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GOITER
DR SYED UBAID
Associate professor of surgery
INTRODUCTION
Diseases of the thyroid gland invariably leads
to enlargement of the gland.
The term GOITER is applied to a...
GOITER
 The normal thyroid gland is impalpable. The term
goitre (from the Latin guttur = the throat) is used to
describe ...
Causes of thyroid disease
inflammatory
Acute
Subacute
chronic
toxic
Primary
secondary
autoimmune
Hashimoto
Reidel thyroidi...
Classification of thyroid swellings
 Simple goitre (euthyroid)
 Toxic goiter
 Neoplastic
 Inflammatory
 Other (Amyloi...
Classification of thyroid swellings
 Simple goitre (euthyroid)
1.Physiological
Pubertal ,Pregnancy
2.Diffuse hyperplastic...
Classification of thyroid swellings
Inflammatory
1. Autoimmune
Chronic lymphocytic thyroiditis Hashimoto’s
disease
2.Granu...
Simple goiter
Aetiology
Simple goitre may develop as a result of stimulation of the
thyroid gland by TSH,
 Inappropriate ...
Simple goiter
 There is chronic deficiency of Thyroxine (T4) and or
triiodotrynine (T3) in the body which in turn causes
...
Classification of simple goiter
simple diffuse goiter
simple colloid goiter
simple nodular goiter
Pathophysiology
Chronic absence of T4/T3 causes elevated
level of TSH, which then leads to diffuse
homogenous hypertrophy...
Pathophysiology
Differential response to TSH leads to
formation of nodules within the gland.
Several nodules may coalesc...
Clinical presentation
Gradual onset of painless anterior neck
swelling, usually long standing in
endemically iodine defic...
Clinical presentation
• Obstruction of airways
• Laryngeal nerve compression
• Esophageal obstruction
• Neck veins obstruc...
Investigation in simple goiter
Thyroid function test
– thyroxine (T4),
– tri iodothyronine (T3),
– thyroid stimulating hor...
Thyroid scan with radioactive iodine
(I123 or I131)
• In this investigation a traceable radioactive Iodine or
Technetium i...
Antithyroid receptors antibodies
This type of investigation is done
in patients suspected to have
stimulatory auto antibod...
Radiological investigations
Normal AP and lateral
chest X-rays may
demonstrate
retrosternal extension
of the goiter
(retro...
Thoracic inlet X-rays
may demonstrate
compression or
deviation of the
trachea, this
important to
anesthetist if surgery
is...
USG NECK
Thyroid is homogeneous & slightly hyperechoic.
The normal thyroid gland is 2 cm or less in both the transverse
dimension and depth, and is 4.5–5.5 cm in length& 0.5 mm i...
A diffusely enlarged thyroid gland with an isthmus width
of 1.5 cm.
Computed tomography
may be indicated if
more details are
needed before surgery
or there is suspicion of
malignancy
transfo...
Fine needle aspiration cytology
To rule out malignancy of thyroid.
benign,
malignant,
suspicious malignant,
inconclus...
Treatment and prevention of simple
goiter
Dietary
• Iodine supplementation in iodine deficient
areas, food iodine fortific...
Surgery indications
In patients with obstructive
symptoms,
When malignancy is suspected
clinically or after FNAC,
Hyper...
Hypothyroidism is a condition
characterized by abnormally low
thyroid hormone production.
Because thyroid hormone affect...
 Medications and food (GOITROGENS)
 Pituitary or hypothalamic disease
 Severe iodine deficiency
 Thyroid destruction (...
DRUGS
Anti-thyroid
Cough medicines
Sulfonamides
Lithium
Phenylbutazone
PAS
iodine
Oral hypoglycemic agents
GOITROG...
FOOD
Soybeans
Millet
Cassava
Cabbage
Excess iodine or lithium ingestion, which
decrease release of thyroid hormone
GO...
Goitrogens(cassava, lima beans, maize, bamboo
shoots, and sweet potatoes)
In this condition, the thyroid gland is usually
enlarged (goiter) and has a decreased ability
to make thyroid hormones.
...
Increased antibodies to the enzyme, thyroid
peroxidase (anti-TPO antibodies).
Patient with Hashimoto's thyroiditis has o...
The likelihood of this depends on a number of
factors including the dose of iodine given,
along with the size and the act...
If for some reason the pituitary gland or the
hypothalamus are unable to signal the thyroid
and instruct it to produce th...
 A pituitary injury may result after brain surgery or if
there has been a decrease of blood supply to the
area. In these ...
• In areas of the world where there is an iodine
deficiency in the diet, severe hypothyroidism
can be seen in 5% to 15% of...
 The symptoms of hypothyroidism are often subtle.
They are not specific (which means they can mimic
the symptoms of many ...
 Fatigue
 Depression
 Modest weight gain
 Cold intolerance
 Excessive sleepiness
 Dry, coarse hair
 Constipation
 ...
• As the disease becomes more severe, there
may be puffiness around the eyes, a
slowing of the heart rate, a drop in body
...
www.freelivedoctor.com
A diagnosis of hypothyroidism can be suspected
in patients with fatigue, cold intolerance,
constipation, and dry, flaky s...
 Thyroid stimulating hormone (TSH) assays are the
most sensitive screening tool for primary
hypothyroidism.
 The general...
Treatment of hypothyroidism requires life-long
levothyroxine (T4) therapy.
