Anterior Neck Pain Research Articles

Pre-operative embolisation of the thyroid artery in a patient with a large papillary carcinoma of the thyroid

To demonstrate the usefulness of pre-operative selective embolisation of the thyroid arteries in an unusual case with a large, vascular thyroid tumour. A 29-year-old man presented with a large papillary carcinoma of the thyroid (weighing approximately 300 g on palpation) with extension to the mediastinum and compression of the trachea. A computed tomography scan of the neck and thorax revealed a large tumour the solid part of which was enhanced after contrast medium application, indicating a substantial vascular supply. Pre-operative selective embolisation of both superior thyroid arteries and one inferior thyroid artery, using gelatin sponge particles, was performed 4 days before surgery, under conventional angiography. After selective embolisation of these thyroid arteries, the patient experienced mild anterior neck pain and mild fever. This procedure allowed a significant reduction in blood perfusion to the tumour, which facilitated its surgical removal without blood transfusion. Pre-operative selective embolisation of both superior thyroid arteries and one inferior thyroid artery may be an effective, minimally invasive procedure for patients with a large, vascular thyroid tumour.

Takayasu arteritis developing during treatment of ulcerative colitis with infliximab

A 22-year-old female with ulcerative colitis that was successfully treated with infliximab (IFX), and remained stable following tapered discontinuation of prednisolone, developed anterior neck pain and elevation of C-reactive protein following her fourth administration of IFX. She was diagnosed with Takayasu arteritis (TA) based on neck ultrasound and computed tomography angiography. This is the first report describing the development of TA during treatment of UC with IFX.

Immediate Changes in Widespread Pressure Pain Sensitivity, Neck Pain, and Cervical Range of Motion After Cervical or Thoracic Thrust Manipulation in Patients With Bilateral Chronic Mechanical Neck Pain: A Randomized Clinical Trial

Randomized clinical trial. To compare the effects of cervical versus thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain on pressure pain sensitivity, neck pain, and cervical range of motion (CROM). Evidence suggests that spinal interventions can stimulate descending inhibitory pain pathways. To our knowledge, no study has investigated the neurophysiological effects of thoracic thrust manipulation in individuals with bilateral chronic mechanical neck pain, including widespread changes on pressure sensitivity. Ninety patients (51% female) were randomly assigned to 1 of 3 groups: cervical thrust manipulation on the right, cervical thrust manipulation on the left, or thoracic thrust manipulation. Pressure pain thresholds (PPTs) over the C5-6 zygapophyseal joint, lateral epicondyle, and tibialis anterior muscle, neck pain (11-point numeric pain rating scale), and cervical spine range of motion (CROM) were collected at baseline and 10 minutes after the intervention by an assessor blinded to the treatment allocation of the patients. Mixed-model analyses of covariance were used to examine the effects of the treatment on each outcome variable, with group as the between-subjects variable, time and side as the within-subject variables, and gender as the covariate. The primary analysis was the group-by-time interaction. No significant interactions were found with the mixed-model analyses of covariance for PPT level (C5-6, P>.210; lateral epicondyle, P>.186; tibialis anterior muscle, P>.268), neck pain intensity (P = .923), or CROM (flexion, P = .700; extension, P = .387; lateral flexion, P>.672; rotation, P>.192) as dependent variables. All groups exhibited similar changes in PPT, neck pain, and CROM (all, P<.001). Gender did not influence the main effects or the interaction effects in the analyses of the outcomes (P>.10). The results of the current randomized clinical trial suggest that cervical and thoracic thrust manipulation induce similar changes in PPT, neck pain intensity, and CROM in individuals with bilateral chronic mechanical neck pain. However, changes in PPT and CROM were small and did not surpass their respective minimal detectable change values. Further, because we did not include a control group, we cannot rule out a placebo effect of the thrust interventions on the outcomes. Therapy, level 1b.J Orthop Sports Phys Ther 2012;42(9):806-814, Epub 18 June 2012. doi:10.2519/jospt.2012.4151.

