5. neck masses
Family physicians frequently encounter neck masses in adult
patients.A careful medical history should be obtained, and a
thorough physical examination should be performed.The
patient's age and the location, size, and duration of the mass are
important pieces of information. Inflammatory and infectious
causes of neck masses, such as cervical adenitis and cat-scratch
disease, are common in young adults. Congenital masses, such as
branchial anomalies and thyroglossal duct cysts, must be
considered in the differential diagnosis. Neoplasms (benign and
malignant) are more likely to be present in older adults. Fine-
needle aspiration and biopsy and contrast-enhanced computed
tomographic scanning are the best techniques for evaluating
these masses.
American academy of family physician. 2015
6. Central Neck
is the most commonduct cystthyroglossalThe
congenital anomaly of the central portion of the neck .This
anomaly is caused by a tract of thyroid tissue along the
pathway of embryologic migration of the thyroid gland from
the base of the tongue to the neck.The thyroglossal duct
cyst is intimately related to the central portion of the hyoid
bone and usually elevates along with the larynx during
swallowing. It may contain the patient's only thyroid tissue.
8. procedure, whichSistrunkis theThe treatment of choice
involves complete excision of the thyroglossal duct cyst,
including the central portion of the hyoid bone. If necessary,
excision extends to the base of the tongue.
9. Thyroid nodule
Thyroid nodules are common in the general population,
especially in women. Nonpalpable nodules are often found
when patients undergo diagnostic imaging such as
ultrasonography and computed tomography of the chest
and neck. For these incidentalomas, current guidelines
recommend the same diagnostic strategy that is
recommended for palpable nodules.Although the risk of
malignancy in any given nodule is small, thyroid cancer must
be considered in the differential diagnosis. Family physicians
should understand the rationale for the evaluation of
nodules and be able to perform an evidence-based
assessment.
American academy of family physician. 2015
10. presentation
Thyroid nodules are often noticed by patients as a lump or
protrusion in the lower anterior neck. Large nodules can
cause compressive symptoms, such as difficulty swallowing
or a choking sensation. Nodules may be single or multiple,
hard or soft, and tender or nontender.
Nodules may also be found by physicians on routine
examination. Clinical examination of the thyroid is difficult
in persons with large necks. Nodules 1 cm or smaller are
rarely detected by palpation.
American academy of family physician. 2015
14. Red flags:
1- patient aged >65y
2-solitary nodule increasing in size.
3-history of neck irradiation.
4-unexplained hoarseness of voice .
5- cervical lymphadenopathy.
6- very young patient.
15. Screening for Thyroid Dysfunction: Clinical Summary of the
USPSTF Recommendation
Population
Nonpregnant, asymptomatic adults
Recommendation
No recommendation
Grade: I statement (insufficient evidence)
Risk assessment
Risk factors for an elevated thyroid-stimulating hormone (TSH) level include female sex,
advancing age, white race, type 1 diabetes, Down syndrome, family history of thyroid disease,
goiter, previous hyperthyroidism, and external-beam radiation in the head and neck area. Risk
factors for a low TSH level include female sex; advancing age; black race; low iodine intake;
personal or family history of thyroid disease; and ingestion of iodine-containing drugs, such as
amiodarone.
Screening tests
The primary screening test for thyroid dysfunction is serum TSH testing. Multiple tests over 3 to
6 mounth should be performed to confirm or rule out abnormal findings. Follow-up testing of
serum thyroxine (T4) levels in persons with persistently abnormal TSH levels can differentiate
between subclinical (normal T4) and “overt” (abnormal T4) thyroid dysfunction.
16.
17. Introduction
The proper treatment of hyperthyroidism depends on
recognition of the signs and symptoms of the disease and
determination of the etiology.The most common cause of
hyperthyroidism is Graves’ disease. Other common causes
include thyroiditis, toxic multinodular goiter, toxic
adenomas, and side effects of certain medications.
