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  1. 1. GOITREDr Echebiri, PromiseState House Medical Centre, Aso Rock, Abuja.5th December,2011.
  2. 2. CONTENTS• Definition• Overview• Background• Pathophysiology• Classification• Presentation• Investigations• Differential Diagnoses• Treatment• Prognosis
  3. 3. DEFINITION An enlarged thyroid gland. -Clinically palpable gland.-Gland enlargement more than twice of the normal size.
  4. 4. OVERVIEW• Geography: Worldwide, the most common cause of goiter is iodine deficiency.Approximately 800million people subsist on iodine-deficient diet.In industrialized countries,goiter is more often due to Hashimoto’s thyroiditis.
  5. 5. OVERVIEW• Sex: The female-to-male ratio is 4:1.Thyroid nodules are more likely to be malignant in menThe frequency of goiters decreases with advancing age. although the incidence of thyroid nodules increases with advancing age.• Race: No racial predilection exists.
  6. 6. BACKGROUNDThyroid gland surface marking
  7. 7. BACKGROUNDHypothalamo-Pituitary-Thyroid Axis
  8. 8. BACKGROUND Thyroid anatomy
  9. 9. BACKGROUND Thyroid physiology
  10. 10. BACKGROUND• TRH:Produced by Hypothalamus. Release is pulsatile,circadian. Downregulated only by T3. Travels through portal venous system to adenohypophysis. Stimulates TSH formation.• TSH: Produced by Adenohypophysis Thyrotrophs.Up regulated by TRH .Down regulated by T4, T3.
  11. 11. BACKGROUND Travels through portal venous system to cavernous sinus, then thyroid gland. Stimulates several processes Iodine uptake Colloid endocytosis Growth of thyroid gland.• Thyroid Hormone: Majority of circulating hormone is T4  98.5% T4  1.5% T3
  12. 12. BACKGROUNDTotal Hormone load is influenced by serum binding proteins Albumin 15% Thyroid Binding Globulin 70% Transthyretin 10%Regulation is based on the free component ofthyroid hormone
  13. 13. BACKGROUND Hormonal interplay TRHTSH T4,T3
  15. 15. CLASSSIFICATIONS Based on growth pattern Goitre Nodular Diffuse Hypothalamic disease Multinodular: Pituitary disease Uninodular: Iodine Iodine Cysts deficiency deficiency(endemic, sporadiBenign thyroid Thyroiditis c) neoplasms Sarcoidosis Grave’s diseaseThyroid cancers Thyroid hormone insensitivity
  16. 16. CLASSIFICATIONS Based on size of gland Grade III • Invisible • Palpable GradeII • Visible • Palpable • Visible Grade I • Palpable • Retrosternal extension
  17. 17. CLASSIFICATIONS Based on activity of gland Hyperthyroid (toxic)Hypothyroid
  19. 19. PRESENTATION• History:Anterior neck swellingPain: Haemorrhage, inflammation, necrosis, or Malignant transformationCompressive symptoms: Dysphagia, dyspnea, stridor, plethora or hoarsenessSymptoms of hyperthyroidism or hypothyroidism
  20. 20. PRESENTATION• Physical ExaminationCharacterisation of thyroid swellingCheck for signs of hyperthyroidism/hypothyroidismCheck for signs of compression(Pemberton manoeuvre).Check for signs of malignancy
  21. 21. PRESENTATIONHyperthyroidism versus Hypothyroidism
  22. 22. INVESTIGATIONS• Laboratory Studies: TRH TSH Total T3, T4 Free T3, T4 RAIU Thyroglobulin Antibodies: Anti-TPO, Anti-TSHr
  23. 23. INVESTIGATIONS• Imaging Studies:Ultrasonography:Evaluate goiter size, consistency, and nodularity. Localize nodules for ultrasonographically guided biopsy.X Rays:Usually AP and Lateral with thoracic inlet.Retrosternal goitre extension.Presence of calcification.
  24. 24. INVESTIGATIONSComputed tomography (CT) scanning: Delineate the relationship of the thyroid gland to nearby structures.CT-guided biopsies.Radionuclide isotope scanning are used to assess thyroid function and anatomy in hyperthyroidism, as shown below.
  26. 26. INVESTIGATIONSSpirometry: The flow-volume loop is useful in determining the functional significance of compressive goiters.Histology:fine needle aspiration or core biopsy.
  27. 27. DIFFERENTIAL DIAGNOSES• Pseudogoitre• Thyroglossal cyst• Sublingual dermoid• Lymphadenopathy(bull’s neck).• Thyroid lipomas• Thyroid lymphomas
  28. 28. TREATMENT• Observation Small goiter Euthyroid Asymptomatic• Medications: Hypothyroidism: Thyroid hormone replacement with levothyroxine. Hyperthyroidism:May require medications to normalize hormone levels for example propylthiouacil,Methimazole Inflamed thyroid gland, aspirin or a corticosteroid
  29. 29. TREATMENT• Surgery: Removing all or part of the thyroid gland-Thyroidectomy.Large goiters with compressionMalignancyWhen other forms of therapy are not practical or ineffective• Radioactive iodine: Treatment results in diminished size of goiter, but eventually may also cause a hypothyroid state.
  30. 30. TREATMENT• Minimally-invasive modalitiesEndoscopic subtotal thyroidectomyEmbolization of thyroid arteriesPlasmaphoresisPercutaneous ethanol injection into toxic noduleL-Carnitine supplementation may improve symptoms and may prevent bone loss
  31. 31. PROGNOSIS• Complications of thyroidectomy:• Thyrotoxic storm• Bleeding• Infection• Hypoparathyroidism• Injury to recurrent laryngeal nerve• Injury to superior laryngeal nerve• Hypothyroidism
  32. 32. PROGNOSIS• A small percentage of multinodular goiters do lead to hyperthyroidism.• Benign goiters have a good prognosis,furthermore,the risk of malignant transformation is low.
  33. 33. THANK YOU