Urgent considerations

See Differentials for more details

Rapidly enlarging neck mass

A rapidly enlarging neck mass may present with airway obstruction leading to stridor. This is a medical emergency that requires urgent intervention. The patient may also have dysphonia and dysphagia. Presentation with a rapidly expanding neck mass and a paralyzed vocal cord is an ominous sign for a thyroid malignancy. Anaplastic thyroid cancer and primary thyroid lymphoma (usually B cell) should be considered in the differential diagnosis of any rapidly enlarging neck mass.[2]

Sudden enlargement of thyroid adenomas and hyperplastic nodules can also be caused by hemorrhage into the nodule. This often leads to acute pain as the nodule enlarges; however, the degree of compression is usually not as severe as that which arises from an aggressive malignancy.

Incidentally noted neck masses

Masses detected incidentally during physical examination or on imaging warrant further evaluation with a neck ultrasound and fine needle aspiration (FNA) depending on imaging characteristics.[33][34][35]​​​ Thyroid nodules noted to be metabolically active during PET (i.e., prominent focal uptake in the thyroid) scans should also have FNA to rule out malignancy.[36]​ Diffuse thyroid uptake on PET is likely to be due to Hashimoto thyroiditis and a low risk for malignancy.[23][36]​​​​

Palpable neck mass in setting of elevated calcium and parathyroid hormone

Parathyroid carcinoma is seen in less than 1% of patients with parathyroid disorders.[31] Compared to patients with benign primary hyperparathyroidism, parathyroid carcinoma may present at a younger age, with more severely elevated parathyroid hormone and calcium levels, and a palpable neck mass (up to 75% of cases); a palpable neck mass is an uncommon finding in benign hyperparathyroidism.[31]​​ Between 10% and 30% of patients with parathyroid carcinoma will have metastatic disease at presentation, most commonly to the lung, bone, or liver.[31]

Differentiated thyroid cancer

Confirmed or suspected cases of differentiated thyroid cancer (papillary thyroid cancer and its variants as well as follicular thyroid cancer) require referral for surgical management.[2]​ Clinicopathologic assessment of the patient and the tumor are required for preoperative risk stratification to determine treatment options.[1][2][18]​ Specific management guidelines exist for children with differentiated thyroid cancer.[37]

Medullary thyroid cancer

Confirmed or suspected cases of medullary thyroid cancer require referral for multidisciplinary consultation, including surgical and endocrinological evaluation.

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