Anterior Neck Pain Due to Hyoid Malformation

Anterior neck pain often presents a challenging problem for the otolaryngologist because of the various causes. We report an unusual case of an asymmetric hyoid bone impinging on the carotid sheath with resulting pain on head rotation. Although rare, awareness of this condition is vital in successful treatment as surgical intervention provides immediate and long-term resolution of the symptoms.

Subacute Thyroiditis With Coexisting Papillary Carcinoma Diagnosed by Immediately Repeat Fine Needle Aspiration: A Case Report

Subacute granulomatous thyroiditis (SAT) is a spontaneously remitting inflammatory disease that is probably caused by viral infection. It has typical findings on ultrasound (US) which consist of focal ill-defined hypoechoic areas and no vascular flow in the hypoechoic areas on Doppler ultrasound. Papillary thyroid carcinoma is the most common type of thyroid cancer, and is often detected incidentally on US. However, SAT with coexisting papillary carcinoma is very rare. We report a case of SAT with coexisting papillary carcinoma diagnosed by immediate repeat US-guided fine needle aspiration (FNA). A 44-year-old woman was referred to our center for FNA of a thyroid nodule. She had anterior neck pain beginning 2 months prior to presentation and was treated at a local medical clinic. The thyroid US demonstrated a 1.2 x 0.8 cm nodule in the left lobe of the thyroid and ill-defined hypoechoic areas in both lobes of the thyroid. We performed US-guided FNA on that lesion. One week later, the cytology report was benign. Therefore, we performed repeat aspiration, which revealed papillary thyroid carcinoma. Total thyroidectomy was performed along with dissection of the central compartment of the neck and the nodule was confirmed to be papillary carcinoma without lymph node metastasis. The other portion of the thyroid showed the typical pathologic features of SAT. J Med Cases. 2012;3(5):308-311 doi: https://doi.org/10.4021/jmc665w

Neuromyelitis Optica Spectrum Disorder: 2-Deoxy-2-[&lt;sup&gt;18&lt;/sup&gt;F]Fluoro-D-Glucose Positron Emission Tomography Findings

A 51-year-old female with a history of rheumatoid arthritis rapidly developed anterior neck pain and paresis in the left upper and lower extremities and right lower extremity, sensory disturbance in the left upper and lower extremities, and bladder and rectal disorder. Adduction of the left eye and abduction of the right eye were also disturbed. Spinal magnetic resonance imaging demonstrated severe edema in the C1-T5 levels, which then deteriorated rapidly over 3 days, and lesions enhanced with gadolinium in the C1-C3 and C5-T3 levels. 2-Deoxy-2-[18F]fluoro-D-glucose positron emission tomography study demonstrated the inflammatory sites as segmental enhanced accumulation in the C1-C3, C5-C6, and T1 levels. The serum anti-aquaporin 4 antibody level was positive and she was diagnosed with neuromyelitis optica spectrum disorder. Marked improvement in the neurological conditions, concomitant with reduced spinal cord edema, was obtained by steroid pulse therapy.

Medullary Thyroid Cancer: It is a pain in the neck?

Medullary thyroid cancer (MTC) commonly presents with lymph node (LN) metastases, and has a worse prognosis than papillary thyroid cancer (PTC). Tumor size and LN involvement have been shown to affect stage of disease; however, to our knowledge, ours is the first study that attempts to correlate anterior neck pain on presentation with the extent of disease. We performed a retrospective review of patients with MTC who underwent an operation from February 1998 through December 2008. We compared the symptom of anterior neck pain with the pathologic extent of disease. Our control group comprised patients who underwent an operation for PTC. Analysis was performed using the Fisher's exact test and the Mann-Whitney test. Of the 109 patients with MTC, 50 (46%) met our inclusion criteria. Of the 50 patients with MTC, 11 presented with neck pain, compared to 3 of the 50 patients with PTC (p = 0.041). Of those 11 patients, 9 (82%) had LN involvement on final pathology, as compared with 14 (36%) of the 39 without neck pain (p = 0.014). Of patients with neck pain, 18% were diagnosed at stage I to II and 82% at stage III to IV, compared to 64% at stage I to II and 36% at stage III to IV (p = 0.014). Our study demonstrates that more patients with MTC present with anterior neck pain than do patients with PTC and that patients with MTC and neck pain have an increased risk of LN metastases. The results of this study suggest that MTC patients, who present with concomitant neck pain, should undergo a total thyroidectomy, prophylactic bilateral central neck dissection, and ipsilateral lateral neck dissection.

