Common neck conditions – such as thyroid nodules – range from benign, self-limiting lumps to malignancies and serious systemic conditions, so having a systematic approach is key. Endocrine surgeon Wen T. Shen, MD, MA, offers guidance on everything from physical exams to presurgical workups, including key factors in risk assessment, when to order imaging (and what type), and how to pick up on hyperparathyroidism, an underdiagnosed disorder with wide-ranging symptoms.
welcome everyone. Thanks for taking a little bit of time during your lunch hour to hear about common neck masses. And yes that was all accurate in terms of my background and my current position. I'd like to basically reiterate that endocrine surgery is a branch of general surgery that deals specifically with thyroid parathyroid adrenal and endocrine pancreas. And we'll be focusing today on common neck masses. So kind of a broad overview on some of the things that you might encounter in a primary care practice. But I'd like to focus specifically in the second half of the talk on the two of the areas that I encounter very commonly in my practice which are thyroid modules and the work up and treatment of primary hyper parathyroid is um and like Michelle said I'd like to leave some time for questions through the Q. And A at the end. So in terms of an outline first, I did not include a disclosure slide. I do not have any financial disclosures. In terms of an outline, We'll talk a little bit about the anatomy of the neck very, very briefly. This is not intended to be comprehensive an atomic discussion by any stretch but just to get you re familiarized with this very complex and fascinating area of the body. Then I'd like to give you some common types of neck masses and perhaps a scheme or a rubric for thinking about how to evaluate and diagnose common neck masses. And then a little bit of an algorithm of what to do when you find a neck mass. And then as mentioned, I'd like to spend really the second half of this talking about two common conditions thyroid nodules in primary hyperthyroidism, which I think classify as two types of neck masses that you will most likely commonly encounter in primary care. My old mentor dr Clark doctor or Low clark who was the endocrine surgeon extraordinaire at UCSF and really one of the most world famous endocrine surgeons anywhere really loved art. And he really imprinted on me the necessity of bringing together the art and science of medicine. And so I'd like to intersperse my talks with some some some art slides and this is an example of a Modigliani. And as a thyroid surgeon, I don't like this because that's a very long neck and in order to capture or get a hold of the thyroid, you have to really know where to go. However, it is an example of the beautiful anatomy of the neck and this is a an an atomic schematic. And again, we are not going to go into great detail. But I wanted to demonstrate to you that the neck is a very high traffic, valuable real estate part of the body with numerous blood vessels, nerves, valuable structures such as the arrow digestive track the track an esophagus and of course the thyroid, which we're going to talk about. And this schematic is really meant to highlight that complexity, but also to remind us that when you're doing a neck exam, One of the most common things you can or constant things you can identify is going to be your thyroid cartilage, the so called Adam's Apple, and that the thyroid itself does rest usually about two finger breaths below that thyroid cartilage. And it's very interesting that the thyroid cartilage and the thyroid gland are named the same, but they are actually located different different places and that's really due to the shape. The shapes are similar and so the names are similar, but the locations are a little bit different. So if you are a palpitating the thyroid, it's a little bit below your so called Adam's apple or thyroid cartilage. The other things I'm going to emphasize include the carotid artery and then the lateral neck lymph node basin, which I'll show you a schematic of. Here. Again, not meant to be a comprehensive an atomic overview, but really to show you that there is a very rich lymphatic plexus in the neck. And the notes that I'd like to focus on for the purposes of this talk are those along the so called jugular chain which you can try to appreciate along that anterior border, the sternum plata mr muscle And then all the way down into the super club vehicular fossa. And again to demonstrate that the neck has a very, very rich lymphatic drainage system with between 200 and 300 lymph nodes and these can be a harbinger of other types of disease, which I'll get to in just a little bit. And you can see that neck masses are common across cultures and around the world. This is an example of a Nigerian woodcut demonstrating a person with a goiter. So when thinking about neck masses, there are numerous classification schemes and we could get very, very nitty gritty and complex with this. But I'd like to keep it relatively simple and I'll tell you, even in the ways, even though I