Download MBBS Surgery Presentations 56 Thyroid Gland Lecture Notes

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To understand:

? The development and anatomy of the thyroid

glands.

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? The physiology and investigation of thyroid

function.

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? The treatment of thyrotoxicosis and thyroid

failure.

The indications for and technique of thyroid

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surgery

? The management of thyroid cancer
Mention the causes of Thyrotoxicosis. Discuss the

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clinical features and management of primary

thyrotoxicosis.

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Classify thyroid neoplasms. Discuss the management of

solitary thyroid nodule.

Describe how wil you proceed with the diagnosis and

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treatment of a 40 y old female with multinodular goitre.

Discuss the etiology, clinical features, diagnosis and

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treatment of MNG.

Discuss the etio pathology,clinical features, diagnosis

and treatment of Grave's disease.

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Discuss the classification and clinical features of

thyroiditis.

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Discuss the etio pathology,clinical features, diagnosis

and treatment of thyroid malignancies.

SHORT NOTES

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Complications of thyroid surgery.
Development of thyroid and anomalies.
Ectopic thyroid
Eye signs in Grave's disease

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Jod Basedow thyrotoxicosis
MEN syndrome
Thyroglossal cyst/fistula
Thyroid storm

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CLINICAL ANATOMY

VASCULAR SUPPLY
LYMPHATIC DRAINAGE

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Most important when considering surgical treatment

of thyroid carcinoma.

Paratracheal nodes; tracheoesophageal groove lymph

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nodes; mediastinal nodes in the anterior and superior

position; jugular lymph nodes in the upper, middle,

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and lower distribution; and retropharyngeal and

esophageal lymph nodes.

Laterally, cervical lymph nodes within the posterior

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triangle.

Papillary carcinoma of the thyroid is commonly

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associated with adjacent nodal metastasis.

Medullary carcinoma has a strong predilection for

metastatic lymphatic involvement, usually within the

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central compartment (the space between the internal

jugular veins).

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RELATIONS

The gland is enclosed in the pretracheal fascia,

covered by the strap muscles and overlapped by the

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sternocleidomastoids.

The anterior jugular veins course over the isthmus.

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On the deep aspect of the thyroid lie the larynx and

trachea, with the pharynx and oesophagus behind and

the carotid sheath on either side.

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Two nerves lie in close relationship to the gland; in

the groove between the trachea and oesophagus lies

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the recurrent laryngeal nerve and deep to the upper

pole lies the external branch of the superior laryngeal

nerve passing to the cricothyroid muscle.

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PHYSIOLOGY

IODIDE TRAPPING.

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OXIDATION to iodine by thyroid peroxidase.
IODINATION of tyrosine residues to mono

and di iodotyrosine.

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COUPLING.


HORMONE SYNTHESIS
PHYSIOLOGY

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TRH secreted by hypothalamus.
Stimulates TSH secreted by ant pituitary.
Stimulates the thyroid gland to synthesise

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T3 and T4.

T3 and T4 have negative feedback inhibition

on TSH and TRH.

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PHYSIOLOGY

The thyroid hormones secreted by the gland

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are in bound form and free form.

Free form is biologically active.
The hormones once liberated are bound to

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serum proteins- name?

T3 has a rapid onset of action and a much

shorter half life than T4.

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Thyroid hormone synthesis is inhibited by?


CONGENITAL DISEASES

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DEVELOPMENT

The thyroid develops

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from a bud which

pushes out from the

floor of the pharynx

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and then descends to

its definitive position

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in the neck.
THYROGLOSSAL CYST

LINGUAL THYROID

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Occurs as a failure of normal descent of the thyroid

Presents as a lump in the foramen caecum or in the front

of the neck near the body of the hyoid bone.

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In all cases of unexplained nodules in the line of thyroid

descent, a radio-iodine scan should be performed to

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ensure that there is normal thyroid tissue in the correct

place before the lump is removed.

Enlargement of a lingual thyroid can cause airway

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obstruction, dysphagia, or bleeding.

Most lingual thyroid glands can be suppressed with

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thyroid hormone administration.

In resistant lingual thyroids, radioactive iodine treatment

may be given.

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ECTOPIC THYROID TISSUE

Can be found in the central compartment of the

neck, under the lower poles of normal thyroid or in

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the anterior mediastinum.

Lateral aberrant thyroid

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PENDRED'S SYNDROME

A rare autosomal recessive condition

characterised by incomplete oxidation of

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trapped iodide prior to organification.

