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Case 338

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Male patient, 47 years old, reporting pulsatile neck mass on the right side, with progressive growth in the past 8 years, asymptomatic. Hypertensive, alcoholic, ex-smoker, denies coronary artery disease or previous stroke. Treatment for syphilis in 2010. No family history of similar lesions, allergies and/or use of medication. Absence of neurologic deficits and wide, rhythmical and symmetrical peripheral pulses.

Considering the clinical history and the picture above, what is the most likely diagnosis?

a) Aneurysm

25%

b) Schwannoma

25%

c) Hodgkin lymphoma

25%

d) Lymph node metastasis

25%
   

Image analysis

Image 1. Picture revealing mass in the right side of the neck, with 13 cm in its larger diameter, located at cervical level V (posterior cervical triangle) - (red circle).

Highlights

- Neck masses represent relatively common and slightly symptomatic impairment;

- Its etiology is diverse (inflammatory/infectious, neoplastic or vascular);

- The neoplastic etiology is the most frequent after 40 years old (up to 80% of the cases);

- The vascular etiology (aneurysm) is the main cause of pulsatile mass;

- USG is the first choice exam in the investigation of neck masses;

- CT is better for evaluation of deep lesions and staging of malignant lesions;

- Computed angiotomography and angiography are important exams for surgical planning in case of aneurysm.

References

- Ketonen P, Meurala H, Harjola P, Mattila S, Ketonen L. Aneurysm of the Inferior Thyroid Artery and the Thyreocervical Trunk. Report of Four Cases. The Thoracic and Cardiovascular Surgeon.1981;29(01):60-61.

- Pérez-García C, Malfaz C, del Valle Diéguez M, Fortea Gil F, Saura Lorente J, Echenagusia, Boyra M et al. Embolization through the thyrocervical trunk: vascular anatomy, variants, and a case series. Journal of NeuroInterventional Surgery. 2018; neurintsurg-2018-013808.

- Pynnonen M, Gillespie M, Roman B, Rosenfeld R, Tunkel D, Bontempo L et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults. Otolaryngology-Head and Neck Surgery. 2017;157(2_suppl):S1-S30.

- Rosenberg T, Nolder A. Pediatric Cervical Lymphadenopathy. Otolaryngologic Clinics of North America. 2014;47(5):721-731.

 Authors

Gabriel Sousa Santos, 5th year medical student at Universidade Federal de Minas Gerais.

Email: gabrielssantos86[at]gmail.com

Elaine Kimie Iwayama Ikematu, 5th year medical student at Universidade Federal de Minas Gerais.

Email: elaineiwayama[at]gmail.com

Supervisors

Guilherme de Castro Santos, specialist in Vascular Surgery and Vascular Ultrasonography with Doppler and Assistant Professor at the Department of Surgery at Medical School of UFMG.

Email: gcs2000[at]gmail.com

Tulio Pinho Navarro, specialist in Vascular Surgery, Angioradiology and Endovascular Surgery. Adjunct Professor at the Department of Surgery at Medical School of UFMG.

Reviewers

Lucas Bruno, Rafael Valério, William Alves, Bernardo Finotti, Thiago Ruiz, Professor José Nelson M. Vieira, Professor Viviane Santuari Parisotto Marino.

Translated by

Gabriella Yuka Shiomatsu, 4th year medical student at Universidade Federal de Minas Gerais.

Email: gabriellashiomatsu[at]gmail.com

Test question

State Commission for Medical Residency - CEREM BAHIA - Unified Medical Residency Process (2015, Modified) -Male patient, 64 years old, hypertensive and ex-smoker (quit smoking 10 years ago), completely asymptomatic, during the urologic routine evaluation received the ultrasonographic diagnosis of increase of the abdominal aorta dimensions, quantified as 4,8 cm latero-lateral and 5,6 cm anteroposterior. His father had two aneurysms in the left iliac artery. Considering the presented history, the main risk factors for the abdominal aorta aneurysm in the case are:

a) Age above 60 years, male, dimensions, hypertension

25%

b) Age above 60 years, male, dimensions, hypertension, family history of aneurysm

25%

c) Male, smoking, hypertension, family history of aneurysm

25%

d) Age above 60 years, male, smoking, hypertension

25%

e) Age above 60 years, male, smoking, hypertension, family history of aneurysm

25%
   

Commentics

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