Solitary Thyriod Nodule , History Examination and Investigations

1. SOLITARY THYRIOD NODULE
DR IRSHAD BALOCH
Junior Registrar SUII
BMCH Balochistan

2. SOLITARY THYRIOD NODULE
• Definition= a discrete swelling in an otherwise
impalpable gland is called Isolated or Solitary
Thyriod Nodule

3. CHIEF COMPLAINTS
• Dysphagia/Dyspnea
• Hoarseness of voice
• Pain
• Swelling

4. HISTORY
• Introduction and Informed consent
• Name
• Age
• Sex
• Occupation
• Resident of
• Comorbidities

5. • SWELLING =
• Duration ,Onset insidious/Acute
• Noticed by
• Progression / Change in size
• H/O of Trauma
• Multiplicity /Any other swelling in neck ,oral
cavity or Body
• Associated pain and fever

6. Differentiating hypo and
hyperthyroidism
• Weight loss or weight gain
• Change in appetite, anorexia
• Change in voice, persistent worsening of voice
• Cold and heat intolerance
• Bladder and bowel habit
• Changes in menstruation
• Palpitation and nervousness
• Hair fall
• Tremor
• Insomnia

7. Eye problems
• Difficulty in eye closer
• Diplopia
• Pain

8. Disease complications
• Chest pain , haemoptysis
• Dysphagia , dyspnea
• Persistent worsening of voice
• Rapid increase in swelling
• Hematemesis
• Skull mets, headache
• Jaundice
• Painful bone mets

9. Risk factors
• diet = Cabbage , spinach, turnip, corn
• Salt = iodinated or not

10. Drug history
• Any medication for this problem/ any
giotrogenic drugs.
• Any radiation exposure.

11. Family History
• MEN 2 related cancer = Pheochromocytoma
= Medullary thyroid ca
=Primary hyperparathyroidism
• COWDEN Syndrome(PTEN mutation)=
=differentiated thyriod Ca
=CABreast
=Multiple hamartoma

12. • Personal History = Any addiction
• Past Medical and Surgical History

13. Examination
• 1= TOXIC OR NON TOXIC
• Tremors of outstretched hands
• Warm /sweaty palm
• Pulse
• EYE SIGNS= 1. Exopthalmos
• 2.Lid lag (von grafe,s sign)
• 3.Convergence/diplopia

14. • Myopathy = inability to get up from chair is
called plumer sign.
• Bruit

15. 2 Benign / Malignant
• Voice changes , WT loss .
• Fixity ( restriction to lateral mobility )
• Consistency
• Lymph nodes
• Berrys sign

16. 3=Retrosternal extension
• Pressure Symptoms
• Pemberton sign
• Palpate Trachea
• Look for Lower limit
• Percussion note (Dull).

17. D/Ds
• Dominant nodule of a multinodular goiter
• Thyroid adenoma
• Thyroid cyst
• Thyroid ca
• Localized form of thyrioditis
• Colliod goiter

18. INVESTIGATIONS
• 1= Thyroid function tests
• 2= U/S
• A= u/s is a non invasive and portable imaging
study of thyroid gland with the added advantage
of no radiation exposure.
• B= it can detect a nodule of size as small as 0.3
mm.
• It is helpful in the evaluation of thyriod nodules,
giving following informations

20. • Distingushing solid from cystic
• Size and multicentricity
• Echogenicity and echotexture
• Shape and borders
• Presence of calcifications
• Vascularity
• To guide FNAC
• For assessing cervical lymphadenopathy

21. U/S FINDINGS FOR LN METASTASIS
• Change of shape of node from oval to round
• Loss of fatty hilum
• Microcalcifications
• Complex texture
• More than 10 mm
• Hypervascularity
• Cystic change

22. FNAC
• An adequate smear should have at least six
clusters of cells each containing about 10 cells.
• Possible FNAC reports of FNAC
• Thy1= non diagnostic ( repeat FNAC)
• Thy2 = Non neoplastic ( follow up 6-18
months)
• Thy3= follicular (tru-cut biopsy)
• Thy 4= suspicious of malignancy ( Surgery)

23. • Thy 5. Malignant ( Surgery)

24. ADVANTAGES OF FNAC
• Diagnostic accuracy is about 95%
• Sensitivity 83%
• Specificity 92%
• Will Give a definitive diagnosis
• 1= colloid nodule
• 2= thyroiditis
• 3=papillary, medullary , anaplastic ca ,
lymphoma.

25. DISADVANTAGES OF FNAC
• Cant differentiate follicular adenoma from
carcinoma.
• Loss of tissue architecture
• Least informative
• False negatives

26. Thyriod scan
• Indication
• Solitary nodule
• Retrosternal gioter
• Ectopic thyriod tissue
• Hot nodule =increased activity of nodule as
compared to the gland.
• Warm nodule=similar activity of the nodule as
compared to rest of the gland.

27. • Cold nodule= dec activity of the nodule as
compared to the rest of gland.

28. THYRIOD SCAN

29. CT SCAN/ MRI
• Ct and MRI provide excellent imaging of
thyriod gland and adjacent nodes.
• are particulary useful in evaluating the extent
of large ,fixed or substernal goiters which cant
be evaluated by U/S and their relationship to
the airway and vascular structures.

30. CT for Retrosternal extension

31. CT OF RETROSTERNAL GOITER

32. MANAGMENT
• Solitary thyriod nodule
• FNAC RESULT
• 1=BENIGN= Observe , repeat FNAC in one 1
year.
• 2=Malignant= total thyriodectomy
• 3=INDETERMINATE OR FOLLICULAR
NEOPLASM OR SUSPICIOUS=

33. • TSH = if TSH normal=surgery
• if TSH low= scintiscan for cold nodule
• 4=INADEQUATE= repeat FNAC

34. CLASSIFICATION
• THYRIOD NEOPLASMS= Benign or malignant
• MALIGNANT =PRIMARY OR SECONDARY
• 1= SECONDARY= breast , Colon , Kidney,
Melonoma

35. PRIMARY( depending on cell of origin)
• 1=LYMPHOCYTES= Lymphoma
• 2=Parafollicular cells= MTC
• 3=FOLLICULAR CELLS. DIFFERENCIATED(
PAPILLARY AND FOLLICULAR THYRIOD
CANCER) OR UNDIFFERENCIATED
(ANAPLASTIC , MEDULLARY CANCERS AND
LYMPHOMA)