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Recently had a patient while on a Peds EM shift with an interesting presentation. Not sure how many of us have had this case, so this should serve as a helpful reminder for management.
15yF with no significant PMHx presenting with a “knot in my throat.” Per patient report, she woke up the morning of presenting to the ED with a palpable knot. Unsure how long it had been present, but she happened to notice it that morning. Denies hx of fever, chills, changes in energy level, palpitations, shortness of breath, odonyphagia, dysphagia, changes in menstrual cycle, recent URI, changes in hair or nail quality nor irradiation to the neck. Mother was really concerned because 2 people in her family had either thyroid carcinoma or nodules removed. One was diagnosed in her 20s.
On physical exam:
General: AFVSS
HEENT: NCAT, EOMI, PERRLA, no evidence of exophthalmos
Neck: Supple, Trachea midline, R anterio-lateral neck mass – approx 1.5cm x 2cm. Firm to palpation and located anatomically near superior pole of R thyroid lobe. Moves with swallowing. No associated erythema or fluctuance. No cervical lymphadenopathy.
Lungs: CTAB,
CVS: RRR, no m/r/g. Pulses equal. No peripheral edema.
So you get labs: CBC,TSH, Free T4
All within normal limits
Beside USN revealed what appeared to a multicystic nodule in the R thyroid lobe where the patient’s palpable mass was located. So let’s get a formal USN.
Formal reveals that patient actually has multiple nodules. The largest being approx 3cm x 2cm x 2cm, and read as a colloid nodule.
Let’s recap:
We have a 15yF presenting with an asymptomatic thyroid nodule, who is euthyroid based on hx, physical exam, and labs. What’s next??
1. Discuss the case with a Pediatric Endocrinologist. Nothing acutely needs to be done; however, she should have outpatient followup with an endocrinologist to help keep surveillance of her nodules.
2. Add testing for Thyroid specific antibodies to rule out Hashimoto’s thyroiditis and other autoimmune inflammatory processes. Consider adding Anti thyroid peroxidase (Anti-TPO) and Anti-Thyroglobulin antibodies.
3. Ultrasound simply characterizes the mass that we’ve palpated. Yes, the nodule was read as a “colloid nodule,” which is fairly common regarding thyroid nodules; however, this needs to be confirmed by Cytopathology. Nuclear studies can be done but not recommended in isolation. Such studies can be helpful when determining whether a nodule is “hot” or “cold.” Simply speaking, is there increased thyroid uptake or not. CT and MRI imaging is not cost effective in the initial stages of evaluation.
4. Lastly, the best way to determine whether a nodule is benign or malignant, you have to sample the source via Fine Needle Aspiration Biopsy (FNAB). Await the cytopathology results and return to #1.