GOITRE MANAGEMENT

1. CMT06210: Apprenticeship in Internal
Medicine
Session 3 : Goitre
Total Sessio time: 120 minutes
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2. Learning tasks
At the end of this session, students are expected to be able
to:
• Define of goitre
• Explain etiology/risk factors of goitre
• Explain classification of goitre
• Explain clinical features of goitre
• Explain the management of goitre
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3. Activity: Brainstorming
• What is goitre?
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4. Definition
Goitre
• Enlargement of The Thyroid Gland (Local or Diffuse)
• Based on Hyperplasia Or Degeneration.
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5. Classification
• Diffuse Goitre.
• Multi-Nodular Goitre.
• Solitary Thyroid Nodule.
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6. Diffuse Goitre
• More Commonly Non-Toxic.
• May be Toxic.
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7. Diffuse Non-Toxic Goitre
• Compensatory Hypertrophy & Hyperplasia due to Decrease in
T3 & T4.
• Diffusely Involves Whole Gland.
• Not Associated With Hypo or
Hyperthyroidism.
• Age between 15-25 yrs
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8. Activity: Brainstorming
• What are the causes Diffuse Non-Toxic Goitre?
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9. Causes (1)
• Physiological Goitre:
o Puberty or Pregnancy.
• Dietary Iodine Deficiency:
o In Areas Far From Sea.
• Dietary Goitrous Agents:
o Cabbage & Turnips.
o Calcium or Flouride in water.
o Lithium, Phenylbutazone, Thiouracil, Carbimazole.
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10. Causes (2)
• Hereditary.
• Treated Graves’ Disease.
• Rare Cause:
o Lymphoma.
o Anaplastic.
o Thyroiditis (Autoimmune or de-Quervain’s).
o Amyloidosis.
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11. Treatment
• Small:
– No Treatment.
– Reassurance.
– Iodine Support.
• Large/Pressure Symptoms or Cosmesis:
– Near-Total Thyroidectomy.
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12. Fate (of Diffuse Non-Toxic Goitre)
• Revert to Normal.
• Stays the Same.
• Progress to Multi-Nodular Goitre.
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13. Multi-Nodular Goitre
• Progression from Diffuse Simple Goitre.
• Upto 2 kg.
• Multinodular Focal Hyperplasia.
• Mostly Euthyroid.
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14. Causes
• Progressive Enlargement of Diffuse Goitre.
• Sporadic.
• Previous Irradiation to Neck.
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15. Clinical Presentation
• Discomfort..
• Irritating Cough.
• Dysphagia.
• Features of Hyperthyroidism.
• Hoarseness of voice.
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16. Treatment
• Medical
oThyroxine if hypothyroidism present
• Surgery:
oTotal Thyroidectomy or
oNear-Total Thyroidectomy.
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17. Solitary Thyroid Nodule
• 5% of Adult Population.
• 50% Large Nodule in multi nodular goitre.
• 50% True Solitary.
• 80% are Adenomas.
• 10% Carcinomas.
• 10% Cyst / Fibrosis / Thyroiditis
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18. Management
• Full Clinical Assessment including;
• Thyroid function tests (TSH, T3 and T4)
• Thyroid ultrasound.
• Final needle aspiration biopsy to exclude malignancy
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19. Treatment
• Colloid Cyst:
o Repeat FNAC & Reassurance.
• Simple Cyst:
o <4cm→ Reassurance.
o >4cm → Lobectomy.
• Follicular Cells:
o Lobectomy → Completion Thyroidectomy.
• Papillary Carcinoma:
o Total Thyroidectomy.
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20. Investigating Thyroid
• Thyroid function tests (TSH, T3 and T4)
• Thyroid ultrasound.
• Final needle aspiration biopsy to exclude
malignancyAntibodies.
• Serum Cholesterol.
• CXR.
• Iodine Isotope Scan.
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21. Key Points
• Toxic Goitre are Rarely Malignant.
• All Solitary Goitre Need to Exclude Malignancy.
• Surgery is Rarely Needed in Autoimmune or Inflammatory
Thyroid Disease.
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22. Evaluation
• What are the etiology of simple goitre?
• Which type of goitre require thorough investigations?
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