Case 16

23 y/o with no significant PMHx, presents with complaint of sore throat and anterior neck swelling that was noted upon waking up this morning. Patient reports she went to kickboxing last night and did some yoga, but denies any strenuous exercise. No recent illness, no fever, no chills no weight loss, no past HX of present symptoms, no change in voice or difficulty eating.

On exam, well appearing female with prominent swelling to left anterior neck, just lateral to trachea, mass is tender and slightly mobile.

Initial vitals:

T: 96.7 P:89 R:18 BP: 136/ 90 Sat: 97% on RA

Here is the mass by ultrasound:

Questions:

  1. What is in your differential diagnosis for this patient?
  2. What vascular structure may be compromised given the location of the mass?
  3. What are the most life-threatening complications that could occur given the presentation and location of the mass?
  4. Which follow-up studies/labs would you order on this patient? Which findings on your studies would lead you to a particular diagnosis in you differential?

Answers

1. What is in your differential diagnosis for this patient?

  • Abscess, thyroglossal duct cyst, branchial cleft cyst, cervical adenitis, neoplasm.

2. What vascular structure may be compromised given the location of the mass?

  • Carotid, internal jugular vein 

3. What are the most life-threatening complications that could occur given the presentation and location of the mass?

  • Airway obstruction from compression of the trachea
  • Vascular complications (s/a thrombosis of the internal jugular vein, carotid artery erosion and rupture)
  • If the mass is found to be infectious and addition concern is septic emboli: These emboli can lead to pulmonary, brain, or joint seeding and resultant abscesses.

4. Which follow-up studies/labs would you order on this patient? Which findings on your studies would lead you to a particular diagnosis in you differential?

  • CT w/contrast. CT scan can indicate the location, boundaries, and relation of the mass to surrounding neurovascular structures. Abscesses are seen as low-density lesions with rim enhancement, occasional air fluid levels, and loculations.