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THYROID GLAND

LEARNING OBJECTIVES

To understand:

? The development and anatomy of the thyroid

glands.

? The physiology and investigation of thyroid

function.

? The treatment of thyrotoxicosis and thyroid

failure.

The indications for and technique of thyroid

surgery

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

clinical features and management of primary

thyrotoxicosis.

Classify thyroid neoplasms. Discuss the management of

solitary thyroid nodule.

Describe how wil you proceed with the diagnosis and

treatment of a 40 y old female with multinodular goitre.

Discuss the etiology, clinical features, diagnosis and

treatment of MNG.

Discuss the etio pathology,clinical features, diagnosis

and treatment of Grave's disease.

Discuss the classification and clinical features of

thyroiditis.

Discuss the etio pathology,clinical features, diagnosis

and treatment of thyroid malignancies.

SHORT NOTES

Complications of thyroid surgery.
Development of thyroid and anomalies.
Ectopic thyroid
Eye signs in Grave's disease
Jod Basedow thyrotoxicosis
MEN syndrome
Thyroglossal cyst/fistula
Thyroid storm


CLINICAL ANATOMY

VASCULAR SUPPLY
LYMPHATIC DRAINAGE
Most important when considering surgical treatment

of thyroid carcinoma.

Paratracheal nodes; tracheoesophageal groove lymph

nodes; mediastinal nodes in the anterior and superior

position; jugular lymph nodes in the upper, middle,

and lower distribution; and retropharyngeal and

esophageal lymph nodes.

Laterally, cervical lymph nodes within the posterior

triangle.

Papillary carcinoma of the thyroid is commonly

associated with adjacent nodal metastasis.

Medullary carcinoma has a strong predilection for

metastatic lymphatic involvement, usually within the

central compartment (the space between the internal

jugular veins).

RELATIONS

The gland is enclosed in the pretracheal fascia,

covered by the strap muscles and overlapped by the

sternocleidomastoids.

The anterior jugular veins course over the isthmus.

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.

Two nerves lie in close relationship to the gland; in

the groove between the trachea and oesophagus lies

the recurrent laryngeal nerve and deep to the upper

pole lies the external branch of the superior laryngeal

nerve passing to the cricothyroid muscle.


PHYSIOLOGY

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

and di iodotyrosine.

COUPLING.


HORMONE SYNTHESIS
PHYSIOLOGY

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

T3 and T4.

T3 and T4 have negative feedback inhibition

on TSH and TRH.

PHYSIOLOGY

The thyroid hormones secreted by the gland

are in bound form and free form.

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

serum proteins- name?

T3 has a rapid onset of action and a much

shorter half life than T4.

Thyroid hormone synthesis is inhibited by?


CONGENITAL DISEASES

DEVELOPMENT

The thyroid develops

from a bud which

pushes out from the

floor of the pharynx

and then descends to

its definitive position

in the neck.
THYROGLOSSAL CYST

LINGUAL THYROID

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.

In all cases of unexplained nodules in the line of thyroid

descent, a radio-iodine scan should be performed to

ensure that there is normal thyroid tissue in the correct

place before the lump is removed.

Enlargement of a lingual thyroid can cause airway

obstruction, dysphagia, or bleeding.

Most lingual thyroid glands can be suppressed with

thyroid hormone administration.

In resistant lingual thyroids, radioactive iodine treatment

may be given.
ECTOPIC THYROID TISSUE

Can be found in the central compartment of the

neck, under the lower poles of normal thyroid or in

the anterior mediastinum.

Lateral aberrant thyroid

PENDRED'S SYNDROME

A rare autosomal recessive condition

characterised by incomplete oxidation of

trapped iodide prior to organification.

Associated with sensorineural deafness,

mild primary hypothyroidism with a non-toxic

diffuse goitre.

It may be confirmed by a positive

perchlorate discharge test.
TESTS OF THYROID FUNCTION

EVALUATION OF PITUITARY- THYROID
FEEDBACK LOOP

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

Only a small fraction of the total (0.03% of

T4 and 0.3% of T3) is free.

