Neonate with a large neck mass

The purpose of this series is to describe the prenatal diagnosis and pregnancy outcome of fetuses affected with Dandy-Walker malformation in which a posterior cyst herniated through a bony defect of the occipital skull, foramen magnum, or both. Two- and 3-dimensional sonography were used to examine 2 fetuses with poorly delineated cerebellar structures and a large posterior cystic neck mass. Fetal magnetic resonance imaging (MRI) was added to this evaluation as a complementary diagnostic modality. Three-dimensional sonography helped characterize the precise site of cyst herniation through the occipital skull or foramen magnum. Fetal MRI confirmed the sonographic findings. Neonatal MRI studies identified heterotopic gray matter as evidence of a neuronal migration disorder in both fetuses. The second fetus also had agenesis of the corpus callosum. Retrospective review of the fetal MRI (25.9 weeks' menstrual age) and 3-dimensional sonographic (18.7 weeks' menstrual age) studies confirmed ventricular wall nodularity involving the occipital horns of the second fetus. The antenatal detection of a large posterior cystic neck mass and a poorly defined or nonvisualized cerebellar vermis suggest Dandy-Walker malformation with a herniated cyst. Three-dimensional sonography and fetal MRI are important adjunctive methods that can be used to evaluate the herniation site and a possible neuronal migrational disorder.

<b>Introduction:</b> Large fetal neck masses can present a major challenge for securing an airway at birth with associated risks of hypoxia, brain injury and death. Teratomas of the oropharynx are rare, presenting 3% of teratomas in childhood, and are treated by surgical excision. If respiratory distress accompanies the lesion, priority must be given to the securing of the airway.<b> Case History:</b> We present a case of an infant who was diagnosed antenatally as having a huge oropharyngeal teratoma. The anaesthetic, surgical and neonatology teams were ready to perform surgical excision depending on the placental circulation immediately after securing the airway. The tumour weighed 1591 g and was 20 x 22 x 12 cm. The patient was a male and weighed 715 g. Histopathology showed Grade II teratoma. <b> Conclusion:</b> Large fetal neck masses can present a major challenge for securing an airway at birth with associated risks of hypoxia, brain injury and death. A multidisciplinary team approach combined with an accurate prenatal diagnosis obtained through fetal ultrasound is the key to a successful outcome. Ex utero intrapartum treatment (EXIT) that is based on the placental blood during intubation, tracheostomy or surgical excision is the standard procedure.

A 57-year-old female had a total thyroidectomy for Hürthle cell carcinoma. Pathology revealed Hürthle cell carcinoma replacing the right thyroid lobe and isthmus and Hashimoto's thyroiditis in the left lobe. Panels A and B (Fig. 1) show the histological findings in the right thyroid (hematoxylin & eosin [H&E], X200) demonstrating large, polygonal Hürthle cells with abundant granular cytoplasm, moderately pleomorphic nuclei with mitosis (arrows). The tumor cells are arranged in follicles (Fig. 1A) with occasional papillary areas (Fig. IB). Postoperatively, the patient was treated with radioactive iodine and post ablative whole-body scan was negative for distant metastases. The patient presented 3 months later with a large right neck mass (approximately 4 X 54 cm) and fever. Fine-needle aspiration of the mass revealed malignant cells consistent with Hürthle cell carcinoma. Computed tomography (CT) scan of the chest showed multiple large cardiac masses in the right ventricle and right atrium, and an embolus occluding the right main pulmonary artery. Echocardiogram demonstrated two large masses with areas of necrosis in the right ventricle and right atrium (Fig. 2, arrows). Cardiac catheterization with biopsy was nondiagnostic and the patient underwent open heart biopsy which showed metastatic Hürthle cell carcinoma. Figure 1C and ID show the histology of the cardiac metastases of the Hürthle cell carcinoma involving the myocardium of the right atrium and the pericardium. The neoplastic Hürthle cells are arranged in small groups and follicles (Panel C) with occasional papillary areas (Fig. ID). The serum thyroglobulin level was undetectable. Intracardiac metastases of thyroid cancer are rare with only a few reported cases in the literature (1-3). It has been described with follicular, papillary and anaplastic carcinoma. Overall the prognosis is poor and the average survival is a few months (1-3).

A 67 year old white woman presented to her family doctor in January 2013 with a small asymptomatic thyroid swelling. Her serum thyroid stimulating hormone (TSH) concentration was high (37...

