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  1. 1. Benign thyroid disorders Present by Chananya Karunasumetta
  2. 2. hyperthyroidism <ul><li>Result from excess of circulating hormone </li></ul><ul><ul><li>Grave’s disease </li></ul></ul><ul><ul><li>Toxic nodular goiter </li></ul></ul>
  3. 3. Grave’s disease <ul><li>It is an autoimmune disease of unknown cause </li></ul><ul><li>F:M = 5:1 </li></ul><ul><li>40 – 60 yr </li></ul>
  4. 4. Grave’s disease <ul><li>Etiology </li></ul><ul><ul><li>Autoimmune process , unknown causes </li></ul></ul><ul><ul><li>Postpartum state </li></ul></ul><ul><ul><li>Iodine excess </li></ul></ul><ul><ul><li>Bacterial or viral infection </li></ul></ul><ul><ul><li>Genetic factor </li></ul></ul>
  5. 5. Grave’s disease <ul><li>The process causes sensitized T – helper lymphocyte to stimulate B lymphocyte which produce Ab. directed against the thyroid h. Receptor = TSH binding Ab </li></ul>
  6. 6. Grave’s disease <ul><li>Clinical features </li></ul><ul><ul><li>Hyperthyroidism symptoms </li></ul></ul><ul><ul><li>50 % develop clinically opthalmopathy </li></ul></ul><ul><ul><ul><li>Lid lag , lid retraction , chemosis , proptosis ,blindness </li></ul></ul></ul><ul><ul><li>1- 2 % dermopathy </li></ul></ul><ul><ul><ul><li>pretibial myxedema </li></ul></ul></ul><ul><ul><li>Thyroid is usually diffusely and symmetrically enlarged </li></ul></ul>
  7. 7. Grave’s disease <ul><li>Diagnosis test </li></ul><ul><ul><li>TFT = TSH ↓ , T3 ↑ ,T4↑ </li></ul></ul><ul><ul><li>123 I uptake ↑ </li></ul></ul><ul><ul><li>Anti Tg and anti TPO Ab ↑ 75 % </li></ul></ul><ul><ul><li>TSH –R or TS Ab ↑ 90 % </li></ul></ul>
  8. 8. Grave’s disease <ul><li>Treatment </li></ul><ul><ul><li>Antithyroid drugs </li></ul></ul><ul><ul><ul><li>PTU 100 – 300 mg three times daily </li></ul></ul></ul><ul><ul><ul><li>Methimazole 10 – 30 mg three times daily </li></ul></ul></ul><ul><ul><ul><li>SE = rarely , agranulocytosis </li></ul></ul></ul><ul><ul><ul><li>Beta block 20 -40 mg four times daily </li></ul></ul></ul><ul><ul><ul><li>Thyroxine 0.05 – 0.10 mg to prevent hypothyroidism , suppress TSH secretion </li></ul></ul></ul>
  9. 9. Grave’s disease <ul><li>Radioactive iodine therapy </li></ul><ul><ul><li>131 I </li></ul></ul><ul><ul><li>Associate with hypothyroid 70 % at 11 yr </li></ul></ul><ul><ul><li>Used in </li></ul></ul><ul><ul><ul><li>Older Pt. With small or moderate size goiters </li></ul></ul></ul><ul><ul><ul><li>Relapse after medical or Sx treatment </li></ul></ul></ul><ul><ul><li>Contraindication </li></ul></ul><ul><ul><ul><li>Pregnant or breast feeding </li></ul></ul></ul><ul><ul><ul><li>Young patients </li></ul></ul></ul><ul><ul><ul><li>Pt. With ophthalmopathy </li></ul></ul></ul>
  10. 10. Grave’s disease <ul><li>Surgical treatment </li></ul><ul><ul><li>Confirmed cancer or suspicious thyroid nodule </li></ul></ul><ul><ul><li>RAI is contraindicated </li></ul></ul><ul><ul><li>Allergies to antithyroid drugs </li></ul></ul><ul><ul><li>Compressive symptoms </li></ul></ul><ul><ul><li>Rapid control of hyperthyroidism </li></ul></ul><ul><ul><li>Poor compliance for medication </li></ul></ul>