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

T3 resin uptake test

THYROID AUTOANTIBODIES

TPO antibodies
Anti thyroglobulin antibodies
Antimicrosomal antibodies


THYROID IMAGING
1) Chest X-Ray.

THYROID IMAGING

USG
Helps in determining

the nature of swelling.

USG guided FNAC.
Helps in detecting

MetastaticLNs.

Followup.


THYROID IMAGING

CT scan
To know the extent of

malignancy and

reterosternal extension.

THYROID SCINTIGRAPHY

Provide information about thyroid activity , the size and

extent of the gland.

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

the gland.

The principal benefits of isotope scanning are in

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

thyroidectomy for carcinoma.
THYROID SCINTIGRAPHY

A hot nodule is one that takes up isotope while the

surrounding thyroid tissue does not.

Here, the surrounding thyroid tissue is inactive

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

normal thyroid tissue around it.

A cold nodule does not take up isotope

FNAC

IOC for discrete thyroid swellings.
Thy1- Non-diagnostic
Thy2- Non-neoplastic
Thy3 -Follicular
Thy4 -Suspicious of malignancy
Thy5- Malignant
MISCELLANEOUS
Serum calcitonin
Serum thyroglobulin-concentrations > 50g/l indicate

probable residual or recurrent tumour.

Concentrations >100 g/l strongly suggest the

presence of pulmonary or skeletal metastases.

Flow cytometry for identifying diploid tumours, which

have a good prognosis, and aneuploid tumours,

which have a poor prognosis.

CLINICAL FEATURES
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

endocrine activity.

The history will establish whether one or both

classes of symptoms are present, and examination

then aims to elicit the relevant physical signs.

NECK SYMPTOMS

A lump in the neck

Discomfort on swallowing

Dyspnoea

Hoarseness






HYPOTHYROIDISM

ADULT (MYXEDEMA)

? Hypothyroidism in adults THs.
? Could be:

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

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

- lack of iodine.

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

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

HYPOTHYROIDISM
Autoimmune thyroiditis (chronic lymphocytic

thyroiditis)

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

acid,Amiodarone,Cytokines and iodides in excess)

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

Inadequate thyroid hormone production during fetal

and neonatal development.

2 types- Endemic and Sporadic
A hoarse cry, macroglossia and umbilical hernia in

a neonate with features of thyroid failure suggests

the diagnosis.

Tt is by thyroxine.

ADULT HYPOTHYROIDISM

The symptoms are:

The signs are:

? tiredness;

? bradycardia;

? mental lethargy;

? cold extremities;

? cold intolerance;

? dry skin and hair;

? weight gain;

? periorbital puffiness;

? constipation;

? hoarse voice;

? menstrual disturbance;

? bradykinesis, slow

? carpal tunnel syndrome

movements;

? delayed relaxation

phase of ankle jerks


MYXEDEMA

The signs and symptoms

of hypothyroidism are

accentuated.

The facial appearance is

typical-supraclavicular

puffiness, a malar flush

and a yellow tinge to the

skin.

Myxoedema coma,

characterised by altered

mental state, hypothermia

and a precipitating

medical condition, for

example cardiac failure or

infection.

DIAGNOSIS AND TREATMENT

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

characteristic of autoimmune disease.

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

dose.
THYROTOXICOSIS
Describe the causes
Discuss the pros and cons of the three major treatment
options
Know how to prepare a patient for operation
Describe appropriate surgical procedures
Know about early and late postoperative management

THYROTOXICOSIS

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

gland producesand secretes excessive amounts of

the free thyroid hormones.

Thyrotoxicosis

hypermetabolic clinical syndrome which occurs

when there are elevated serum levels of T3 and/or

T4.

Thyrotoxicosis can also occur without

hyperthyroidism.
THYROTOXICOSIS

Clinical types are:
? diffuse toxic goitre (Graves' disease);
? toxic nodular goitre;
? toxic nodule;
? hyperthyroidism due to rarer causes.