Takayasu arteritis: severe consequences of delayed diagnosis

Takayasu arteritis (TA) is a rare, large-vessel granulomatous vasculitis of unknown aetiology. TA is a panarteritis characterized by T lymphocyte, monocyte and macrophage infiltration of the arterial wall, leading to marked intimal myofibroblast proliferation and fibrosis of the media and adventitia. This results in severe arterial stenosis, occlusion or aneurysmal dilatation.1 TA affects primarily the aorta and its main branches, especially the common carotid (CCA), subclavian (SCA) and pulmonary arteries.2 The clinical manifestations follow two phases. In the early pre-pulseless phase, patients may complain of systemic symptoms including fever, weight loss, malaise, headaches, carotidynia, myalgia and arthralgia. In the later pulseless phase, commonly appearing months–years later,2 symptoms reflect end-organ ischaemia and include limb claudication and neurological symptoms. Decreased or absent peripheral pulses, aortic regurgitation, arterial bruits and systemic arterial hypertension are common. The non-specific nature of presenting symptoms and the lack of specific laboratory markers delays the diagnosis, with potentially life-threatening consequences.2,3 Moreover, although diagnostic criteria exist,4 patients presenting with early pre–stenotic disease may not fulfil them.5 Review of our 68 patients showed that 17 required angioplasty or surgery. We suggest that a significant delay in diagnosis of >12 months contributed to the need for surgery in 10 of the 17 patients. In support of this and with their consent, we use the histories of four patients that demonstrate the serious consequences associated with delayed diagnosis, and propose that this might be prevented by increased clinical awareness of TA and early use of non-invasive imaging. A 25-year-old British woman presented to her general practitioner (GP) with anterior neck pain, malaise and fatigue. Lymphadenopathy was diagnosed and she received treatment with antibiotics. The symptoms persisted and she developed occasional dizziness and transient loss of vision in the right eye. The …

Complication of oesophagoscopy and anticoagulation

Most reported injuries of the oesophagus are due to endotracheal intubation or oesophagoscopy.1 Procedures that involve intubation of the pharynx are commonly performed and currently anticoagulation is not thought to be a contra-indication. We highlight a case that may have been prevented, if anticoagulation had been stopped prior to the procedure. A 58-year-old man attended for an elective transoesophageal echocardiogram (TOE). Transthoracic echocardiography had previously been unrewarding due to large body habitus. The patient was anticoagulated with warfarin (chronic AF) and had a persistent cough. Coughing during oesophageal intubation forced the examination to be abandoned. On waking, the patient described pain in the left anterior neck. ENT identified a tender swelling in the left neck, left submucosal supraglottic swelling and dysphonia. A CT scan showed surgical emphysema and a 4-cm haematoma. His INR was 1.5 and warfarin was stopped, but not reversed. He was transferred to the ENT unit, where he was managed with steroids, antibiotics and fluids. His symptoms and signs resolved after several days and he was discharged uneventfully. Injuries to the pharynx and oesophagus may have life-threatening sequelae. In recent history, TOE is performed in anticoagulated patients during cardiac valve replacements, which may be more commonly seen in the future in an ageing population. This case raises interesting questions such as should anti-coag-ulated patients undergoing oesophagoscopy have their anticoagulation reversed (when medically safe)?2 Further, should we have a higher threshold for surgical intervention given the uncomplicated resolution of symptoms in this patient? Procedures involving pharyngeal intubation may be traumatic with potentially severe consequences but may be managed conservatively on occasion.

