Hashimoto's thyroiditis is a chronic autoimmune thyroid disorder characterized by the presence of goiter and hypothyroidism. It is caused by antibodies attacking the thyroid and impairing its function. The main symptoms are those of hypothyroidism like fatigue and weight gain. Treatment involves lifelong thyroid hormone replacement therapy via levothyroxine to manage hypothyroidism. Surgery may be indicated for large goiters causing obstruction, suspicious nodules, symptoms refractory to medication, or cosmetic reasons. Fine needle aspiration is important to screen for thyroid cancer.

1. Hashimoto`s thyroiditis
from surgical point of view
By
Abdallah Rashad Temerik , M.Sc ,MRCSEd
Assistant lecturer of general surgery
Assiut University Hospital 2023

2.  Autoimmune Hashimoto’s thyroiditis is a chronic autoimmune
thyroid disorder characterized by the presence of goiter in many
cases, hypothyroidism in several cases and the presence of
antibodies to thyroid antigens in the blood.
 Autoimmune thyroiditis affects 5–7 times more women than
men, The most commonly affected age range in Hashimoto
thyroiditis is 30-50 years .

3. Etiology
 The initiating process in Hashimoto thyroiditis is not well
understood.
 Antibodies as anti-thyroid peroxidase (anti-TPO),
antithyroglobulin (anti-Tg) lead to impairment in thyroid
function……The result is inadequate thyroid hormone
production and secretion, although initially, preformed T4 and
T3 may "leak" into the circulation from damaged cells.
 Hashimoto thyroiditis has a markedly higher association with
other autoimmune diseases, including pernicious anemia,
adrenal insufficiency, celiac disease, and type 1 diabetes
mellitus.

4.  Elevated levels of iodide in the diet are associated with autoimmune
thyroid disease as prevalence of antithyroid antibodies has been
observed to be high in residents in areas with iodine excess.
 Autoimmune thyroiditis (Hashimoto's disease) is less common in
susceptible individuals who live in regions with dietary iodine deficiency

5.  A study by Mazokopakis et al indicated that an association
may exist between vitamin D deficiency and the
development of Hashimoto thyroiditis. The study, which
included 218 patients with Hashimoto thyroiditis, found
serum 25-hydroxy vitamin D levels to be negatively
correlated with anti-TPO levels in all patients, with the anti-
TPO levels being significantly greater in the 186 patients who
were vitamin D deficient. After receiving oral vitamin D3
supplementation for 4 months, serum anti-TPO levels in the
vitamin D deficient patients were determined to be
significantly reduced.

6. Clinical presentation
 Hypothyroidism is usually insidious in onset, with signs and symptoms
slowly progressing over months to years. Most commonly, patients do
not relate a history suggestive of transient hyperthyroidism secondary to
increased T4 and T3 levels resulting from thyrocyte destruction.
 The presentation of patients with hypothyroidism may be subclinical,
without any symptoms, and may be found simply from routine screening
of thyroid function. The usual finding is an elevated TSH level. The early
compensatory increase in TSH tends to maintain a nearly normal thyroid
function and keeps the patient in a euthyroid state.

7. Clinical presentation
 The most frequent clinical findings in chronic autoimmune thyroiditis
are goiter and hypothyroidism or both.
 The thyroid gland is typically enlarged, firm, and rubbery, without
any tenderness. However, it may be normal in size or not palpable at
all.
 Common, early presenting symptoms of hypothyroidism, such as
fatigue, constipation, dry skin, and weight gain.
 Other symptoms of hypothyroidism include the following: Cold
intolerance, Slowed movement and loss of energy, depression,
dementia and Hair loss from an autoimmune process.

8. Physical Examination
 Bradycardia
 Puffy face and periorbital edema typical of hypothyroid facies
 Hair loss involving the scalp, the lateral third of the eyebrows,
and possibly skin, genital, and facial hair.
 Peripheral edema of hands and feet, typically nonpitting
 Thickened and brittle nails

9. Workup for diagnosis
 Serum TSH Test :- This is a sensitive test of thyroid function;
levels are raised in Hashimoto thyroiditis and is usually the initial
laboratory abnormality detected as the pituitary gland attempts
to increase thyroid hormone production from the failing thyroid
gland.
 Free T4 and T3 levels.
 Thyroid autoantibodies :- The presence of thyroid
autoantibodies, typically anti-thyroid peroxidase (anti-TPO) and
antithyroglobulin (anti-Tg)). , delineates the cause of
hypothyroidism as Hashimoto thyroiditis or its variant. However,
10-15% of patients with Hashimoto thyroiditis may be antibody
negative.