THYROTOXICOSIS

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

autoimmune endocrine diseases.

The whole of the functioning thyroid tissue is

involved.

Hypertrophy and hyperplasia are due to abnormal

thyroid-stimulating antibodies (TSH-RAbs)
THYROTOXICOSIS

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

before the Hyperthyroidism.

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

are inactive and it is the internodular thyroid tissue

that is overactive.

THYROTOXICOSIS

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

may be part of a generalised nodularity or a true

toxic adenoma.

It is autonomous and its hypertrophy and

hyperplasia are not due to TSH-RAb.

TSH secretion is suppressed by the high level of

circulating thyroid hormones and the normal thyroid

tissue surrounding the nodule is itself suppressed

and inactive.
THYROTOXICOSIS-CLINICAL FEATURES

The symptoms are:

The signs are:

? tiredness;

? tachycardia;

? emotional lability;

? hot, moist palms;

v ? heat intolerance;

? exophthalmos;

? weight loss;

? lid lag/retraction;

? excessive

? agitation;

appetite;

? thyroid goitre and

? palpitations.

bruit.

GRAVE'S OPHTHALMOPATHY

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

deposition of glycosaminoglycan in the extraocular

muscles. There is orbital swelling, stare, diplopia,

periorbital edema, and at times, pain.

The fibrotic stage is a convalescent phase and may

result in further diplopia and lid retraction. It

improves spontaneously in 64% of patients
PRETIBIAL MYXEDEMA


Elevated, firm, nonpitting, localized thickening over the

lateral aspect of the lower leg, with bilateral involvement.

Milder cases do not require therapy other than treatment

of the thyrotoxicosis.

Therapy with topical steroids applied under an occlusive

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

In severe cases, pulse glucocorticoid therapy may be

tried.

ACROPACHY

Clubbing of fingers with osteoarthropathy,

including periosteal new bone formation, may

occur.

This almost always occurs in association with

ophthalmopathy and dermopathy.

No therapy has been proven to be effective.
WORKUP

TSH levels usually are suppressed to immeasurable

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

Subclinical hyperthyroidism is defined as a

suppressed TSH level (<0.5 U/mL in many

laboratories) in combination with serum

concentrations of T3 and T4 that are within the

reference range.
Thyroid autoantibodies: The most specific

autoantibody for autoimmune thyroiditis is an

enzyme-linked immunosorbent assay (ELISA) for

anti-TPO antibody (thyroperoxidase).

SCANNING

Graves disease is associated with diffuse enlargement

of both thyroid lobes, with an elevated uptake .

A toxic multinodular goiter demonstrates an enlarged

thyroid with multiple nodules and areas of both

increased and decreased isotope uptake .

Subacute thyroiditis usually demonstrates very low I-123

isotope uptake.

A toxic adenoma demonstrates a solitary hot nodule

with suppression of function in the surrounding normal

thyroid tissue .
MANAGEMENT

ANTITHYROID DRUGS

SURGERY

RADIOIODINE

ANTI THYROID DRUGS

Carbimazole, methimazole and propylthiouracil

are most commonly used.

Reduce the synthesis of thyroid hormones by

inhibiting the iodination of tyrosine residues.

Carbimazole also has an immunosuppresive

action.

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

4 wks.

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

ADVANTAGE
No surgery and no use of radioiodine.
q DISADVANTAGE
Tt is prolonged and the failure rate is atleast 50%
Some goitres enlarge and become more vascular

during tt.

Side effects are agranulocytosis or aplastic anemia

SURGERY

Usually done when there is a large goitre,poor drug

compliance,recurrence.

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

hypocalcemia,permanent

hypoparathyroidism,recurrent laryngeal nerve palsy.
SURGERY

ADVANTAGE
Goitre is removed.
Cure is rapid and cure rate is high.
? DISADVANTAGE
Recurrenc occurs in 5%
Every operation carries mortality and morbidity.
Post op thyroid insufficiency

RADIOIODINE

131I is given orally as a single dose and is

trapped and organified in thyroid.

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

effective.