This is a more stable form of thyroid hormone...
Cretinism
 Hypothyroidism developing in infancy/early
childhood
 Severe mental retardation occurs in iodine
deficient ar...
Cretinism
Clinical features:
 Impaired skeletal development
 Impaired CNS development
 Inadequate maternal thyroid horm...
www.freelivedoctor.com
Toxic goiter, thyrotoxicosis or
hyperthyroidism
 Hyperthyroidism is a condition in which an overactive
thyroid gland is p...
Causes of hyperthyroidism
 Graves' Disease
 Functioning adenoma ("hot nodule") and
toxic multinodular goiter (TMNG)
 Ex...
Primary hyperthyroidism
Grave’s disease
Graves’s disease is an autoimmune disease of
the thyroid gland, in which there is...
Primary hyperthyroidism
Grave’s disease
These antibodies include
– thyroid stimulating immunoglobulin (TSI
antibodies),
– ...
Primary hyperthyroidism
Grave’s disease
Graves' disease is hereditary and is up to five
times more common among women than...
The triggers for Grave's disease include:
stress,
smoking,
radiation to the neck,
medications,
Infectious organisms s...
In patients with secondary hyperthyroidism,
there is a pre existing thyroid pathology for
example goiter or inflammatory ...
In this form of secondary hyperthyroidism,
there is hypersecreting toxic nodule in the
background of multinodular goiter ...
• This form of secondary hyperthyroidism
is characterized by presence of benign
glandular nodule in the thyroid gland,
usu...
• In this form of secondary hyperthyroidism,
there is a hormone producing tumor
elsewhere in the body.
• For example metas...
In this form, excess hormone has been
introduced into the body.
An example is what is called thyrotoxicosis
factitious w...
• This is another cause of excess thyroid
hormone production; an adenoma in the
pituitary gland (which normally controls
t...
Post viral thyroiditis with transient self limiting
thyrotoxicosis (Subacute de Quervain’
thyroiditis); this form of hype...
Inflammation of the thyroid gland may occur
after a viral illness (Subacute thyroiditis).
This condition is associated w...
Central nervous system
Central nervous system features are very
common in patients with primary
thyrotoxicosis.
tremors ...
Increased metabolic rate
weight loss,
 heat intolerance,
excessive sweating, and
tiredness cause by muscle weakness
as...
Cardiovascular;
very common in patients with secondary
hyperthyroidism.
They include
awareness of heart beats (palpitat...
Gastro intestinal tract (GIT);
loss of body weight despite having good or
increased appetite, and
increase bowel motions...
Genital urinary tract (GUT)
irregular menstruation,
amenorrhea,
loss of libido and
erectile dysfunctions
Ophthalmological features
Eye symptoms as is the case for central
nervous system are common in Grave’s
disease.
Eye prot...
True exophthalmos :
actual protrusion of the eyeballs.
It is an autoimmune disease
Infiltration of retro bulbar tissue wit...
B. Certain eye signs :
1. Stellwag's sign :
Staring look with infrequent blinking.
2.Dalrymple's sign :
rim of sclera is s...
Exophthalmos can lead to
exposure conjunctivitis,
keratitis (corneal ulceration) and
perforation.
Ophthalmoplegia or ...
Grave’s Opthalmopathy
• Class 0 — No symptoms or signs
• Class I — Only signs, no symptoms
(eg, lid retraction, stare, lid...
Clinical features Primary
Hyperthyroidism (Grave’s)
Secondary
Hyperthyroidism (Plumer)
Age Young age Elderly
Onset Abrupt ...
 A rare presentation of thyrotoxicosis, there is extreme
signs of thyrotoxicosis associated with severe metabolic
disturb...
1. Medical treatment
2. Symptomatic treatment
3. Antithyroid treatment
Treatment of thyrotoxicosis
Medications which either target the thyroid
hormones or symptoms.
Indications include;
primary thyrotoxicosis in small ...
• This targets central nervous system and
cardiovascular symptoms.
• Beta adrenergic blockers are the mainstay of
symptoma...
Fevers are treated with cooling measures
and antipyretics.
Intravenous glucocorticoids are indicated if
adrenal insuffic...
These drugs either blocks iodine binding to
tyrosine and decrease antibody titers
(Carbimazole) or block iodine binding a...
Antithyroid drugs
Inhibitors of hormone synthesis
1.Propylthiouracil (PTU)
2.Methimazole (Tapazole)
Blockade of hormone ...
• The drug of choice
• Recommended as DOC for women who are
pregnant or breastfeeding.
• Dosage:
– HYPERTHYROIDSM:
• 300 –...
• THYROTOXIC CRISES:
– Initial 200 – 300 mg PO q4 – 6hr initially on day 1
(may require 800 – 1200mg/day),
– Then reduce g...
All patients must be euthyroid before
embarking in surgery, ECG, CXR, and
Echocardiogram must be done to rule out
arrhyth...
 Graves disease in young,
 large gland or in patients with exophthalmos,
 multi-nodular or solitary nodule,
 unrespons...
Subtotal thyroidectomy; leaves about 8-10 gram
of thyroid tissue, either 4-5gram on each side or
8-10 gram on one side.
...
Hemorrhage
• Primary is a type of bleeding which occur
during surgery due to arterial or venous cut,
• Reactionary bleedin...