Associated with sensorineural deafness,

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mild primary hypothyroidism with a non-toxic

diffuse goitre.

It may be confirmed by a positive

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perchlorate discharge test.
TESTS OF THYROID FUNCTION

EVALUATION OF PITUITARY- THYROID

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FEEDBACK LOOP

1)Serum TSH assay
2)TRH stimulation test
SERUM T3 AND T4 LEVELS

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Only a small fraction of the total (0.03% of

T4 and 0.3% of T3) is free.

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Assays of total hormones are now obsolete.
Estimation of free T3 and free T4.

T3 resin uptake test

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THYROID AUTOANTIBODIES

TPO antibodies
Anti thyroglobulin antibodies
Antimicrosomal antibodies

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THYROID IMAGING
1) Chest X-Ray.

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THYROID IMAGING

USG
Helps in determining

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the nature of swelling.

USG guided FNAC.
Helps in detecting

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MetastaticLNs.

Followup.

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THYROID IMAGING

CT scan
To know the extent of

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malignancy and

reterosternal extension.

THYROID SCINTIGRAPHY

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Provide information about thyroid activity , the size and

extent of the gland.

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Helpful in showing retrosternal extension.
Material used is Tc 99m, I123,I131.
Cold nodule: 80% benign,20% malignant.
Hot nodule: 5-9% malignant.
Warm nodule: take up the same radioactivity as rest of

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the gland.

The principal benefits of isotope scanning are in

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confirming the presence of a `hot/toxic' nodule in the

thyroid gland in a thyrotoxic patient, and in identifying

metastases or residual local disease after total

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thyroidectomy for carcinoma.
THYROID SCINTIGRAPHY

A hot nodule is one that takes up isotope while the

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surrounding thyroid tissue does not.

Here, the surrounding thyroid tissue is inactive

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because the nodule is producing such high levels of

thyroid hormones that TSH secretion is suppressed.

A warm nodule takes up isotope, as does the

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normal thyroid tissue around it.

A cold nodule does not take up isotope

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FNAC

IOC for discrete thyroid swellings.
Thy1- Non-diagnostic
Thy2- Non-neoplastic

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Thy3 -Follicular
Thy4 -Suspicious of malignancy
Thy5- Malignant
MISCELLANEOUS
Serum calcitonin

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Serum thyroglobulin-concentrations > 50g/l indicate

probable residual or recurrent tumour.

Concentrations >100 g/l strongly suggest the

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presence of pulmonary or skeletal metastases.

Flow cytometry for identifying diploid tumours, which

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have a good prognosis, and aneuploid tumours,

which have a poor prognosis.

CLINICAL FEATURES

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There are two broad categories of symptoms :

those occurring as a result of the enlargement of

the gland itself and those related to its disordered

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endocrine activity.

The history will establish whether one or both

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classes of symptoms are present, and examination

then aims to elicit the relevant physical signs.

NECK SYMPTOMS

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A lump in the neck

Discomfort on swallowing

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Dyspnoea

Hoarseness

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HYPOTHYROIDISM

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ADULT (MYXEDEMA)

? Hypothyroidism in adults THs.
? Could be:

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1ry hypothyroidism ... (diseases is in the gland)

- autoimmune disease such as "Hashimoto's thyroiditis".

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- lack of iodine.

- absence of deiodination enzyme.
T3 & T4 reflex TSH.
2ry hypothyroidism ... (disease is higher up)

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TRH TSH T3 & T4.
? Follicular cells become less active.

HYPOTHYROIDISM

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Autoimmune thyroiditis (chronic lymphocytic

thyroiditis)

Non-goitrous: Primary myxoedema

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Goitrous: Hashimoto's disease
Iatrogenic
After thyroidectomy
After radioiodine therapy
Drug induced (anti-thyroid drugs, para-aminosalicylic

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acid,Amiodarone,Cytokines and iodides in excess)

Dyshormonogenesis
Goitrogens

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Secondary to pituitary or hypothalamic disease
Thyroid agenesis
Endemic cretinism---- due to iodine deficiency
CRETENISM

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Inadequate thyroid hormone production during fetal

and neonatal development.

2 types- Endemic and Sporadic

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A hoarse cry, macroglossia and umbilical hernia in

a neonate with features of thyroid failure suggests

the diagnosis.

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Tt is by thyroxine.

