Thyroid swelling and management. In detail case discussion of thyroid swelling and its management. Details of examination as well included in the slide.

1. THYROID SWELLING
EVALUATION AND MANAGEMENT
Presenter- Dr. Sreenivas Kamath K

2. FREQUENTLY ASKED QUESTIONS
• Management of thyroid nodule (10m)
• Enumerate the causes for thyroid swelling and thyroid nodule
management
• Thyroglobulin
• Zuker tubercle and its surgical importance

3. PATIENT WITH NECK SWELLING

4. HISTORY
• Age/ Gender
• Asymptomatic- Cosmetic concern
• Discomfort or pain
• Pressure symptoms- Dyspnoea, Dysphagia, Dysphonia.
• History suggestive of Hyperthyroidism/Thyrotoxicosis- increased
appetite, loss of weight, palpitation, sweating, heat intolerance
menstrual irregularities
• History suggestive of Hypothyroidism- loss of appetite, weight
gain, lethargy, cold intolerance, menstrual irregularities.

5. EXAMINATION
•Vitals – Pulse, Blood pressure, Temperature.
•Signs of hypo/Hypercalcemia
•Voice assessment- IDL, Indirect Laryngoscopy,
Flexible laryngoscopy
•Stridor.

6. EXAMINATION
• Inspection
Position Size Shape Skin changes
Surface Movement
Pembertson’s
sign

7. EXAMINATION
• Palpation
• Front
• Standing at back
• Swallowing
Lahey Crile’s
Consistency
Extent
Tenderness
Mobility
Surrounding
structure

8. Kocher test Berry’s sign

9. EXAMINATION
• Percussion- to rule out retrosternal extension

10. EXAMINATION
• Auscultation
• Thyroid thrill- Guttman sign

11. EXAMINATION
• Neck node status
• FIRST ECHELON LN- paralaryngeal, paratracheal,
prelaryngeal (Delphian)
• Level II-IV- lateral group
• Level VI and VII- central group

12. GRAVES- OPHTHALMIC SIGNS
• Von graefe’s sign- lagging behind of the upper eyelids
when the patient looks downwards
• Stellwag’s sign- retraction of upper eye lids
• Dalrymples sign- widening of palpebral fissure
• Joffroy’s sign- absence of wrinkling of the forehead on
looking up
• Mobius sign- difficulty in convergence of eye.

13. DD FOR THYROID SWELLING

14. AMERICAN THYROID ASSOCIATION
ATA GUIDENLINES

15. Thyroid nodule
Normal or raised TSH
USG
No Nodule/
lesion <1cm
Very Low
suspicion
Benign
pattern
Low
Suspicion
Intermediate
suspicion
High
Suspicion
FNAC not
recommended
FNAC if
>1cm
FNAC if
>1.5cm
FNAC if
>2cm
FNAC

16. FNAC
Bethesda
classification
Non diagnostic Benign AUS/FLUS FN/FSN Suspicious Malignancy
Repeat
FNAC
No surgery
Surgery

17. INVESTIGATIONS
•Blood investigations.
•TSH- subclinical, overt hypo/hyperthyroidism
•Free T3 and Free T4
•TPO (thyroid peroxidase) antibodies – Hashimottos
•Routine blood investigation for surgery

18. INVESTIGATIONS
• ULTRASOUND THYROID- Best imaging modality for thyroid
evaluation.
• Accurate size, characteristics, extent of pathology, relation to
surrounding structure and nodal status
• Ease of performing, non invasive
• Affordability and availability

19. USG
• Normal gland
Homogenous echotexture

20. USG
• Benign Nodule
• Small
• Hyperechoic
• Internal lucencies, known as
the “comet tail” sign
• Spongiform texture is also
common

21. USG
• Follicular adenoma
• Well encapsulated
• Surrounded by normal thyroid tissue
-Halo sign

22. USG
• Papillary carcinoma
• hypoechoic nodule with punctate, internal
microcalcifications

23. USG
• USG features suggestive of malignancy
• Solid appearance (hypoechogenicity)
• Increase vascularity
• Micro-calcification
• Irregular margins
• Absence of Halo sign

26. IMAGING
• Xray- Neck AP- Lateral
• Compression/Devation of trachea
• Substernal extension
• CT/MRI
• only an ancillary use to ultrasound
• To assess the compression of near by structures and to assess substernal
extension
• 18F-FDG-position emission tomography (PET) has generally been used to
localize thyroid cancer recurrence in patients with raised Tg levels