American academy of family physician. 2015
18. Common Etiology and Clinical Diagnosis
of Hyperthyroidism:
Graves’ disease
Toxic adenoma
Toxic multinodular goiter
Thyroiditis
19. Hyperthyroidism
T = Tremor
H = Heart rate up
Y =Yawning [fatigability]
R = Restlessness
O = Oligomenorrhea &
amenorrhea
I = Intolerance to heat,
D =Diarrhea
I = Irritability
S = Sweating
M = Musle wasting & weight
loss
E = Exophthalmos
22. GRAVES’ DISEASE
1-Graves’ disease is the most common cause of
hyperthyroidism, accounting for 60 to 80 percent of all
cases.
2- It is an autoimmune disease caused by an antibody, active
against the thyroid-stimulating hormone (TSH) receptor,
which stimulates the gland to synthesize and secrete excess
thyroid hormone. It can be familial and associated with
other autoimmune diseases.
3-An infiltrative ophthalmopathy accompanies Graves’
disease in about 50 percent of patients.
American academy of family physician. 2015
23. ophthalmopathy
1- periorbital edema.
2-conjunctival edema (chemosis).
3- poor lid closure.
4- extraocular muscle dysfunction ( diplopia).
5- proptosis ( exophthalmos) .
6- lid lag sign (von Graefes sign): lagging of the upper eyelid
on downward rotation of the eye.
7- lid retraction : sclera is visible above the superior corneal
limbus.
25. Toxic adenoma
Toxic adenomas are autonomously functioning nodules that
are found most commonly in younger patients and in
iodine-deficient areas.
American academy of family physician. 2015
27. Toxic multinodular goiter
1-Toxic multinodular goiter causes 5 percent of the cases of
hyperthyroidism in the United States and can be 10 times
more common in iodine-deficient areas.
2-It typically occurs in patients older than 40 years with a
long-standing goiter, and has a more insidious onset than
Graves’ disease.
American academy of family physician. 2015
28. Lymphocytic thyroiditis, postpartum
thyroiditis, medication-induced
thyroiditis
Pathophysiology:
Leakage of hormone from gland.
Gland size:
Moderately increased.
Nodularity:
None.
Tenderness:
Nontender
American academy of family physician. 2015
29. Thyroiditis
Thyroiditis is a general term that refers to inflammation of
the thyroid gland and encompasses several clinical
disorders.The family physician will most commonly
diagnose thyroiditis because of abnormal results on thyroid
function testing in a patient with symptoms of thyroid
dysfunction or anterior neck pain.
American academy of family physician. 2015
30. Subacute thyroiditis
Leakage of hormone from gland.
Gland size:
Increased.
Nodularity:
None.
Tenderness:
Tender
American academy of family physician. 2015
31. Subacute thyroiditis (subacute
granulomatous thyroiditis, giant cell
thyroiditis, de Quervain thyroiditis)
Presentation:
Thyroid pain; hyperthyroidism followed by transient
hypothyroidism most commonly.
Etiology:
Post viral.
Diagnosis:
Thyroid function tests; elevatedTPO antibody levels; low
radioactive iodine uptake in the hyperthyroid phase.
American academy of family physician. 2015
32. Complication:
Euthyroidism is generally achieved by 18 months, but up to
15% of patients become permanently hypothyroid; rarely
recurs.
Treatment:
Beta blockers can be considered for significant hyperthyroid
symptoms (in the hyperthyroid phase); levothyroxine for
symptomatic hypothyroidism (in the hypothyroid phase) and
permanent hypothyroidism.
American academy of family physician. 2015
34. KEY RECOMMENDATIONS FOR PRACTICE
1-Patients with subacute thyroiditis should be started on high-
dose acetylsalicylic acid or nonsteroidal anti-inflammatory drugs
as first-line therapy. C
2-Corticosteroid therapy for subacute thyroiditis should be
initiated in patients with severe neck pain or minimal response
to acetylsalicylic acid or nonsteroidal anti-inflammatory drugs
after four days. C
3-Patients with severe thyroid pain and systemic symptoms (e.g.,
high fever, leukocytosis, cervical lymphadenopathy) should
undergo fine-needle aspiration to rule out infectious thyroiditis.
