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THYROID CASE
PRESENTATION
Dr. TARAKA KRISHNA
MBBS; MS, EFIAGES, FIAGES,FISCP
EX FELLOW IN SURGICAL ONCOLOGY,
TATA
EXAM CASES
 Multinodular goiter
 Solitary nodule
 Carcinoma thyroid
 1. History of complaints
 2. History of pressure effects
 3. History of toxicosis
 4. History of hypothyroidism
 5. History of malignancy
Swelling
1. Onset
2. Duration
3. Rate of growth
 Slow growing - Papillary carcinoma,
Follicular carcinoma
 Fast growing - Anaplastic carcinoma
thyroid case presentation.pptx Kamala's Lakshaman palatial
thyroid case presentation.pptx Kamala's Lakshaman palatial
Pain
Goiter is usually painless.
 Pain is seen in cases of:
1. Hemorrhage
2. Malignancy infiltrating the nerves
3. Thyroiditis
4. Anaplastic carcinoma
Pressure Effects
1. History of dyspnea or stridor
2. History of dysphagia
3. History of hoarseness of voice
4. History of syncope
History of suggestive of Horner’s
syndrome
– Ptosis
– Miosis
– Anhidrosis
– Enophthalmosis
Dyspnea in thyroid
 Tracheomalacia in long standing MNG
 Retrosternal extension
 Cardiac failure due to secondary
thyrotoxicosis
 Infiltration by anaplastic carcinoma.
Hoarseness of voice
 Infiltration of recurrent laryngeal nerve
by malignancy.
 Edema of vocal cord.
History of Thyrotoxicosis
History of common to thyrotoxicosis:
 Excessive sweating
 Loss of weight in spite of good
appetite
 Heat intolerance
 Diarrhea
 Amenorrhea (decreased
menstruation)
History of primary thyrotoxicosis:
Thyroid swelling and toxic features
appear simultaneously in primary
thyrotoxicosis
 1. Mainly CNS symptoms
– Tremor
– Insomnia
– Muscle weakness
 2. Eye signs are common
– Exopthalmos
– Double vision
History of secondary thyrotoxicosis:
Mainly cardiovascular system symptoms
• – Palpitations
• - Ectopic beats
• – Cardiac arrhythmias
• – Dyspnea on exertion
• – Chest pain
• – Edema of ankle
• – Congestive cardiac failure.
History of Hypothyroidism
 Decrease in appetite but increase in
weight
 Hoarseness of voice
 Falling hair (lateral eyebrows)
 Constipation
 Cold intolerance
 Menorrhagia followed later by
amenorrhea (due to anemia)
History of Malignancy
 Bone pain (Bone)
 Dyspnea; cough with hemoptysis
(lung)
 Loss of weight and loss of appetite
 History of Jaundice (liver)
PAST HISTORY
 History of diabetes, hypertension,
ischemic heart disease, bronchial
asthma;
 History of previous surgery
 History of drugs (Antithyroid drugs,
thyroxine, sulfonyl ureas)
 History of irradiation in childhood
(leads to papillary carcinoma)
History of irradiation
Used for treatment of
1. Tinea capitis
2. Thymic enlargement
3. Enlarged tonsils and adenoids
4. Acne vulgaris
5. Hemangioma
6. Hodgkin disease
PERSONAL HISTORY
 History of consuming vegetables
(Brassica family, cabbages)
 History of smoking , alcohol.
Menstrual History
 Oligomenorrhea—hyperthyroidism
 Menorrhagia—hypothyroidism.
Family History
 Deficiency goiter
 Dyshormonogenetic goiter
 Medullary carcinoma of thyroid (MEN
IIa, IIb).
General Examination
 General condition
 Anemia
 Nourishment
 Lymphadenopathy
 Blood pressure
 Pulse rate
Criles grading of pulse rate
 Sleeping pulse rate measured after
giving phenobarbitone
 Grade I : 90 to 100/mt
 Grade II : 100 to 110/mt
 Grade III : >110/mt
LOCAL EXAMINATION
 Inspection
 Swelling
 Number
 Site—front of neck
 Size
 Shape—butterfly shaped/Hemispherical
(for Solitary nodules)
 Surface
 Skin over the swelling
 Plane of the swelling
 Pulsation
 Movement with deglutition*
 Movement with protrusion of tongue*
 Look for the lower border of swelling
 Retrosternal goiter
SVC compression Dilatation of
subcutaneous veins over anterior part
of upper thorax
Pemberton sign: to diagnose
retrosternal goiter compression
Raise both arm over head, until they
touch the ears, Maintain the position
for a while Congestion of face and
distress occurs due to obstruction of
great veins of thorax
thyroid case presentation.pptx Kamala's Lakshaman palatial
 On stretching the deep fascia by
extending the neck, swelling becomes
more prominent.
