We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Radiological Case of the Month FREE

Juan Bass, MD, FRCSC; S. Muirhead, MD, FRCPC
[+] Author Affiliations

From the Departments of Surgery (Dr Bass) and Pediatrics (Dr Muirhead), Children's Hospital of Eastern Ontario, Ottawa.

Section Editor: Beverly P. Wood, MD

Arch Pediatr Adolesc Med. 2000;154(5):523-524. doi:10.1001/archpedi.154.5.523.
Text Size: A A A
Published online

A PREVIOUSLY healthy 15½-year-old boy with a 7-day history of intermittent fever with temperatures up to 38.5°C, anorexia, nausea, irritability, persistent migraine headaches, and a 9.5-kg weight loss was seen in the emergency department complaining of left lateral neck pain. No discrete masses were palpable, and the thyroid and overlying skin felt normal. On day 9 symptoms persisted, and the left thyroid lobe was enlarged (4-cm long) and firm. A clinical diagnosis of subacute thyroiditis was made, and nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed pending results of thyroid function tests. Two days later he returned with a further 2.7-kg weight loss, dysphagia, positional dyspnea, and marked fatigue. The left thyroid lobe was hard, tender, and 6.5-cm long. The isthmus and the right lobe felt normal, and there was no cervical lymphadenopathy. Tracheal compression was present on chest radiograph, and ultrasonography was performed (Figure 1). An inadequate sample was obtained for fine-needle aspiration; no purulent material was aspirated. Serum thyroxine levels from day 7 were markedly elevated at 97.9 pmol/L (reference range, 10-25 pmol/L), and TSH was incompletely suppressed at 0.03 mIU/L. Antimicrosomal antibodies were present at a titer of 1:1600 and thyroglobulin antibodies at 155.6 pmol/L (reference range, 0-32 pmol/L). Failure of response to NSAIDs led to the administration of a tapering course of prednisone. A barium esophagram was performed and demonstrated the cause of the problem (Figure 2).

Antibiotics were administered with normalization of thyroid function test findings and clinical status during 4 weeks; however, a unilateral goiter persisted. An ultrasonogram of the thyroid showed a 2.9 × 5.5 × 2.9-cm homogenous mass within the left thyroid lobe. No cystic components were present, and some hyperemia and bilateral cervical chain lymphadenopathy were noted. After administrating antibiotics, the patient underwent direct laryngoscopy. An opening of a fistula from the left pyriform sinus was identified, and a left hemithyroidectomy was performed. During the dissection of the upper pole, laryngoscopy was repeated, and light was applied directly to the pyriform sinus with its transillumination identified in the operative field. The sinus tract was identified and transected, and a probe was introduced through the sinus and visualized with the laryngoscope (Figure 3). The fistulous tract was completely resected. On histopathologic examination there was fibrosis within the left lobe of the thyroid and the fistulous tract was lined with squamous epithelium.




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

6 Citations

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Evidence to Support the Update

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Evidence Summary and Review 1