27. IMAGING
• Scintiscanning-
• 99mTc- most commonly used
• To localize congenital anatomical defects of the thyroid
• To distinguish between thyrotoxicosis caused by destructive
thyroiditis and hyperthyroidism

28. SITES OF DISTANT METASTASIS
• Lungs- MC 80-85%
• Bones 5-10%
• Brain 1%
• Liver, kidney, adrenal gland, pituitary gland, or skin. Other
rare sites

29. FINE NEEDLE ASPIRATION BIOPSY
• Choice of tool for diagnosis of thyroid
swelling
• Reserved for lesion >1cm, can be done in
smaller lesion if there are signs of
malignancy on imaging

30. FNAC- BETHESDA REPORTING
Class I
• Non-diagnostic or unsatisfactory
• Virtually acellular specimen Other (obscuring blood, clotting artefact, etc.)Cyst fluid only
Class II
• Benign
• Benign nodule, hashimoto’s Thyroiditis, Subacute Thyroiditis
Class III
• Atypia of undetermined significance or follicular lesion of undetermined significance

31. Class IV
• Follicular neoplasm or suspicious for a follicular neoplasm
Class V
• Suspicious for malignancy
• Papillary, Medullary, Metastatic, Lymphoma.
Class VI
• Malignant
FNAC- BETHESDA REPORTING

32. FNAC
• FNAC in a Mutli nodular goitre ???
• FNAC in multinodular goitre is not done routinely
• Done
• if USG shows suspicious characteristics
• Serial USG shows increase in size/ change in node characteristics

33. FNAC- LIMITATION
• Follicular pattern most commonly encountered
• MNG as well follicular neoplasia will have same FNAC picture
• Oncocytic cells – Hashimottos as well as papillary carcinoma
• Thus basic criteria should be met to report FNAC- 6 groups of
follicular cells
• FNAC induce HPE changes- Worrisome Histopathological
Alterations Following FNAC of Throid gland (WHAFFT)

34. INDIVIDUAL PATHOLOGY AND THEIR
MANAGEMENT

35. BENIGN SWELLINGS
• Goitre (Multinodular Goitre)
• Latin word- Tumidum gutter- Swollen throat
• Volume more than 18ml in female and 25ml in male

36. MNG- ETIOLOGY
• Genetics
• Smoking
• Natural goitrogens- cassava
• Autoimmune thyroid disease (Graves’ or Hashimoto’s disease)
• Iodine deficiency
• Malignancy
• Dyshormonogenesis,
• Infiltrative disease
• Very rare causes of thyroid enlargement are thyrotropin (TSH)-secreting
pituitary tumors and thyroid hormone resistance

37. MNG- PATHOGENESIS
• STAGES OF MNG
• Stage I- stage of diffuse hypertrophy and hyperplasia
• Stage II- Due to fluctuating level of TSH because of pregnancy,
Lactation, Menstruation, etc- some areas get converted to active
follicles.
• Stage III- The active follicle ultimately undergoes necrosis and
many such necrosed follicles join to form a nodule. Many such
nodules forms Mutli nodular goitre

38. MNG
• Clinical feature-
• Asymptomatic
• Visible when more
than 40ml
• 30–85% - develop/
present with
compressive
symptoms
Shin JJ, Grillo HC, Mathisen D, et al. The surgical management of goiter:
part I. Preoperative evaluation. Laryngoscope. 2011;121(1):60-67.

39. MNG

40. MNG
WHO grading of Goitre
• Grade 0: Impalpable/invisible
• Grade 1a: Palpable but invisible even in full extension
• Grade 1b: Palpable in neutral position/visible in extension
• Grade 2: Visible but no palpation required to make diagnosis
• Grade 3: Visible at a distance

41. MNG
• Investigations
• USG
• FNAC

42. GOITRE
ASYMPTOMATIC

43. MNG
• Diffuse swelling- Asymptomatic, with no cosmetic embarrassment-NO
ACTION
• Thyroxine therapy- controversial
• Effectiveness in iodine-sufficient populations is limited; only 17–25% of
thyroid nodules shrink > 50% with levothyroxine suppression
Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid
cancer. Thyroid. 2009;19(11):1167-214. Epub 2009/10/29.
Mackle T, Meaney J, Timon C. Tracheoesophageal compression associated with substernal goitre. Correlation of symptoms with cross-sectional imaging findings. J
Laryngol Otol. 2007;121(4):358-61.

