differential diagnosis of a solitary neck mass given their high incidence compared with other possibilities. Thyroid nodules do not stain positive for PTH. In addition, imaging the thyroid with the autofluorescence camera, the thyroid nodules are more likely to look heterogeneous with both bright and dim spots, especially in multinodular goiter. The absence of recent fever or infection coupled with the 4-month history of the mass excludes most causes of reactive viral lymphadenopathy. Reactive lymphadenopathy typically lasts for up to 2 weeks. If caused by EBV, lymphadenopathy may persist for up to 6 weeks. Thyroglossal duct cysts are typically midline lesions occurring anywhere between the foramen cecum to the suprasternal notch, but most commonly are diagnosed at or just below the hyoid bone. They are frequently diagnosed during childhood in association with infection or a history of infection. However, physicians should not exclude thyroglossal duct cysts based by age alone because some patients may present for the first time during adulthood.

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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.

References
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