I. Overview
Neck masses are one of the common symptoms in otorhinolaryngology-head and neck surgery. Due to the diverse nature of the masses, the majority of patients are at a loss as to what to do, and they are currently divided into four categories according to their etiology and pathology.
①Neoplastic masses ;
② inflammatory masses;
(iii) congenital masses;
④Other.
The clinical manifestations of neck masses have a certain regularity, namely the 80% rule proposed by Skandalakis: adult neck masses are mostly benign tumors, accounting for about 80%, and malignant tumors are rare; lymph node metastases are predominant among malignant tumors, accounting for about 80%; most malignant tumors metastasizing to the middle and upper neck come from the oral cavity, nasal cavity, pharynx and larynx, accounting for about 80%; malignant tumors metastasizing to the lower 1/3 of the neck and clavicle Most of the malignant tumors in the upper region are from the lower respiratory tract, breast, and urinary tract. Regarding the course of the disease Skandalakis summarized the 3 7 laws, i.e. 7d are mostly inflammatory, 7 months are mostly tumors, and 7 years are mostly congenital masses. The thyroid disease retrieved by the netizens today has its own peculiarities. The thyroid gland is an endocrine organ located on both sides of the trachea in the middle of the neck, and the neck mass is the most common manifestation of thyroid disease, so we summarize the diagnosis and management of thyroid masses, and other masses are described again.
Second, the classification of thyroid masses.
Thyroiditis
1. Subacute thyroiditis
2.Chronic lymphocytic thyroiditis
3. chronic fibrous thyroiditis
Nodular goiter
Thyroid adenoma
Thyroid cancer
1.Papillary thyroid adenocarcinoma
2.Follicular adenocarcinoma of the thyroid
3.Medullary carcinoma of the thyroid gland
4.Undifferentiated carcinoma of the thyroid
Thyroid lymphoma
Auxiliary examination
1.Thyroid nuclide scan (generally preferred method)
The nodules are classified into “hot nodules” and “cold nodules” according to their ability to take up radionuclides. “Hot nodules are almost always benign. “Cold nodules have the possibility of cancer, but multiple cold nodules are mostly benign adenomas or nodules; hot nodules suggest increased function and high uptake of radionuclides.
2.B ultrasound scan (routine examination method)
A single solid nodule has a higher chance of malignancy, while a mixed nodule also has the possibility of malignancy, while a simple cystic nodule has a lower chance of malignancy.
3.Guided fine needle aspiration.
This test is simple, safe and helps a lot to identify benign and malignant nodules.
4.CT scan (an extremely valuable method to evaluate thyroid lesions)
It can clarify 90% of lesions and evaluate the extent of lesions and the relationship between surrounding structures; if there are small or sand-like calcifications on nodules, they may be sand bodies of papillary carcinoma. Large and irregular calcifications can be seen in degenerative nodular goiter or thyroid cancer.
5. Thyroid function measurement
Functionally autonomous toxic nodules are mostly hyperthyroid, and early stages of subacute thyroiditis can also be hyperfunctional. Thyroid function in chronic lymphocytic thyroiditis can be normal, hyperactive or hypothyroid. Most of the thyroid nodules caused by the remaining lesions have normal function.
Diagnosis and management of thyroid nodules
Medical history: the younger the age, the greater the likelihood of malignancy; (children, young men); the rapid appearance and increase in size in a short period of time, the greater the likelihood of malignancy, although attention is paid to identifying the possibility of bleeding papillary cystadenoma.
Signs: a single nodule has a higher chance of malignancy than multiple nodules; benign adenomas have a smooth surface, soft texture, and great mobility when swallowed; malignant ones have an uneven surface, hard texture, and little mobility when swallowed; the presence of enlarged lymph nodes is helpful for differentiation.
V. Treatment principles
For benign multiple nodules, if there is no hyperthyroidism and normal thyroid function, treatment with dry thyroid preparations can be performed first, and most of the lobes of the gland should be removed if there is no improvement; for single hot nodules, the possibility of cancer is small, so surgery or nuclear therapy is required; for cold nodules, surgery is required; for suspected malignant nodules, early surgery is required; for cystic nodules, simple cyst removal is possible; for solid nodules, the nodules, their envelope and the surrounding 1cm wide If the nodule is solid, the nodule, its envelope and the surrounding 1 cm wide normal tissue should be removed as a whole, or most of the affected gland should be removed. If the nodule is solid, the whole nodule, its envelope and surrounding 1 cm wide normal tissue should be removed or most of the affected gland should be excised. The next step of treatment should be decided by the result of freezing.
VI. Postoperative endocrine therapy for differentiated thyroid cancer
Adjusted according to TSH level.
The dose of alternative therapy should be slightly higher for men than women, slightly higher for young people than for the elderly, and the dose for the elderly should be reduced by 10%-15%.
The initial dose should be small, 1/2 to 1/4 tablet/time, once/day; gradually increase the dose, once every 2-4 weeks, with each increment of 1/2 to 1/4 tablet, and the maintenance dose can be reached in 2 to 3 months until normal.
It takes 4-6 weeks for TSH to be balanced, and TSH and T4 can be measured only 4-6 weeks after each dose change until they are normal.
The more severe the hypothyroidism and the longer the duration of the disease, the lower the starting dose
Suppressive therapy: Given that TSH is a follicular epithelial growth factor, it is important to suppress TSH secretion as much as possible in differentiated thyroid cancer. Long-term T4 suppressive therapy can significantly improve the patient’s outcome and is the standard treatment for thyroid cancer.