44. MNG
• Radioactive iodine therapy-
• 131I induces shrinkage in 44% in 2 years- Weschem et al
• Induces shrinkage in 32% of cases after high dose of 131I – Bonnema
et al
• Subsequent hypothyroidism
• Reactive increase in size- Relative contraindication in substernal
goitres.

45. GOITRE
ASYMPTOMATIC SYMPTOMATIC,
painful, bleed
into cyst.
COSMETIC
CONCERN
FIT/ YOUNG UNFIT/ ELDERLY
SURGICAL
MANAGEMENT
MEDICAL
MANAGEMENT

46. MNG
• Symptomatic cases-
• Pressure symptoms- dyspnea, dysphagia, dysphonia
• Discomfort
• Recurrent bleeds into degenerated areas
• Cosmetic problems

47. SURGICAL INDICATION FOR MNG
1. Significant regional aerodigestive tract symptoms (dyspnea,dysphagia, dysphonia)
2. Tracheal deviation on CT
3. Interval growth
4. Masses greater than 5 cm
5. Goiter with subclinical or clinical hyperthyroidism
6. Suspected or proven thyroid malignancy
7. Substernal goiter
8. Cosmetic deformity

48. MNG
• Surgical techniques
• Lobectomy
• Total thyroidectomy
• Subtotal thyroidectomy
• Hemithyroidectomy
• Dunhill procedure

49. THYROIDECTOMY
Brief history :
1646- the first thyroidectomy was done- patient died and doctor was
imprisoned.
Later in 19th centuary it was again popularised by Theodor kocher and Albert
Theodor Billroth
Theodor Kocher is called the father of modern thyroidectomies

50. SURGERIES OF THYROID

51. MNG- LOBECTOMY
• Lobectomy: the removal of the one lobe, often performed with a thyroid
isthmusectomy- Hemithyroidectomy
• Thyroid isthmusectomy (TI): the excision of the thyroid isthmus, often with the
pyramidal lobe of the gland, a procedure that should be reserved for nodules in the
isthmus which measure no more than 4 cm in diameter and do not encroach
significantly on either lobe.

52. MNG- TOTAL THYROIDECTOMY
• Total thyroidectomy (TT): the excision of the entire thyroid gland

53. MNG- SUBTOTAL THYROIDECTOMY
• The bilateral excision of more than one half of the thyroid gland on each side
together with the isthmus. This technique is currently not recommended..

54. MNG- DUNHILL THYROIDECTOMY
• Near-total thyroidectomy or Dunhill’s thyroidectomy (NTT): the excision of 90%
of the gland, leaving a small remnant of tissue on one side at the level of the Berry’s
ligament.

55. PRE OPERATIVE
• General anaesthesia with endotracheal intubation
• Prophylactic antibiotics are not indicated
• Neck slightly hyperextended by placing a bolster between the scapulae
• Head stabilised on a head ring
• Table tilted to 30º anti-Trendelenberg position to reduce venous engorgement
• Head is free-draped to allow turning of the head

60. ICA
ITA
Esophagus

62. POST OPERATIVE CARE
• Position- 45 degree head up
• Steroid- post operative steroid injection has multiple benefits-
adjuvant for analgesia, antiemetic and reduces the chances of
neuropraxia
• Antibiotic coverage
• Analgesic
• Oral intake 4 hours after surgery
• Drain removal. Monitoring of drainage volume should be every 8
hours. If the volume is less than 20 mL at 24 hours or 10 mL at 8
hours, the drain may be removed.
• Suture removal- 7 days
• Post operative vocal cord check

63. COMPLICATION OF
THYROIDECTOMY
• Hematoma- 1/150 surgery
• Develops usually in 6 hrs, or later if patient is on anti DVT
measures
• Can be superficial hematoma or deep hematoma
• Deeep hematomas are dangerous
• Hypoparathyroidism
• Develop hypocalcaemia
• Temporary hypopcalcaemia in 10% and permanent in 1 %

