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  • 1. GOITREDr Echebiri, PromiseState House Medical Centre, Aso Rock, Abuja.5th December,2011.
  • 2. CONTENTS• Definition• Overview• Background• Pathophysiology• Classification• Presentation• Investigations• Differential Diagnoses• Treatment• Prognosis
  • 3. DEFINITION An enlarged thyroid gland. -Clinically palpable gland.-Gland enlargement more than twice of the normal size.
  • 4. OVERVIEW• Geography: Worldwide, the most common cause of goiter is iodine deficiency.Approximately 800million people subsist on iodine-deficient diet.In industrialized countries,goiter is more often due to Hashimoto’s thyroiditis.
  • 5. OVERVIEW• Sex: The female-to-male ratio is 4:1.Thyroid nodules are more likely to be malignant in menThe frequency of goiters decreases with advancing age. although the incidence of thyroid nodules increases with advancing age.• Race: No racial predilection exists.
  • 6. BACKGROUNDThyroid gland surface marking
  • 7. BACKGROUNDHypothalamo-Pituitary-Thyroid Axis
  • 8. BACKGROUND Thyroid anatomy
  • 9. BACKGROUND Thyroid physiology
  • 10. BACKGROUND• TRH:Produced by Hypothalamus. Release is pulsatile,circadian. Downregulated only by T3. Travels through portal venous system to adenohypophysis. Stimulates TSH formation.• TSH: Produced by Adenohypophysis Thyrotrophs.Up regulated by TRH .Down regulated by T4, T3.
  • 11. BACKGROUND Travels through portal venous system to cavernous sinus, then thyroid gland. Stimulates several processes Iodine uptake Colloid endocytosis Growth of thyroid gland.• Thyroid Hormone: Majority of circulating hormone is T4  98.5% T4  1.5% T3
  • 12. BACKGROUNDTotal Hormone load is influenced by serum binding proteins Albumin 15% Thyroid Binding Globulin 70% Transthyretin 10%Regulation is based on the free component ofthyroid hormone
  • 13. BACKGROUND Hormonal interplay TRHTSH T4,T3
  • 15. CLASSSIFICATIONS Based on growth pattern Goitre Nodular Diffuse Hypothalamic disease Multinodular: Pituitary disease Uninodular: Iodine Iodine Cysts deficiency deficiency(endemic, sporadiBenign thyroid Thyroiditis c) neoplasms Sarcoidosis Grave’s diseaseThyroid cancers Thyroid hormone insensitivity
  • 16. CLASSIFICATIONS Based on size of gland Grade III • Invisible • Palpable GradeII • Visible • Palpable • Visible Grade I • Palpable • Retrosternal extension
  • 17. CLASSIFICATIONS Based on activity of gland Hyperthyroid (toxic)Hypothyroid
  • 19. PRESENTATION• History:Anterior neck swellingPain: Haemorrhage, inflammation, necrosis, or Malignant transformationCompressive symptoms: Dysphagia, dyspnea, stridor, plethora or hoarsenessSymptoms of hyperthyroidism or hypothyroidism
  • 20. PRESENTATION• Physical ExaminationCharacterisation of thyroid swellingCheck for signs of hyperthyroidism/hypothyroidismCheck for signs of compression(Pemberton manoeuvre).Check for signs of malignancy
  • 21. PRESENTATIONHyperthyroidism versus Hypothyroidism
  • 22. INVESTIGATIONS• Laboratory Studies: TRH TSH Total T3, T4 Free T3, T4 RAIU Thyroglobulin Antibodies: Anti-TPO, Anti-TSHr
  • 23. INVESTIGATIONS• Imaging Studies:Ultrasonography:Evaluate goiter size, consistency, and nodularity. Localize nodules for ultrasonographically guided biopsy.X Rays:Usually AP and Lateral with thoracic inlet.Retrosternal goitre extension.Presence of calcification.
  • 24. INVESTIGATIONSComputed tomography (CT) scanning: Delineate the relationship of the thyroid gland to nearby structures.CT-guided biopsies.Radionuclide isotope scanning are used to assess thyroid function and anatomy in hyperthyroidism, as shown below.
  • 26. INVESTIGATIONSSpirometry: The flow-volume loop is useful in determining the functional significance of compressive goiters.Histology:fine needle aspiration or core biopsy.
  • 27. DIFFERENTIAL DIAGNOSES• Pseudogoitre• Thyroglossal cyst• Sublingual dermoid• Lymphadenopathy(bull’s neck).• Thyroid lipomas• Thyroid lymphomas
  • 28. TREATMENT• Observation Small goiter Euthyroid Asymptomatic• Medications: Hypothyroidism: Thyroid hormone replacement with levothyroxine. Hyperthyroidism:May require medications to normalize hormone levels for example propylthiouacil,Methimazole Inflamed thyroid gland, aspirin or a corticosteroid
  • 29. TREATMENT• Surgery: Removing all or part of the thyroid gland-Thyroidectomy.Large goiters with compressionMalignancyWhen other forms of therapy are not practical or ineffective• Radioactive iodine: Treatment results in diminished size of goiter, but eventually may also cause a hypothyroid state.
  • 30. TREATMENT• Minimally-invasive modalitiesEndoscopic subtotal thyroidectomyEmbolization of thyroid arteriesPlasmaphoresisPercutaneous ethanol injection into toxic noduleL-Carnitine supplementation may improve symptoms and may prevent bone loss
  • 31. PROGNOSIS• Complications of thyroidectomy:• Thyrotoxic storm• Bleeding• Infection• Hypoparathyroidism• Injury to recurrent laryngeal nerve• Injury to superior laryngeal nerve• Hypothyroidism
  • 32. PROGNOSIS• A small percentage of multinodular goiters do lead to hyperthyroidism.• Benign goiters have a good prognosis,furthermore,the risk of malignant transformation is low.
  • 33. THANK YOU