A 9-year-old girl is evaluated due to a neck mass. The patient first noticed the swelling 2 weeks ago after a viral respiratory illness. The lesion is mildly tender and is not enlarging. She has not had heat or cold intolerance or recent change in appetite or weight. The patient has no other medical conditions. Vital signs are within normal limits. Physical examination shows a 2x2 cm, soft mass in the midline just above the thyroid cartilage. The mass moves superiorly when she is instructed to swallow. There are no other palpable neck masses. The remainder of the examination reveals no abnormalities. Serum TSH is within normal limits.
Which of the following is the most appropriate diagnostic test to obtain prior to treatment of this patient's neck lesion?

Question

A 9-year-old girl is evaluated due to a neck mass.  The patient first noticed the swelling 2 weeks ago after a viral respiratory illness.  The lesion is mildly tender and is not enlarging.  She has not had heat or cold intolerance or recent change in appetite or weight.  The patient has no other medical conditions.  Vital signs are within normal limits.  Physical examination shows a 2x2 cm, soft mass in the midline just above the thyroid cartilage.  The mass moves superiorly when she is instructed to swallow.  There are no other palpable neck masses.  The remainder of the examination reveals no abnormalities.  Serum TSH is within normal limits. 
Which of the following is the most appropriate diagnostic test to obtain prior to treatment of this patient's neck lesion?

Quizplus · Accepted Answer

Explanation: 11ec2b69_beaa_aed7_8f63_63483238067a_MD0005_00 This child with a midline neck mass that moves superiorly with swallowing has a thyroglossal duct cyst (TDC). A TDC is often detected when it becomes secondarily infected after an upper respiratory tract infection, leading to erythema and tenderness. It may also be noted incidentally. The thyroid gland is formed as an outpouching from the pharyngeal epithelium at the base of the tongue. It then descends to the base of the anterior neck via the thyroglossal duct. If the duct fails to atrophy normally, a TDC can develop from the epithelial remnants within the duct. Because the tract connects to the base of tongue, protrusion of the tongue or swallowing causes the TDC to move superiorly. descends Ectopic thyroid tissue is commonly associated with a TDC and may be the only site of functioning thyroid tissue. Therefore, imaging of the thyroid (ultrasound or CT scan) should be obtained prior to definitive treatment. (Choice A) Congenital anomalies of the larynx (eg, laryngomalacia, vallecular cyst, laryngeal cleft) may require barium swallow because their presence (or treatment) may affect swallowing. A TDC does not typically affect swallowing because it is located outside the larynx. (Choice B) Because of the risk of coronary artery aneurysms, echocardiogram should be performed on all patients with suspected Kawasaki disease. However, patients with this condition have ≥5 days of fever and ≥4 of the following: nonexudative conjunctivitis, mucositis, rash, extremity changes, and cervical adenopathy. Kawasaki disease (Choice C) A peripheral blood smear may be indicated for suspicion of either lymphoma or infectious mononucleosis, both of which can present with a neck mass in a child. However, the mass would be located in the lateral neck. (Choice D) Head and neck squamous cell carcinoma often presents with a cervical neck mass. It has a propensity to metastasize to the lungs, so a staging chest CT scan is indicated. However, squamous cell carcinoma nearly always presents in adults, and the mass would be located in the lateral neck rather than at midline. Educational objective: A thyroglossal duct cyst often presents in children after an upper respiratory tract infection as a fluctuant mass that moves superiorly when swallowing. Imaging of the thyroid should be done to identify ectopic thyroid tissue. References: Congenital neck masses. (http://www.ncbi.nlm.nih.gov/pubmed/30396417) Surgical management outcomes of recurrent thyroglossal duct cyst in children - a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/25890397) Thyroglossal duct cyst and ectopic thyroid: surgical management. (http://www.ncbi.nlm.nih.gov/pubmed/25439547)

A 9-Year-Old Girl Is Evaluated Due to a Neck Mass