C
American academy of family physician. 2015
37. interpretation
TSH: 0.05-4.70 mIU/mL.
FT4: 12,00- 22 pmol/L.
FT3:2,80-7.10pmol/L.
TSH: LOW , freeT4: normal , freeT3: normal
Mild ( subclinical ) hyperthyrodism.
TSH: LOW , free T4: high or normal, free T3: high or normal.
Hyperthyroidism.
38. Treatment of Hyperthyroidism:
)atenelol,propanololblockers(Beta
Inhibit adrenergic effects.
Indication:
Prompt control of symptoms; treatment of choice for
thyroiditis; first-line therapy before surgery, radioactive
iodine, and antithyroid drugs; short-term therapy in
pregnancy.
CONTRAINDICATIONS :
Use with caution in older patients and in patients with pre-
existing heart disease, chronic obstructive pulmonary
disease, or asthma.
American academy of family physician. 2015
39. Iodides
Block the conversion ofT4 to T3 and inhibit hormone release.
Indication:
Rapid decrease in thyroid hormone levels; preoperatively when
other medications are ineffective or contraindicated; during
pregnancy when antithyroid drugs are not tolerated; with
antithyroid drugs to treat amiodarone induced hyperthyroidism.
Complication:
common side effects of sialadenitis, conjunctivitis, or acneform
rash; interferes with the response to radioactive iodine.
American academy of family physician. 2015
40. PTU)andmethimazoledrugs (Antithyroid
Interferes with the organification of iodine; PTU can block
peripheral conversion of T4 toT3 in large doses.
Indication:
Long-term treatment of Graves’ disease PTU is treatment
of choice in patients who are pregnant and those with
severe Graves’ disease; preferred treatment by many
endocrinologists for children and for adults who refuse
radioactive iodine; pretreatment of older and cardiac
patients before radioactive iodine or surgery; both
medications considered safe for use while breastfeeding.
American academy of family physician. 2015
41. Radioactive iodine
Concentrates in the thyroid gland and destroys thyroid
tissue.
Indication:
radioactive iodine is the treatment of choice for most
patients with Graves’ disease and multinodular goiter, toxic
nodules in patients older than 40 years, and relapses from
antithyroid drugs.
contraindicated in patients who are pregnant or
breastfeeding; can cause transient neck soreness, flushing,
and decreased taste.
American academy of family physician. 2015
42. Surgery (subtotal thyroidectomy)
Reduces thyroid mass.
Indication:
Treatment of choice for patients who are pregnant and children
who have had major adverse reactions to antithyroid drugs, toxic
nodules in patients younger than 40 years, and large goiters with
compressive symptoms; can be used for patients who are
noncompliant, refuse radioactive iodine, or fail antithyroid drugs,
and in patients with severe disease who could not tolerate
recurrence; may be done for cosmetic reason.
Complication:
Risk of hypothyroidism (25 percent) or hyperthyroid relapse (8
percent); temporary or permanent hypoparathyroidism or
laryngeal paralysis (less than 1 percent).
American academy of family physician. 2015
43.
44.
45.
46.
47. Hypothyroidism is defined as failure of the thyroid
gland to produce sufficient thyroid hormone to meet the
metabolic demands of the body.
Under activity of the thyroid gland may be primary from
disease of thy thyroid gland or much less commonly
secondary to hypothalamic or pituitary diseases
(secondary hypothyroidism)
It is much more common in women& the incidence
increases with age
5th edition Essentials of Kumar&clark’s clinical medicine
American academy of family physician 2015
48. AUTOIMMUNE THYRODITIS
IATROGENIC
DRUG INDUCE
IODINE DEFICIENCY
SUBCLINICAL HYPOTHYRODISIM
CONGINITAL HYPOTHYRODISM
MYXEDEMA COMA
Common Etiology and Clinical
Diagnosis of Hypothyroidism:
49. Autoimmune thyroditis
((Hashimoto thyroiditis
The Most Common Cause of Hypothyroidism
The name Hashimoto's thyroiditis is derived from
the 1912 pathology report by Hashimoto
describing patients with goiter and intense
lymphocytic infiltration of the thyroid as "struma
lymphomatosa"
Uptodate
50. It is characterized clinically by gradual thyroid
failure, with or without goiter formation, due to
autoimmune-mediated destruction of the thyroid
gland involving apoptosis of thyroid epithelial
cells.