deal with this on a daily basis, I try to keep things relatively simple in my at least initial clinical thinking. And then you can branch out from there based upon your clinical suspicion. But when I think about neck masses, I like to put them in three big buckets or big boxes and these are three areas uh probably may seem pretty intuitive, but they can help guide your decision making as you try to evaluate a neck mass that's presented to you. And I like to break it down into congenital masses, infectious or inflammatory masses. And then thirdly is neo plastic, which is really the area that I think people are most concerned about the possibility of a malignancy. So three broad categories. We're going to talk about a few examples and of course I'm not gonna be able to cover all the different kinds of neck masses, but I'd like to highlight some examples of the different categories. And here's an example of something that we encounter both in the pediatric as well as the adult population. This is an example of a congenital neck mass called the break your cleft cyst. And you can see here this is an anterior view of a woman's neck. Is probably a middle aged woman demonstrating a lateral cystic neck mass. And these are typically going to present as painless cystic outcroppings here in the lateral neck and they can be anywhere from up here under the jaw to a little bit further down and they typically are not gonna be too painful, although occasionally they can become infected. But this is an example of a bronchial cleft cyst and again a lateral it's a lateral type of cystic congenital abnormality and this is a schematic and again we're not going to focus on the specific details of this, but I'd like to show you that this can be anywhere up and down this lateral aspect of your neck here and the typical treatment of these when they're encountered is to respect them and remove them. Often times it will be done in the congenital period if it's or not in general in the infancy period when a kid presents with it. But if it presents later in an adult, we also do usually recommend removal because of the potential for possible infection and the fact that in this position it can be cosmetically unsightly. Here's another example of a congenital neck mass and in contrast to the bronchial cleft cyst which presents laterally. This is an example of a medial or midline structure. Tyra glassell duct cyst. And this is also something that can present both in childhood but also in adulthood and here you can see it's something that's going to be a round cystic structure. Typically in the midline here and can be as high up is right under the chin, near the hyoid bone and typically not too painful unless it gets infected. In addition to the risk of infection. These also can harbor some thyroid tissue within them because they come from the same embry logic sources the thyroid gland and believe it or not. In some rare instances they can harbor thyroid cancer and so similar to a bronchial cliff cyst. We typically will recommend removing these if these get passed about a centimeter or two in size and are either clinically detectable or in the cases where they might get infected. And so thyroid colossal duct cyst, another example of a congenital neck mass. This is a schematic showing a side view of a thyroid colossal duct cyst showing its embry a logic origin coming from the frame and seek them at the base of the tongue. Also showing its connection to the remainder of the thyroid gland and I also want to emphasize not to get into too much detail but when we do surgery for thyroid glassell duct cyst, we can't just remove the cyst. We do what's called a Sistrunk operation, which is where we also remove the central portion of the hyoid bone to prevent recurrence. So thyroid colossal duct cyst, Branko classicists, two examples of congenital neck masses. Here's something that I bet a lot of you see in primary care, which is examples of infectious or inflammatory neck masses, specifically reactive lymph nodes most commonly occurring after an upper respiratory infection. These can be very common, especially in kids. Uh and this is an example in a young young lady with a posterior auricular nodal enlargement here. These are typically going to be self limited and not a problem. And again, usually preceded by some kind of antecedent. You agree Another example of cervical lymph nodes that can become enlarge mononucleosis pretty classically. This is an example here showing the posterior auricular as well as a sub mandibular gland, sub manipulate. No excuse me, that can enlarge and obviously mononucleosis can present with enlargement of spleen and lymph nodes in other areas. But oftentimes the presenting area is going to be here in the upper cervical region, usually self limited and not much to do in these cases, I'm going to transition now to talk a little bit about some neo plastic neck masses and this is something that's very commonly seen. This is a right thyroid nodule. This is an anterior view of a woman's neck and you can see here, there's a fullness and asymmetry in the right