64. COMPLICATION OF
THYROIDECTOMY
• Nerve injury
• Nerves that can be injured are RLN, SLN, vagus and
sympathetic trunk

65. GOLDEN RULES OF
THYROIDECTOMY
• Key principles of thyroid dissection
1. Avoid dividing any structures in the tracheoesophageal groove until
the nerve is definitively identified
2. Identify the nerve low in the neck, well below the inferior thyroid
artery, at the level of the lower pole of the thyroid gland, or below
3. Keep the nerve in view during the subsequent dissection of the
thyroid away from the larynx
4. Minimize the use of powered dissection posterior to the thyroid
5. Treat every parathyroid gland as though it were the last; use
parathyroid autograft liberally when parathyroid gland appearance
is changed

66. MNG- RETROSTERNAL EXTENSION
• Special consideration.

68. MALIGNANT SWELLINGS
• Well differentiated thyroid carcinoma
• Medullary carcinoma
• Anaplastic carcinoma
• Metastatic thyroid cancer

69. WELL DIFFERENTIATED THYROID
MALIGNANCY
• Cancers arising from the follicular cell
• Papillary, follicular, and Hurthle cell carcinomas of the thyroid gland
• Incidence is 12.9/lakh population
• Good prognosis
• Mainstay of management is surgical, followed by radioiodine ablation/
TSH suppression

70. WDTC
• Investigations-
• Contrast enhanced CT is usually avoided as it causes Iodine saturation and delay in
radioiodine ablation treatment by almost 2-3 months

71. WHO CLASSIFICATION OF THYROID
NEOPLASIA

72. WDTC- TNM

75. CHANGES IN AJCC 8TH ED
•The age at diagnosis cutoff used for staging was
increased from 45 years to 55 years.
•Minor extrathyroidal extension was removed from
the definition of T3 disease.
•T3a is a new category and refers to a tumor >4 cm
in greatest dimension limited to the thyroid gland.

76. CHANGES IN AJCC 8TH ED
• T3b is a new category and is defined as a tumor of any
size with gross extrathyroidal extension invading only
strap muscles (sternohyoid, sternothyroid, thyrohyoid, or
omohyoid muscles).
• Central group of LN includes both 6 and 7
• The pN0 designation is clarified as one or more
cytologically or histologically confirmed benign lymph
node
• Histological grading is removed

77. WDTC
• Treatment depends both on patient factor as well as tumor factor
• Total thyroidectomy is recommended
• if the primary tumour size is >4cm
• Multifocal disease
• Bilateral disease
• Extrathyroid extension
• Nodal spread
• Distant metastasis

78. • Relative indications of total thyroidectomy
• Age >55yrs
• History of radiation exposure
• Familial history
• Adverse histopathological features
• Potential difficulty in follow up

79. PROGNOSTIC FACTORS- WDTC
Low risk High risk
Patient variable
Age 15-55 Age <15 and >55
Female Male
No family history Family history of thyroid malignancy
Tumour Variable
Tumor <4cm Tumour >4cm
Unilateral disease Bilateral disease
No extrathyroidal extension Extrathyroidal extension
No vascular invasion Vascular invasion
No lymphatic metastasis Lymphatic metastasis
Iodine avid tumors Aggressive histological variants – Hurthle cell,
cell, columnar cell, diffuse sclerosis, insular
Distant metastasis- absent Distant metastasis present

80. WDTC
Papillary carcinoma thyroid microcarcinoma
Tumour size no greater than 1 cm
Good prognosis
2 sets of patients
1. The ones that were diagnosed by post operative histology ( LOW RISK)
2. The ones that were diagnosed Pre-operatives on USG/ other imaging modalities (
HIGH RISK)

81. WDTC
•Surgical situations
•Involvement of RLN
•Involvement of Trachea
•Involvement of esophagus

83. WDTC
• Role of Prophylactic Neck dissection ??
• Incidence is 20-50%
• No added benefit in doing lateral neck dissection in N0
cases
• Central dissection may be done for primary lesion >4cm

84. Perithyroid Peritracheal Paratracheal Prelaryngeal
Superior
Mediastinal

85. USG- NODE FEATURES
• Pathological lymph nodes
• Round shape
• Absent hilum
• Calcification
• Intranodal necrosis,
• Reticulation
• Matting
• Peripheral vascularity

86. INDICATION FOR CND
• Confirmed involvement
• RLN involvement
• Medullary thyroid carcinoma
• Aggressive histological variant
• Elective-T3 T4
•

87. CENTRAL NECK DISSECTION

89. RADIOIODINE ABLATION
• Can be done only after total thyroidectomy
Benefits – increased survival, less recurrence and better monitoring using
thyroglbulins

90. WDTC- RADIOABLATION
Tumor size >4cm
Extrathyroidal extension
Distant Metastasis
Tumor <1cm
Unifocal
Papillary or follicular
variant,
No angioinvasion
No Extension
√ x
?