 Trial’s sign: for trachealm position
 prominence of sternocleidomastoid on
the side of deviation of trachea.
 Pizzilo’s method :
 In case of obese and short necked
individuals Ask the patient to keep the
hands behind the head and ask to
push head backwards against clasped
hand on occiput.
thyroid case presentation.pptx Kamala's Lakshaman palatial
 Lahey’s method:
To palpate right lobe push the right lobe
with right hand to right side and
palpate with left hand
 Crile’s method : Place the thumb on
the thyroid while the patient swallows;
this method is used to diagnose
doubtful nodules
thyroid case presentation.pptx Kamala's Lakshaman palatial
1. Surface : Smooth - Colloid goiter, Grave’s
disease
Bosselated - Multinodular goiter
2. Consistency :
o Soft - Colloid goiter, Graves disease
o Firm - SNG, MNG
o Hard - Carcinoma, Riedel’s thyroiditis
3. Mobility : Restricted in malignancy and
chronic thyroiditis
4. Palpate the lower border:
thyroid case presentation.pptx Kamala's Lakshaman palatial
5. Pressure effects:
 Trachea - Kocher’s test
 (Slight push on lateral lobes will produce stridor in case
of obstructed trachea.)
 Carotid artery - Carotid sheath is pushed back by
benign swelling where carotid pulsations felt.
 Sympathetic trunk - Horners syndrome
 - Enophthalmos
 - Miosis
 - Anhidrosis
 - Ptosis
 Palpate for thrill
thyroid case presentation.pptx Kamala's Lakshaman palatial
 Berry’s sign Malignant thyroid engulfs
the carotid sheath completely hence
pulsation not felt.
 PERCUSSION
 Over manubrium to Rule out Retrosternal
extension.
thyroid case presentation.pptx Kamala's Lakshaman palatial
 Lateral aberrant thyroid: These are
metastatic lymph nodes from an occult
papillary carcinoma of thyroid.
Tremors
 In the tongue (with tongue inside the oral
cavity—should not ask the patient to
protrude the tongue for tremors) and
outstretched hands.
Diagnosis
 Anatomical diagnosis :
MNG/SNG/Diffuse
 Functional diagnosis :
Toxic/Euthyroid/Hypothyroid
 Pathological diagnosis :
Benign/Malignant
INVESTIGATIONS
I. Routine
 Hb percent, TC, DC, ESR, BT, CT
 Urine albumin, sugar, deposits
 Blood urea, sugar, blood
grouping/typing
 X-ray chest
 ECG all leads
II. Specific
 X-ray neck AP/lateral view
 ENT examination
 Sleeping pulse rate
 USG—neck
 Thyroid assay—(thyroid profile)
 Serum calcium
III. For individual cases
 Fine needle aspiration cytology
 Radioactive iodine uptake study
 Thyroid antibodies
 Thyroglobulin
 Lymph node biopsy—to Rule out
malignancy
 Thyroid scan
USG neck
To differentiate
 Cystic or solid swelling
 Multinodular or solitary nodular
 To find nodes
X-ray of neck
1. Position of trachea
2. Retrosternal extension
3. Cervical spondylosis
4. Calcifications -
i. Benign dystrophic
ii. Psammoma bodies
5. Barium swallow X-ray (esophagus
compression)
6. Metastasis to skull
Fine Needle Aspiration
Cytology
 Procedure : • Using 23G/24 G needle
Indications : • Solitary nodule thyroid
 Multinodular thyroid
 To Rule out malignancy
Contraindication : Thyrotoxicosis
 FNAC cannot differentiate follicular adenoma
and carcinoma, because the differentiation is
based on capsular invasion.