10. Ultrasonography and FNAC
 it is useful for assessing thyroid size, echotexture, and, most
importantly, confirming the presence of a thyroid nodule, in
defining a nodule as solid or cystic, and benign or malignant.
 Ultrasonography is useful in facilitating fine-needle aspiration of
nodules. Then, a definite diagnosis of benign versus malignant
thyroid lesion can be confirmed only by cytologic or histologic
examination of thyroid tissue.

11. Hashimoto`s thyroiditis and malignancy
Nodules suspicious for malignancy
 Ultrasonography show signs suggestive of malignancy, such as
irregular margins, a poorly defined halo, micro calcification, and
increased vascularity on Doppler.
 rapid growth of the nodule
 symptoms of local infiltration such as voice hoarseness, dysphagia
or dyspnea
 If the nodule is hard, irregular, attached to the neighboring tissues
or there are enlarged lymph nodes.
 The possibility of malignancy in a nodule is increased in young and
older ages, especially in male patients
 History of radiation in the head or neck and chest.

12. Hashimoto`s thyroiditis and malignancy
 A study conducted by Nys et al. in 165 cases of Hashimoto thyroiditis
with nodules or pseudonodules found 4% differentiated thyroid cancer
and 1% non-Hodgkin’s lymphoma.
 The risk for papillary thyroid carcinoma is increased in patients with
Hashimoto thyroiditis.
 (Indeed, a prospective study by Silva de Morais et al indicated that any
patient with Hashimoto thyroiditis presenting for thyroid nodule
evaluation has a greater risk of malignancy than do patients without
Hashimoto thyroiditis who present with nodules [23.3% vs 15.9%,
respectively].)

13. Hashimoto`s thyroiditis and malignancy
 a study by Liang et al suggested that in patients with papillary thyroid
carcinoma, those with concurrent Hashimoto thyroiditis have a better
prognosis than do patients without it.
 Subjects with both papillary thyroid carcinoma and Hashimoto
thyroiditis tended to have a smaller tumor size, a less advanced TNM
stage, and a decreased lymph node metastasis rate.

14. Hashimoto`s thyroiditis and malignancy
 A literature review by Travaglino et al found that with regard to
evidence of the presence of Hashimoto thyroiditis, the pooled
prevalence was 78.9% in patients with primary thyroid lymphoma.
 A significantly higher prevalence of Hashimoto thyroiditis was found in
patients with mucosa-associated lymphoid tissue (MALT) lymphoma or
with mixed MALT/diffuse large B-cell lymphoma (DLBCL) than in those
with DLBCL alone.

15. Treatment
 The treatment of choice for Hashimoto thyroiditis (or
hypothyroidism from any cause) is thyroid hormone replacement.
The drug of choice is orally administered levothyroxine sodium,
usually for life.
 Upon the initiation of the levothyroxine replacement therapy, check
thyroid function tests, specifically TSH, initially every 6-8 weeks as
dose adjustments are made. After the attainment of the clinical
euthyroid state and a normal TSH level, patients and the TSH levels
may be checked every 6-12 months.

16.  patients are on medications, such as ferrous sulfate, calcium
supplementation, and multivitamins, that have the potential to
impair the absorption of levothyroxine and therefore to affect the
TSH level. Patients need to be advised to separate these
medications from levothyroxine by at least 4 hours.
 Although glucocorticoid therapy can modulate the thyroiditis and
acutely improve thyroid function the risk associated with the dose
and duration of such therapy is considered to outweigh the
benefit.

17. Complications of overreplacement with levothyroxine
sodium Include the following:
 Accelerated bone loss
 Reduction in bone mineral density
 Osteoporosis
 Increased heart rate
 Increased cardiac wall thickness
 Increased contractility
 increase the risk of cardiac arrhythmias (especially atrial
fibrillation), particularly in the elderly population.

18. Indications for surgery in hashimoto`s
thyroiditis
A large goiter with obstructive symptoms, such as
dysphagia, voice hoarseness, and stridor, caused by
extrinsic obstruction of airflow.
Presence of a malignant nodule - As found by
cytologic examination via fine-needle aspiration

19. Indications for surgery in hashimoto`s
thyroiditis
Inability to rule out malignancy in prescence of
nodules or rapid growth.
Local symptoms refractory to LT4 therapy.
Cosmetic reasons - For large goiters.

20.  Total thyroidectomy is the technique of choice in
surgical treatment of Hashimoto’s thyroiditis which
warrants a radical and definitive control of the
disease, without any risk of relapse

21. Take home message
 Perform fine-needle aspiration of any dominant or suspicious thyroid
nodules to exclude malignancy or the presence of a thyroid
lymphoma
 The treatment of choice for Hashimoto thyroiditis is thyroid
hormone replacement.
 Indications for surgery in hashimoto`s thyroiditis:- A large goiter with
obstructive symptoms , Presence of a malignant or suspicious
nodule, symptoms refractory to LT4 therapy and Cosmetic reasons