咽頭・頸部食道魚骨異物の３例

Fishbones commonly lodge in the pharynx and are usually found in direct vision or pharyngolaryngoscopy. They perforate the pharyngeal or esophageal wall and penetrate the thyroid gland relatively rarely. We report three unusual cases involving fishbone migration to extrapharyngeal space. Case 1 was a 52-year-old woman reporting foreign-body sensation after swallowing a fishbone. Computed tomography (CT) showed a fishbone behind the right tonsil, removed orally in right tonsillectomy and ultrasonography. Case 2 was an 88-year-old woman reporting painful dysphagia. Ultrasonography detected a strong linear echo extending from the esophagus to the left thyroid gland lobe. The bone was removed in endoscopy, followed by an uneventful course. Case 3 was a 93-year-old woman seen for pharyngeal and anterior neck pain, found endoscopically to involve a fishbone stuck in the esophageal wall and removed endoscopically. After removal, cervical CT showed air retained in and around the left thyroid gland lobe. Cervical CT 11 days later showed a thyroid gland abscess. We continued administering antibiotics and drained pus through a syringe, enabling a successful, nonsurgical conclusion. Some 14 cases of fishbones penetrating the thyroid gland have, to our knowledge, been reported, with 13 requiring surgical intervention. Successful conservative nonsurgical intervention thus appears to be the first case in Japan of an acute thyroid abscess so treated.

Takayasu's Arteritis in a Patient with Crohn's Disease: An Unexpected Association during Infliximab Therapy

We report a 20-year-old woman with Crohn's disease (CD) who developed anterior neck pain while being treated with the anti-tumor necrosis factor (TNF)-alpha monoclonal antibody, infliximab. She showed no symptoms suggestive of active CD except for tenderness along the left common carotid artery with marked increases in serum TNF-alpha and inflammatory reactions. Based on thickened walls of large vessels with enhancement effects on computed tomography, she was diagnosed as having associated Takayasu's arteritis (TA), which was successfully treated with corticosteroid. Even if CD is controlled by infliximab, other autoimmune disorders, such as TA, may develop as a complication.

Spontaneous pneumomediastinum: benefits of contrast computed tomography imaging

We report a case of spontaneous pneumomediastinum presenting with chest and anterior neck pain. The clinical findings, differential diagnosis and selection of radiological investigations are discussed. Spontaneous pneumomediastinum is an uncommon condition usually presenting in young patients. Presentation to the otolaryngology department occurs due to the presence of symptoms such as neck pain. Differential diagnoses must be considered and excluded, using the clinical features and the results of radiological investigation. Once the diagnosis is confirmed, conservative management is undertaken. Spontaneous pneumomediastinum is uncommon and the clinical features are variable. The recommended investigation is a computed tomography scan with orally administered, water soluble contrast to exclude important differential diagnoses and thus enable definitive diagnosis.

Spinal Cord Stimulation as a Novel Approach to the Treatment of Refractory Neuropathic Mediastinal Pain

Spinal cord stimulation (SCS) offers new hope for patients with neuropathic pain. SCS "neuromodulates" the transmission and response to "painful" stimuli. The efficacy of SCS has been established in the treatment of a variety of neuropathic pain conditions and more recently in refractory angina pectoris, peripheral vascular disease, and failed back surgery syndrome. Recent publications suggest that visceral pain could be successfully treated with SCS. We report the first successful use of a spinal cord stimulator in the treatment of refractory neuropathic mediastinal, esophageal, and anterior neck pain following esophagogastrectomy.