ADULT HYPOTHYROIDISM

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The symptoms are:

The signs are:

? tiredness;

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? bradycardia;

? mental lethargy;

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? cold extremities;

? cold intolerance;

? dry skin and hair;

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? weight gain;

? periorbital puffiness;

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? constipation;

? hoarse voice;

? menstrual disturbance;

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? bradykinesis, slow

? carpal tunnel syndrome

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movements;

? delayed relaxation

phase of ankle jerks

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MYXEDEMA

The signs and symptoms

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of hypothyroidism are

accentuated.

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The facial appearance is

typical-supraclavicular

puffiness, a malar flush

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and a yellow tinge to the

skin.

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Myxoedema coma,

characterised by altered

mental state, hypothermia

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and a precipitating

medical condition, for

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example cardiac failure or

infection.

DIAGNOSIS AND TREATMENT

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Low T4 and T3 levels with a high TSH.
What will happen in Pituitary failure?
High serum levels of TPO antibodies are

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characteristic of autoimmune disease.

Treatment-
Oral thyroxine (0.10?0.20 mg) as a single daily

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dose.
THYROTOXICOSIS
Describe the causes
Discuss the pros and cons of the three major treatment
options

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Know how to prepare a patient for operation
Describe appropriate surgical procedures
Know about early and late postoperative management

THYROTOXICOSIS

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THYROTOXICOSIS v/s HYPERTHYROIDISM?
Hyperthyroidism is a condition in which the thyroid

gland producesand secretes excessive amounts of

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the free thyroid hormones.

Thyrotoxicosis

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hypermetabolic clinical syndrome which occurs

when there are elevated serum levels of T3 and/or

T4.

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Thyrotoxicosis can also occur without

hyperthyroidism.
THYROTOXICOSIS

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Clinical types are:
? diffuse toxic goitre (Graves' disease);
? toxic nodular goitre;
? toxic nodule;

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? hyperthyroidism due to rarer causes.

THYROTOXICOSIS

Diffuse toxic goitre

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Graves' disease, occurs in younger women .
Associated with eye signs.
50% of patients have a family history of

autoimmune endocrine diseases.

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The whole of the functioning thyroid tissue is

involved.

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Hypertrophy and hyperplasia are due to abnormal

thyroid-stimulating antibodies (TSH-RAbs)
THYROTOXICOSIS

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Toxic nodular goitre
A simple nodular goitre is present for a long time

before the Hyperthyroidism.

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Middle-aged or elderly.
Very infrequently associated with eye signs.
The syndrome is that of secondary thyrotoxicosis.
In many cases of toxic nodular goitre the nodules

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are inactive and it is the internodular thyroid tissue

that is overactive.

THYROTOXICOSIS

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Toxic nodule
A toxic nodule is a solitary overactive nodule, which

may be part of a generalised nodularity or a true

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toxic adenoma.

It is autonomous and its hypertrophy and

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hyperplasia are not due to TSH-RAb.

TSH secretion is suppressed by the high level of

circulating thyroid hormones and the normal thyroid

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tissue surrounding the nodule is itself suppressed

and inactive.
THYROTOXICOSIS-CLINICAL FEATURES

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The symptoms are:

The signs are:

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? tiredness;

? tachycardia;

? emotional lability;

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? hot, moist palms;

v ? heat intolerance;

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? exophthalmos;

? weight loss;

? lid lag/retraction;

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? excessive

? agitation;

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appetite;

? thyroid goitre and

? palpitations.

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bruit.

GRAVE'S OPHTHALMOPATHY

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2 clinical phases:
The inflammatory stage and the fibrotic stage
The inflammatory stage is marked by edema and

deposition of glycosaminoglycan in the extraocular

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muscles. There is orbital swelling, stare, diplopia,

periorbital edema, and at times, pain.

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The fibrotic stage is a convalescent phase and may

result in further diplopia and lid retraction. It

improves spontaneously in 64% of patients

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PRETIBIAL MYXEDEMA


Elevated, firm, nonpitting, localized thickening over the

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lateral aspect of the lower leg, with bilateral involvement.

Milder cases do not require therapy other than treatment

of the thyrotoxicosis.

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Therapy with topical steroids applied under an occlusive

plastic dressing film for 3-10 weeks has been helpful.

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In severe cases, pulse glucocorticoid therapy may be

tried.

ACROPACHY

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Clubbing of fingers with osteoarthropathy,

including periosteal new bone formation, may

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occur.