  11. 11. Grave’s disease <ul><li>Total or near total thyroidectomy </li></ul><ul><ul><li>Coexcistent thyroid cancer </li></ul></ul><ul><ul><li>Severe opthalmopathy who refused RAI </li></ul></ul><ul><ul><li>Life – threatening reaction to antithyroid medications </li></ul></ul>
  12. 12. Grave’s disease <ul><li>Subtotal thyroidectomy </li></ul><ul><ul><li>Leaving 4 -7 g remnant </li></ul></ul><ul><ul><li>Bilateral subtotal thyroidectomy , Hartley – Dunhill procedure </li></ul></ul><ul><ul><li>2 – 10 % recurrent rate </li></ul></ul><ul><ul><li>> 40 % hypothyroid </li></ul></ul>
  13. 13. Toxic multinodular goiter <ul><li>Usually older than 50 yr </li></ul><ul><li>Hx of nontoxic multinodular goiter </li></ul><ul><li>Hyperthyroidism </li></ul><ul><ul><li>Autonomous </li></ul></ul><ul><ul><li>precipitated </li></ul></ul>
  14. 14. Toxic multinodular goiter <ul><li>Diagnostic studies </li></ul><ul><ul><li>Blood tests </li></ul></ul><ul><ul><li>RAI = increase uptake </li></ul></ul>
  15. 15. Toxic multinodular goiter <ul><li>Treatment </li></ul><ul><ul><li>Control hyperthyroidism </li></ul></ul><ul><ul><li>Surgical resection is prefered = subtotal thyroidectomy </li></ul></ul><ul><ul><li>RAI is reserved for elderly Pt. = poor operative risk </li></ul></ul>
  16. 16. Plummer’s disease ( toxic adenoma ) <ul><li>Hyperthyroid from a single hyper functioning nodule </li></ul><ul><li>Young Pt. </li></ul><ul><li>PE = solitary thyroid nodule </li></ul><ul><li>RAI scanning show hot nodule </li></ul><ul><li>Rarely malignancy </li></ul><ul><li>Small nodule = med Rx or RAI </li></ul><ul><li>Large nodule = surgery </li></ul>
  17. 17. Thyroiditis <ul><li>inflammatory disorders </li></ul><ul><li>Classified </li></ul><ul><ul><li>Acute </li></ul></ul><ul><ul><li>Subacute </li></ul></ul><ul><ul><li>Chronic </li></ul></ul>
  18. 18. Acute ( suppurative ) thyroiditis <ul><li>Infection can seed </li></ul><ul><ul><li>Hematogenous or lymphatic route </li></ul></ul><ul><ul><li>Direct spread </li></ul></ul><ul><ul><li>Penetrating trauma </li></ul></ul><ul><ul><li>immunosuppression </li></ul></ul>
  19. 19. Acute ( suppurative ) thyroiditis <ul><li>Organism </li></ul><ul><ul><li>Streptococcus , anaerobes </li></ul></ul><ul><li>More common in children </li></ul><ul><ul><li>URI </li></ul></ul><ul><ul><li>Otitis media </li></ul></ul><ul><li>Characteristic </li></ul><ul><ul><li>Severe neck pain , fever , chill, odynophagia , and dysphonia </li></ul></ul>
  20. 20. Acute ( suppurative ) thyroiditis <ul><li>Diagnosis </li></ul><ul><ul><li>CBC = leukocytosis </li></ul></ul><ul><ul><li>FNA biopsy for Gram’s strain , C/S , cytology </li></ul></ul><ul><ul><li>CT scan </li></ul></ul><ul><ul><li>Ba swallowing </li></ul></ul>
  21. 21. Acute ( suppurative ) thyroiditis <ul><li>Treatment </li></ul><ul><ul><li>Parenteral ATB </li></ul></ul><ul><ul><li>Drainage of abscess </li></ul></ul><ul><ul><li>Complete resection of the sinus tract </li></ul></ul>
  22. 22. Subacute thyroiditis <ul><li>Can painful or painless form </li></ul><ul><li>Etiology is unknown </li></ul>
  23. 23. Subacute thyroiditis <ul><li>Painful thyroiditis </li></ul><ul><ul><li>Commonly occur in 30 – 40 yr , woman </li></ul></ul><ul><ul><li>Sudden or gradual of neck pain </li></ul></ul><ul><ul><li>URI </li></ul></ul><ul><ul><li>Gland is enlarge , tender ,firm </li></ul></ul><ul><li>Progress four stage </li></ul><ul><li>Lab = TSH ↓,T4↑,T3↑ ,ESR > 100 </li></ul><ul><li>Self limited ,symptomatic Rx = NSAID </li></ul><ul><li>Steroids use in severe case </li></ul>
