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MANAGEMENT THYROID

DISORDERS. Dr. L.D Lugaria


• Introduction
• Goitre
• Thyrotoxic Goitre.
• Solitary Thyroid nodule.
• Hyperthyroidism.
• Toxic Multinodular Goitre.
• Malignant Thyroid Tumours.
MANAGEMENT OF THYROID
DISORDERS- Introd
• Background knowledge- Anatomy, physiology,
biochemistry of the thyroid gland.
• Thyroid Disorders : Congenital or Acquired
–Congenital :Atresia, incomplete
descent/ectopic, Enzyme deficiency.
-Acquired :
.Infections-(bacterial, T.B, Viral)
.Tumours –(Benign or
Malignant).
.Autoimmune (Circulating immunoglobulin)
ANATOMY
• Position (5th -7th cervical vertebrae ant.
Neck)
• Relations and related important structures
(Trachea, esophagus, carotids, sup/inf.
laryngeal nerves, parathyroid glands).
• Layers- (skin to gland)
• Size
• Blood supply-Arterial (sup./inf. Thyroid).
-Venous (sup. Inf. Mid thyroid).
MANAGEMENT
• History- symptoms: pain, ant. Neck
swelling, Metabolic derangement,
obstructive.
• P.E- Signs: Mass anterior neck, Metabolic.
• INVEST. –TFTs (T3, T4, TSH) ,U/S, AITI,
X-ray, U/S, FNA, Biopsy, Radioisotope
studies.
• Treatment- Medical or surgical or
combined
GOITRE
• Goitre defn.- thyroid gland enlargement.
• Goitre –physiological (puberty, pregnancy)
- pathological (toxic or nontoxic).
• Incidence varies: regions, F>M.
• Goitre- endemic, sporadic, drug reaction
• Variations- size, shape, consistency.
• Clinical Features: asymptomatic/ symptomatic.
• Symptomatic-compression (trachea, esophagus),
Bleeding
• INVEST: T3,T4,TSH.
• Treatment (symptomatic/cosmesis)- subtotal
thyroidectomy.
THYROTOXIC GOITRE
Def.- Diffuse enlargement of the thyroid gland,
T3&T4 raised.
Causes- High TSH or TSH like proteins
THYROIDITIS: Sub acute, Autoimmune or Riedel’s
• Sub acute (De Quervan's disease)-rare
- A flue like illness, with diffuse painful gland
swelling.
-Thyroid Abs may be raised.
--Due to viral infection.
–-Usually resolves.
THYROTOXIC GOITRE…
• Autoimmune Thyroiditis (Hashimoto’s disease).
–Thyroid follicles destroyed by immunocompetent
lymphocytes. –Serum
Abs: against thyroglobulin, thyroid cell cytosol, and microsomes.

