for medical students

1. MULTINODULAR GOITRE
ANAKHA RAJENDRAN
23

4.  MNG is a discordant growth with functionally and structurally altered thyroid
follicles presenting as multiple nodules in thyroid.
 It maybe due to fluctuation in TSH level; other causes include iodine deficiency,
goitrogens, hereditary, dyshormonogenesis.

5. STAGES OF MNG FORMATION
 Stage of hyperplasia and hypertrophy
 Stage of fluctuation in TSH
 Stage of formation of nodules.inactive

6. PATHOGENESIS
 Persistent TSH stimulation
 Diffuse hyperplasia of gland ..all active lobules and uniform iodine intake
 When there is Fluctuation of TSH level
 Mixed areas of active and inactive lobules develop due to Increased sensitivity of
follicular cells to TSH
 Active lobules become more vascular and hyperplastic
 Haemorrhages causes central necrosis leaving a rim of active follicles
 Necrotic lobules coalesce .Nodule formation filled with colloid
 Internodular tissue is active
 Many nodules formed -> MNG

7. C/F
 More common in middle age females
 Slowly progressive disease
 Multiple nodules of different sizes
 Firm, nodular, non tender, moves with deglutition
 Recent increase in size signifies malignant transformation or haemorrhage.
 Positive Kocher’s test is due to compression of trachea (tracheomalacia /scabbard’s
trachea) in long standing MNG.
 Nodule when calcified becomes harder; necrosis softens the nodule.
 Carotid infiltration
 Pembertons Sign

9. COMPLICATIONS
 Secondary thyrotoxicosis(30%)
 Follicular carcinoma of thyroid(10%)
 Haemorrhage in a nodule
 Tracheal obstruction, calcification
 Cosmetic problem

10. INVESTIGATIONS
 T3, T4, TSH, US neck, FNAC. (Dominant)
 XRAY neck- ring calcification, position and compression of trachea
 Indirect laryngoscopy- vocal cords; occult RLN palsy
 Radioisotope iodine scan
 Routine blood investigations, serum calcium
 CT scan/ MRI – retrosternal extension

13. TREATMENT
 Surgery preferred – irreversible, complications, cosmetic
 Total thyroidectomy is preferred
 Subtotal thyroidectomy (8g)
 Partial thyroidectomy/ Hartley Dunhill operation
 Post operative L- thyroxine (fluctuation; recurrence)
 Prevention- 0.1-0.2mg L- thyroxine, iodine- rich diet, iodized salts,avoid
goitrogenic diet and drugs

14. THANK YOU