The presence of serum thyroid autoantibodies
may be sufficient evidence for Hashimoto's
disease
Uptodate
51. Several antibodies and antigen-specificT cells directed
against thyroid antigens have been described in chronic
autoimmune thyroiditis.The major antigens are:
Thyroglobulin (Tg)
Thyroid peroxidase (TPO, historically known as the
“microsomal” antigen)
The thyrotropin (TSH) receptor
52. IATROGENIC
The second most common cause after treatment of
hyperthyroidism:
Thyroidectomy
Radioactive iodine
External neck irradiation for head and neck cancer
Blueprints family medicine 3rd edition
54. Subclinical hypothyroidism
Subclinical hypothyroidism is a biochemical diagnosis
defined by a normal-range free T4 level and an elevated
TSH level
American academy of family physician. 2015
58. Investigation
T3T4TSH
Low or normalLow or normalincrease1ry
hypothyroidism
lowlowlow2ry
hypothyroidism
NormalnormalslightSubclinical
hypothyroidism
5th edition Essentials of Kumar & clark’s clinical medicine
59.
60. Screening
Family physician should evaluate for thyroid dysfunction in
all patient with symptoms of hypothyroidism.
Screening of asymptomatic patientmay be consider in
those with risk factors for hypothyroidism, such as history
of autoimmune disaes ,history of head or neck irradtion,
previous radioactive iodine therapy, presence of
goiter,family history of thyroid diseas or treatment with
drug known to influence thyroid function.
American academy of family physician. 2015
66. 1.6 mcgkgday(initial dosage)Non pregnant
25-50 mcg daily starting dose increase by
25mcgevery three to four weeks until full
replacement
Older patient
+cardiac disease
increase to nine doses weekly (one extra dose on
two days of the week) at earliest knowledge of
2pregnancy; refer to endocrinologist
Pregnant patient
TSH < 10 mIU per L: 50 mcg daily, increase by
25 mcg daily every six weeks until TSH = 0.35
to 5.5 mIU per L
Patient with
subclinical
hypothyroidism
26
mcg per kg per day6.1mIU per L:10TSH ≥
67. Congenital hypothyroidism
Congenital hypothyroidism can cause mental retardation
(cretinism) unless thyroid therapy is initiated within two
weeks of birth
The condition typically is permanent, although transient
hypothyroidism can result from transmission of maternal
medications, maternal blocking antibodies, or iodine
deficiency or excess
70. MYXEDEMA COMA
. Myxedema coma is a rare but extremely severe
manifestation of hypothyroidism
most commonly occurs in older women who have a
history of primary hypothyroidism
Mental status changes including lethargy, cognitive
dysfunction, and even psychosis, and hypothermia are the
hallmark features of myxedema coma. Hyponatremia,
hypoventilation, and bradycardia can also occur
5th edition Essentials of Kumar&clark’s clinical medicine
71. Investigation :
is givenhormonbefore thyroidcortisol,&4SerumTSH,T
Full blood count,serum ureaand electrolyes,blood glucose and
blood cultures
ECG monitoring for cardic arrhythmias
72. Treatment:
T3 orally or intravenously 2.5-5 microgram every 8 h
Oxygen (by mechanical ventilation if necessary)
Gradual rewarming
Hydrocortisone 100 mg i.v. 8 h
Glucose infusion to prevent hypoglycemia
Supportive management of comatose patient
5th edition Essentials of Kumar&clark’s clinical medicine
American Academy of family physician
73. 45 years old female known cases of DM on metformin 750
ml BID present to her family physician for her usual
follow up, her physician note that her weight continues
increase since she start her follow up.
Her weight in 1st visit was 60 kg
Her weight after 3 months 65 kg
Her weight after 6 months 72 kg
