Violin Trauma Inducing Painful Thyroid Mass

A 39 Y/O female noted pain and tenderness over a neck mass which in her opinion was new. She noted that the size decreased over the next few days. The pain and tenderness was less severe when she finally saw me one week after the onset of her pain. She had a family history of thyroid disease. There was a slightly tender mass in the left lobe. She also had enlarged thyroid gland in addition to the mass. Painful thyroid swellings are usually virus infections causing Subacute Thyroiditis. However, the Sed.Rate and radioiodine uptake were normal. This made SAT unlikely. The next is a cyst. Rapid fluid buildup in a cyst will cause pain. The ultrasound showed a solid mass in a diffuse enlarged goiter. It is rare for cancer to cause pain, but Pseudothyroiditis due to cancer needed to be ruled out. The needle biopsy was abnormal with cells suggestive of Medullary Cancer, but the calcitonin was normal. The spindle cells were worrisome for anaplastic cancer, but the Thyroglobulin was markedly elevated, making anaplastic unlikely.

Because, in 30 years I have never seen this, I sent the biopsy to a expert pathologist. The report was a total shock. The mass was a thyroid nodule that had necrosed, and the abnormal cells were reactive, not cancer. The destruction was due to infarct, not tumor necrosis. The cause became clear, when I remembered, that the patient was a violinist, and asked me on the first visit if it could be caused by the violin touching her left neck while playing for hours. I of course, told her no, as there were many things more likely than Violin trauma! Well the patient was right again.

The literature on traumatic injuries to the thyroid is limited. Seat Belt Thyroiditis, and Martial Arts Thyroiditis have been described. I have one case of bloody cyst formation after a liposuction probe hit an unknown large goiter, during fat removal in the neck. Also one lady who fell off a ladder and landed on the spikes of a picket fence. She had a large bleed into the thyroid gland. I had to think back to 1970's when I had a man who complained of pain, and a biopsy of the mass was similar to the Violin Lady. That time, it was called anaplastic by a different expert, now retired, pathogist. The surgery was a shock, but a happy one when it was just a infarcted nodule in a simple goiter. He lived for 20 years, whereas if we were right, he would have had 6 months to live!

The surgery on the Violin Lady was cancelled, and she will return to see if this nodule will liquefy, and reduce in size. A follow up biopsy to look for the a rare possible cancer that necrosed will be done. Usually tumors necrose when you do a biopsy. However, the biopsy was done AFTER the painful syndrome began.

This benign painful nodule syndrome has been described in breast masses, as well. The longer I practice thyroidology, the more exciting it gets. You would think that I must have seen everything in 30+ years. Well there is always something new. In the 1990's I saw my first 3 cases of AIDS Thyroidits in one month! I have not seen another case since. Prior to my article, there were 6 cases reported in the world English literature. I saw half that total in 4 weeks! Medicine has a rhythim and I would not be surprised to see two more Violin Thyroidits cases before the new year!

Yours truly, and goodbye,