A patient presented with swelling in front of neck in midline which moves on deglutition. Which among the following will be the MOST likely diagnosis?

1. A

   Thyroglossal Cyst

2. B

   Solitary thyroid nodule in isthmus

3. C

   Subhyoid bursitis

4. D

   Lipoma

Appeared in: NORCET -4 , 2023

Explanation

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• A thyroglossal duct cyst is the most common congenital neck mass and the most frequent cause of a midline neck swelling that moves with deglutition.
• The cyst develops from remnants of the thyroglossal duct, which connects the developing thyroid gland to the base of the tongue.
• Its attachment to the hyoid bone causes it to elevate when the patient swallows, a key diagnostic feature presented in the question.
• While movement with tongue protrusion is a more specific sign, its absence in the question stem does not negate that a thyroglossal cyst is the most probable cause based on prevalence.

Why Other Options Were Wrong

• Option A: A solitary nodule in the thyroid isthmus is also midline and moves with swallowing. However, it is statistically less common as the cause of a midline neck mass compared to a thyroglossal cyst.
• Option C: Subhyoid bursitis is an inflammation of a bursa near the hyoid bone. While it presents as a midline swelling that moves with swallowing, it is a very rare condition and therefore not the 'most likely' diagnosis.
• Option D: A lipoma is a superficial tumor of fat tissue. It is not attached to the deep structures of the neck (like the larynx or hyoid bone) and therefore does not move up and down with swallowing.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Differential diagnosis of a midline neck swelling based on clinical signs to guide bedside assessment, documentation, and the next nursing action.
• Accurate diagnosis of neck masses is crucial as they can range from benign congenital cysts to malignant tumors. The physical exam is the first and most important step.
• A nurse's role includes careful observation and documentation of the characteristics of a swelling (location, size, consistency, mobility) to assist in diagnosis.
• A key nursing action during assessment is to provide the patient with a glass of water and observe the neck during swallowing to confirm mobility, as described in the question.

How to Approach the Question

• First, identify the key features from the patient's presentation: 1) midline neck swelling, and 2) it moves with deglutition (swallowing).
• Next, evaluate each option against these two features.
• Option A (Thyroid nodule), B (Thyroglossal cyst), and C (Subhyoid bursitis) can all present as midline swellings that move with swallowing. Option D (Lipoma) does not move with swallowing and can be eliminated.
• The question asks for the 'MOST likely' diagnosis. This requires knowledge of prevalence.
• Compare the remaining options. Thyroglossal cyst is the most common cause of a midline neck mass that moves with swallowing. A thyroid isthmus nodule is also possible but less common. Subhyoid bursitis is rare.
• Therefore, based on statistical probability, the thyroglossal cyst is the most likely answer.

Concept Tested & Keywords

• Concept Tested: Differential diagnosis of a midline neck swelling based on clinical signs.
• Stem keywords: swelling, front of neck, midline, moves on deglutition
• Lead-in keywords: MOST likely diagnosis
• Clinical cues: Location: Midline neck swelling is a key localizing sign.
• Clinical cues: Mobility: Movement with deglutition points to a structure attached to the larynx or hyoid bone.

Question ID

Q6x00pRnbTRBYY6te6fXVr

Copy ID

Reference Book

E6 Medicine Davidson Principles Practice 24e p. 662-664

E6 Pathology- ROBBINS & COTRAN PATHOLOGIC BASIS OF DISEASE 10TH Ed p. 746-748