Neck Mass
Triage Note: “Pt is here for sob and feels like she is having panic attacks. Might have a problem with her thyroid.”
Initial Vitals
T 36.6 C HR 65 BP 122/67 RR 18 O2 sat 97% on RA.
Presentation
29-year-old female presents to emergency department complaint of shortness of breath. She reports having increasing neck swelling over the past 3 months. She received an ultrasound prior primary care provider which demonstrated a left-sided mass, which she describes as "goiter". Also states that her thyroid levels were "low" but states that she was not started on any medication. She is pending her first appointment with an endocrinologist next month, and is also pending thyroid biopsy. She endorses that over the last week she has felt several episodes of lightheadedness. Also reports that upon waking up this morning she felt increased shortness of breath and "heaviness" in her throat. Does report uncomfortable feeling when swallowing but is able to drink and eat. Denies drooling, fever, cough, lower extremity swelling. No additional symptoms reported. Patient denies additional comorbidities.
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GENERAL: Alert, not in acute distress
HEAD: Head is normocephalic and atraumatic
EYES: EOMI. PERRLA. No scleral icterus. No conjunctival injection
ENT/Neck: Large palpable mass, left greater than right on neck without audible stridor. No tripoding or drooling, no tongue elevation. No oropharyngeal swelling.
RESPIRATORY: No respiratory distress. Clear b/l breath sounds
CV: Regular rate and rhythm. Capillary refill less than 2 seconds.
ABDOMEN: Soft, non-distended, non-tender. No guarding. No rebound.
EXTREMITIES: Normal
SKIN: No rash/lesions
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CBC: WBC 4.7, Hgb 12.2, Plt 213
CMP: Na 138, K 3.6, Cl 104, Co2 22, BUN 10, Cr 0.7, Ca 9.3, Alb 3.9, TP 7.9, T bili 0.3, Alb phos 75, AST 12, ALT 21
Hcg Neg
T4 Free 0.69
TSH 0.214
CT Soft Tissue Neck with Contrast
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“Very large and vividly enhancing mass is seen emanating from the left lobe of the thyroid gland. There is substantial displacement of the larynx and the cervical segment of the trachea which is also narrowed. The mass is seen measuring 5.0 x 6.3 x 9.5 cm (AP, TRV, CC). Fat planes with the adjacent strap musculature, larynx, and trachea are lost. The common carotid artery is displaced laterally but not encased and the intervening fat plane is maintained. The prevertebral soft tissues are maintained in the cervical spine is uninvolved. The right lobe of the thyroid gland is mildly heterogeneous but otherwise unremarkable.”
ED Course Outcome/Discussion
This patient's presentation is consistent with a thyroid mass causing impression of the trachea. On CT imaging patient had rightward displacement of the larynx and trachea due to the size of her thyroid mass which was concerning for thyroid carcinoma. While no emergent airway intervention was required, the patient was closely monitored and was transferred to a tertiary center for ENT evaluation. It was suspected that the patient's dizziness and lightheadedness may have been related to adjacent mass effect on her carotid sinus.
Takeaway Points
Dizziness/lightheadedness could be caused by compression/mass effect of the carotid sinus.
Patients may use incorrect terminology or diagnoses when referring to their conditions (“goiter”). Trust but verify!
Communicate both subjective complaints, such as shortness of breath, and objective findings when transferring a patient for higher level of care.
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