Respiratory obstruction
• Apart from hematoma formation, the
following can also cause airway obstruction
post thyroidectom...
Recurrent laryngeal nerve injury
• Recurrent laryngeal nerve injury can be
– unilateral leading to hoarseness of voice &
d...
Superior laryngeal nerve damage
• Superior laryngeal nerve injury may also
occur in difficult surgery,
• loss of function ...
Thyroid insufficiency
Thyroid insufficiency following
thyroidectomy may occur 2 to 5 years later,
it may occurs as high as...
Parathyroid insufficiency
• Hypoparathyroidism occurs when both parathyroid
glands are accidentally traumatized, devascula...
Keloid scar and hypertrophic scars
• Keloid and hypertrophic scars are late
complication of thyroidectomy, occurring
sever...
Hematoma and bleeding
• This is one of the most common complications
in thyroid surgery. When suspected, reopen the
wound ...
Respiratory obstruction and recurrent
laryngeal nerve damage
• Intubate the patient immediately if
obstruction is severe, ...
Hypoparathyroidism
• Symptoms and signs of hypocalcaemia
include circumoral paresthesias, mental
status changes, tetany, c...
Thyroid storm
• Supportive measures which includes IV
fluids ice packs and antipyretics, oxygen
mask 8litres per second, a...
Retrosternal goiter
What is Retrosternal goiter
• a goitre with a portion of its mass located in
the mediastinum
Why
 Primary intra-thoracic goitres arise from aberrant thyroid tissue
which is ectopically located in the mediastinum, r...
Types
• Plunging goiter : rise with deglutition and then
descent again through the thoracic inlet
• Mediastinal goiter : l...
How
• Short-necked individuals
• Usually after middle age
• Intrathracic goiter more common in men
Symptoms
• May remain symptomless for years
• Dyspnea due to displacing and compressing on
the trachea
• The Dyspnea aggra...
Signs
• Inspection
Signs
• Palpation : thyroid gland enlarged
Signs
• Percussion of the sternum may reveal
retrosternal dullness
Investigations
• X-ray
Investigations
 X-ray
Investigations
• CT
Investigations
• CT
Investigations
• CT
Investigations
• Tc99m
Investigations
• Fiberscope
Treatment
• Thyroidectomy is the only line of treatment
• Mostly via cervical approach , rarely a median
sternotmy is requ...
Thank you!!
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dr syed ubaid associate professor of surgery

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  1. 1. GOITER DR SYED UBAID Associate professor of surgery
  2. 2. INTRODUCTION Diseases of the thyroid gland invariably leads to enlargement of the gland. The term GOITER is applied to any enlargement of the thyroid gland regardless of the cause.
  3. 3. GOITER  The normal thyroid gland is impalpable. The term goitre (from the Latin guttur = the throat) is used to describe generalised enlargement of the thyroid gland.  A discrete swelling (nodule) in one lobe with no palpable abnormality elsewhere is termed an isolated (or solitary) swelling.  Discrete swellings with evidence of abnormality elsewhere in the gland are termed dominant nodule.
  4. 4. Causes of thyroid disease inflammatory Acute Subacute chronic toxic Primary secondary autoimmune Hashimoto Reidel thyroiditis simple Physiological Colloidal nodular neoplastic Benign malignant
  5. 5. Classification of thyroid swellings  Simple goitre (euthyroid)  Toxic goiter  Neoplastic  Inflammatory  Other (Amyloid)
  6. 6. Classification of thyroid swellings  Simple goitre (euthyroid) 1.Physiological Pubertal ,Pregnancy 2.Diffuse hyperplastic Multinodular goitre  Toxic goiter 1.Diffuse (Graves’ disease) 2.Multinodular 3.Toxic adenoma  Neoplastic 1.Benign 2.Malignant
  7. 7. Classification of thyroid swellings Inflammatory 1. Autoimmune Chronic lymphocytic thyroiditis Hashimoto’s disease 2.Granulomatous (De Quervain’s thyroiditis) 3. Fibrosing (Riedel’s thyroiditis) 4. Infective Acute (bacterial thyroiditis,viral thyroiditis, ‘subacute thyroiditis’) Chronic (tuberculous, syphilitic)
  8. 8. Simple goiter Aetiology Simple goitre may develop as a result of stimulation of the thyroid gland by TSH,  Inappropriate secretion from the anterior pituitary a microadenoma  In response to a chronically low level of circulating thyroid hormones. 1. The most important factor in endemic goitre is dietary deficiency of iodine, Goitrogens in food. 2. Defective hormone synthesis (Dyshormonogenesis) probably accounts for many sporadic goitres.
  9. 9. Simple goiter  There is chronic deficiency of Thyroxine (T4) and or triiodotrynine (T3) in the body which in turn causes compensatory elevation of TSH because of the lack of necessary negative feedback.  Prolonged stimulation of TSH in attempt to bring normal thyroid hormones level leads to simple goiter.  Such phenomenon may occur in the following settings; physiological e.g. puberty, pregnancy, lactation Iodine deficiency Enzymatic deficiency for example in Pendred’s syndrome which is caused by peroxidase deficiency,
  10. 10. Classification of simple goiter simple diffuse goiter simple colloid goiter simple nodular goiter
  11. 11. Pathophysiology Chronic absence of T4/T3 causes elevated level of TSH, which then leads to diffuse homogenous hypertrophy and hyperplasia of follicular cells and colloid (secretory follicles) in efforts to produces more thyroid hormones. This is usually a reversible change. The enlarged thyroid hyper involuted with colloid is called colloid goiter.