aspect of the patient's neck. In my practice and endocrine surgery. I encounter neck masses that are referred to me by a by a variety of different physicians. Of course endocrinologists probably the top refers to my practice but also a lot of primary care doctors. But you would also see some patients being referred from their obstetricians during a prenatal visit or during a gynecologic exam. Some dentists or oral maxillofacial surgeons who are firmly patients that they detect during their pre op or their their uh oral exam. They'll also feel the neck. And then some people people will just self refer because they find something that feels a little bit bigger in their neck. A classic thing that can be reported as men who cannot button up their shirt collar because of an enlarged thyroid mass or thyroid goiter. Other things were a loved one will notice across the breakfast table that their that their partner or spouse has a little bit of fullness or enlargement there in the neck. So there's many paths. And I didn't even mention the radiographic discovery which is maybe now increasingly one of the most increasingly common ways that people get detected with thyroid masses during an ultrasound for parroted uh for example during a C. T. Scan for neck pain or for cervical spine evaluation. The neck gets captured during a ct of the chest or the ct of the head. And so again incidental discovery of thyroid masses is also relatively common. So this is a right thyroid mass seen from the outside. Then this is a schematic showing on the inside what it's going to look like. Again to emphasize that the thyroid gland itself sits a little bit below that thyroid cartilage. And so when you're examining and palpitating that's going to be just a little bit lower down on the prominence of the adam's apple here. And I just covered the three big buckets, right, congenital, infectious and inflammatory and neo plastic. And obviously there's a lot of different possibilities. This is not meant to be anything you want to memorize or think about really more than the fact that I just like the the idea this is a pneumonic that I found online kittens and I don't think any of, I don't know if you learn this in medical school, I certainly didn't learn this pneumonic and I find it probably overly complex and a lot more difficult to remember than just three big buckets. But it shows you that there are a lot of different other possibilities and I'd be happy to talk about some of these other ones during the Q and A. If if anyone has questions but I will focus, as I mentioned most on thyroid and parathyroid and just a little so when you were presented with a patient with the neck mass. Besides kind of doing your initial history and physical, there are some focused questions and focused bits of information that you can try to garner from the from the patient. Very obvious helpful information include the age of the patient because certain neck masses are more common in kids versus and adults. And as you get older, your concern for malignancy does go up the duration of time, whether it's kind of a new onset thing or something that's been there for a long time, whether there have been any recent infection, specifically any kind of upper respiratory type infections, we'll talk about some risk factors in a little bit environmental exposures and patient behaviors and really when you're doing your exam, sometimes you can really tell something bad or good based upon how it feels if it's hard or fixed, it feels like a rock there in the neck. That's probably something that you're going to have to expedite and get evaluated because the chances of that being a malignancy of some kind are much higher. Yeah, so let's go into some detail. I always like the opportunity to show a picture of my kids and they are and how teenagers in high school. So I really need to update my slides, but this is just to emphasize the point that younger age is usually less likely to result in some kind of neo plastic or malignant mass, although obviously not impossible. So you do have to think about the congenital and the infections inflammatory uh, ideologies more likely. However, these patients obviously still do deserve some attention and follow up For older patients. As I already mentioned, there is an increased overall risk of malignancy. Most of the guidelines for work up of neck masses draw that line at 40, which I take offense to but I guess that does mean older age nowadays. But either way, if you do present with the new neck mass and and someone who's over 40, that's typically something that's going to deserve some some attention and follow up some of the risk factors that you can ask about tobacco use is associated with a higher risk for a variety of different malignancies, including some head and neck cancers, but also lung cancer can metastasize to the super particular region or sometimes rarely to neck nodes, patients who are chronic abusers of alcohol, also higher risk for head and neck malignancies. HPV status uh certainly can increase your risk but certain types of head neck malignancies um and