During this period the symptoms are

controlled by beta blockers.

Contraindications are pregnancy,active

graves ophthalmopathy.

Complications are

hypothyroidism,malignancies of thyroid and

gi tract.
RADIOIODINE

No surgery and prolonged drugs.
DISADVANTAGE
Isotope facilities must be available.
High incidence of hypothyroidism which may reach 75

-80% after 10 yrs.

Indefinite follow up.
Increased risk of malignancy.

CHOICE
1.DIFFUSE TOXIC GOITRE-

Over 45-Radioiodine

Under 45-Surgery for large goitre and drugs for small

goitre.

2.TOXIC NODULAR GOITRE-

SURGERY.

3.TOXIC NODULE-

Surgery or Radioiodine

4.RECURRENT THYROTOXICOSIS AFTER

SURGERY-

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

ophthalmopathy.

Antithyroid drugs and thyroidectomy do not

influence the course of the ophthalmopathy,

whereas radioiodine treatment may exacerbate

preexisting ophthalmopathy but can be prevented

by glucocorticoids.

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

autoimmune reactions.

GRAVE'S OPHTAHLMOPATHY

For mild-to-moderate ophthalmopathy, local therapeutic

measures (eg, artificial tears and ointments, sunglasses,

eye patches, nocturnal taping of the eyes, prisms,

elevating the head at night) can control symptoms and

signs.

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

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

decompression
PRE OP PREPARATION

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

12wks is given. when euthyroid the dose is reduced

to 5mg t.d.s.

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

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

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

peripheral conversion of T4 to T3.

POSTOPERATIVE COMPLICATIONS

Haemorrhage
Respiratory obstruction
Recurrent laryngeal nerve paralysis and voice

change

Thyroid insufficiency
Parathyroid insufficiency
Thyrotoxic crisis
Wound infection
Hypertrophic or keloid scar
Stitch granuloma


GOITRE
Know how to describe thyroid swellings

Use appropriate investigations

Know the indications for surgery

Select the appropriate procedure

Describe and manage postoperative complications

CLASSIFICATION OF GOITRE

Simple goitre (euthyroid)

Diffuse hyperplastic

Physiological
Pubertal
Pregnancy

Multinodular goitre

Toxic
Diffuse

Graves' disease

Multinodular
Toxic adenoma
Neoplastic
Benign
Malignant
CLASSIFICATION OF GOITRE

Inflammatory

Autoimmune
Chronic lymphocytic thyroiditis
Hashimoto's disease
Granulomatous
De Quervain's thyroiditis
Fibrosing
Riedel's thyroiditis

Infective

Acute (bacterial thyroiditis, viral thyroiditis, `subacute

thyroiditis')

Chronic (tuberculous, syphilitic)

Inflammato Hyperplasi

Tumours

Others

ry

a

Benign

Malignant

Graves

Multinodular Follicular

Papillary Colloid cyst

Disease

goitre

adenoma

Hashimoto's Non-toxic

Follicular

Thyroid

thyroiditis

goitre

lymphoma

De

Anaplastic

Acute

Quervain's

suppurative

thyroiditis

Medullary




SIMPLE GOITRE

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

decrease release of thyroid hormone

Goitrogens(cassava, lima beans, maize, bamboo

shoots, and sweet potatoes)

-Inborn errors of metabolism causing defects in

biosynthesis of thyroid hormones

- Exposure to radiation

-Thyroid hormone resistance


Side-effects of pharmacological therapy

such as:

Amiodarone :

inhibits peripheral conversion of thyroxine to

triiodothyronine; also interferes with

thyroid hormone action.

Phenobarbitone, phenytoin, carbamazepine,

Rifampcin:

induce metabolic degradation of T3 and T4.

? If No Iodine T3 & T4 TRH TSH

growth (size) of the gland simple goiter.














HOW GOITER IS FORMED?

WITH LACK OF IODINE ...