  12. 12. Pathophysiology Differential response to TSH leads to formation of nodules within the gland. Several nodules may coalesce and lead to formation of multinodular goiter. The nodules may undergo secondary changes; central necrosis, cystic degeneration, hemorrhage, calcification and malignant changes (3%).
  13. 13. Clinical presentation Gradual onset of painless anterior neck swelling, usually long standing in endemically iodine deficient areas. Recent onset of pain or increase in size may indicate secondary changes. The enlarged gland may also affect neighboring structures and lead to wide range of symptoms and signs.
  14. 14. Clinical presentation • Obstruction of airways • Laryngeal nerve compression • Esophageal obstruction • Neck veins obstruction • Superior vena cava syndrome (Pemberton’s sign).
  15. 15. Investigation in simple goiter Thyroid function test – thyroxine (T4), – tri iodothyronine (T3), – thyroid stimulating hormones (TSH) – thyrotropin releasing hormone (TRH). • This helps to know if the thyroid gland is normally, hyper or hypo functioning.
  16. 16. Thyroid scan with radioactive iodine (I123 or I131) • In this investigation a traceable radioactive Iodine or Technetium is injected into the blood stream, the thyroid gland concentrates radioactive iodine. • The concentrated radioactive iodine can be detected by gamma camera. • I123 has a shorter half life as compared to I131 and therefore preferred because it has less exposure of the patient to radiation. • Thyroid scan may show hot nodules (which takes more radioactive iodine than the rest of gland) in secondary hyperthyroidism, however most simple goiters have normal uptake or Cold nodules (which does not take radioactive iodine). • Cold nodules are likely to be malignant.
  17. 17. Antithyroid receptors antibodies This type of investigation is done in patients suspected to have stimulatory auto antibodies as is the case in Grave’s disease (primary hyperthyroidism).
  18. 18. Radiological investigations Normal AP and lateral chest X-rays may demonstrate retrosternal extension of the goiter (retrosternal shadow)
  19. 19. Thoracic inlet X-rays may demonstrate compression or deviation of the trachea, this important to anesthetist if surgery is contemplated (difficult intubation).
  20. 20. USG NECK Thyroid is homogeneous & slightly hyperechoic.
  21. 21. The normal thyroid gland is 2 cm or less in both the transverse dimension and depth, and is 4.5–5.5 cm in length& 0.5 mm ithmus.
  22. 22. A diffusely enlarged thyroid gland with an isthmus width of 1.5 cm.
  23. 23. Computed tomography may be indicated if more details are needed before surgery or there is suspicion of malignancy transformation.
  24. 24. Fine needle aspiration cytology To rule out malignancy of thyroid. benign, malignant, suspicious malignant, inconclusive or inadequate aspirate. If follicular pattern is seen, lobectomy is done to exclude follicular carcinoma, because the can only be differentiated by demonstrating capsular invasion.
  25. 25. Treatment and prevention of simple goiter Dietary • Iodine supplementation in iodine deficient areas, food iodine fortification is one of the best preventive measures of goiters. Medical Thyroxin supplementation • In patients with diffuse hyperplastic goiter for several months (0.1 to 0.2mg per day).
  26. 26. Surgery indications In patients with obstructive symptoms, When malignancy is suspected clinically or after FNAC, Hyper functioning nodules For cosmetic reasons
  27. 27. Hypothyroidism is a condition characterized by abnormally low thyroid hormone production. Because thyroid hormone affects growth, development, and many cellular processes, inadequate thyroid hormone has widespread consequences for the body. HYPOTHYROIDSM
  28. 28.  Medications and food (GOITROGENS)  Pituitary or hypothalamic disease  Severe iodine deficiency  Thyroid destruction (from radioactive iodine or surgery)  Hashimoto's thyroiditis  Lymphocytic thyroiditis (which may occur after hyperthyroidism) Aetiology
  29. 29. DRUGS Anti-thyroid Cough medicines Sulfonamides Lithium Phenylbutazone PAS iodine Oral hypoglycemic agents GOITROGENS
  30. 30. FOOD Soybeans Millet Cassava Cabbage Excess iodine or lithium ingestion, which decrease release of thyroid hormone GOITROGENS
  31. 31. Goitrogens(cassava, lima beans, maize, bamboo shoots, and sweet potatoes)
  32. 32. In this condition, the thyroid gland is usually enlarged (goiter) and has a decreased ability to make thyroid hormones. Hashimoto's is an autoimmune disease in which the body's immune system inappropriately attacks the thyroid tissue. Hashimoto's is 5 to 10 times more common in women than in men Hashimoto's thyroiditis
  33. 33. Increased antibodies to the enzyme, thyroid peroxidase (anti-TPO antibodies). Patient with Hashimoto's thyroiditis has one or more other autoimmune diseases such as diabetes or pernicious anemia Hashimoto's can be identified by detecting anti-TPO antibodies in the blood Hashimoto's thyroiditis
  34. 34. The likelihood of this depends on a number of factors including the dose of iodine given, along with the size and the activity of the thyroid gland. If there is no significant activity of the thyroid gland six months after the radioactive iodine treatment, it is usually assumed that the thyroid will no longer function adequately. The result is hypothyroidism. Similarly, removal of the thyroid gland during surgery will be followed by hypothyroidism. Thyroid destruction secondary to radioactive iodine or surgery