Disclosure: Q.F. de Leon: None. F.P. Salvador-Badilles: None. K. Tolentino: None. P.D. Maningat: None. Background: Thyrotropin-secreting pituitary adenoma is the rarest type of functioning pituitary adenoma with co-secretion of growth hormone (GH) being the most common associated endocrinopathy. To date, this is the first reported case of TSH/GH-producing adenoma co-existing with differentiated thyroid cancer (DTC) in the Philippines and fourth globally. Clinical Case: A 65-year-old female with history of multiple thyroid surgeries presented with recurrent thyroid nodules, thyrotoxicosis and acromegaly features. Diagnostics showed persistently elevated FT4 and FT3 with non-suppressed TSH (without thyroid hormone replacement), elevated IGF-1 and positive growth hormone suppression test. Imaging revealed a pituitary macroadenoma (1.6 x 1.2 x 1.3 cm) without compression effects and a large neck mass (4.6 x 6.8 x 8.7 cm) causing tracheal displacement. Despite lacking access to genetic testing for thyroid hormone resistance, clinical features alongside biochemical findings and imaging suggested TSH/GH-producing pituitary adenoma. A surgical dilemma arose as to whether thyroid or pituitary surgery should be prioritized. Given the possibility of thyroid malignancy based on the history of recurrent and rapidly enlarging neck mass despite benign findings on biopsy, thyroid surgery was done with preoperative Methimazole treatment to achieve euthyroid state. Histopathological findings of papillary thyroid carcinoma (1.3 cm, TNM stage 1, low recurrence risk) further complicated management. Due to its rare occurrence, there is no consensus regarding the management of TSH/GH-producing pituitary adenoma co-existing with DTC. Recommendations to reduce serum TSH to prevent tumor recurrence may be challenging in patients with TSHoma due to persistent TSH secretion. Postoperatively, Levothyroxine was started but TSH suppression was inadequate. Due to the patient’s age and low recurrence risk with high-normal FT4 levels, we are reluctant to increase the Levothyroxine dose. Preoperative use of somatostatin receptor ligand (SRL) is crucial in controlling thyroid hormone levels, reducing tumor size, lowering IGF-1 and minimizing surgical risks in patients with severe comorbidities (pharyngeal thickening, severe OSA, heart failure). Pituitary surgery was delayed due to difficult intubation during the initial surgery. Given elevated thyroglobulin on follow-up, we plan to address the DTC with surgery or radioactive iodine (RAI) if surgery is not feasible. Post-RAI, SRL will be initiated to lower IGF-1 and TSH while awaiting pituitary surgery. Conclusion: Recurrent thyroid nodules despite multiple surgeries may indicate an underlying pituitary pathology, necessitating surgery as primary treatment with medical options like SRLs. The co-existence of a DTC complicates management requiring individualized treatment to optimize outcomes. Presentation: Monday, July 14, 2025

Significant differences exist between airways of the neonate and the adults. Anaesthetic management of airway may be challenging in neonates and young infants with large neck masses like cystic hygroma because these patients are at risk for sudden complete airway occlusion resulting in hypoventilation and hypoxemia. Cystic hygroma are benign, but can be disfiguring. It is a condition which usually affects children. Treatment is surgical excision under general anaesthesia either one or multistage resections.

Ex-utero intrapartum treatment (EXIT) is performed for fetuses diagnosed with large neck masses. A case report of a fetus diagnosed with a large cystic hygroma and cord around the neck who was delivered by EXIT is presented. The airway challenges and optimal positioning is discussed.

Large thyroid masses present several potential difficulties for anaesthetists. These include distortion of the airway, endocrine disturbances, and metastatic effects. A typical case is presented and the anaesthetic management and considerations are described.

Multiple myeloma involving the thyroid cartilage is a very uncommon disease entity. Only 10 cases have been reported in the international literature to date and as such it constitutes a...

Anaplastic thyroid carcinoma is fatal if unresectable. However, improved survival has been reported after gross total resection and multimodality therapy. In this report, we describe the contrast-enhanced high-resolution CT characteristics of anaplastic thyroid carcinoma in 57 patients. Anaplastic thyroid carcinoma presented as a large neck mass with necrosis in 82% of cases. The tumors demonstrated common extrathyroidal extension (91%). Sixty-two percent of tumors demonstrated calcification. Visceral space invasion involved the esophagus (62%), trachea (57%), and larynx (29%). Carotid artery encasement was present in 42%, and 43% involved the internal jugular vein. Sixty-three percent had lateral compartment lymphadenopathy; 58% of these nodes were necrotic, and 11% were cystic. No metastatic nodes had calcification. Central compartment lymphadenopathy was seen in 56% of cases, and lateral retropharyngeal lymphadenopathy was detected in 12%. Knowledge of these imaging features aids in guiding the approach to the initial tissue diagnosis with either fine-needle aspiration or core biopsy, assessing the feasibility of surgical resection, and determining prognosis.

