Connections: Red flags for thyroid issues in pediatrics | Fall 2018

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From the OHSU Doernbecher Children’s Hospital

Lourdes Quintanilla-Dieck, M.D., headshot

Lourdes Quintanilla-Dieck, M.D.

As a head and neck surgeon in the Department of Pediatric Otolaryngology, Dr. Quintanilla-Dieck’s area of specialty is pediatric thyroid lesions, which is also the focus of her research.

When a child or adolescent comes into a provider’s office with a throat lump, the most common scenario is an inflamed lymph node. However, clues in the physical exam and family history may suggest a thyroid nodule or mass. These pediatric thyroid issues are not common — about 1 in 100 youth — but require quick action if discovered to be concerning. Though most lumps will be benign, we need a heightened awareness in pediatrics, as thyroid nodules have a higher malignancy rate in children than in adults.

Warning signs in patient history or physical exam

A patient’s history may make him or her more likely to have cancer risk. A family history of cancer or certain genetic syndromes, such as multiple endocrine neoplasia or Cowden syndrome, are reasons for heightened awareness. Also, if a patient has undergone radiation treatment, he or she has an elevated risk for cancer, especially in the thyroid.

A patient should have an ultrasound if any of these symptoms are present on exam:

  • The lump is more than 2 cm in size.
  • The lump is close to midline and to the thyroid.
  • There are multiple enlarged lumps.
  • The lump is firm and not mobile.
  • The lump has persisted for over two months and/or continues to grow.

If the lump is on the side of the neck, smaller than 1 cm, soft and mobile, it is more likely an inflamed lymph node and a recent virus may explain tenderness. A wait-and-see approach is reasonable.

Ultrasound and next steps

An ultrasound is the best initial imaging test for any neck mass in pediatric patients. The results should verify any abnormalities and narrow the differential diagnosis. If a thyroid nodule is present, it could be a small cyst, but a solid nodule may need a biopsy and should prompt a referral to a specialist. There are benign thyroid conditions including multinodular goiter, autoimmune thyroiditis, hemorrhagic cysts. There are also lesions that can mimic a thyroid nodule including branchial cleft cyst, dermoid cyst and thymic cyst. However, there is also the risk of thyroid cancer and lymphoma.

Streamlined diagnosis, multidisciplinary treatment

At OHSU, we take a team approach by coordinating appointments with a pediatric endocrinologist and a pediatric head and neck surgeon through our Pediatric Thyroid Nodule Clinic, the only one in the state. Both specialists evaluate the patient together. Because the differential diagnosis can be challenging when it comes to thyroid issues, we strongly believe that this coordinated effort is beneficial for the patient and for expedited treatment. Additionally, we manage patients who have an underlying diagnosis that carries an increased risk of nodules or thyroid cancer. Thyroid cancer is rarer and more aggressive in children, but outcomes are still quite favorable with timely treatment.

When to refer or consult:

  • Patient has a neck mass that originates from the thyroid or around the thyroid.
  • Imaging consistent with a thyroid nodule.

Contact us

OHSU Doernbecher Children’s Hospital is available to answer questions about thyroid nodules or masses.