Hypothalamus

COLD

TR

+

H

Anterior

pituitary

TS

+

NO or low

H

Thyroi

Lack of

feedback

iodine

inhibition

d gland

Poo

+++

r

Low T3 or T4

Growth of

release

the gland

NATURAL HISTORY

Persistant growth stimulation cause diffuse

hyperplasia ,all lobules are composed of

active follicles and iodine uptake is uniform

.This is a diffuse hyperplastic goiter .

Mixed pattern develops with areas of active

lobules and areas of inactive lobule as a

result of fluctuating stimulation.

Active lobules become more vascular &

hyperplastic untill haemorrhage occur

causing central necrosis & leaving only a

surrounding rind of active follices.
Necrotic lobules __

form nodules filled with

either iodine-free colloid

or a mass of new but

inactive follicles.

Continual repetition

of this process result

in a nodular goiter.

CLINICAL FEATURES

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

simulate carcinoma.

A painful nodule or the sudden appearance or rapid

enlargement of a nodule may be because of

haemorrhage or carcinoma.
INVESTIGATIONS

Serum TSH.
USG neck.
Thyroid autoantibodies.
Plain X-Ray neck.
FNAC.

COMPLICATIONS

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

Iodised salt.
INDICATIONS OF SURGERY:

Cosmesis
Retrosternal extension.
Compressive symptoms.
Suspected malignancy.

WHAT SURGERY???

Total thyroidectomy

Subtotal thyroidectomy leaving up to 4 g of

relatively normal tissue in each remnant.

Total lobectomy on the more affected side with either

subtotal resection (Dunhill procedure) or no intervention

on the less affected side.

DISCRETE THYROID SWELLING

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

isolated and about 30% are dominant.

The importance lies in the increased risk of

neoplasia compared with other thyroid swellings.

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

are follicular adenomas.
CLINICALLY DISCRETE SWELLINGS

What are the risk factors which suggest that a

discrete swelling is malignant????

When will you suspect malignancy in a discrete

swelling????

CLINICALLY DISCRETE SWELLINGS

Causes???
Investigation???
CLINICALLY DISCRETE SWELLINGS

INDICATIONS OF SURGERY?
All proven malignant nodules.
Cytologically proven follicular adenoma.
Suspicious nodules.
Cystic nodules which recur following aspiration.
Nodules producing obstructive symptoms.
Toxic nodule.
Cosmesis.
Patient's wish.

RETROSTERNAL GOITRE
RETROSTERNAL GOITRE

Arise from the lower pole of a nodular goitre.

Short neck and strong pretracheal muscles incresase

the negative intrathoracic pressure which tends to draw

these nodules into the superior mediastinum.

Symptomless.

Dyspnoea, particularly at night,

Cough and stridor

Dysphagia.

Engorgement of facial, neck and superficial chest wall

veins.

Obstruction of the superior vena cava

Recurrent nerve paralysis

RETROSTERNAL GOITRE

CXR

CT Scan.

Surgery.
THYROID INCIDENTALOMA

THYROID INCIDENTALOMA

Due to the increased use of imaging modalities for

non-thyroid head and neck pathology.

Clinically unsuspected and impalpable thyroid

swellings.

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

annual review.




Thyroid incidentaloma

on US, MRI or CT scan

Greater than 1.5 cm

radiation exposure

Less than 1.5 cm

US, MRI or CT ?cancer

US, MRI or CT scan

benign

FH thyroid cancer

US guided

FNAC

Observe

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

cell- and antibody-mediated immune processes.

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

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

Inadequate thyroid hormone production and

secretion.

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

from damaged cells.

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

years.

WORKUP

TFT.

USG.

Complete blood count.

Total and fractionated lipid profile.
WORKUP

Basic metabolic panel: Glomerular filtration rate, renal

plasma flow, and renal free water clearance are all

decreased in hypothyroidism and may result in

hyponatremia.

Creatine kinase: Creatine kinase levels, predominantly

the MM isoenzyme from skeletal muscle and the

aldolase enzyme, are frequently elevated in severe

hypothyroidism.

Prolactin: Prolactin may be elevated in primary

hypothyroidism

TREATMENT

The treatment of choice for Hashimoto thyroiditis is

thyroid hormone replacement.