This almost always occurs in association with

ophthalmopathy and dermopathy.

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No therapy has been proven to be effective.
WORKUP

TSH levels usually are suppressed to immeasurable

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levels (<0.05 ?IU/mL) in thyrotoxicosis.

Subclinical hyperthyroidism is defined as a

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suppressed TSH level (<0.5 U/mL in many

laboratories) in combination with serum

concentrations of T3 and T4 that are within the

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reference range.
Thyroid autoantibodies: The most specific

autoantibody for autoimmune thyroiditis is an

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enzyme-linked immunosorbent assay (ELISA) for

anti-TPO antibody (thyroperoxidase).

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SCANNING

Graves disease is associated with diffuse enlargement

of both thyroid lobes, with an elevated uptake .

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A toxic multinodular goiter demonstrates an enlarged

thyroid with multiple nodules and areas of both

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increased and decreased isotope uptake .

Subacute thyroiditis usually demonstrates very low I-123

isotope uptake.

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A toxic adenoma demonstrates a solitary hot nodule

with suppression of function in the surrounding normal

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thyroid tissue .
MANAGEMENT

ANTITHYROID DRUGS

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SURGERY

RADIOIODINE

ANTI THYROID DRUGS

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Carbimazole, methimazole and propylthiouracil

are most commonly used.

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Reduce the synthesis of thyroid hormones by

inhibiting the iodination of tyrosine residues.

Carbimazole also has an immunosuppresive

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action.

Clinical improvement occurs within 10-14 days.
Pt is clinical y and biochemical y euthyroid by 3-

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4 wks.

Tt is continued for 12-18 months.
ANTI THYROID DRUGS

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ADVANTAGE
No surgery and no use of radioiodine.
q DISADVANTAGE
Tt is prolonged and the failure rate is atleast 50%

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Some goitres enlarge and become more vascular

during tt.

Side effects are agranulocytosis or aplastic anemia

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SURGERY

Usually done when there is a large goitre,poor drug

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compliance,recurrence.

Subtotal thyroidectomy is done.
Contraindication is previous thyroid surgery.
Complications are hypothyroidism,transient

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hypocalcemia,permanent

hypoparathyroidism,recurrent laryngeal nerve palsy.
SURGERY

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ADVANTAGE
Goitre is removed.
Cure is rapid and cure rate is high.
? DISADVANTAGE

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Recurrenc occurs in 5%
Every operation carries mortality and morbidity.
Post op thyroid insufficiency

RADIOIODINE

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131I is given orally as a single dose and is

trapped and organified in thyroid.

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There is alag period of 4-12 wks before it is

effective.

During this period the symptoms are

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controlled by beta blockers.

Contraindications are pregnancy,active

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graves ophthalmopathy.

Complications are

hypothyroidism,malignancies of thyroid and

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gi tract.
RADIOIODINE

No surgery and prolonged drugs.

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DISADVANTAGE
Isotope facilities must be available.
High incidence of hypothyroidism which may reach 75

-80% after 10 yrs.

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Indefinite follow up.
Increased risk of malignancy.

CHOICE

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1.DIFFUSE TOXIC GOITRE-

Over 45-Radioiodine

Under 45-Surgery for large goitre and drugs for small

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goitre.

2.TOXIC NODULAR GOITRE-

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SURGERY.

3.TOXIC NODULE-

Surgery or Radioiodine

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4.RECURRENT THYROTOXICOSIS AFTER

SURGERY-

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Over 45-Radioiodine,Under 45-Drugs.
Correction of hyperthyroidism is important for the

ophthalmopathy.

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Antithyroid drugs and thyroidectomy do not

influence the course of the ophthalmopathy,

whereas radioiodine treatment may exacerbate

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preexisting ophthalmopathy but can be prevented

by glucocorticoids.

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In the long term, thyroid ablation may be beneficial

for ophthalmopathy because of the decrease in

antigens shared by the thyroid and the orbit in the

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autoimmune reactions.

GRAVE'S OPHTAHLMOPATHY

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For mild-to-moderate ophthalmopathy, local therapeutic

measures (eg, artificial tears and ointments, sunglasses,

eye patches, nocturnal taping of the eyes, prisms,

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elevating the head at night) can control symptoms and

signs.

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If the disease is active (1) high-dose glucocorticoids, (2)

orbital radiotherapy, (3) both, or (4) orbital

decompression

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PRE OP PREPARATION

Carbimazole in the dose of 30-40mg daily for 8-

12wks is given. when euthyroid the dose is reduced

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to 5mg t.d.s.