then patients who are immunocompromised or at higher risk. And so these are some of the different kinds of risk factors to ask about. I neglected to mention in this power point or in this bullet point list here, radiation exposure to the head, neck or face is also a known risk factor for the development of thyroid cancer. And so patients I have a lot of patients in my practice here in SAn Francisco, our hospital serves the Russian population of the Richmond district in the Western edition. And there are a lot of patients who emigrated here to to the United States after the 1986 Chernobyl disaster. So it is something that you can ask about radiation exposure. Other patients who have been treated for childhood malignancy with with external beam radiation is another instance where patients can have exposure to radiation. This is not meant to be a comprehensive guidelines by any stretch I just wanted to demonstrate to you. These are the 2017 clinical practice guidelines from the American Association Otolaryngologist and had next surgeons just to show you the major branch points, which we've pretty much already covered. They say in an adult neck mass. The first thing you're going to ask about is a preceding infection. But then you go down and look at some of the clinical factors such as those risk factors, how the thing feels, et cetera. And so again, really asking about antecedent infections and then also how does it feel And look in terms of imaging studies? I think the two most valuable imaging studies if you're going to evaluate a neck mass. Our CT scan and ultrasound, I'd say ultrasound obviously has less radio or no radiation. Uh it's pretty readily done. We do it in almost every one of our patients in our endocrine surgery clinic cT scan obviously has a little bit more has actual radiation. Perhaps a little more cost. Both of them are very useful. This is an example of a cross sectional analysis of the neck using CT scan. And you see the level of fidelity demonstrating even the blood vessels that are going through the neck here. And this is an example of a thyroid ultrasound showing the beautiful thyroid isthmus here and the bilateral lobes, the trachea and the esophagus. So ultrasound and cT standard both very helpful depending on what exactly are trying to look for. I would say for thyroid ultrasound will be my 1st 1st line imaging modality. We use fine needle aspiration biopsy for solid neck mass is suspected of being malignant and it's something that we do pretty commonly are endocrinologists at UCSF do them in the office. We have a drop inside of pathology clinic at UCSF for all patients with palpable neck mass. And it can also be done under ultrasound guidance to help facilitate targeting and making sure you get a good sample. It's done with local anesthetic and is very useful and I'll talk about its utility for thyroid nodules and just a little bit. So here's another example of art. This is a virgin mary with a goiter very common. If you look at renaissance paintings a lot of the women had a depiction of Boyer, probably a pretty common clinical entity during that time period. Um and also was considered a sign of femininity and femininity and fertility by many artists. So that's my signal to transition to the next part of my presentation here. So I'm going to talk a little bit about thyroid nodule and these are an incredibly common clinical entity in terms of palpable thyroid modules, they estimate 5% of women, 1% of men. But it's really the non palpable ones that we are getting. A lot of referrals for nowadays. And a lot of them are found during ultrasound examination or imaging modalities such as cT scan. As already mentioned. I tell our endocrine surgery fellows and the surgery residents that I work with here at UCSF jokingly, of course that if you wanted to get busy as a thyroid surgeon, you just go down to the bus stop or the grocery store and just start ultrasound and people, you will find thyroid modules. That's obviously not a great public health maneuver and I would not recommend that to anyone in seriousness but it demonstrates affect. These are very, very common clinical entities and it's a really broad range. And this is from the 2015 american thyroid associate american thyroid association guidelines On management of thyroid modules and thyroid cancer, which estimated between 19 and 68% of the population. You're going to find a thyroid nodule, some kind. And as you get older, the more likely you are to develop a thyroid nodule thankfully the majority of these are not going to be malignant and the estimate is somewhere between 7 to 15% of thyroid nodule detective will be malignant and there are multiple factors that are going to change your overall pretest probability or your overall risk of having a thyroid malignancy, things like age, gender, family history and as I mentioned already radiation exposure when you were presented with a patient with a thyroid nodule, whether it's self detected radio graphically detected, I think it's very important to just try to keep to the same clinical algorithm and try to assess