The drug of choice is orally administered

levothyroxine sodium, usually for life.

Indications for surgery

A large goiter with obstructive symptoms such as

dysphagia, voice hoarseness, and stridor from extrinsic

obstruction to airflow.

Presence of a malignant nodule, as found by cytologic

examination by fine-needle aspiration.

Presence of a lymphoma diagnosed on fine-needle

aspiration.

Cosmetic reasons for unsightly large goiters
REIDEL'S THYROIDITIS

A rare, chronic inflammatory disease of the thyroid

gland characterized by a dense fibrosis that

replaces normal thyroid parenchyma.

The fibrotic process invades adjacent structures of

the neck and extends beyond the thyroid capsule.

This feature differentiates RT from other

inflammatory or fibrotic disorders of the thyroid.

Because of the encroachment beyond the thyroid

capsule, other problems can be associated with RT,

including hypoparathyroidism, hoarseness (due to

recurrent laryngeal involvement), and stridor (due to

tracheal compression).
PATHOPHYSIOLOGY

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

pathogenesis for RT:

The presence of antithyroid antibodies in a significant

percentage of patients with RT (67% of 178 cases

reviewed in one study)2

The pathological features of cellular infiltration, including

lymphocytes, plasma cells, and histiocytes

The frequent presence of focal vasculitis on pathologic

examination

The favorable response of a subset of patients with RT

to treatment with systemic corticosteroids

CLINICAL FEATURES

History
Nonpainful, rapidly growing thyroid mass.
Hard, fixed, painless goiter- stony or woody.
Most patients are euthyroid. Hypothyroidism is

noted in approximately 30% of cases.

Local compressive symptoms.
Hypoparathyroidism.
Clinical features closely resemble those of

anaplastic carcinoma of the thyroid.

One distinguishing feature of RT is the absence of

associated cervical adenopathy.
CLINICAL FEATURES

Approximately one third of patients with RT have an

associated extracervical manifestation of multifocal

fibrosclerosis (eg, retroperitoneal fibrosis,

mediastinal fibrosis, orbital pseudotumor,

pulmonary fibrosis, sclerosing cholangitis, lacrimal

gland fibrosis, fibrosing parotitis).

MANAGEMENT

ROUTINE TESTS.

FNAC,BIOPSY.

SURGERY.
DEQUAIRVEIN'S

THYROIDITIS

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

diffusely tender with systemic symptoms.

Hyperthyroidism occurs initially, sometimes

followed by transient hypothyroidism.

Complete recovery in weeks to months is

characteristic.
PATHOPHYSIOLOGY

A viral infection like coxsackievirus, Ebstein-Barr,

mumps, measles, adenovirus, echovirus, and

influenza.

A strong association exists with human leukocyte

antigen (HLA)-B35.

EPIDEMIOLOGY

Sex

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

Age

A peak incidence in the fourth and fifth decades

of life
HISTORY

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

clinical disease. The natural course of the disease can

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

with pain. Symptoms of hyperthyroidism also may be

present.

The transient asymptomatic and euthyroid phase lasts 1-

3 weeks.

The hypothyroid phase lasts from weeks to months, and

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

The recovery phase is characterized by normalization of

thyroid structure and function.

S|S

Local symptoms

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

throat, or occiput; and is aggravated by swallowing and

head movement;

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

Constitutional symptoms (often absent)
S|S

Symptoms of hyperthyroidism (palpitations,

tremulousness, heat intolerance, sweating,

nervousness) occurring in the initial phase of the

disease

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

Symptoms of hypothyroidism, occurring in the late

phase of the disease

Mostly mild or moderate

Hypothyroidism lasts weeks to months

WORKUP

Usually, the diagnosis is made on clinical grounds,

and the only laboratory studies needed initially are

those to determine whether hyperthyroidism is

present, including TSH and free T4.

If any doubt exists as to whether de Quervain

thyroiditis is the correct diagnosis, 2 other tests may

be helpful.

