A big lump in the anterior cervical area: a differential diagnosis

The decision making process when a patient has a mass in the anterior neck must be quick and precise because a vocal cord paralysis, a tracheal estenosis or a pulmonary aspiration can be present….

CLINICAL CASE: A 80-year-old woman without previous disease started to notice a lump on her anterior cervical area. This lump was growing during a period of three months. The patient has neither dyspnea no cough but an important sialorrea was present.

A first biopsy was reported as carcinoma.

CLINICAL EVOLUTION: The physician attending was trying to workout a thyroid cancer because the mass was clearly palpable on the anterior neck. A second biopsy was interrupted due to an important bleeding. No vocal cord palsy was present.

FINAL DIAGNOSIS: A second review of the CAT/scan for a second radiologist located the lump in the superior esophageal area. There was an infiltration of the left thyroid lobe.

COMMENTS: When you see a clinical situation like the one described here, some doctors are prone to locate the origin in the thyroid gland beacause is a logical way of thinking and also because there is a much more effective treatment. However, sialorrea, is usually associated with an esophageal location.

A                                                                                               B

Figures A and B: tumor with origin in the superior esophageal area with infiltration of the left thyroid gland.

A DIFFERENTIAL DIAGNOSIS:

At the same time we saw another 60-year-old female patient. She had a previous diagnosis of endometrial cancer three years ago. Also she has a diagnosis of  a goiter followed without problems during the last five years but she started to feel  the growth of a lump very rapidly on the anterior cervical area. The physical examination showed a vocal cord palsy and she started with dyspnea and estridor.

Final Diagnosis: Anaplastic thyroid carcinoma

C

Figure C: A right thyroid mass with tracheal deviation and cricoid and thyroid cartigale infiltration.

LESSONS LEARNED

Some details are very important for a correct diagnois. Sialorrea is a symptom related with the esophageal area. Respiratory symptoms and  a vocal cord palsy are more common in thyroid problems due to the tracheal anatomical proximity.