91. • Low dose – 1.1 Mbq
• High dose – 3.7Gbq

92. WDTC- EXTERNAL BEAM
RADIOTHERAPY
• Gross local tumor invasion
• Residual/ Reccurant tumor
• IMRT is the radiotherapy of choice

93. WDTC
• Assessment of Treatment
• Radioablation
• Day 2-10 scan
• Scan at 9-12 months
• Stimulated thyroglobulin scan (<0.5mcg/L)
• Usg neck
• Whole body radioisotope scan

94. WDTC- FOLLOW UP

95. WDTC- TSH SUPPRESSION

96. MEDULLARY CARCINOMA
• 0.4%-1.8% in among nodular thyroid disease
• Arises from C cells
• C cells are derived from neural crest
• Produce- Calcitonin, Calcitonin Gene related peptide
(CGRP), Carcinoembryonic antigen (CEA)

97. MEDULLARY CARCINOMA
• C cell hyperplasia
• Multifocal diffuse quantitative increase in the number of C cells
• Neoplastic: typically nodular and diffuse and indistinguishable from
invasive MTC cells
• Reactive/physiological: typically diffuse, associated with
hypercalcaemia, hyperparathyroidism, chronic lymphocytic
thyroiditis and follicular thyroid tumours

98. MEDULLARY CARCINOMA
• Medullary carcinoma can be either sporadic or familial
• Sporadic is usually solitary and unilateral
• Familial is multifocal and bilateral
• Accounts for 25% of cases MCT
• Multiple endocrine neoplasia type 2A (MEN 2A): >50% of cases
• Multiple endocrine neoplasia type 2B (MEN 2B): 5% of cases
• Familial medullary thyroid cancer (FMTC).
• RET proto-oncogene (chromosome 10q11.2

99. MCT- INVESTIGATIONS
Calcitonin
• Basal levels gives a gross idea regarding the disease extent
• 10-40pg/ml- nodal spread can be expected
• 100-400pg/ml distant metastasis can be expected
• False positive results are noted in autimmune disease and NET of
other organs
Urine/ plasma catecholamine
To rule of possibility of phaeochromocytoma

100. • Serum calcium levels-
• Need to look out for parathyroid disorders- primary hyper parathyroidism
• RET mutation analysis
• If found positive then the first order relatives should be subjected to gene analysis as
well

101. MCT- NODAL SPREAD
• Nodal metastasis happen at a early stage (75%)
• Ipsilateral nodes in 80% and contralateral nodes in 50%
• Skip metastasis is noted in 20%

102. MCT - SURGERY
Clincial evident MCT Incidental MCT
Total thyroidectomy
+
Central compartment Neck
dissection
+
Lateral selective neck dissection*
*if USG suggestive of involvement
* If central compartment is
positive in intraoperative frozen
section
1. Size > 1cm – same as clinical
evident
2. <0.5cm, post op calcitonin is
normal -then completion
thyroidectomy may not be
necessary
3. MCT <0.5cm with elevated
calcitonin- Complerion
thyroidectomy with neck
dissection

103. ANAPLASTIC CARCINOMA
• Extreme end of differentiation
• Occurs in older age group (60 and above)
• Male femal ratio 3:2
• Median survival rate is 3-5 months
• Role of surgery is very less
• Mainstay of treatment is chemoradiotherapy

104. ANAPLASTIC CARCINOMA
• Typical radiation doses would be hyperfractionated 60–70 Gy
in 40–45 fractions over 4–5 weeks or daily fractions such as
60–70 Gy in 30–35 fractions
• Chemotherapeutic agents the taxanes (paclitaxel or
docetaxel), doxorubicin and cisplatin have the greatest clinical
effect. Docetaxel (60 mg/m2 i.v. every 3 weeks) can stabilize
disease for a time and rarely results in a complete response

105. REFEENCE
Scott brown 8th ed
Thyroid and parathyroid – Thieme
ATA guidenlines
Sataloff ENT head and neck