Relapsing Polychondritis

Relapsing Polychondritis

A swollen, red scar

In April, 2006, a 55-year-old woman was referred to our department with redness, swelling, and severe pain at the front of the neck, below the cricoid cartilage. Her symptoms had started a few months previously, and had gradually worsened since. In 1982, the patient had been diagnosed with a euthyroid multinodular goitre; one nodule had compressed her trachea, so she had undergone a partial thyroidectomy. She had been prescribed thyroxine ever since. She had no other medical history of note. The patient's previous thyroid disorder, anterior neck pain, and swelling led to a provisional diagnosis, on referral, of acute thyroiditis.

Fulminant Supraglottitis fromNeisseria meningitidis

Fulminant Supraglottitis from<i>Neisseria meningitidis</i>

Throat Trauma - Soccer

HISTORY: A 21-year-old female college soccer player sustained a throat injury. During the last eight minutes of a late season game, the soccer player jumped vertically to head the ball. At the same time, two opposing players from the front and back of the player were positioning themselves to also advance the ball. As all three players jumped simultaneously to head the ball, this soccer player was caught between the two opposing players. She suffered an anterior and posterior head-to-neck collision. There was no observed loss of consciousness. She complained of anterior neck pain that radiated to her posterior neck. No initial shortness of breath or hemoptysis but player complained of throat pain and hoarseness. The player denied any numbness or parasthesias in her upper or lower extremities. PHYSICAL EXAMINATION: Initial On-field examination; General: supine, alert and anxious Neck: (+) Anterior neck pain in Zone II. Trachea was midline and tender, no crepitus, no bleeding in the oropharynx or nasal mucosa, no visible obstruction, dentition intact. Cervical spine examination showed paraspinal muscle tenderness but no bony midline tenderness. Lungs: symmetric respiration, transmitted upper airway sounds, otherwise clear to auscultation bilaterally, no wheezing. Musculoskeletal: strength intact bilaterally in upper and lower extremities. Neurological: intact to tactile stimuli bilaterally in upper and lower extremities. Vital Signs per EMS: BP 110/70 HR 100 RR 28. DIFFERENTIAL DIAGNOSIS: Laryngeal edema Laryngeal spasm Vocal Cord paralysis Vocal Cord hematoma Foreign Body obstruction Bronchospasm TEST AND RESULTS: Pulse Oximetry: 99% RA FINAL WORKING DIAGNOSIS: Trauma induced Laryngeal injury with possible spinal column injury TREATMENT AND OUTCOMES: Cervical spine immobilized with rigid cervical collar and spinal board. Player was given supplemental oxygen via mask and transferred to outside Trauma Center. During EMS transport, hoarseness progressed into stridor with increased respiratory rate and increased shortness of breath. Upon arrival to the Trauma Center, player taken for emergent tracheotomy and further airway management. Cervical spine management per outside hospital protocol.

Early and Mid-Term Results of Drug-Eluting Stent Implantation in Unprotected Left Main

The development of Graves disease (GD) after subacute thyroiditis (SAT) is rare, with approximately 31 reported cases, of which only 5 occurred in men. We describe a case of GD diagnosed based on newly elevated thyroid-stimulating immunoglobulin (TSI) and thyroid-stimulating hormone (TSH) receptor autoantibody (TRAb) levels after SAT.A 32-year-old Chinese man presented with right anterior neck pain, swelling, sore throat, cough, and fever. He had a diffuse tender goiter but no proptosis, lid lag, or stare. His TSH level was 0.03 mIU/mL (normal range [NR] 0.45-5.33 mIU/mL), serum free thyroxine (FT4) level was 2.40 ng/dL (NR 0.61-1.44 ng/dL), total triiodothyronine (TT3) level was 113 ng/dL (NR 87-178 ng/dL), TSI level was <0.10 IU/L (NR < 0.10 IU/L), and erythrocyte sedimentation rate was 21 mm/h (NR < 15 mm/h). After 7 weeks of prednisone, the symptoms resolved, FT4 level was 0.95 ng/dL, and TT3 level was 91 ng/dL. At 11 weeks after SAT onset, the TSH level was <0.01 mIU/mL, TT3 level was 257 ng/dL, FT4 level was 3.03 ng/dL, TSI level was 1.94 IU/L, then 3.42 IU/L 2 weeks later, TRAb level was 8.72 IU/L (NR < 2 IU/L), and erythrocyte sedimentation rate was 4 mm/h. After 1 month of methimazole, the FT4 level was 1.32 ng/dL and TT3 level was 110 ng/dL. Genetic testing revealed human leukocyte antigen-B35 and DRB1∗15:01 positivity.GD after SAT is thought to be due to the activation of thyroid autoimmunity induced by SAT in genetically susceptible individuals.This case illustrates the induction of thyroid autoimmunity after SAT, resulting in GD, supporting TSI and/or TRAb testing if hyperthyroidism recurs. The presence of HLA alleles associated with SAT and GD suggests a genetic contribution to the development of thyroid autoimmunity.

