THYROID DISEASES

Anatomy of Thyroid Gland

Arterial supply
• Sup. thyroid artery
(branch of ext carotid artery)

• Inf. thyroid artery

(branch of thyrocervical trunk)

• Thyroidea ima (from

brachiocephalic artery/arch of
aorta)
Anatomy of Thyroid Gland
Venous drainage
• Sup. Thyroid (drains into
internal jugular vein)

• Middle thyroid (drains

into internal jugular vein)

• Inf. thyroid (drain into left

brachiocephalic vein)
 Ectopic Thyroid & Anomalies
Lingual

Median ectopic thyroid

Lateral aberrant thyroid

Pyramidal lobe

Intrathoracic aberrant thyroid

 Ectopic Thyroid & Anomalies
• Median ectopic
• Lingual thyroid thyroid
– Rounded swelling at
– Upper part of the neck
back of tongue
– Mistaken for
– May cause dysphagia,
thyroglossal cyst
impairment of speech,
resp obstruction,
hemorrhage • Lat aberrant thyroid
– ‘normal’ thyroid
laterally must be
considered & treated
as mets in cervical LN
from occult papillary
thyroid ca
 Ectopic Thyroid & Anomalies
• Thyroglossal cyst
– Any part of thyroglossal
tract
– Midline
– Move upward on protrusion
of tongue
– >1cm, excised because
prone for infection
– Infected cyst often mistaken
for abcess & incised 
thyroglossal fistula
 Ectopic Thyroid & Anomalies
• Thyroglossal fistula
– Infection/inadequate
removal of throglossal
cyst
– Cutaneous opening
drawn upward on
protussion of tounge
– Discharge mucus 
recurrent attack of
inflammation
 Classification of Thyroid Swelling
• Simple goiter (euthyroid) • Inflammatory
– Diffuse hyperplastic – Autoimmune
• Physiological • Hashimoto’s ds
– Multinodular • Chronic lymphocytis
thyroiditis
– Granulomatous
• Toxic • De Quervain’s thyroiditis
– Diffuse : Grave’s disease – Fibrosing
– Multinodular • Riedel’s thyroiditis
– Toxic adenoma – Infective
• Acute (bacterial & viral
• Neoplastic thyroiditis)
• Chronic (TB, syphilis)
– Benign
– Other
– Malignant
• amyloid
 Simple Goiter
• Aetiology
– Iodine deficiency
– Dyshormogenesis
– Goitrogens

• The natural history of simple goiter

– Persistent growth stimulation causes diffuse hyperplasia
– Mixed patterns develops with areas of active and inactive
lobules as result of fluctuating stimulation
– Active lobules become more vascular and hyperplastic until
haemorrhage occurs, causing central necrosis
– Necrotic lobules coalesce to form nodules filled with either
iodine-free colloid or a mass of new but inactive follicles
– Continual repetition of these processes result in a nodular goitre
 Diffuse Hyperplastic Goiter
• Correspond to the 1st stages of natural
history
• Childhood (endemic areas), puberty,
pregnancy
• soft, diffuse and may become large
enough to cause discomfort.
 Nodular Goiter
• Later stage of natural history of
simple goitre
• Multiple  multinodular goitre
• may be colloid or cellular
• cystic degeneration and
haemorrhage is common
• Can develop retrosternal goitre
– dyspnea, cough, stridor, SVC
obstuction
 Solitary Nodule
• 70% are clinically • Ix
isolated, 30% dominant – TFT
– autoAb titres
• May have risk of
– Isotope scan
neoplasia
• Hot/cold
• 15% isolated - malignant • 80% cold & only 15%
• 30-40% - follicular malignant
adenomas – U/s : solid/cyst
– FNAC
• Remainders – non
neoplastic, colloid
degeneration, thyroiditis,
cysts
 Hypothyroidism

Autoimmune thyroiditis (Hashimoto’s ds, 1o

myxodema)
Iatrogenic
Dyshormongenesis
Goitrogens
2o to pituitary or hypothalamic disease
Endemic cretinism
 Signs &
Symptoms
 Hashimoto’s disease
• destruction of thyroid cells by various cell-
and Ab-mediated immune processes.
• Ab bind and blocking the TSH 
inadequate thyroid hormone production
and secretion
• Middle age woman
• Uniformly enlarge & firm (occ
asymmetrical & irregular)
• Thyroglobulin & microsomal Ab (90%)
 Hashimoto’s disease
• TFT
– Low T4 & T3
– High TSH

• Treatment
– levothyroxine sodium, usually for life.
– goal of therapy is to restore a clinically and
biochemically euthyroid state.
– standard dose is 1.6-1.8 mcg/kg lean body weight per
day
 Hyperthyroidism

Diffuse toxic goitre (Graves’ disease)

Toxic nodular goitre
Acute thyroiditis
Gestational thyrotoxicosis
Exogenous iodine
Drugs- amiodarone
Thyrotoxicosis factitia
TSH-secreting pituitary tumours
Metastatic differentiated thyroid carcinoma
Hcg-producing tumours
Hyperfunctioning ovarian teratoma
thyrotoxicosis factitia (rare)
 1 vs 2 hyperthyroidism
o o