Iodides in the form of lugol's iodine is used 2-3 wks

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prior to surgery.dose is 30 drops t.d.s.it reduces the

size and vascularity of the gland.

Propranol acts on the target organs and not on the

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gland itself. Dose is 40mgt.d.s.it inhibits the

peripheral conversion of T4 to T3.

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POSTOPERATIVE COMPLICATIONS

Haemorrhage
Respiratory obstruction
Recurrent laryngeal nerve paralysis and voice

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change

Thyroid insufficiency
Parathyroid insufficiency

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Thyrotoxic crisis
Wound infection
Hypertrophic or keloid scar
Stitch granuloma

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GOITRE
Know how to describe thyroid swellings

Use appropriate investigations

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Know the indications for surgery

Select the appropriate procedure

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Describe and manage postoperative complications

CLASSIFICATION OF GOITRE

Simple goitre (euthyroid)

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Diffuse hyperplastic

Physiological
Pubertal

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Pregnancy

Multinodular goitre

Toxic

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Diffuse

Graves' disease

Multinodular

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Toxic adenoma
Neoplastic
Benign
Malignant
CLASSIFICATION OF GOITRE

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Inflammatory

Autoimmune
Chronic lymphocytic thyroiditis

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Hashimoto's disease
Granulomatous
De Quervain's thyroiditis
Fibrosing
Riedel's thyroiditis

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Infective

Acute (bacterial thyroiditis, viral thyroiditis, `subacute

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thyroiditis')

Chronic (tuberculous, syphilitic)

Inflammato Hyperplasi

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Tumours

Others

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ry

a

Benign

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Malignant

Graves

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Multinodular Follicular

Papillary Colloid cyst

Disease

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goitre

adenoma

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Hashimoto's Non-toxic

Follicular

Thyroid

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thyroiditis

goitre

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lymphoma

De

Anaplastic

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Acute

Quervain's

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suppurative

thyroiditis

Medullary

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SIMPLE GOITRE

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Stimulation of the thyroid gland by TSH.
The most common cause iodine deficiency.
Increased demand.
Excess iodine or lithium ingestion, which

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decrease release of thyroid hormone

Goitrogens(cassava, lima beans, maize, bamboo

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shoots, and sweet potatoes)

-Inborn errors of metabolism causing defects in

biosynthesis of thyroid hormones

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- Exposure to radiation

-Thyroid hormone resistance

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Side-effects of pharmacological therapy

such as:

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Amiodarone :

inhibits peripheral conversion of thyroxine to

triiodothyronine; also interferes with

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thyroid hormone action.

Phenobarbitone, phenytoin, carbamazepine,

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Rifampcin:

induce metabolic degradation of T3 and T4.

? If No Iodine T3 & T4 TRH TSH

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growth (size) of the gland simple goiter.

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HOW GOITER IS FORMED?

WITH LACK OF IODINE ...

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Hypothalamus

COLD

TR

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+

H

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Anterior

pituitary

TS

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+

NO or low

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H

Thyroi

Lack of

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feedback

iodine

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inhibition

d gland

Poo

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+++

r

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Low T3 or T4

Growth of

release

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the gland

NATURAL HISTORY

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Persistant growth stimulation cause diffuse

hyperplasia ,all lobules are composed of

active follicles and iodine uptake is uniform

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.This is a diffuse hyperplastic goiter .

Mixed pattern develops with areas of active

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lobules and areas of inactive lobule as a

result of fluctuating stimulation.

Active lobules become more vascular &

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hyperplastic untill haemorrhage occur

causing central necrosis & leaving only a

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surrounding rind of active follices.
Necrotic lobules __

form nodules filled with

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either iodine-free colloid

or a mass of new but

inactive follicles.

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Continual repetition

of this process result

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in a nodular goiter.

CLINICAL FEATURES

Euthyroid.

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Neck swelling which moves on swallowing.
Rule out compressive symptoms.
Hardness and irregularity, due to calcification, may

simulate carcinoma.

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A painful nodule or the sudden appearance or rapid

enlargement of a nodule may be because of

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haemorrhage or carcinoma.
INVESTIGATIONS

Serum TSH.
USG neck.

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Thyroid autoantibodies.
Plain X-Ray neck.
FNAC.