Spectrum and Prognostic Significance of Arrhythmias on Ambulatory Holter Electrocardiogram in Hypertrophic Cardiomyopathy

The development of Graves disease (GD) after subacute thyroiditis (SAT) is rare, with approximately 31 reported cases, of which only 5 occurred in men. We describe a case of GD diagnosed based on newly elevated thyroid-stimulating immunoglobulin (TSI) and thyroid-stimulating hormone (TSH) receptor autoantibody (TRAb) levels after SAT.A 32-year-old Chinese man presented with right anterior neck pain, swelling, sore throat, cough, and fever. He had a diffuse tender goiter but no proptosis, lid lag, or stare. His TSH level was 0.03 mIU/mL (normal range [NR] 0.45-5.33 mIU/mL), serum free thyroxine (FT4) level was 2.40 ng/dL (NR 0.61-1.44 ng/dL), total triiodothyronine (TT3) level was 113 ng/dL (NR 87-178 ng/dL), TSI level was <0.10 IU/L (NR < 0.10 IU/L), and erythrocyte sedimentation rate was 21 mm/h (NR < 15 mm/h). After 7 weeks of prednisone, the symptoms resolved, FT4 level was 0.95 ng/dL, and TT3 level was 91 ng/dL. At 11 weeks after SAT onset, the TSH level was <0.01 mIU/mL, TT3 level was 257 ng/dL, FT4 level was 3.03 ng/dL, TSI level was 1.94 IU/L, then 3.42 IU/L 2 weeks later, TRAb level was 8.72 IU/L (NR < 2 IU/L), and erythrocyte sedimentation rate was 4 mm/h. After 1 month of methimazole, the FT4 level was 1.32 ng/dL and TT3 level was 110 ng/dL. Genetic testing revealed human leukocyte antigen-B35 and DRB1∗15:01 positivity.GD after SAT is thought to be due to the activation of thyroid autoimmunity induced by SAT in genetically susceptible individuals.This case illustrates the induction of thyroid autoimmunity after SAT, resulting in GD, supporting TSI and/or TRAb testing if hyperthyroidism recurs. The presence of HLA alleles associated with SAT and GD suggests a genetic contribution to the development of thyroid autoimmunity.

Spontaneous short-term remission of primary hyperparathyroidism from infarction of a parathyroid adenoma

We report a 39-yr-old woman with spontaneous short-term remission of primary hyperparathyroidism (PHPT). She was referred to our Department for PHPT with bilateral kidney stones diagnosed elsewhere; at the time of our observation she had developed anterior neck pain associated with swelling and tenderness. Biochemical data (serum ionized calcium and PTH) suggested a remission of the PHPT. The local symptoms gradually improved and disappeared over the next several days without therapy. Serum ionized calcium and PTH levels remained normal for up to 11 months. Subsequently, the patient had a recurrence of PHPT with mild hypercalcemia and elevated PTH levels. The patient underwent surgery and pathological examination revealing a 1.0 x 1.2 cm parathyroid adenoma with areas of necrosis with hemosiderinladen macrophages. In conclusion, we describe a case of spontaneous short-term remission of PHPT due to infarction of parathyroid adenoma.