in short management of goiter

1. Welcome to CME program
topic
Management of goiter
Dr. Md. Shahadad Hossain
Department of surgery

2. Goiter
 Any enlargement of thyroid gland is called goiter
 Daily iodine requirement= 0.1- 0.15mg
 Endemic goiter occur in geographical areas
with iodine-depleted soil, usually regions
away from the sea coast.
 Common in central Asia and central Africa ,certain
areas of Australia, including Tasmania and areas along the Great
Dividing Range

3. Pathogenesis
 Dietary iodine deficiency or intake of goitrogens Decreased formation of T3 & T4 Reduced
level of T3 & T4 in the circulation Increased secretion of TSH by anterior pituitary Persistent
TSH stimulation of thyroid gland Hyperplasia of thyroid follicles & generation of new follicle
Increased uneven accumulation of colloid or thyroglobulin within the follicles Rupture of
follicles & vessels Hemorrhage & calcification Scarring & development of goiter.

4. Causes of goiter
Type Varieties Causes
Simple goiter
(euthyroid)
Diffuse hyperplasia Physiological , Puberty ,pregnancy
Multinodular goiter
toxic Diffuse(Graves Disease)
Multinodular
Toxic adenoma
Neoplastic Benign
Malignant
inflammatory autoimmune Chronic lymphatic thyroiditis
Hashimoto’s thyroiditis
Granulomatous DE Quervain’s thyroiditis
Fibrosing Riedel’s thyroiditis
Infective Acute (bacterial , viral, “subacute
thyroiditis”)
Chronic (TB , syphilis)
Others Amyloid

5. Cont…
 Thyroid neoplasm
Type
Benign Follicular
adenoma
Malignant primary Papillary Ca
Follicular Ca
Medullary Ca
Anaplastic Ca
lymphoma
secondary metastatic/ local
infiltration

6. Presentation
 Asymptomatic
 Only swelling in front of the neck
 Some patient may come with feature of
hypothyroidism or hyperthyroidism.
 Few patient may metastatic feature of thyroid
malignancy.

7. Hypothyroidism
 Weight gain
 Cold intolerance
 Fatigue, somnolence
 Dry skin
 Dry hair
 Menorrhagia

8. Hyperthyroidism
 Weight loss despite normal or
 increased appetite
 Heat intolerance, sweating
 Palpitations, tremor
 Dyspnoea, fatigue
 Irritability, emotional lability

9. Assessment
 Brief history from the patient
 Clinical examination
 Investigation
Laboratory
Imaging
 Histopathology

10. Cont…
 History
Age ,
sex,
H/o weight loss
,H/o hoarseness of voice,
H/o dysphagia,
Duration of lump ,
slowly growing or rapidly growing ,
Painful or not,
food habit & home town,
h/o bone pain & cough

11. Cont…
 Clinical examination
 Inspection:
enlarged/ not
Look for JVP
Any scar of surgery
Skin color , any prominent vein
Cervical lymphnode (visible enlarged/not)
Moves with swallow & deglutination

12. Cont..
 Palpation : tender/non tender
solitary/multinodular,
shape & surface ,
consistency,
cervical lymphadenopathy,
hepatomegaly
 Percussion : for retrosternal extension
 Auscultation: thyroid bruit

13. Investigation
 Thyroid profile(TSH,FT3,FT4)
 Thyroid autoantibodies
 Serum calcium
 Thyroid USG
 FNAC
 Thyroid scan
 X-ray neck with thoracic inlet A/P &lateral view
 CT-scan
 Indirect laryngoscopy

14. Cont…
USG of thyroid X-ray of neck with thoracic
inlet

15. Cont..
Different view of CT scan showing goiter

16. Cont..
Thyroid scan Indirect laryngoscope view

17. Malignancy

18. Treatment of endemic goiter
 Iodine supplementation
 If pressure effect occur then we have go for surgery
 Surgery : total thyroidectomy with life long thyroxine supplementation

19. Treatment of Graves disease
 Antithyroid drugs ( carbimazole , methimazole, propylthiouracil)
 Radio-iodine therapy
 Surgery : Total thyroidectomy with life long thyroxine supplementation

20. Treatment of inflammatory goiter
 Autoimmune :
Steroid
Antithyroid drug
Thyroxine supplementation
 Bacterial :
Nonspecific: antibiotic
Specific : anti TB therapy
 Viral:
Usually self limiting only supportive treatment

21. Treatment of nodular goiter
 Solitary nodular goiter : Hemi thyroidectomy
 Multinodular goiter
Simple : subtotal thyroidectomy
Toxic : total thyroidectomy with life long thyroxine
supplementation

22. Treatment of neoplastic goiter
 follicular/ papillary/ medullary carcinoma: Total thyroidectomy with life long
thyroxine supplementation
 Anaplastic carcinoma : Isthmasectomy + external brim radiotherapy

23. Types of thyroid surgery
 Total thyroidectomy
 Subtotal thyroidectomy
 Near-total thyroidectomy( Dunhill procedure)
 lobectomy

24. Complication of thyroidectomy
 During operation
Hemorrhage
Recurrent/ superior laryngeal
nerve injury
Accidental removal of parathyroid
gland
Trachea & esophagus injury
 Early post-operative complication
Reactionary hemorrhage
Hypoparathyroidism
Tetany
Infection of wound
 Late
 Hypothyroidism
 Recurrent thyrotoxicosis
 Hypertrophic scar

25. Thyroid emergency
 Thyrotoxic crisis:
It is a life threatening complication of thyrotoxicosis
 Clinical feature :
raised temperature
Tachycardia
Convulsion
Excessive sweating
Cardiac arrhythmia on ECG
Treatment :
1. Ice cold sponging
2. Injectable β- blocker
3. Anticonvulsant (diazepam,phenobarbiton)
4. Anti thyroid drugs