the risk of the clinical risk of malignancy using a couple different questions and other tools of course, a complete history and physical examination. I think in terms of a screening test for thyroid function. TSH alone is usually sufficient rather than a full thyroid panel unless you were suspected some some element of hyper or hypothyroidism or autoimmune thyroid disease. As already mentioned, I think ultrasound is the best first line imaging modality for further evaluation of the thyroid. It gives you great clarity of the thyroid itself, other nah jewels that might be present that weren't detected before the surrounding cervical lymph node basins. So ultrasound is excellent. Again, we do it in our office for almost every patient being evaluated for thyroid problem and then finding the aspiration biopsy is not indicated for every single thyroid nodule. In fact, there are now a few different radiographic uh risk stratification um algorithms and systems. The most widely used I think is the tirades classification scheme which allows, ultrasonography is to assign a risk score, forgiven nodule and then depending on that risk stratification score as well as the tumor size and other clinical factors. We then can make the decision whether or not to needle biopsy this nodule so not every thyroid nodule equals F. N. A. Otherwise would be paying a lot of different people. There are radiographic risk stratification systems for helping guide you to determine who gets a nodule as who gets a biopsy. And when you do do a thyroid fine needle aspiration biopsy it gets pretty complicated pretty quickly and I don't want to go into all the details here but I want to show you that the site a pathologic site, a pathologic analysis of the needle biopsies for thyroid modules is now classified according to the 2009 Bethesda stratification system. And this breaks the answers or it breaks the results down into six different categories. And rather than dwell on all these different details, I wanted to show you that basically as you go up in categories. So but that's 23456 your risk of malignancy increases and the chance that you might need some form of thyroid operation for diagnostic or therapeutic purposes increases. But that's the one is pretty easy. That's a non diagnostic or unsatisfactory sample which usually means you got to repeat it. But these other categories going from Bethesda 2345 up to six. Give you an increased risk of malignancy the higher you go up and at any point during this we welcome and underwent surgery. You sending the patient for us to talk about or evaluate their thyroid nodule. I want to then emphasize that it's not so simple as just these pathetic criteria. If you get Bethesda three or four, which are these so called indeterminant categories which are listed as follicular lesions, follicular nia plas ums 80 P of undetermined significance. Again, Bethesda three or four. Now we have available a variety of molecular testing uh systems which allow us to look at the highest risk molecular profiles for different kinds of thyroid cancer. And it's typically used in this uh in this table. It shows for both testified as well, but I'd say it's really more for Bethesda three and four, the so called indeterminant categories. I do not want to focus on the exact tests and this this slide is actually way out of date, even though it's just from a few years ago at UCSF typically used the piracy panel but there are other ones that are commercially available and you have to ask your local pathologist what they're doing and what's available. Um And it does differ institution by institution. This is just another example showing the various different kinds of genes that we're testing for. And this allows us to give us a slightly better cancer risk. But oftentimes you do end up, as you can see here doing diagnostic thyroid surgery in order to best classify uh these uh these thyroid nodules. I'm going to pause there and I wanted to leave time at the end for some questions about the further evaluation of thyroid modules. You notice I did not talk about the management of thyroid cancer, gliders, great disease. I'm very happy to talk about any clinical cases. You might have questions you might have about thyroid surgery. But I wanted to really emphasis what happens when you get presented with the thyroid nodule and the current armamentarium of tests and diagnostic modalities for us to evaluate these and basically try to determine the risk of malignancy. Here's another example of a goiter in Western art. Uh keep looking around at a different kinds of old paintings and and you'll start to your I will start to be caught by these. I'd like to shift gears a little bit and talk about something that doesn't usually present with a neck mass. But it is a form of neck mass that's usually uh diagnosed on a biochemical basis. And that's the diagnosis and treatment of primary hyper parathyroid is um And this is actually an incredibly common problem. We estimate that there are more than 100,000 new cases diagnosed in the US every year. And I show you a picture of an iceberg