thyroid disorders includes thyrotoxicosis, hypothyroidism, thyroiditis, and thyroid malignancy

1. CLINICAL ASPECTS
OF
THYROID DISORDERS
Alaa Wafa MD
Associate Professor of Internal Medicine
PGDIP DM Cardiff University UK
Diabetes & Endocrine Unit.
Mansoura University
( Sem 5 ) 2015

2. Janet ,,Case 5 Scenario
 A 30-year-old woman
 Nervousness, irritability, palpitations
and heat intolerance.
 Lost 9.1 kg despite a good appetite.
 Her eyes bulge.
 Diffuse enlargement thyroid gland.
 Carbimazole and propranolol are
prescribed.

3. Where to look for
Thyroid Gland?

4. Clinical Anatomy of Thyroid

5. Where to look for Thyroid ?

6. Clinical Exam. of Thyroid
• Have patient seated on a chair
• Inspect neck before & after
swallowing
• Examine with neck in relaxed
position
• Palpate from behind the patient
• Remember the rule of finger tips
• Use the tips of fingers for
palpation
• Palpate firmly down to trachea

7. Clinical Exam of Thyroid

8. Goiter
• A swollen thyroid
gland
• Assessment;
– how big, how quickly
has it developed, is
it smooth or nodular,
is it painful, any
associated lymph
nodes, any sudden
changes, is it big
enough to cause
local symptoms (e.g.
breathing problems)

10. Thyromegaly

17. The Neck
Lateral view of enlarged thyroid.

18. The Neck
Carcinoma thyroid.

19. Goiter.

20. Aspects That Will Be Addressed
• Hyperthyroidism
• Hypothyroidism
• Thyroiditis

21. Hyperthyroidism

22. Hyperthyroidism Symptoms
 Hyperactivity/ irritability
 Heat intolerance and sweating
 Palpitations
 Fatigue and weakness
 Weight loss with increase of appetite
 Diarrhoea
 Polyuria
 Oligomenorrhoea, loss of libido

23. Hyperthyroidism Signs
 Tachycardia (AF)
 Tremor
 Goiter
 Warm moist skin
 Proximal muscle
weakness
 Lid retraction or
lag
 Gynecomastia

24. Causes of Hyperthyroidism
Most common
causes
 Graves disease
 Toxic multinodular
goiter
 Autonomously
functioning nodule
Rarer causes
 Thyroiditis or other
causes of destruction
 Thyrotoxicosis factitia
 Iodine excess (Jod-
Basedow phenomenon)
 Secondary causes (TSH
or ßHCG)

25. Graves Disease
 Autoimmune disorder
 Abs directed against TSH receptor
with intrinsic activity. Thyroid and
fibroblasts
 Responsible for 60-80% of
Thyrotoxicosis
 More common in women

26. Graves Disease Eye
Signs(Ophthamopathy)
N - no signs or symptoms
O – only signs (lid retraction
or lag) no symptoms
S – soft tissue involvement
(peri-orbital oedema)
P – proptosis (>22
mm)(Hertl’s test)
E – extra ocular muscle
involvement (diplopia)
C – corneal involvement
(keratitis)
S – sight loss (compression
of the optic nerve)

27. Ophthalmopathy
 Signs of Graves’s ophthalmopathy are
divided into two components:
 1) Spastic: Stare, lid lag and lid retraction
which account for the “frightened” facies.
 2) Mechanical: Proptosis of varying
degrees,ophthalmoplegia,and congestive
occulopathy characterized by
chemosis,conjunctivitis,periorbital
swelling and the potential complications
of corneal ulceration,optic neiritis and
optic atrophy.

29. Hyperthyroid Eye Disease
 Hyperthyroidism (any cause)
 Lid lag, lid retraction and stare
 Due to increased adrenergic
tone stimulating the levator
palpebral muscles.
 True Graves’ Ophthalmopathy
 Proptosis
 Diplopia
 Inflammatory changes
• Conjunctival injection
• Periorbital edema
• Chemosis
 Due to thyroid autoAb’s that
cross-react w/ Ag’s in
fibroblasts, adipo-cytes, +
myocytes behind the eyes.

30. Neonatal hyperthyroidism born to mother
with Graves’ disease
A Color Atlas of Endocrinology p51

32. “Exophthalmos”

33. Proptosis
Lid lag
Thyroid Ophthalmopathy

34. Ophthalmopathy in Graves
Periorbital edema and chemosis

36. Ophthalmopathy in Graves
Occular muscle
palsy

37. Severe Exophthalmia

41. Dermopathy
• Usually occurs over the dorsum of the legs or feet
and is termed localized or pretibial myxedema.
• It is usually a late phenomenon
• The affected area is usually demarcated from the
normal skin by being raised and thickened and
having a peau d’ orange appearance;it may be
pruritic and hyperpigmented.
• The most common presentation is non pitting
oedema,but lesions maybe plaque like,nodular or
polypoid.
• Clubbing of the fingers and toes accompanies and is
termed thyroid acropachy