  35. 35. If for some reason the pituitary gland or the hypothalamus are unable to signal the thyroid and instruct it to produce thyroid hormones, a decreased level of circulating T4 and T3 may result, even if the thyroid gland itself is normal. If this defect is caused by pituitary disease, the condition is called "secondary hypothyroidism." If the defect is due to hypothalamic disease, it is called "tertiary hypothyroidism." Pituitary or Hypothalamic disease
  36. 36.  A pituitary injury may result after brain surgery or if there has been a decrease of blood supply to the area. In these cases of pituitary injury, the TSH that is produced by the pituitary gland is deficient and blood levels of TSH are low.  Hypothyroidism results because the thyroid gland is no longer stimulated by the pituitary TSH. This form of hypothyroidism can, therefore, be distinguished from hypothyroidism that is caused by thyroid gland disease, in which the TSH level becomes elevated as the pituitary gland attempts to encourage thyroid hormone production by stimulating the thyroid gland with more TSH. Pituitary injury
  37. 37. • In areas of the world where there is an iodine deficiency in the diet, severe hypothyroidism can be seen in 5% to 15% of the population. Severe iodine deficiency:
  38. 38.  The symptoms of hypothyroidism are often subtle. They are not specific (which means they can mimic the symptoms of many other conditions) and are often attributed to aging.  Patients with mild hypothyroidism may have no signs or symptoms.  The symptoms generally become more obvious as the condition worsens and the majority of these complaints are related to a metabolic slowing of the body. Symptoms of hypothyroidsm
  39. 39.  Fatigue  Depression  Modest weight gain  Cold intolerance  Excessive sleepiness  Dry, coarse hair  Constipation  Dry skin  Muscle cramps  Increased cholesterol levels  Decreased concentration  Vague aches and pains  Swelling of the legs Common symptoms
  40. 40. • As the disease becomes more severe, there may be puffiness around the eyes, a slowing of the heart rate, a drop in body temperature, and heart failure. • In its most profound form, severe hypothyroidism may lead to a life- threatening coma (myxedema coma). • In a severely hypothyroid individual, a myxedema coma tends to be triggered by severe illness, surgery, stress, or traumatic injury.
  41. 41. www.freelivedoctor.com
  42. 42. A diagnosis of hypothyroidism can be suspected in patients with fatigue, cold intolerance, constipation, and dry, flaky skin. A blood test is needed to confirm the diagnosis. When hypothyroidism is present, the blood levels of thyroid hormones can be measured directly and are usually decreased. However, in early hypothyroidism, the level of thyroid hormones (T3 and T4) may be normal. Diagnosis of hypothyroidism
  43. 43.  Thyroid stimulating hormone (TSH) assays are the most sensitive screening tool for primary hypothyroidism.  The generally accepted reference range for normal serum TSH is 0.40 – 4.2 mlU/L.  If the levels are above the reference range then the next step is to measure free Thyroxine (T4).  Patients with primary hypothyroidism usually have elevated TSH levels and decreased free hormone levels.  In patients with hypothalamic or pituitary dysfunction, TSH levels do not increase in appropriate relation to the low free T4 levels
  44. 44. Treatment of hypothyroidism requires life-long levothyroxine (T4) therapy. This is a more stable form of thyroid hormone and requires once a day dosing, whereas T3 is much shorter-acting and needs to be taken multiple times a day. Synthetic T4 is readily and steadily converted to T3 naturally in the bloodstream, 100 to 150 micrograms per day Treatment of hypothyroidism
  45. 45. Cretinism  Hypothyroidism developing in infancy/early childhood  Severe mental retardation occurs in iodine deficient areas of world (i.e., Himalayas, inland China, Africa)  May also be sporadic, owing to enzyme deficiencies   thyroid hormone synthesis
  46. 46. Cretinism Clinical features:  Impaired skeletal development  Impaired CNS development  Inadequate maternal thyroid hormone prior to fetal thyroid gland formation  SEVERE mental retardation  Normal brain development if maternal thyroid deficiency occurs after fetal thyroid gland development
  47. 47. www.freelivedoctor.com
  48. 48. Toxic goiter, thyrotoxicosis or hyperthyroidism  Hyperthyroidism is a condition in which an overactive thyroid gland is producing an excessive amount of thyroid hormones that circulate in the blood.  Thyrotoxicosis is a toxic condition that is caused by an excess of thyroid hormones from any cause.  Thyrotoxicosis can be caused by an excessive intake of thyroid hormone or by overproduction of thyroid hormones by the thyroid gland.  Hyperthyroidism can be primary or secondary depending on the etiology.
  49. 49. Causes of hyperthyroidism  Graves' Disease  Functioning adenoma ("hot nodule") and toxic multinodular goiter (TMNG)  Excessive intake of thyroid hormones  Abnormal secretion of TSH  Thyroiditis (inflammation of the thyroid gland)  Excessive iodine intake
  50. 50. Primary hyperthyroidism Grave’s disease Graves’s disease is an autoimmune disease of the thyroid gland, in which there is a circulating autoantibody which resembles TSH. The autoantibody binds to and stimulates G- protein coupled thyrotropin receptors on thyroid gland leading to thyroid hormone release and hyperplasia.
