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Thyroiditis
Hashimoto's
De-quervain's, Reidel's
Solitary thyroid nodule approach
Dept of Surgery
Thyroiditis
? Inflammation of the thyroid gland
? Acute illness
? Severe thyroid pain
? Manifested primarily by thyroid dysfunction
Types
Acute
? Streptococcus and anaerobes (70% Escherichia coli, Pseudomonas
(Suppurative)
aeruginosa, Haemophilus influenzae, Eikenel a corrodens,
Thyroiditis
Corynebacterium, Coccidiomycosis species
? More common in children
? Diagnosis : leukocytosis on blood tests and FNA biopsy for Gram's stain,
culture, and cytology
? Treatment : parenteral antibiotics and drainage of abscesses
Subacute
? Painful or painless
Thyroiditis
? Post viral inflammatory response, Genetic predisposition, autoimmune
? TSH is decreased, and thyroglobulin, T4 and T3 levels are elevated
? beta blockers and thyroid hormone replacement (after hyperthyroid
phase)
? Surgery for recurrent attacks
Chronic
? Hashimoto's
Thyroiditis
? Reidel's
? De-quervain's
Hashimoto Thyroiditis
? First described by hashimoto, in 1912, as struma
lymphomatosa--
? Transformation of thyroid tissue to lymphoid tissue
? Most common inflammatory disorder of the thyroid
? Leading cause of hypothyroidism
Etiology
? Autoimmune process
? Increased intake of iodine
? Medications: interferon, lithium, and amiodarone
? Inherited predisposition
? Chromosomal abnormalities : turner's syndrome and
down syndrome.
? Associations with hla-b8, dr3, and dr5 haplotypes
Pathogenesis
Activation of CD4+T (helper) lymphocytes
T cells recruit cytotoxic CD8+T cells to the thyroid.
Hypothyroidism results from:
? destruction of thyrocytes by cytotoxic t cells
? autoantibodies, which lead to complement fixation and killing by natural
killer cells or block the TSH receptor
Antibodies are directed against the three main antigens
? Tg (60%)
? TPO (95%)
? TSH-R (60%)
? sodium/iodine symporter (25%)
Apoptosis (programmed cell death) also implicated
Pathology
? Gland is diffusely infiltrated by small
lymphocytes and plasma cells,
occasionally shows well-developed
germinal centers
? Thyroid follicles are smaller than normal
with reduced amounts of colloid and
increased interstitial connective tissue
? Follicles are lined by h?rthle or
askanazy cel s, which are characterized
by abundant eosinophilic, granular
cytoplasm.
Clinical Presentation
? Male: female ratio 1:10 to 20)
? Ages of 30 and 50 years.
? Minimal y or moderately enlarged firm gland
? 20% of patients present with hypothyroidism
? 5% present with hyperthyroidism ( hashitoxicosis)
Diagnostic Studies
TSH T4 and T3 levels
Thyroid autoantibodies
FNA biopsy if solitary suspicious nodule or a
rapidly enlarging goiter
Treatment
Overtly hypothyroid:
? Thyroid hormone replacement therapy
Subclinical hypothyroidism:
? Male patients
? TSH greater than 10 mu/L
? Euthyroid patients to shrink large goiters
? Surgery may occasional y be indicated for suspicion of malignancy
or for goiters causing compressive symptoms or cosmetic
deformity
De Quervain's thyroiditis
? First described in 1904
? Granulomatous thyroiditis
? Viral infections: Adenovirus, Coxsackievirus, Influenza
virus, Epstein barr virus, Mumps, Echovirus & Enterovirus
? Less common than Hashimoto's thyroiditis
? Gland swel s up is very painful and tender
? Patient becomes hyperthyroid but the gland cannot take
up iodine so the radioactive iodine uptake is very low
? Absence of thyroid antibodies differentiates this
condition from autoimmune thyroiditis
? Recovery is invariably complete and response to
prednisolone is so dramatic that it is almost diagnostic
Riedel's Thyroiditis
? Riedel's struma or invasive fibrous thyroiditis
? Replacement of al or part of the thyroid parenchyma by
fibrous tissue
Etiology :
? Autoimmune diseases, such as pernicious anemia and
graves' disease
? Mediastinal, retroperitoneal, periorbital, and retro-orbital
fibrosis
? Sclerosing cholangitis
? Women between the ages of 30 and 60 years.
Presentation:
? Painless, hard anterior neck mass
? Dysphagia
? Dyspnea
? Choking
? Hoarseness
? Symptoms of hypothyroidism & hypoparathyroidism
? Hard, "woody" thyroid gland
Diagnosis:
? Open thyroid biopsy
Treatment:
? Surgery
? Thyroid hormone replacement
? Corticosteroids and tamoxifen
Solitary Thyroid Nodule
An isolated nodule in the thyroid gland
Benign:
? Cysts
? Adenoma-
? Papil ary
? Fol icular
? Hurthle cel type
? Toxic Adenoma- solitary hyper-functioning thyroid nodule
? Non toxic Adenoma-solitary nonfunctioning thyroid nodule
Malignant:
? Primary
? Metastatic
? Nodules common, whereas cancer relatively uncommon
? Higher in women (1.2:1 4.3:1)
? Estimated 5-15% of nodules are cancerous
? Although cancer more common in women, a nodule in a man
is more likely to be cancer
Workup of a solitary thyroid nodule
Laboratory Studies
Most patients with thyroid nodules are euthyroid
? Blood TSH level
? Serum Tg levels
? Serum calcitonin levels
? RET oncogene mutations
? 24-hour (urine) for vanillylmandelic acid (VMA),
metanephrine, and catecholamine
Imaging
Ultrasound is helpful for:
? detecting nonpalpable thyroid nodules
? differentiating solid from cystic nodules
? identifying adjacent lymphadenopathy
? Fol ow up of size of suspected benign nodules
CT and MRI are unnecessary in the routine evaluation
of thyroid tumors, except for large, fixed, or substernal
lesions.
Scanning the thyroid with 123I or 99mTc for evaluating
patients for "hot" or autonomous thyroid nodules
Management
? Malignant tumors are treated by thyroidectomy
? Simple thyroid cysts: aspiration
If the cyst persists after three attempts at aspiration,
unilateral thyroid lobectomy is recommended.
? Lobectomy is also recommended for:
? cysts greater than 4 cm in diameter
? complex cysts with solid and cystic components
Management
? If a colloid nodule is diagnosed by FNA biopsy, patients should
still be observed with serial ultrasound and Tg measurements.
? l-thyroxine in doses sufficient to maintain a serum TSH level
between 0.1 and 1.0 U/mL may also be administered.
? Thyroidectomy should be performed if:
? Nodule enlarges on TSH suppression, compressive symptoms
? Cosmetic reasons
? H/o previous irradiation of the thyroid gland
? Family history of thyroid cancer
This post was last modified on 08 April 2022