43. Thyroid Dermopathy
Pink and skin coloured papules, plaques on the shin

47. Thyroid Acropachy
Thyroid acropachy. This is most marked in the index fingers and
thumbs

48. Graves with Acropathy
Graves Goiter Acropathy

49. Clubbing and
Osteoarthropathy
Thyroid Acropathy

50. Onycholysis

51. Investigations
 Thyroid function test:
 TSH- Undetectable
 T4 - Raised
 T3 - Raised
 TSH-receptor antibodies(TRAb)-elevated
in Graves’s disease
 Isotope scanning- Increased uptake

53. Nucleotide Scintigraphy

54. Graves Disease

55. Graves Disease
I 123 or TC 99m Normal v/s
Graves

56. Toxic Multinodular Goiter
(TMG)

57. Thyrotoxicosis- Treatment
Three modalities:
 Radioactive iodine
 antithyroid drugs
 surgery

58. Hyperthyroidism (Treatment)
1) β-blockers (symptom control)
 Propranolol (Inderal ®)
2) 131-RAIA (70% thyroidologists prefer)
 Dosing
• Graves: 10-15 mCi
• Toxic MNG/Adenoma: 20-30 mCi
 Absolute contraindications
• Pregnancy and lactation (excreted in breast milk)!
 Pregnancy should be deferred for at least 6 months
following therapy with radio-active 131
 It is advisable to avoid 131-Rdio-active iodine therapy in
patients with active moderate severe Graves’
ophthalmopathy.

59. Hyperthyroidism (Treatment)
3) Antithyroid Drugs (30% thyroidologists prefer)
 Propylthiouracil (PTU)
• 100 mg bid-tid to start
 Methimazole
• 10X more potent the PTU
• 10 mg bid-tid to start
 Complications of ATD’s
• Agranulocytosis (1/200-500)
• usually presents w/ acute pharyngitis/ tonsilitis or
pneumonia.
• Rash
• Hepatic necrosis, Cholestatic jaundice
• Arthralgia

60. Hyperthyroidism (Treatment)
4) Surgery (sub-total thyroidectomy)
 Indications
• Patient preference
• Large or symptomatic goiters
• When there is question of malignancy
 Need to be euthyroid prior to surgery
• To ↓ the risk of arrhythmias during induction of anesthesia
• To ↓ the risk of thyroid storm post operatively
• ATD’s + β-blockers
 Risks
• Permanent hypoparathyroidism
• Recurrent laryngeal nerve problems
• Permanent hypothyroidism

61. Hypothyroidism

62. Hypothyroidism Symptoms
 Tiredness and
weakness
 Dry skin
 Feeling cold
 Hair loss
 Difficulty in
concentrating and
poor memory
 Constipation
 Weight gain with
poor appetite
 Hoarse voice
 Menorrhagia, later
oligo and
amenorrhoea
 Paresthesias
 Impaired hearing

63. Hypothyroidism Signs
 Dry skin, cool extremities
 Puffy face, hands and feet
 Delayed tendon reflex
relaxation
 Carpal tunnel syndrome
 Bradycardia
 Diffuse alopecia
 Serous cavity effusions

64. infant cretin

70. Causes of Hypothyroidism
 Autoimmune
hypothyroidism
(Hashimoto’s,
atrophic thyroiditis)
 Iatrogenic
(I123treatment,
thyroidectomy,
external irradiation of
the neck)
 Drugs: iodine excess,
lithium, antithyroid
drugs, etc
 Iodine deficiency
 Infiltrative disorders
of the thyroid:
 amyloidosis,
 sarcoidosis,
 haemochromatosis,
 scleroderma

71. Lab Investigations of
Hypothyroidism
 TSH , free T4 
 Ultrasound of thyroid – little value
 Thyroid scintigraphy – little value
 Anti thyroid antibodies – anti-TPO
 S-CK , s-Chol , s-Trigliseride 
 Normochromic or macrocytic anemia
 ECG: Bradycardia with small QRS
complexes

72. Treatment of
Hypothyroidism
 Levothyroxine
 If no residual thyroid function 1.5 μg/kg/day
 Patients under age 60, without cardiac
disease can be started on 50 – 100 μg/day.
Dose adjusted according to TSH levels
 In elderly especially those with CAD the
starting dose should be much less (12.5 – 25
μg/day)

73. Thyroiditis

74. Thyroiditis
 Acute: rare and due to suppurative
infection of the thyroid
 Sub acute: also termed de
Quervains thyroiditis/
granulomatous thyroiditis – mostly
viral origin
 Chronic thyroiditis: mostly
autoimmune (Hashimoto’s)

75. Thyroiditis
 The most common form of
thyroiditis is Hashimoto thyroiditis,
this is also the most common cause
of long term hypothyroidism
 The outcome of all other types of
thyroiditis is good with eventual
return to normal thyroid function

76. Thank
you
dralaawafa@hotmail.com