Anaplastic carcinoma of the thyroid in a 12-year old girl

Third and fourth branchial anomalies are rare, accounting for less than 10% of all branchial anomalies. The piriform fossa sinus tract (PFST) typically presents with left-side suppurative thyroiditis, although it can present earlier in neonates as a non-inflamed cystic neck mass. PFST poses a considerable diagnostic challenge with variable clinical and imaging features, leading to long delays to definitive diagnosis and appropriate management. To analyse the patterns of presentation and imaging findings in children with PFST, with a particular focus on neonatal presentation. This was a retrospective review of the clinical presentation, imaging findings and management in 16 cases of PFST presenting to our tertiary children's hospital between 2003 and 2018. Cases were identified by medical records and picture archiving and communication system (PACS) search using relevant International Classification of Diseases (ICD)-10 coding. Age at presentation ranged from prenatal to 16years, with a male-to-female ratio of 2:1. All patients presented with neck swelling. Thirteen patients (81%) had suppurative thyroiditis at initial presentation. Two patients had severe thyroiditis/mediastinitis that required intensive care unit admission. Three neonates presented with noninfected, asymptomatic large cystic neck masses; two of these were detected prenatally and misdiagnosed as lymphatic malformations with subsequent spontaneous clinical resolution that later represented with evidence of PFST. The PFST was on the left side in 15/16 (94%) patients. All patients had neck imaging before definitive diagnosis. Imaging studies included radiographs, ultrasound, computed tomography, magnetic resonance imaging and barium esophagram studies. No single modality was diagnostic of PFST in all patients. Seventy-five percent of patients had multimodal imaging before diagnosis. All PFSTs were confirmed by endoscopic visualisation. Management of PFST was by endoscopic cauterisation in 13 patients and open surgery in 2. One patient did not require surgical correction. Our study highlights the complex nature of PFST. The anomaly is uncommon, has variable clinical and imaging features and may have a lengthy, complicated course if not considered at initial presentation. An episode of suppurative thyroiditis in a child should prompt investigation for PFST. We describe atypical presentations with cystic masses in neonates that appear to resolve but represent later as typical clinical features of PFST.

A 40-year-old man presented with a large left neck mass after recent treatment of mixed testicular nonseminomatous germ cell tumor with metastasis to the retroperitoneal and mediastinal lymph nodes. What is your diagnosis?

A 72-year-old woman presented with a large pulsatile anterior right neck mass with compressive symptoms of dysphagia and hoarseness. This was due to a large (6 cm by 4 cm) postcarotid endarterectomy pseudoaneurysm of the right common carotid artery. Successful endovascular exclusion of the pseudoaneurysm was performed with a Viabahn stent graft with significant decrease in the size on follow-up. Other endovascular options such as coil embolization and thrombin injection are also discussed. It is important to exclude infection as the cause of postendarterectomy pseudoaneurysm before considering endovascular repair over surgical repair.

Patient: Female, 22-year-oldFinal Diagnosis: Central line infection • cystic hygroma • pregnancySymptoms: Cystic hygroma • neck mass • pregnancyMedication: —Clinical Procedure: Cesarean section • ex utero intrapartum treatment • fiberoptic bronchoscopy • general anesthesia • laryngoscopy • rigid bronchoscopy • spinal anesthesia • video laryngoscopySpecialty: Anesthesiology • Obstetrics and Gynecology • OtolaryngologyObjective:Congenital defects/diseasesBackground:This report describes a case of delivery of an infant with airway compression due to cystic hygroma at 37 weeks’ gestation requiring a multidisciplinary decision to use a combination of ex utero intrapartum treatment (EXIT) and airway palliation at cesarean section. This infant did not require support with extracorporeal membrane oxygenation (ECMO).Case Report:A 22-year-old G1P0 woman with past medical history of morbid obesity underwent an EXIT procedure due to a large fetal neck mass. Anesthesia included a narcotic-only single-shot spinal, total intravenous anesthesia (TIVA) was used for maintenance, and high-dose volatile anesthetics and nitroglycerin infusion was used for complete uterine relaxation. The infant’s airway was secured by the otolaryngologist, after which delivery was completed. Sevoflurane and nitroglycerin were discontinued and the previous TIVA was restarted. Uterotonics were aggressively administered to prevent uterine atony, and the patient was extubated.Conclusions:This report shows the importance of a multidisciplinary approach to the management of delivery of infants with airway obstruction. This case demonstrates the approach to the decision for the use of EXIT combined with airway palliation, as ECMO was not combined with EXIT in this case.