L-T4 dose: 2.2~2.5 μ/(kg.d);
Total dose <150 μ/d
TSH suppression between 0.05 and 0.1 U/L
L-T4: levothyroxine tablets, synthetic thyroxine, stable and reliable potency. 20 μ/tablet, 50 μ/tablet, 100 μ/tablet and 125 μ/tablet, currently available in China.
T3: triiodothyronine, synthetic, stable 5 μ/tablet, 25 μ/tablet, 50 μ/tablet, too strong for cardiovascular effects, used only in hypothyroid crisis.
Dry thyroxine tablets. Only absorbed through the intestinal tract, less stable potency, inexpensive. 40 mg/tablet, 40-60 mg/d, individual patients need 80-120 mg/d.
VII. TNM stage
T stage (papillary carcinoma, follicular carcinoma and medullary carcinoma)
T1: The maximum diameter does not exceed 2cm and is confined to the thyroid gland.
T2: the maximum diameter is greater than 2cm, but not more than 4cm, confined to the thyroid gland.
T3: maximum diameter is greater than 4cm, confined to the thyroid gland; or regardless of the size of the tumor, but breaks through the thyroid peritoneum to reach the thyroid muscle of the sternum or the soft tissue in front of the thyroid gland.
T4a: The tumor breaks through the thyroid peritoneum and invades the following tissue structures: subcutaneous soft tissue, larynx, trachea, esophagus and laryngeal nerve.
T4b: The tumor invades the prevertebral fascia, mediastinal vessels or envelops the carotid artery.
T4a: regardless of tumor size, confined to the thyroid gland.
T4b: regardless of tumor size, it breaks through the thyroid peritoneum.
N stage
N1: Regional lymph node metastasis.
N1a: Regional lymph node metastasis in area VI (pre-tracheal, paratracheal including anterior laryngeal lymph nodes)
N1b: Metastases to regional lymph nodes other than zone VI including unilateral, bilateral or contralateral cervical or upper mediastinal lymph nodes.
M stage: M0 without distant metastasis; M1 with distant metastasis
Clinical staging
Papillary and follicular carcinoma under 45 years of age
Stage I: Any T, any N and M0; Stage II: Any T, any N and M1
Papillary and follicular carcinoma and medullary carcinoma at 45 years of age and older
Stage I: T1N0MO; Stage II: T2NOMO;
Stage III: T3NOMO; T1-3N1aMO
Stage IVA: T4aNON1aMO T1T2T3N1bMO; Stage IVB: T4b any NMO;
Stage IVC: anyT anyNM1
Undifferentiated carcinoma (stage IV in all cases)
Stage IVA: T4a any NMO; Stage IVB: T4b any NMO Stage IVC: any T any NM1
VIII. Classic cases
Case 1: The patient, female, 28 years old, visited our department for a neck mass. After examination, multiple thyroid adenomas on the right side were considered and a right thyroid lobectomy + isthmus was performed, with good postoperative wound healing. The postoperative wound is healing well. At the present follow-up, the neck wound is healing well with no significant scarring and no recurrence of tumor.
Wound condition on the fifth day after surgery.
The stitches were removed on the seventh postoperative day. It can be seen that the wound is healing well and the incision is beautiful, meeting the desire of women for aesthetics.
Case 2: The patient was a 74-year-old female who came to our department for “20 years after papillary thyroid cancer surgery, recurrence with lymph node metastasis in the neck for 2 years”, one year after partial thyroidectomy followed by Y-knife treatment of the neck mass. After the perioperative treatment of hypothyroidism and hypertension, the right cervical lymph node dissection + mass removal was performed, and the wound healed well after surgery.
Preoperative mass
Preoperative cervical angiography.
Postoperative situation after stitch removal
Case 3: The patient, a 22-year-old female, presented with a neck mass and preoperative relevant tests suggested a thyroid mass. On November 16, 2009, the right thyroid mass was removed under general anesthesia, and intraoperative freezing suggested papillary carcinoma. There was no significant discomfort at the two-year follow-up.
Postoperative day 6
Case 4: The patient, a 33-year-old female, visited our department for a left-sided neck mass. After examination, she was considered to have a left-sided thyroid adenoma and underwent a left-sided thyroid lobectomy. The post-operative incision healed well. The thyroid function was normal and the neck incision healed well at the 2-month post-operative follow-up.
Insight: Beautiful postoperative incision, few complications and complete tumor removal are the wishes of the patients and the goals of medical workers.
First of all, thyroid masses occur more in female patients and if operated, many of them are young and beautiful girls who have higher requirements for surgical incisions. Therefore, we choose more low and small incisions under the condition of ensuring good exposure of surgical field, and choose intraoperative button sutures for satisfactory healing of postoperative incisions;
Secondly, in order to completely remove the tumor, many patients need to remove the lobe of thyroid gland. It is very important to protect the recurrent laryngeal nerve to avoid postoperative hoarseness and respiratory difficulty, so the operation requires the surgeon to have skilled anatomical skills to facilitate good exposure of the recurrent laryngeal nerve and important blood vessels, so as to lay a good foundation for fine surgery, and the rest of the operation will be very easy, with less bleeding, clear vision and good postoperative healing.
Finally, careful preparation before surgery (thorough and necessary examination of the patient, preparation of the surgeon’s skills, and careful care after surgery are also indispensable for a perfect surgical procedure.