COMPLICATIONS

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Respiratory obstruction.
Secondary Thyrotoxicosis.
Carcinoma (Follicular).
PREVENTION AND TREATMENT OF SIMPLE

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GOITRE

Iodised salt.
INDICATIONS OF SURGERY:

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Cosmesis
Retrosternal extension.
Compressive symptoms.
Suspected malignancy.

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WHAT SURGERY?

Total thyroidectomy

Subtotal thyroidectomy leaving up to 4 g of

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relatively normal tissue in each remnant.

Total lobectomy on the more affected side with either

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subtotal resection (Dunhill procedure) or no intervention

on the less affected side.

DISCRETE THYROID SWELLING

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WHAT IS SOLITARY SWELLING OF THYROID?
WHAT IS DOMINANT SWELLING?
About 70% of discrete thyroid swellings are

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isolated and about 30% are dominant.

The importance lies in the increased risk of

neoplasia compared with other thyroid swellings.

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15% of isolated swellings are malignant, 30?40%

are follicular adenomas.
CLINICALLY DISCRETE SWELLINGS

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What are the risk factors which suggest that a

discrete swelling is malignant?

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When will you suspect malignancy in a discrete

swelling?

CLINICALLY DISCRETE SWELLINGS

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Causes?
Investigation?
CLINICALLY DISCRETE SWELLINGS

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INDICATIONS OF SURGERY?
All proven malignant nodules.
Cytologically proven follicular adenoma.
Suspicious nodules.
Cystic nodules which recur following aspiration.

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Nodules producing obstructive symptoms.
Toxic nodule.
Cosmesis.
Patient's wish.

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RETROSTERNAL GOITRE
RETROSTERNAL GOITRE

Arise from the lower pole of a nodular goitre.

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Short neck and strong pretracheal muscles incresase

the negative intrathoracic pressure which tends to draw

these nodules into the superior mediastinum.

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Symptomless.

Dyspnoea, particularly at night,

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Cough and stridor

Dysphagia.

Engorgement of facial, neck and superficial chest wall

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veins.

Obstruction of the superior vena cava

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Recurrent nerve paralysis

RETROSTERNAL GOITRE

CXR

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CT Scan.

Surgery.
THYROID INCIDENTALOMA

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THYROID INCIDENTALOMA

Due to the increased use of imaging modalities for

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non-thyroid head and neck pathology.

Clinically unsuspected and impalpable thyroid

swellings.

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Generates needless anxiety.
Can be safely managed expectantly by a single

annual review.

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Thyroid incidentaloma

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on US, MRI or CT scan

Greater than 1.5 cm

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radiation exposure

Less than 1.5 cm

US, MRI or CT ?cancer

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US, MRI or CT scan

benign

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FH thyroid cancer

US guided

FNAC

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Observe

HASHIMOTO'S THYROIDITIS
Characterized by the destruction of thyroid cells by

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cell- and antibody-mediated immune processes.

The thyroid gland is typically goitrous.
Antithyroid peroxidase (anti-TPO), antithyroglobulin

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(anti-Tg),TSH receptor-blocking antibodies.

Inadequate thyroid hormone production and

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secretion.

Initially, (T4) and (T3) may "leak" into the circulation

from damaged cells.

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10-15 times more common in females.
The most commonly affected age range is 30-50

years.

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WORKUP

TFT.

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USG.

Complete blood count.

Total and fractionated lipid profile.

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WORKUP

Basic metabolic panel: Glomerular filtration rate, renal

plasma flow, and renal free water clearance are all

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decreased in hypothyroidism and may result in

hyponatremia.

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Creatine kinase: Creatine kinase levels, predominantly

the MM isoenzyme from skeletal muscle and the

aldolase enzyme, are frequently elevated in severe

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hypothyroidism.

Prolactin: Prolactin may be elevated in primary

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hypothyroidism

TREATMENT

The treatment of choice for Hashimoto thyroiditis is

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thyroid hormone replacement.

The drug of choice is orally administered

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levothyroxine sodium, usually for life.

Indications for surgery

A large goiter with obstructive symptoms such as

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dysphagia, voice hoarseness, and stridor from extrinsic

obstruction to airflow.

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Presence of a malignant nodule, as found by cytologic

examination by fine-needle aspiration.

Presence of a lymphoma diagnosed on fine-needle

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aspiration.

Cosmetic reasons for unsightly large goiters
REIDEL'S THYROIDITIS

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A rare, chronic inflammatory disease of the thyroid

gland characterized by a dense fibrosis that

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replaces normal thyroid parenchyma.