here because I think most endocrinologists and under insurgents believe that there's actually a lot more patients out there with this condition who are not being diagnosed. And as you remember, the condition is almost always a benign condition which results from the autonomous overproduction of parathyroid hormone or puth by an abnormal parathyroid gland or glands. And as you remember, they're typically most people have four parathyroid glands, two on each side. And in the condition of primary hyper parathyroid is um it's typically one enlarged solitary parathyroid adenoma. Although multi gland disease can happen and I want to break it down again pretty simply. And we can certainly get into the nitty gritty of talking about the elements of parathyroid disease. But when I get presented with a patient with suspected primary hyper parathyroid is um I follow the same clinical algorithm that dr quan Yang doo, who is my boss and mentor and the chief of endocrine surgery here at UCSF the way he taught me when I was a medical student. And it's to ask three basic questions about the patient with suspected primary hyperthyroidism. And some of these may seem incredibly simplistic and even maybe completely silly. But you'd be surprised because you can get confused very quickly when you start asking these questions and sometimes patients don't quite Fit in the in in one black and white category. And these questions are, does the patient actually have the diagnosis of primary hyperthyroidism? The second question if they do have the diagnosis is operation indicated. And there are some criteria for that, which I'll go over and third and only then do you start talking about localization studies because at that point you're planning for surgery and you're really only ordering those localization studies to plan for surgery not to make the diagnosis. So it's a biochemical diagnosis and the imaging studies really only come about when you are planning to do an operation important distinction in terms of making the diagnosis. It starts with a few different blood tests and I'd say the basic blood tests and these are based upon the most recent american association of Under cancer. Jin's guidelines published in 2016 for the management of primary hyperthyroidism, they recommend a serum calcium, also a parathyroid hormone or p th Not all patients but not all patients will get a 24 hour urine calcium. But if you are not certain of the diagnosis that can help to distinguish or help you to make that diagnosis And then vitamin d. hydroxy is also very very useful test. Other tests that you can use to help make this diagnosis include ionized calcium. Some some physicians will use phosphate and look for a decreased serum phosphate. Um But I'd say overall really to get the diagnosis definitely a calcium and P. Th vitamin D. And then in certain instances the 24 hour urine calcium. And there can be some conditions that mimic primary hyper parathyroid is um I'll give you some examples. I get referred probably about four or five times a year a patient with vitamin D. Deficiency either a primary vitamin D. Deficiency or something secondary to a malabsorption of syndrome from celiac or other kind of gut malabsorption syndromes or patients who have had bariatric surgery will also have some element of malabsorption and not be able to process or metabolize vitamin D. And calcium in the same way. So just making sure that they actually have a diagnosis of primary hyperthyroidism for 24 hour urine calcium. You can use that to help rule out something called benign familial hyper cast, serious hyper calc MIA when a patient has a altered set point and regulation of their calcium. And again, it's called benign. Not because of benign malignant, benign because it doesn't really cause a problem. It's just going to lead to the patient having a very low 24 hour urine calcium and then typically some mild hyper calc MIA. But it's not a surgically correctable disease. So that was the first question does the patient of the diagnosis in terms of indications for operation? Well, it's pretty simple if the patient has signs and symptoms of hyperglycemia, that surgery is indicated and there are a lot of different kinds of signs and symptoms that you can ask about. I find it most helpful to break it down again relatively simply into the different organ systems that are most likely to be affected by the primary hyperthyroidism but that hyperglycemia and those would be the bones, the kidneys and the brain. And then also important is the heart because you can have cardiac manifestations of this disease, but I'm not going to really get into that right here will talk about bone, brain and kidney and with the bones. You can ask about fractures, about bone pain. You can see if the patients had a bone scan with any element of osteoporosis or osteopenia with the kidneys. You can ask about the history of kidney stones, frequency of urination. So either pagliery or knocked urea is relatively common with this disease. And then you can also measure G. F. R. And look and making sure that their that their renal function