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Clinical Challenge
September 16, 2021

Cystic Neck Mass in a Middle-aged Woman

Author Affiliations
  • 1Robert Larner College of Medicine, University of Vermont, Burlington
  • 2Division of Otolaryngology, University of Vermont Medical Center, Burlington
JAMA Otolaryngol Head Neck Surg. 2021;147(11):999-1000. doi:10.1001/jamaoto.2021.2400

A 44-year-old woman presented to the otolaryngology clinic with a 6-month history of a right neck mass with compressive symptoms. She first noticed swelling that progressed to pressure and dyspnea while supine. She reported fatigue but denied pain, voice change, weight loss, hemoptysis, and dysphagia. A physical examination revealed a visible and palpable fullness to the right neck without overlying cutaneous or sinus tract changes. Results of a complete blood cell count, a thyroid stimulating hormone test, triiodothyronine and levorotatory thyroxine testing, and a complete metabolic panel were normal. Ultrasonography showed a 7.9 × 6.3-cm septate cystic mass lateral to the right thyroid gland. A contrast-enhanced computed tomography scan of the neck demonstrated a large, nonenhancing cystic-appearing lesion abutting the lateral and posterior margins of the right thyroid lobe and extending from the level of the piriform sinus to the thoracic inlet (Figure). Ultrasound-guided fine-needle aspiration revealed clear fluid with a parathyroid hormone (PTH) level of 67 pg/mL (reference range, <100 pg/mL; to convert to ng/L multiply by 1.00). A barium swallow study showed no communication between the cyst and the piriform sinus. Excision in the operating room was performed, and right thyroid lobectomy was necessary because of the intimate association of the lesion to the thyroid lobe.

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1 Comment for this article
Assy of PTH after FNAB
Massimo Giusti, Associate Professor | Endocrinologist, Centro Clinico Diagnostico Priamar, Savona, Italy
In the case report is not clear the institutional cut-off for PTH assay (PTH-FNAB). In my experence the PTH levels in FNAB in solid and cystic parathyroid are more hight than in periferal PTH (not reported in the case-report. According to ref 3 the PTH content of cyst fluid ranged from 896 to 921 057 pg/mL while in this case FNAB-PTH is only67 pg/ml (hook effect?). For differental diagnosis you can perform also Tg-FNAB an amylasi -FNAB. Why this was not scheduled in the diagnostic FNAB.