  24. 24. Subacute thyroiditis <ul><li>Painless thyroiditis </li></ul><ul><ul><li>Autoimmune in origin </li></ul></ul><ul><ul><li>Common in woman 30 – 60 yr </li></ul></ul><ul><ul><li>PE : normal size or slightly enlarged </li></ul></ul><ul><ul><li>Lab : normal ESR </li></ul></ul><ul><ul><li>Beta block , thyroid hormone replacement </li></ul></ul><ul><ul><li>RAI or thyroidectomy indicated in Pt with recurrent </li></ul></ul>
  25. 25. Chronic thyroiditis <ul><li>Lymphocytic ( Hashimoto’s ) thyroiditis </li></ul><ul><li>Etiology </li></ul><ul><ul><li>Autoimmune process </li></ul></ul><ul><ul><li>Activated of T-helper with specific for thyroid Ag ->Recruit of cytotoxic T cell </li></ul></ul><ul><ul><li>apoptosis </li></ul></ul>
  26. 26. Lymphocytic ( Hashimoto’s ) thyroiditis <ul><li>Clinical </li></ul><ul><ul><li>Common in woman 1 : 10 – 20 </li></ul></ul><ul><ul><li>30 – 50 yr </li></ul></ul><ul><ul><li>Minimal or moderate enlarge , firm gland </li></ul></ul><ul><ul><li>20 % hypothyroidism </li></ul></ul><ul><ul><li>5 % hyperthyroidism </li></ul></ul><ul><ul><li>Lab : </li></ul></ul><ul><ul><ul><li>TSH ↑, T4↓, T3↓ </li></ul></ul></ul><ul><ul><ul><li>Thyroid Ab positive </li></ul></ul></ul><ul><ul><ul><li>FNA </li></ul></ul></ul>
  27. 27. Lymphocytic ( Hashimoto’s ) thyroiditis <ul><li>Treatment </li></ul><ul><ul><li>Thyroid hormone replacement in overtly hypothyroidism </li></ul></ul><ul><ul><li>Sx = suspected of malignancy , compressive symptom </li></ul></ul>
  28. 28. Reidel’ s thyroiditis <ul><li>Rare varient of thyroiditis </li></ul><ul><li>Invasive thyroiditis </li></ul><ul><li>Etiology is controversial </li></ul><ul><li>Predominated in woman 30 -60 yr </li></ul><ul><li>Painless , hard anterior neck mass </li></ul><ul><li>DX =open biopsy </li></ul><ul><li>Surgery is the mainstay treatment </li></ul>
  29. 29. Goiter <ul><li>Result from TSH stimulate </li></ul><ul><li>May diffuse, uninodular , or multinodular </li></ul><ul><li>Etiology </li></ul><ul><ul><li>Familial </li></ul></ul><ul><ul><li>Endemic </li></ul></ul><ul><ul><li>Dietary goitrogen </li></ul></ul>
  30. 30. Goiter <ul><li>Clinical </li></ul><ul><ul><li>Most of nontoxic goiter is asymptomatic </li></ul></ul><ul><ul><li>Compression symptom </li></ul></ul><ul><ul><li>PE : soft ,diffuse enlarged gland </li></ul></ul>
  31. 31. Goiter <ul><li>Test </li></ul><ul><ul><li>TSH : normal </li></ul></ul><ul><ul><li>Low or normal free T4 </li></ul></ul><ul><ul><li>RAI uptake : patchy , hot or cold nodule </li></ul></ul><ul><ul><li>FNA in dominant nodule or painful </li></ul></ul>
  32. 32. Goiter <ul><li>Treatment </li></ul><ul><ul><li>Exogenous thyroid hormone </li></ul></ul><ul><ul><li>Surgical </li></ul></ul><ul><ul><ul><li>Size ↑ </li></ul></ul></ul><ul><ul><ul><li>Obstructive symptom </li></ul></ul></ul><ul><ul><ul><li>Substernal extension </li></ul></ul></ul><ul><ul><ul><li>Suspected malignancy </li></ul></ul></ul><ul><ul><ul><li>cosmetic </li></ul></ul></ul>

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