1o (Grave’s ds) 2o
Enlargement of thyroid and toxic Goitre appears first, toxic features
features appear simultaneously develope after an interval
Toxic features are usually severe Toxic features are mild

Nervous manifestations Cvs manifestations

young elderly

Exopthalmos and eye signs are These are absent

common
small, diffuse, smooth large, nodular, irregular
 Signs & symptoms
• Symptoms • Signs
– Tiredness – Tachycardia
– Emotional liability – Hot, moist palms
– Heat intolerance – Eye sign
– LOW • Exopthalmos
– • Lid lag/ retraction
Excessive appetite
• Dilated pupils
– Palpitations • Double vission
– Myopathy – Agitation
– Oligomenorrhea – Thyroid goitre and
bruit
– Fine tremor
 Exophtalmos

Pretibial myxoedema
 Diffuse Toxic Goiter (Grave’s ds)
• autoimmune disease
• Abnormal TSH-Ab bind to TSH 
prolonged effect  increase hormon
• Young women
• No preceding history of goiter
• Smoothy enlarged
• Eye signs
 Toxic Nodular Goiter (2 ) o

• Simple goiter present b4 hyperthyroidism

• Middle aged/elderly
• Many cases, nodule inactive but
intranodular tissue is active
• Nodule activated  hyperthyroidism
 Investigations
• Essential
– Serum TSH (T3 and T4 if abnormal)
– Serum thyroid autoantibodies
– FNAC of all palpable discrete swellings
• Optional
– Calcium and albumin
– CXR and thoracic inlet if tracheal
deviation/retrosternal
– Isotope scan if discrete swelling and toxicity coexist
 Thyroid TSH Free T4 Free T3
funtional (0.3 – 3.3µU -1) (10 – 30 (3.5 – 7.5 µmol-
state nmol-1) 1)

Euthyroid Normal Normal Normal

Thyrotoxic Undetectable High High

Myxoedema High Low Low

Suppressive Undetectable High High

T4 therapy

T3 toxicity Low/Undetectable Normal High

 Treatment of thyrotoxicosis
• Antithyroid drugs – carbimazole
• ß-adrenergic blocking drugs
• Anti-thyroid drugs combined with
subsequent thyroidectomy
• Radioactive iodine-131
 Anti-thyroid Drugs
• restore in euthyroid state and maintain for prolong period in
hope of remission

• Carbimazole
– 10mg 8-hourly
– Continue for 12 months
– Aware of toxic symptoms within 2 weeks, if symptoms
recur further 6 months treatment with surgery is advised
– High relapse rate (60%) after terminating the treatment
(even in 2 or more years of tx)

• Medical tx alone usually confined to 1° hyperthyroidism in

children and adolescents
• Side effects of carbimazole:
- Drug rash
- Fever
- Arthropathy
- Lymphadenopathy
- Agranulocytosis (sore throat)

ß-adrenergic blocking drugs

• Propanolol induces rapid symptomatic
improvement of cvs features in patients
with severe hyperthyroidism
 Surgery for thyrotoxicosis
• Preoperative preparation
– Anti-thyroid drugs
– ß-adrenergic blocking drugs (alternative)

• Extent of resection
– size of gland
– age of patient
– experience of surgeon
– need to minimise risk of recurrent toxicity
• Hemithyroidectomy, total thyroidectomy
(depends)
• It cures by reducing mass of overactive
tissue in diffuse toxic goitre and toxic
nodular goitre
• Advantages: the goitre removed, cure is
rapid and cure rate high if surgery adequate
• Disadvantages: recurrence in 5% of cases
and risk of surgery complications
 Procedures

The thyroid gland is removed.

While the patient is deep asleep Either one lobe of the thyroid gland,
and pain-free (general anesthesia), or the entire gland, is removed,
an incision is made in the front of depending on the disease process
the neck. being treated
Complications of thyroidectomy
• Hormonal disturbances
– Tetany (parathyroid)
– Thyroid crisis
– Hypothyroidism (due to extensive removal of thyroid tissue)
– Late recurrence of hyperthyroidism (d2 inadequate operation in
toxic gland)

• Damage to related anatomical structures

– Recurrent laryngeal nerve
– Injury to trachea
– Pneumothorax

• Complications of any operation

– Haemorrhage
– Sepsis
– Postoperative chest infection
– Hypertrophic scarring (keloid)
 Radioactive Iodine
• destroys thyroid cells
• reduces the mass of functioning thyroid tissue to below a
critical level
• Swallow a glass of water containing radioiodine
• Useful in recurrence of hyperthyroidism after
thyroidectomy (takes 2-3 months)
• high incidence of late hypothyroidism (75-80%) after 10
years
• Contraindicated in pregnant women (affecting infant’s
thyroid)
• No evidence therapeutic radioiodine is carcinogenic or
teratogenic
Neoplasms
 Classification
Follicular epit – diff
Follicular malign 1o
benign • papillary (60%)
adenoma
• follicular (20%)
Follicular epit – undiff
• anaplastic (10%)
Parafollicular cells
• medullary (5%)
Lymphoid cells
• lymphoma (5%)