is not impaired in terms of the brain. And this is perhaps the most common sight of involvement and the most common presenting complaint. You can ask about fatigue, memory, loss, mood change, other kinds of neurocognitive disturbance. And this is a situation where it's very helpful actually. Task. Usually the spouse or partner will accompany the patient. You can ask, I mean, how does he or she seems and sometimes the spouse will be able to give more insight as to the fact, you know, this person is used to be much more energetic but now take a nap every afternoon. Doesn't play golf anymore. Doesn't like to go on walks and it's just more sluggish and forgetful and having that family member present. Can can help you to elucidate or to suss out different kinds of neurocognitive symptoms. So asking about those symptoms during your review systems is very important for asymptomatic patients. There are criteria as determined by the National Institutes of Health for who benefits from operation. These are for asymptomatic patients, Anyone less than 50 years of age, those who can't really follow up and be tracked or followed A. T. score less than -2.5 indicating osteoporosis, a serum calcium more than one mg per deciliter above the upper limit of normal And a 30% decrease in renal function is measured by G. Fr. Now we can get a lot of debates and I'm happy to talk during our Q. And a about this about who's really a symptomatic because the target audience for this disease or the target population for this disease is typically women ages 50-70 who are typically going through or have gone through menopause and are going through the normal aging process and how to define what's accelerated aging and what's normal aging in the context of someone with primary hyperthyroidism can actually quite challenge. So this is something that's still pretty hotly debated amongst entrepreneur ologists and kind of insurgents. But the idea here is that the patient has any clinical manifestations of hyper calcium mia or hyperthyroidism, they should be considered for surgery localization studies. Again, I want to emphasize this fact that you really don't want to order these unless you're sure of the diagnosis and are referring the patient for surgery. Otherwise it's just an opportunity for a false positive test, additional cost and hassle for the patient And just today I was reviewing my clinic patients for this week and I got referred to patients who have been followed for actually several years with calcium is as high as 11.2 11.3. But the patient had negative imaging studies and therefore was not referred for surgery until now. And it's been a couple years and during that time the patients have a bone loss and you know symptomatic forgetfulness and other neurocognitive things and just overall decline. And it's a shame that that's kind of lost time now. And I really want to emphasize the fact that even with negative imaging studies if the patient meets criteria for surgery they should still be referred for evaluation by an endocrine surgery. In terms of what localization studies to order. The most typical ones are going to be neck ultrasounds are very similar to our work up of thyroid modules. And then for certain patients we do like to use nuclear medicine system. Maybe scan some clinicians prefer for D. C. T. Scan. It's all fine and really I don't want to put the onus necessarily on you as the primary care physician who are working these patients up if you're not sure and don't really want to get into ordering multiple tests we're for them on for further evaluation by either an endocrinologist, foreign under the insurgents such as myself. And we will do these kinds of studies. We'll order these studies. In fact really as already mentioned, every patient who interest my clinic with the thyroid or parathyroid condition is going to get an ultrasound. And in many cases we'll find the offending grand right there. And we actually now in many cases will actually just rely on just the ultrasound and not go on to order the additional nuclear medicine or cT scans, which are more costly and have more radiation. In terms of the actual surgery itself, I'm going to talk a little bit about some of the core principles. We can talk in the question and answer period if you have specific thoughts about what actually goes on in the operating room. But again, to break it down the basic principles and you might be saying, oh my gosh, all these things sound really, really obvious. You'd be surprised. And so I really like to emphasize these things when I'm teaching our fellows and our residents. But when you're doing parathyroid surgery, the bad parathyroid glands glands come out, The good ones should stay in. You should not be respecting normal parathyroid glands. And the goal at the end of the operation is to restore first the p th because that responds more quickly. And we use inter operative parathyroid hormone measurement to monitor the patient's p th during the operation and demonstrate biochemical resolution and then shortly thereafter the calcium levels should come down. And