Radioactive Iodine Uptake
Study
Indications:
1. Doubtful toxicity
2. Ectopic thyroid
3. Autonomous toxic nodule
4. To L/f secondaries in follicular carcinoma after
thyroidectomy.
5. Retrosternal thyroid
Therapeutic uses:
1. Primary thyrotoxicosis >45 years of age.
2. Autonomous thyroid nodule >45 years age.
3. Secondaries in cases of postoperative Follicular
carcinoma I131 can be given.
Indications
1. Solitary nodule
2. Retrosternal goiter
3. Ectopic thyroid tissue
4. Thyroglossal cyst—to find whether the normal
thyroid is present or the cyst is the only thyroid
tissue.
Inference
1. Hot nodule—increased activity than
surrounding, e.g. thyrotoxicosis
2. Warm nodule—same activity as in the
surrounding.
3. Cold nodule—decreased activity than
surrounding
For example: Malignancy, Hemorrhage inside
the colloid degeneration, Post - FNAC.
Indirect Laryngoscopy
 Three percent of individuals may have
silent paralysis of one vocal cord.
 Other cord may be compensating so
far in such cases.
 Medico-legally this must be noted.
1. What are the swellings that move
with deglutition?
i. Thyroid
ii. Thyroglossal cyst
iii. Subhyoid bursitis
iv. Nodes attached to larynx and trachea
v. Laryngocele
2. Why does thyroid swelling move with
deglutition?
i. Pretracheal fascia encloses the
thyroid and gets attached to hyoid
ii. Ligament of Berry—thickened
pretracheal fascia postero-medially
attached above to cricoid cartilage.
iii. Isthmus has some attachment with
trachea directly.
3. Name the conditions where thyroid
swelling has restricted movement with
deglutition?
i. Anaplastic carcinoma
ii. Fixation due to previous surgery
iii. Retrosternal goiter
iv. Riedel’s thyroiditis
Tell the differential diagnosis of solitary nodule
thyroid:
i. Colloid goiter (Most common cause)
ii. Adenoma thyroid: Autonomous functioning of
the nodule without any stimulation by TSH or
thyroid stimulating antibodies.
iii. Dominant nodule of multinodular goiter
iv. Cyst
v. Carcinoma thyroid
vi. Lymphoma
vii. Thyroiditis-Hashimoto’s, Riedel’s, De
Auervain’s
Treatment
 1. Antithyroid drugs
 2. Radioactive iodine
 3. Surgery
THANK YOU

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thyroid case presentation.pptx Kamala's Lakshaman palatial

  • 1. THYROID CASE PRESENTATION Dr. TARAKA KRISHNA MBBS; MS, EFIAGES, FIAGES,FISCP EX FELLOW IN SURGICAL ONCOLOGY, TATA
  • 2. EXAM CASES  Multinodular goiter  Solitary nodule  Carcinoma thyroid
  • 3.  1. History of complaints  2. History of pressure effects  3. History of toxicosis  4. History of hypothyroidism  5. History of malignancy
  • 4. Swelling 1. Onset 2. Duration 3. Rate of growth  Slow growing - Papillary carcinoma, Follicular carcinoma  Fast growing - Anaplastic carcinoma
  • 7. Pain Goiter is usually painless.  Pain is seen in cases of: 1. Hemorrhage 2. Malignancy infiltrating the nerves 3. Thyroiditis 4. Anaplastic carcinoma
  • 8. Pressure Effects 1. History of dyspnea or stridor 2. History of dysphagia 3. History of hoarseness of voice 4. History of syncope
  • 9. History of suggestive of Horner’s syndrome – Ptosis – Miosis – Anhidrosis – Enophthalmosis
  • 10. Dyspnea in thyroid  Tracheomalacia in long standing MNG  Retrosternal extension  Cardiac failure due to secondary thyrotoxicosis  Infiltration by anaplastic carcinoma.
  • 11. Hoarseness of voice  Infiltration of recurrent laryngeal nerve by malignancy.  Edema of vocal cord.