The fibrotic process invades adjacent structures of

the neck and extends beyond the thyroid capsule.

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This feature differentiates RT from other

inflammatory or fibrotic disorders of the thyroid.

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Because of the encroachment beyond the thyroid

capsule, other problems can be associated with RT,

including hypoparathyroidism, hoarseness (due to

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recurrent laryngeal involvement), and stridor (due to

tracheal compression).
PATHOPHYSIOLOGY

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The etiology of Riedel's thyroiditis (RT) is unknown.
An autoimmune process or a primary fibrotic disorder.
The following evidence supports an autoimmune

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pathogenesis for RT:

The presence of antithyroid antibodies in a significant

percentage of patients with RT (67% of 178 cases

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reviewed in one study)2

The pathological features of cellular infiltration, including

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lymphocytes, plasma cells, and histiocytes

The frequent presence of focal vasculitis on pathologic

examination

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The favorable response of a subset of patients with RT

to treatment with systemic corticosteroids

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CLINICAL FEATURES

History
Nonpainful, rapidly growing thyroid mass.
Hard, fixed, painless goiter- stony or woody.

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Most patients are euthyroid. Hypothyroidism is

noted in approximately 30% of cases.

Local compressive symptoms.

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Hypoparathyroidism.
Clinical features closely resemble those of

anaplastic carcinoma of the thyroid.

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One distinguishing feature of RT is the absence of

associated cervical adenopathy.
CLINICAL FEATURES

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Approximately one third of patients with RT have an

associated extracervical manifestation of multifocal

fibrosclerosis (eg, retroperitoneal fibrosis,

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mediastinal fibrosis, orbital pseudotumor,

pulmonary fibrosis, sclerosing cholangitis, lacrimal

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gland fibrosis, fibrosing parotitis).

MANAGEMENT

ROUTINE TESTS.

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FNAC,BIOPSY.

SURGERY.
DEQUAIRVEIN'S

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THYROIDITIS

Most common cause of a painful thyroid gland.
Pain in the region of the thyroid, which is usually

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diffusely tender with systemic symptoms.

Hyperthyroidism occurs initially, sometimes

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followed by transient hypothyroidism.

Complete recovery in weeks to months is

characteristic.

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PATHOPHYSIOLOGY

A viral infection like coxsackievirus, Ebstein-Barr,

mumps, measles, adenovirus, echovirus, and

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influenza.

A strong association exists with human leukocyte

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antigen (HLA)-B35.

EPIDEMIOLOGY

Sex

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Female-to-male ratio of 3-5:1.

Age

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A peak incidence in the fourth and fifth decades

of life
HISTORY

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History
Flulike prodromal episode 1-3 weeks prior to the onset of

clinical disease. The natural course of the disease can

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be divided into the following 4 phases that usually unfold

over a period of 3-6 months:

The acute phase, lasting 3-6 weeks, presents primarily

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with pain. Symptoms of hyperthyroidism also may be

present.

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The transient asymptomatic and euthyroid phase lasts 1-

3 weeks.

The hypothyroid phase lasts from weeks to months, and

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it may become permanent in 5-15% of patients.

The recovery phase is characterized by normalization of

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thyroid structure and function.

S|S

Local symptoms

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Pain over the thyroid that radiates to the neck, ear, jaw,

throat, or occiput; and is aggravated by swallowing and

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head movement;

pain is the presenting symptom in over 90% of cases
Dysphagia
Hoarseness (uncommon)

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Constitutional symptoms (often absent)
S|S

Symptoms of hyperthyroidism (palpitations,

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tremulousness, heat intolerance, sweating,

nervousness) occurring in the initial phase of the

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disease

Hyperthyroidism that usually is mild and rarely is severe
Transient symptoms, usually lasting 3-6 weeks

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Symptoms of hypothyroidism, occurring in the late

phase of the disease

Mostly mild or moderate

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Hypothyroidism lasts weeks to months

WORKUP

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Usually, the diagnosis is made on clinical grounds,

and the only laboratory studies needed initially are

those to determine whether hyperthyroidism is

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present, including TSH and free T4.

If any doubt exists as to whether de Quervain

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thyroiditis is the correct diagnosis, 2 other tests may

be helpful.

Serum thyroglobulin is almost always markedly elevated.