  51. 51. Primary hyperthyroidism Grave’s disease These antibodies include – thyroid stimulating immunoglobulin (TSI antibodies), – thyroid peroxidase antibodies (TPO), and – TSH receptor antibodies
  52. 52. Primary hyperthyroidism Grave’s disease Graves' disease is hereditary and is up to five times more common among women than men Female: male ratio is 9:1 Grave’s disease tends to affect young than older women It causes about two third of all cases of hyperthyroidism These antibodies also react with retrobulbar auto antigens to cause periorbital edema and protrusion of eye ball (exophthalmos).
  53. 53. The triggers for Grave's disease include: stress, smoking, radiation to the neck, medications, Infectious organisms such as viruses.
  54. 54. In patients with secondary hyperthyroidism, there is a pre existing thyroid pathology for example goiter or inflammatory condition which leads to excess production of thyroid hormones or there is an extra thyroid source of hormone production. Secondary hyperthyroidism has high predilection to involve cardiovascular system Secondary hyperthyroidism
  55. 55. In this form of secondary hyperthyroidism, there is hypersecreting toxic nodule in the background of multinodular goiter (Plummer’s disease); This tends to occur in iodine deficient areas (endemic goiters). Multinodular goiter
  56. 56. • This form of secondary hyperthyroidism is characterized by presence of benign glandular nodule in the thyroid gland, usually follicular which secrets excess hormones. Toxic adenoma
  57. 57. • In this form of secondary hyperthyroidism, there is a hormone producing tumor elsewhere in the body. • For example metastatic follicular thyroid carcinoma, choriocarcinoma which produces β-hCG whose alpha chain resembles TSH and thyroid tissue containing teratoma. • The excess thyroid hormones lead to clinical features typical of hyperthyroidism. Ectopic thyroid hormone
  58. 58. In this form, excess hormone has been introduced into the body. An example is what is called thyrotoxicosis factitious which is due to excess intake of thyroxine hormone and Jod-Basedow which is caused by excessive intake of iodine in endemic goiter. Exogenous causes
  59. 59. • This is another cause of excess thyroid hormone production; an adenoma in the pituitary gland (which normally controls the thyroid gland) produces TSH which in turn leads to excess T4 and T3. TSH producing pituitary adenoma
  60. 60. Post viral thyroiditis with transient self limiting thyrotoxicosis (Subacute de Quervain’ thyroiditis); this form of hyperthyroidism is usually painful and may be associated with other systemic symptoms. Radiation induced thyroiditis with release of preformed thyroid hormones is commonly seen in patients undergoing neck radiation Other causes
  61. 61. Inflammation of the thyroid gland may occur after a viral illness (Subacute thyroiditis). This condition is associated with a fever and a sore throat that is often painful on swallowing. The thyroid gland is also tender to touch. There may be generalized neck aches and pains. Inflammation of the gland with an accumulation of white blood cells known as lymphocytes (lymphocytic thyroiditis) may also occur. Thyroiditis
  62. 62. Central nervous system Central nervous system features are very common in patients with primary thyrotoxicosis. tremors which can be observed on the tongue and fingers, nervousness, emotional liability (patients become irritated easily), they may also be lethargic or agitated and usually they have warm and moist hands. Clinical features of hyperthyroidism
  63. 63. Increased metabolic rate weight loss,  heat intolerance, excessive sweating, and tiredness cause by muscle weakness as a result of proteolysis.
  64. 64. Cardiovascular; very common in patients with secondary hyperthyroidism. They include awareness of heart beats (palpitation) due to tonic and chronic effect of excess thyroid hormones, irregular heartbeats (arrhythmia), sleeping tachycardia, high output heart failure and thyroid bruit due to excess blood flow to the gland.
  65. 65. Gastro intestinal tract (GIT); loss of body weight despite having good or increased appetite, and increase bowel motions (diarrhea).
  66. 66. Genital urinary tract (GUT) irregular menstruation, amenorrhea, loss of libido and erectile dysfunctions
  67. 67. Ophthalmological features Eye symptoms as is the case for central nervous system are common in Grave’s disease. Eye protrusion or exophthalmos can be true when it is caused by retrobulbar cellular infiltration and mucopolysaccharide depositions or false exophthalmos when it is caused by elevation of superior eye rid due to hyper activity of levator pulpebral superioris muscle or Muller muscle. The later is caused by increased sympathetic tone.
  68. 68. True exophthalmos : actual protrusion of the eyeballs. It is an autoimmune disease Infiltration of retro bulbar tissue with inflammatory cells & accumulation of inflammatory fluids. Probably due to cross- reaction of thyroid antigen & eye (Schwartz ) C.T showing infiltration of Retro bulbar spaces True exophthalmos
  69. 69. B. Certain eye signs : 1. Stellwag's sign : Staring look with infrequent blinking. 2.Dalrymple's sign : rim of sclera is seen between cornea and the upper lid. 3.Von Graef's sign : Lagging of the upper eye lid 4.Joffroy's sign : Loss of forehead corrugation when looking up 5. Moebius' sign : Lack of convergence (due to ocular myopathy )
  70. 70. Exophthalmos can lead to exposure conjunctivitis, keratitis (corneal ulceration) and perforation. Ophthalmoplegia or eye paralysis can be caused by cellular infiltration. Ophthalmoplegia can be bilateral or unilateral and can be associated with diplopia (double vision).