  • 12. History of Thyrotoxicosis History of common to thyrotoxicosis:  Excessive sweating  Loss of weight in spite of good appetite  Heat intolerance  Diarrhea  Amenorrhea (decreased menstruation)
  • 13. History of primary thyrotoxicosis: Thyroid swelling and toxic features appear simultaneously in primary thyrotoxicosis
  • 14.  1. Mainly CNS symptoms – Tremor – Insomnia – Muscle weakness  2. Eye signs are common – Exopthalmos – Double vision
  • 15. History of secondary thyrotoxicosis: Mainly cardiovascular system symptoms • – Palpitations • - Ectopic beats • – Cardiac arrhythmias • – Dyspnea on exertion • – Chest pain • – Edema of ankle • – Congestive cardiac failure.
  • 16. History of Hypothyroidism  Decrease in appetite but increase in weight  Hoarseness of voice  Falling hair (lateral eyebrows)  Constipation  Cold intolerance  Menorrhagia followed later by amenorrhea (due to anemia)
  • 17. History of Malignancy  Bone pain (Bone)  Dyspnea; cough with hemoptysis (lung)  Loss of weight and loss of appetite  History of Jaundice (liver)
  • 18. PAST HISTORY  History of diabetes, hypertension, ischemic heart disease, bronchial asthma;  History of previous surgery  History of drugs (Antithyroid drugs, thyroxine, sulfonyl ureas)  History of irradiation in childhood (leads to papillary carcinoma)
  • 19. History of irradiation Used for treatment of 1. Tinea capitis 2. Thymic enlargement 3. Enlarged tonsils and adenoids 4. Acne vulgaris 5. Hemangioma 6. Hodgkin disease
  • 20. PERSONAL HISTORY  History of consuming vegetables (Brassica family, cabbages)  History of smoking , alcohol. Menstrual History  Oligomenorrhea—hyperthyroidism  Menorrhagia—hypothyroidism.
  • 21. Family History  Deficiency goiter  Dyshormonogenetic goiter  Medullary carcinoma of thyroid (MEN IIa, IIb).
  • 22. General Examination  General condition  Anemia  Nourishment  Lymphadenopathy  Blood pressure  Pulse rate
  • 23. Criles grading of pulse rate  Sleeping pulse rate measured after giving phenobarbitone  Grade I : 90 to 100/mt  Grade II : 100 to 110/mt  Grade III : >110/mt
  • 24. LOCAL EXAMINATION  Inspection  Swelling  Number  Site—front of neck  Size  Shape—butterfly shaped/Hemispherical (for Solitary nodules)  Surface  Skin over the swelling
  • 25.  Plane of the swelling  Pulsation  Movement with deglutition*  Movement with protrusion of tongue*  Look for the lower border of swelling
  • 26.  Retrosternal goiter SVC compression Dilatation of subcutaneous veins over anterior part of upper thorax
  • 27. Pemberton sign: to diagnose retrosternal goiter compression Raise both arm over head, until they touch the ears, Maintain the position for a while Congestion of face and distress occurs due to obstruction of great veins of thorax
  • 29.  On stretching the deep fascia by extending the neck, swelling becomes more prominent.  Trial’s sign: for trachealm position  prominence of sternocleidomastoid on the side of deviation of trachea.
  • 30.  Pizzilo’s method :  In case of obese and short necked individuals Ask the patient to keep the hands behind the head and ask to push head backwards against clasped hand on occiput.
  • 32.  Lahey’s method: To palpate right lobe push the right lobe with right hand to right side and palpate with left hand  Crile’s method : Place the thumb on the thyroid while the patient swallows; this method is used to diagnose doubtful nodules
  • 34. 1. Surface : Smooth - Colloid goiter, Grave’s disease Bosselated - Multinodular goiter 2. Consistency : o Soft - Colloid goiter, Graves disease o Firm - SNG, MNG o Hard - Carcinoma, Riedel’s thyroiditis 3. Mobility : Restricted in malignancy and chronic thyroiditis 4. Palpate the lower border:
  • 36. 5. Pressure effects:  Trachea - Kocher’s test  (Slight push on lateral lobes will produce stridor in case of obstructed trachea.)  Carotid artery - Carotid sheath is pushed back by benign swelling where carotid pulsations felt.  Sympathetic trunk - Horners syndrome  - Enophthalmos  - Miosis  - Anhidrosis  - Ptosis  Palpate for thrill
  • 38.  Berry’s sign Malignant thyroid engulfs the carotid sheath completely hence pulsation not felt.
  • 39.  PERCUSSION  Over manubrium to Rule out Retrosternal extension.