that's the goal of this whole thing is to restore the biochemical profile of these patients with a normal calcium puth and any time you're in the neck, whether you're doing thyroid surgery, parathyroid surgery, etcetera. The recurrent laryngeal nerve is really the structure that we're trying to avoid injury to and that I would say that if that nerve didn't exist, this would be easy surgery, but it's about the size of a little angel hair, pasta and reliant resides right next to where the parathyroid glands sit, right behind the thyroid gland. And that's the reason why we recommend surgery at high volume centers with experienced surgeons. Because if you don't know how to navigate your way around that mirror of that injuries, that nerve can lead to hoarseness and voice dysfunction, bilateral injury, which really should not happen in this day and age, but bilateral, currently injured nerve injury usually results in the requirement for tracheostomy because of closure of your bilateral vocal quotes. So pretty serious stuff. Now I provide this historical picture, as Michelle mentioned. I have a master's degree in history medicine and I do like to incorporate not just art, but a little bit of history into my discussions. This is a picture of Captain Charles martel who was the first patient in the United States treated for primary hyperthyroidism, Mass. General 1926, which was less than a decade ago. This was essentially an unknown entity. But you can see here on this side you can see him pre diagnosis, he was a ruddy seafaring husky guy and then after the ravages of primary hyper parathyroid is that he had lost seven inches in height, was severely debilitating. I think he was bed bound for a while, had formed multiple kidney and bladder stones and underwent ultimately, I think seven operations at the national hospital before his parathyroid tumor was identified in the chest. And it's a really clear example of the fact that this is terrible disease if left untreated. It also highlights the fact this is a relatively new entity. We've really only been treating this for less than a century. It's now essentially an outpatient procedure. Um it can be pretty quick, most focused parathyroid operations I can do in less than half an hour, but less than a century ago. This is something that could kill you. And with advances in biochemical diagnosis, imaging surgical techniques, etcetera. It's something that now we treat pretty commonly routine. So I'd like to stop here and I'll summarize and then give you a little bit of further information. But I'd like to leave plenty of time for questions. So please enter those in the Q. And A. And I'll be monitoring these and read them at the end of the talk but to summarize and go back to what I've discussed today. I'd like you to think about when you're encountering a neck mass in the clinical setting. The three broad categories right? Congenital masses, infectious or inflammatory uh ideologies and then neo plastic, which is I think what most people are most concerned about including patients themselves age and other clinical factors including those risk factors I highlighted like smoking and radiation exposure etcetera. Can help guide your decision making. And for the most part you are going to do further evaluation with either ultrasound or ct. And in selected instances where you suspect malignancy you can do you can do fine needle aspiration biopsy. For the second half of my talk when I talked about thyroid and parathyroid disease, thyroid nodules are very common and most of them are benign and we're coming across them in a variety of different settings including physical exam. But also increasingly commonly radiographic technology is picking these up and we have different criteria for using F. N. A. To evaluate for malignancy for primary hyper parathyroid is remember to make the biochemical diagnosis before you proceed with any further evaluation and use those blood tests and in rare cases urinary tests to help you cinch that diagnosis the indications for surgery or any kinds of signs or symptoms of hyperglycemia or any kind of signs or symptoms of end organ damage meaning things like impaired renal function or osteoporosis et cetera localization only if you're going to be planning for surgery. Ultrasound is a great first line test system. Maybe scan which the nuclear medicine scan is also very helpful as is for D. C. T. You definitely don't need to order all three. In fact usually one or two is going to be sufficient and if there's any question at all just refer them for further evaluation with either an endocrinologist or an endocrine surgeon such as myself. And again I welcome all of your questions and thoughts. I see some stuff hitting into the Q and A. But I agree with MS. If I did not mentioned my partners, we have five full time endocrine surgeons at UCSF and they're all listed here and I will give the contact information in the next slide. This is our website and I believe these slides are going to be circulated around or if there's any questions just let Michelle or myself know and we can get back to you.