  71. 71. Grave’s Opthalmopathy • Class 0 — No symptoms or signs • Class I — Only signs, no symptoms (eg, lid retraction, stare, lid lag) • Class II — Soft tissue involvement • Class III — Proptosis • Class IV — Extraocular muscle involvement • Class V — Corneal involvement • Class VI — Sight loss (optic nerve involvement)
  72. 72. Clinical features Primary Hyperthyroidism (Grave’s) Secondary Hyperthyroidism (Plumer) Age Young age Elderly Onset Abrupt Gradual Course Remissions & exacerbations Steady course Nervous symptoms +++ + Metabolic manifestations +++ + Eye signs +++ FALSE CV manifestations + +++ Thyroid gland Diffuse Nodular
  73. 73.  A rare presentation of thyrotoxicosis, there is extreme signs of thyrotoxicosis associated with severe metabolic disturbances.  It occurs in patient with hyperthyroidism who has not been well prepared (hyperthyroidism is not controlled) before surgery.  It may also occur in patients with major stress eg major trauma and infection.  Clinical features includes;  hyper-thermia,  tachycardia,  irritability,  profuse sweating and  diarrhea. Thyroid storm (thyrotoxic crisis)
  74. 74. 1. Medical treatment 2. Symptomatic treatment 3. Antithyroid treatment Treatment of thyrotoxicosis
  75. 75. Medications which either target the thyroid hormones or symptoms. Indications include; primary thyrotoxicosis in small gland, primary thyrotoxicosis in young age, pre-operative preparation, post-operative recurrence and patient’s refusal of surgery. Medical treatment
  76. 76. • This targets central nervous system and cardiovascular symptoms. • Beta adrenergic blockers are the mainstay of symptomatic therapy for thyrotoxicosis. • Propranolol in range of 40mg twice or thrice a day has been used with greatest success due to additional benefit of inhibition of peripheral conversion of T4 to T3 Symptomatic treatment
  77. 77. Fevers are treated with cooling measures and antipyretics. Intravenous glucocorticoids are indicated if adrenal insufficiency is suspected. Aggressive hydration of up to 3 – 5 L/d of crystalloid compensates for potentially profound GI and insensible losses. Charcoal hemoperfusion has been shown to be effective in treatment of iatrogenic or intentional ingestion of excessive doses of levothyroxine
  78. 78. These drugs either blocks iodine binding to tyrosine and decrease antibody titers (Carbimazole) or block iodine binding and prevent conversion of T4 to T3 (propylthiouracil). Antithyroid treatment
  79. 79. Antithyroid drugs Inhibitors of hormone synthesis 1.Propylthiouracil (PTU) 2.Methimazole (Tapazole) Blockade of hormone release Lopanoic acid Saturated solution of potassium iodide Lugol solution
  80. 80. • The drug of choice • Recommended as DOC for women who are pregnant or breastfeeding. • Dosage: – HYPERTHYROIDSM: • 300 – 450 mg/day 8 hrly initially (may require up to 600 – 900 mg/day) • Maintenance: 100 – 150 mg/day 8hrly Propylthiouracil (PTU)
  81. 81. • THYROTOXIC CRISES: – Initial 200 – 300 mg PO q4 – 6hr initially on day 1 (may require 800 – 1200mg/day), – Then reduce gradually – Some practitioners propose an initial dose of 600 – 1000mg with gradual dose reduction after initial response. – Maintenance: 100 – 150mg/day PO divided q8 – 12hr • GRAVES DISEASE: – 50 – 150mg PO initially – Maintenance: 50mg PO q8 – 12hr for up to 12 – 18 months, then taper and discontinue if TSH is normal
  82. 82. All patients must be euthyroid before embarking in surgery, ECG, CXR, and Echocardiogram must be done to rule out arrhythmia and heart failure. Thoracic inlet X-ray in huge goiters to rule tracheal deviation and compression as discussed above. Lugol’s iodine reduces risk of hemorrhage. Surgical treatment
  83. 83.  Graves disease in young,  large gland or in patients with exophthalmos,  multi-nodular or solitary nodule,  unresponsive, poor compliance to medical treatment and when there is contraindication to drug e.g. hypersensitivity. Indications for surgical intervention
  84. 84. Subtotal thyroidectomy; leaves about 8-10 gram of thyroid tissue, either 4-5gram on each side or 8-10 gram on one side. Near total thyroidectomy removes nearly all thyroid tissue leaving only about 4gm thyroid tissue; Lobectomy removes the entire lobe one side with isthmusectomy eg in solitary toxic nodule; Partial thyroidectomy; bilateral partial lobectomy eg in multinodular toxic goiter involving both lobes. Types of surgery
  85. 85. Hemorrhage • Primary is a type of bleeding which occur during surgery due to arterial or venous cut, • Reactionary bleeding occurs when a patient’s blood pressure comes to normal after waning of hypotensive anesthetic drugs or due to pain and • Secondary bleeding which occurs 7 days to 2 weeks after surgery, usually due to infection of wound. Complication of thyroid surgery
  86. 86. Respiratory obstruction • Apart from hematoma formation, the following can also cause airway obstruction post thyroidectomy period; – traumatic laryngeal oedema, – bilateral recurrent laryngeal nerve injury leading to vocal cords paralysis, especially in patients with huge thyroid complicated by difficult surgery, – tracheomalacia occurs in patients with huge goiters or those with retrosternal extension.