  • 41.  Lateral aberrant thyroid: These are metastatic lymph nodes from an occult papillary carcinoma of thyroid. Tremors  In the tongue (with tongue inside the oral cavity—should not ask the patient to protrude the tongue for tremors) and outstretched hands.
  • 42. Diagnosis  Anatomical diagnosis : MNG/SNG/Diffuse  Functional diagnosis : Toxic/Euthyroid/Hypothyroid  Pathological diagnosis : Benign/Malignant
  • 43. INVESTIGATIONS I. Routine  Hb percent, TC, DC, ESR, BT, CT  Urine albumin, sugar, deposits  Blood urea, sugar, blood grouping/typing  X-ray chest  ECG all leads
  • 44. II. Specific  X-ray neck AP/lateral view  ENT examination  Sleeping pulse rate  USG—neck  Thyroid assay—(thyroid profile)  Serum calcium
  • 45. III. For individual cases  Fine needle aspiration cytology  Radioactive iodine uptake study  Thyroid antibodies  Thyroglobulin  Lymph node biopsy—to Rule out malignancy  Thyroid scan
  • 46. USG neck To differentiate  Cystic or solid swelling  Multinodular or solitary nodular  To find nodes
  • 47. X-ray of neck 1. Position of trachea 2. Retrosternal extension 3. Cervical spondylosis 4. Calcifications - i. Benign dystrophic ii. Psammoma bodies 5. Barium swallow X-ray (esophagus compression) 6. Metastasis to skull
  • 48. Fine Needle Aspiration Cytology  Procedure : • Using 23G/24 G needle Indications : • Solitary nodule thyroid  Multinodular thyroid  To Rule out malignancy Contraindication : Thyrotoxicosis  FNAC cannot differentiate follicular adenoma and carcinoma, because the differentiation is based on capsular invasion.
  • 49. Radioactive Iodine Uptake Study Indications: 1. Doubtful toxicity 2. Ectopic thyroid 3. Autonomous toxic nodule 4. To L/f secondaries in follicular carcinoma after thyroidectomy. 5. Retrosternal thyroid Therapeutic uses: 1. Primary thyrotoxicosis >45 years of age. 2. Autonomous thyroid nodule >45 years age. 3. Secondaries in cases of postoperative Follicular carcinoma I131 can be given.
  • 50. Indications 1. Solitary nodule 2. Retrosternal goiter 3. Ectopic thyroid tissue 4. Thyroglossal cyst—to find whether the normal thyroid is present or the cyst is the only thyroid tissue.
  • 51. Inference 1. Hot nodule—increased activity than surrounding, e.g. thyrotoxicosis 2. Warm nodule—same activity as in the surrounding. 3. Cold nodule—decreased activity than surrounding For example: Malignancy, Hemorrhage inside the colloid degeneration, Post - FNAC.
  • 52. Indirect Laryngoscopy  Three percent of individuals may have silent paralysis of one vocal cord.  Other cord may be compensating so far in such cases.  Medico-legally this must be noted.
  • 53. 1. What are the swellings that move with deglutition? i. Thyroid ii. Thyroglossal cyst iii. Subhyoid bursitis iv. Nodes attached to larynx and trachea v. Laryngocele
  • 54. 2. Why does thyroid swelling move with deglutition? i. Pretracheal fascia encloses the thyroid and gets attached to hyoid ii. Ligament of Berry—thickened pretracheal fascia postero-medially attached above to cricoid cartilage. iii. Isthmus has some attachment with trachea directly.
  • 55. 3. Name the conditions where thyroid swelling has restricted movement with deglutition? i. Anaplastic carcinoma ii. Fixation due to previous surgery iii. Retrosternal goiter iv. Riedel’s thyroiditis
  • 56. Tell the differential diagnosis of solitary nodule thyroid: i. Colloid goiter (Most common cause) ii. Adenoma thyroid: Autonomous functioning of the nodule without any stimulation by TSH or thyroid stimulating antibodies. iii. Dominant nodule of multinodular goiter iv. Cyst v. Carcinoma thyroid vi. Lymphoma vii. Thyroiditis-Hashimoto’s, Riedel’s, De Auervain’s
  • 57. Treatment  1. Antithyroid drugs  2. Radioactive iodine  3. Surgery