2o Mets – local infiltrate

 Benign Follicular Adenoma
• Clinically, solitary nodules
• F:M = 4:1
• HPE to differentiate adenoma and
carcinoma (in adenoma there is no
invasion of capsule or of pericapsular
blood vessels)
• Tx: wide excision (lobectomy)
 Thyroid carcinoma
• F:M = 3:1 (incidence 3.7 in 100 000)
• Arising in pre-existing goitres
• Reported following radiation of the neck in
childhood
• Clinical features
– Goiter
– LN (papillary ca)
– recurrent laryngeal nerve paralysis (locally
advanced dis.)
– usually euthyroid
• Anaplastic – hard, irregular, infiltrating
 Papillary carcinoma
• Commonest (60%)
• Young adults, adolescents or children
• Slow growing tumour
• Spread
– lymphatic (late and common)
– Blood-born (uncommon)
• Occult carcinoma- enlarged lymph node in the
jugular chain with no palpable abnormality of
thyroid (good prognosis)
• Tx
– combination of surgery (total lobectomy or
thyroidectomy), thyroid suppression by T4 and
radioiodine
numerous papillae having a fibrovascular stalk covered by a single to
multiple layers of cuboidal epithelial cells
 Follicular carcinoma
• Young and middle-aged adults
• Common in area of endemic goiter
• Spreads
– Blood stream (common)
• worsen the prognosis
• mortality rate twice fr papillary ca
– Lymphatic rare
• Tx: same as papillary ca
Invasion of capsule and the vascular spaces in the capsular region in
follicular carcinoma.
 Papillary vs. Follicular ca
Papillary (%) Follicular (%)
Male incidence 22 35
LN mets 35 13
Blood vessel invasion 40 60
Recurrence 19 29
Mortality rate 11 24
Distant mets 45 75
Nodal mets 34 12

Prognosis : PAPILLARY > follicular

 Medullary carcinoma
• Arises from parafollicular C cells
• may secrete calcitonin (tumour marker)
• any age
• F=M
• associated with other cancers in MEN syndrome (type II)
• Deposits of amyloid between the nests of tumour cells
• Lymph node and blood-borne involvement are common
• Tx: total thyroidectomy and lymph node clearance (if
involved)
Characteristic ‘cell balls’ and amyloid in medullary carcinoma
 Anaplastic carcinoma
• elderly
• Rapid local spread takes place with compression
and invasion of the trachea
• Early dissemination to the regional lymphatics
and blood-stream spread to the lung, skeleton
and brain
• Tx
– radical thyroidectomy
– palliative radiotherapy – temporary relieve
(tracheostomy for obstructed airway)
 TNM staging
Primary tumor (T)
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
T1: Tumor 1 cm or less in greatest dimension limited to the thyroid
T2: Tumor more than 1 cm but not more than 4 cm in greatest dimension limited to the
thyroid
T3: Tumor more than 4 cm in greatest dimension limited to the thyroid
T4: Tumor of any size extending beyond the thyroid capsule

Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Regional lymph node metastasis
– N1a: Metastasis in ipsilateral cervical lymph node(s)
– N1b: Metastasis in bilateral, midline, or contralateral cervical or mediastinal lymph node(s)

Distant metastases (M)

MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis
 Prognosis
• Well differentiated tumours
– Long survival even with presence of LN
deposits

• Anaplastic tumours
– Pt dead within a year (due to local invasion or
widespread dissemination)
Thyroiditis
Chronic lymphocytic (autoimmune)
thyroiditis
• Raised titer of thyroid Ab
• Family history of autoimmune disease
• goitre (diffuse or nodular) with characteristic ‘bosselated’
feel
• Common in menopause women
• any age
• mild hyperthyroidism initially and later hypothyroidism
• Dx: raised serum level of thyroid antibodies, FNAC,
biochemical test of thyroid fx if hypothyroidism is present
• Tx: replacement with thyroxine (hypothyroidism),
thyroidectomy maybe necessary if goitre is large
 Granulomatous thyroiditis
• subacute thyroiditis, de Quervain’s thyroiditis
• virus infection
• Features
– pain in the neck
– Fever
– Malaise
– firm, irregular enlargement of one or both thyroid lobes
– Raised ESR
– absent thyroid antibodies
– serum T4 is high or slightly raised
– radioiodine uptake of gland is low
– Self limiting, goitre subsides in few months
• Dx
- confirmed by FNAC & radioactive iodine uptake
- rapid symptomatic response to prednisolone in acute case of
severe pain
 Riedel’s thyroiditis
• Rare
• slightly enlarged but is woody hard with infiltration
of adjacent tissues
• represent late stage of Hashimoto’s disease or
inflammatory origin
• Mistaken for thyroid ca (histologically gland is replaced by
fibrous tissue containing chronic inflammatory cells)
• a/w other conditions such as retroperitoneal
fibrosis, sclerosing cholangitis, and fibrosing
mediastinitis
• Wedge resection of portion of gland if tracheal
compression symptoms develop