Serum thyroglobulin is almost always markedly elevated.
Erythrocyte sedimentation rate (ESR) is usually higher

than 50 mm/h in the initial phase
WORKUP

After the initial inflammatory phase subsides, TSH

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

few months to determine whether hypothyroidism

occurs.

Antibodies to TGB, thyroid peroxidase, and TSH

receptor are usually absent in de Quervain

thyroiditis.

In rare cases with systemic multiorgan involvement,

elevation of serum alkaline phosphatase, gamma-

glutamyl transpeptidase, aminotransferases, and

pancreatic enzymes may occur. Glucose

intolerance has been reported.

TT.

Management is directed towards 2 problems--pain

and thyroid dysfunction.

Pain

Some patients with mild pain require no treatment.

Nonsteroidal anti-inflammatory drugs (NSAIDs), are

used.

If pain does not respond within 3 days, the diagnosis

should be reconsidered.
TT.

Management of thyroid dysfunction

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

mg/d).

If hypothyroidism occurs during the late phase, it is

usually mild and transient. If symptoms are present

or TSH is elevated, the patient needs replacement

therapy with levothyroxine

THYROID NEOPLASMS
THYROID NEOPLASMS
A.BENIGN

a.Follicular adenoma.

b.Hurthle cell adenoma.

c.Colloid adenoma.

d.Papillary adenoma.

B.MALIGNANT(Dunhill classification)

a.Differentiated

1.Papillary CA(60%)

2.Follicular CA(17%)

3.Papillofollicular CA

4.Hurthle cell CA

b.Undifferentiated

1.Anaplastic CA(13%)

C.Medullary CA(6%)

D.Malignant lymphoma(4%)

E.Secondaries.

ETIOLOGY

Radiation exposure.

MNG.

Genetic.

Hashimoto's thyroiditis.
PAPILLARY CA

Most common cancer of thyroid.

Common in females and young age group.

Woolner classification includes

i)occult primary

ii)intrathyroidal.

iii)extrathyroidal

PAPILLARY CA

PATHOLOGY

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

Microscopically it contains cystic spaces with

papillary projections with psammoma

bodies,malignant cells with orphan annie eye

nuclei.
PAPILLARY CA

SPREAD

Slowly progressive tumor.

Multicentric.

Spread is via lymphatics.

PAPILLARY CA
Treatment-----
Total thyroidectomy.

Suppressive dose of L-thyroxine.

Neck dissection if LNs are positive.

PROGNOSIS is good.
PAPILLARY CA

AMES SCORING-
A-Age less than 40.
M-mets
E-extent of primary tumor
S-size less than 4cm has agood prognosis
AGES SCORING-
A-age
G-grade
E-extent
S-size

FOLLICULAR CA

Can occur de novo or in a multinodular goitre.

More aggressive tumor.

Spreads mainly by blood.

Bone secondaries are typically vascular,warm

and pulsatile.

FNAC is inconclusive.

Tt. Is total thyroidectomy.
ANAPLASTIC CA

Occurs in elderly.
Very aggressive tumor of short duration.
Stridor and hoarseness of voice.
Dysphagia.
Fixity to skin.
FNAC is diagnostic.
Tracheostomy and isthmectomy to relieve

obstruction.

Radiotherapy is tt.
Very poor prognosis.

MEDULLARY CA

Arises from parafollicular c cells which

are derived from ultimobranchial body.

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

VIP

Spreads mainly via lymphatics.
Can be sporadic,associated withMENII

syndrome or familial.

Tt. Is total thyroidectomy.


A 30 years old female pregnant in her 14 weeks

developed tremors,

insomnia, intolerance to hot weather and loss of

weight. On examination

she had tachycardia and wide pulse pressure.

a. What is the possible diagnosis

b. How would you investigate it

c. Management of the condition in view of her

pregnancy
A 35 year old housewife is suffering from TNG.

She has been advised a radioiodine scan.

Which other radionuclide scans are available?

Write two merits and two demerits of radioiodine

scan.

This post was last modified on 08 April 2022