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Erythrocyte sedimentation rate (ESR) is usually higher

than 50 mm/h in the initial phase
WORKUP

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After the initial inflammatory phase subsides, TSH

should be monitored at intervals of 4-6 weeks for a

few months to determine whether hypothyroidism

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occurs.

Antibodies to TGB, thyroid peroxidase, and TSH

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receptor are usually absent in de Quervain

thyroiditis.

In rare cases with systemic multiorgan involvement,

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elevation of serum alkaline phosphatase, gamma-

glutamyl transpeptidase, aminotransferases, and

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pancreatic enzymes may occur. Glucose

intolerance has been reported.

TT.

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Management is directed towards 2 problems--pain

and thyroid dysfunction.

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Pain

Some patients with mild pain require no treatment.

Nonsteroidal anti-inflammatory drugs (NSAIDs), are

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used.

If pain does not respond within 3 days, the diagnosis

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should be reconsidered.
TT.

Management of thyroid dysfunction

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In the initial phase of de Quervain thyroiditis,

symptomatic hyperthyroidism can be treated with beta-

blockade (propranolol 10-20 mg qid or atenolol 25-50

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mg/d).

If hypothyroidism occurs during the late phase, it is

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usually mild and transient. If symptoms are present

or TSH is elevated, the patient needs replacement

therapy with levothyroxine

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THYROID NEOPLASMS
THYROID NEOPLASMS
A.BENIGN

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a.Follicular adenoma.

b.Hurthle cell adenoma.

c.Colloid adenoma.

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d.Papillary adenoma.

B.MALIGNANT(Dunhill classification)

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a.Differentiated

1.Papillary CA(60%)

2.Follicular CA(17%)

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3.Papillofollicular CA

4.Hurthle cell CA

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b.Undifferentiated

1.Anaplastic CA(13%)

C.Medullary CA(6%)

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D.Malignant lymphoma(4%)

E.Secondaries.

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ETIOLOGY

Radiation exposure.

MNG.

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Genetic.

Hashimoto's thyroiditis.
PAPILLARY CA

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Most common cancer of thyroid.

Common in females and young age group.

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Woolner classification includes

i)occult primary

ii)intrathyroidal.

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iii)extrathyroidal

PAPILLARY CA

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PATHOLOGY

Grossly it can be soft,firm,solid or cystic.

Microscopically it contains cystic spaces with

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papillary projections with psammoma

bodies,malignant cells with orphan annie eye

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nuclei.
PAPILLARY CA

SPREAD

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Slowly progressive tumor.

Multicentric.

Spread is via lymphatics.

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PAPILLARY CA
Treatment-----
Total thyroidectomy.

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Suppressive dose of L-thyroxine.

Neck dissection if LNs are positive.

PROGNOSIS is good.

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PAPILLARY CA

AMES SCORING-
A-Age less than 40.
M-mets

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E-extent of primary tumor
S-size less than 4cm has agood prognosis
AGES SCORING-
A-age
G-grade

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E-extent
S-size

FOLLICULAR CA

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Can occur de novo or in a multinodular goitre.

More aggressive tumor.

Spreads mainly by blood.

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Bone secondaries are typically vascular,warm

and pulsatile.

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FNAC is inconclusive.

Tt. Is total thyroidectomy.
ANAPLASTIC CA

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Occurs in elderly.
Very aggressive tumor of short duration.
Stridor and hoarseness of voice.
Dysphagia.
Fixity to skin.

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FNAC is diagnostic.
Tracheostomy and isthmectomy to relieve

obstruction.

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Radiotherapy is tt.
Very poor prognosis.

MEDULLARY CA

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Arises from parafollicular c cells which

are derived from ultimobranchial body.

Contains characterstic amyloid stroma.

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Calcitonin is a useful tumor marker.
Tumor also secretes 5 HT,PGs,ACTH,and

VIP

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Spreads mainly via lymphatics.
Can be sporadic,associated withMENII

syndrome or familial.

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Tt. Is total thyroidectomy.


A 30 years old female pregnant in her 14 weeks

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developed tremors,

insomnia, intolerance to hot weather and loss of

weight. On examination

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she had tachycardia and wide pulse pressure.

a. What is the possible diagnosis

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b. How would you investigate it

c. Management of the condition in view of her

pregnancy

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A 35 year old housewife is suffering from TNG.

She has been advised a radioiodine scan.

Which other radionuclide scans are available?

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Write two merits and two demerits of radioiodine

scan.