Histology: Marked lymphocytic infiltration around the destroyed
follicles
–Patient usually euthyroid, occ. thyrotoxic, longterm hypothyroid.
–Most common in
postmenopausal females (F:M=10:1). - Thyroid
gland diffusely enlarged & firm. (Ddx mult. Goitre).
–diagnosis: High circ antithyroid Abs, Histology.
–Long standing : can transform to lymphoma.
–Treatment: Small goitre thyroxin; Large &
symptomatic-subt. Thyroidectomy (difficult).
THYROTOXIC GOITRE…
• Riedel’s thyroiditis.
–Very rare.
–Thyroid tissue replaced by fibrous tissue (firm
painless mass tracheal compression).
• Treatment:
-Sub acute –Resolves.
-Autoimmune Thyroiditis- subtotal thyroidectomy
(difficult and risky due to adhesions).
–Riedel’s- surgical decompression.
SOLITARY THYROID NODULES
• Defn: Painless solitary thyroid nodule. -50%
are conspicuous palpable nodule in a
multinodular gland. -50%
true solitary nodule (50% benign adenomas &
50% cyst or cancer)
• INVEST: FNA, U/S, TFTs (T3 T4 TSH), Isotope
scan (hot, cool or cold).
• TREATMENT:
-Cysts-Aspiration (material for cytology)
–Adenoma- Thyroidectomy.
–Carcinoma (Follicular, medullary, lymphoma)-
Surgery.
HYPERTHYROIDISM
• Due to elevated T3,T4.
• Causes:
-Pr. Thyrotoxicosis (Graves dx)-75%.
–Toxic multinodular goitre.
–Toxic adenoma.
PRIMARY THYROTOXICOSIS.
• Autoimmune-TSH receptors in the thyroid gland
stimulated by circulating immunoglobulins (TSI).
• Gland uniformly hyperactive, very vascular and
usually symmetrically enlarged.
• Histology: Epithelial proliferation with papillary
projections into follicles devoid of colloid.
• TSI cross placental barrier causing IU/neonatal
thyrotoxicosis.
PRIMARY THYROTOXICOSIS..
• CLINICAL FEATURES:
-Usually young female (f : m=8:1)
-FH
–Moderately, uniform diffuse gland enlargement.
-High circulating TSI, T3, T4 and
low TSH. –Metabolic: Feeling hot at rest
and heat intolerance; warm moist skin and weight loss
but high appetite. –
Increased sympathetic activity Tachycardia, palpitations,
arrhythmias (AF), fine hand tremors, retracted upper
eyelid, diorrhoea, anxiety. –Other features:
Exophthalmos, pretibial myxoedema, prox.muscle
myopathy, finger clubbing, menstrual irregularity.
PRIMARY THYROTOXICOSIS..
• DIAGNOSIS:
-History.
–PE
–INVEST.-T3,T4, TSH
• TREATMENT.
–Antithyroid drugs which block iodine incorporation into
tyrosine preventing T3&T4 synthesis.
–Carbimazole 30-60mg/d (4divided doses) 4-6 wks; 5-
15mg/d 12-18m. (Relapse 60-70% in 2yrs
–Radioactive Iodine + Thyroxine replacement therapy.
–Surgery: Subtotal thyroidectomy (70% cure rate &20-
25% recurrence).
TOXIC MULTINODULAR
GOITRE& TOXIC ADENOMA
• 25% of thyrotoxicosis are multinodular (single nodule 1-2% pts).
• Usually follows longstanding nontoxic goitre with 1+ nodules
becoming hyperactive.
• Single adenoma secretes thyroid hormones autonomously & TSH
completely suppressed.
• Clinical features:
- T.mult. Goitre commoner in elderly females.
–Cardiac complications & exophthalmos rare.
• Diagnosis: Isotope scan
-Mult. -Isotope scans for increased uptake
area(s). -Toxic adenoma- Hot nodule with
the rest of the gland “silent”.

• Treatment:
-Multinodular.-subt. Thyroidectomy.
-Toxic adenoma- Lobectomy.
MALIGNANT THYROID
TUMOURS.
• Malignant tumours: -F:M =3:1
–Three main types: Papllary(50%), Follicular (10-
25%),Anaplastic (25-40%). Others: Medullary &
lymphomas.
• Papillary Carcinoma:
-Rare after 40yrs.
–Slow growing solitary thyroid lump
–Enlarged palp. LNs
–Histology :Complex papillary folds lined by several
layers of cuboidal cells projecting into cystic spaces.
–Teatment :Total/Near total Thyroidectomy +
LN removal ; Hormone therapy (T3 20 qid); TSH
monitoring.
-Prognosis: Excellent -90% survival at 10yrs.
MALIGNANT THYROID
TUMOURS…
• Follicular Carcinoma:
-Usually solitary thyroid nodule in 30-50yrs.
–Common
haematogenous spread (20% pts have mets in lungs,
bone or liver). LN spread rare.
–Histology: Malignant cells arranged in
solid masses with rudimentary acini.
–Treatment: Ttl thyroidectomy with
preservation of the parathyroids and removal of all palp.
LNs. –Post op. radioisotope scan (+ve-
therapeutic doses of radio iodine.
–T3 for replacement &suppression
of TSH secretion. Monitoring for rec. (-thyroglobulin).
-Outcome:10yr survival=50%
MALIGNANT THYROID
TUMOURS …
• Anaplastic Carcinoma:
-Rapidly growing, highly
malignant.
-Commoner in elderly pts.
-Local invasion causes hoarseness (RLN),
compression symptoms (dyspnoea, stridor, dysphagia).
Cervical sympathetic involv. (Horner’s syndrome=
pupillary contraction, enophthalmos, narrow palp.
fissure, loss of sweating in head & neck).
-Pulm. Mets common.
–Treatment : Surg. To relieve symptoms;
DXT/Chemo of marginal value. –Prognosis-poor (70%
die 1yrof diagnosis

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