  87. 87. Recurrent laryngeal nerve injury • Recurrent laryngeal nerve injury can be – unilateral leading to hoarseness of voice & dyspnea on exertion, – bilateral incomplete in which the patient can present with stridor (due to irritation of adductor fibers) – bilateral complete with voice loss (aphonia).
  88. 88. Superior laryngeal nerve damage • Superior laryngeal nerve injury may also occur in difficult surgery, • loss of function of this nerve leads to loss of high pitched voice (cricopharyngius paralysis).
  89. 89. Thyroid insufficiency Thyroid insufficiency following thyroidectomy may occur 2 to 5 years later, it may occurs as high as 20 to 45% in patients who have undergone total thyroidectomy
  90. 90. Parathyroid insufficiency • Hypoparathyroidism occurs when both parathyroid glands are accidentally traumatized, devascularized or damaged. • If seen after removal, the glands must be reimplanted on deltoid muscles or sternocleidomastoid muscles. • The incidence of hypoparthyroidisim occurs in less than 0.5% of all patients underwent thyroidectomy. • Parathyroid hormone is responsible for calcium homeostasis (increases GIT calcium reabsorbtion, resorbs bone, reduces renal calcium excretion and enhances phosphorus renal excretion). In absence causes hypocalcaemia.
  91. 91. Keloid scar and hypertrophic scars • Keloid and hypertrophic scars are late complication of thyroidectomy, occurring several years after surgery. • The two can be differentiated because the former forms mass which crosses an incision line and the later does usually cross the incision line.
  92. 92. Hematoma and bleeding • This is one of the most common complications in thyroid surgery. When suspected, reopen the wound immediately and ligate any bleeding vessel (wound exploration and bleeder ligation). • Such treatment should start at bed side if bleeding is severe or when hematoma is obstructive. • Give IV fluids using large bore canula and transfuse if necessary. Management of some important post operative complications
  93. 93. Respiratory obstruction and recurrent laryngeal nerve damage • Intubate the patient immediately if obstruction is severe, or • perform cricothyroidotomy if intubation is not convenient. • Ventilate or give high flow oxygen 8 L/second and make sure an intravenous line is established with crystalloids.
  94. 94. Hypoparathyroidism • Symptoms and signs of hypocalcaemia include circumoral paresthesias, mental status changes, tetany, carpopedal spasm, laryngospasm, seizures, QT prolongation on ECG, and cardiac arrest. • In such condition, a patient is given IV 10mls of 10% Calcium Gluconate over 10 minutes, or calcium carbonate 2.5g to 5g orally.
  95. 95. Thyroid storm • Supportive measures which includes IV fluids ice packs and antipyretics, oxygen mask 8litres per second, and sedatatives. • Specific treatment include giving propranolol 1mg IV as drip repeated if needed, oral Carbimazole or propylthiouracil and Digoxin if heart failure is diagnosed.
  96. 96. Retrosternal goiter
  97. 97. What is Retrosternal goiter • a goitre with a portion of its mass located in the mediastinum
  98. 98. Why  Primary intra-thoracic goitres arise from aberrant thyroid tissue which is ectopically located in the mediastinum, receive their blood supply from mediastinal vessels and are not connected to the cervical thyroid. They are rare, representing less than 1% of all RGs  Secondary RGs develop from the thyroid located in its normal cervical site. Downward migration of the thyroid into the mediastinum is facilitated by negative intra-thoracic pressure, gravity, traction forces during swallowing and the presence of anatomical barriers preventing the enlargement in other directions (thyroid cartilage, vertebral bodies, strap muscles, especially in patients with a short, large neck). These secondary RGs are, characteristically, in continuity with the cervical portion of the gland and receive their blood supply, depending on cervical vessels, almost always through branches of the inferior thyroid artery.
  99. 99. Types • Plunging goiter : rise with deglutition and then descent again through the thoracic inlet • Mediastinal goiter : lie wholly in the chest but are connected with the thyroid and supplied by thyroid vessels through narrow band • Intrathracic goiter : lie wholly in the chest but completely separated from the gland supplied by mediastinal vessels
  100. 100. How • Short-necked individuals • Usually after middle age • Intrathracic goiter more common in men
  101. 101. Symptoms • May remain symptomless for years • Dyspnea due to displacing and compressing on the trachea • The Dyspnea aggravated by any posture that reduces the thoracic inlet as lying down or flexion the neck • The patient prefer to spend the night in a chair • Some time they miss diagnosed as asthmatic • Sometimes there is dysphagia
  102. 102. Signs • Inspection
  103. 103. Signs • Palpation : thyroid gland enlarged
  104. 104. Signs • Percussion of the sternum may reveal retrosternal dullness
  105. 105. Investigations • X-ray
  106. 106. Investigations  X-ray
  107. 107. Investigations • CT
  108. 108. Investigations • CT
  109. 109. Investigations • CT
  110. 110. Investigations • Tc99m
  111. 111. Investigations • Fiberscope
  112. 112. Treatment • Thyroidectomy is the only line of treatment • Mostly via cervical approach , rarely a median sternotmy is required • Devascularization is done via the neck from which the retrosternal portion derived its blood supply • Special care should be exerted to avoid injury of the recurrent laryngeal nerves during the delivery of retrosternal goter
  113. 113. Thank you!!

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