BENIGN THYROID

Case 1

36 F Pampanga

• Enlarging Left Anterior Neck Mass

Chief Complaint: Anterior Neck Mass

• Easy Fatigability• Palpitations• Weight Loss• Consulted a physician

• Prescribed with medications• Provided symptom relief

7 Years PTA

1 Year PTA

ADMISSION

PHYSICAL EXAMINATION• PR = 90/min• RR = 20/min• T = 37 C• No Exophthalmos• Neck:

– Multilobulated firm left mass

– Moves with deglutition– 12 x 10 cm

Salient FeaturesPERTINENT POSITIVE PERTINENT NEGATIVE

•Enlarging left anterior neck mass•Easy fatigability•Palpitations•Weight loss•Neck: - 12 x 10 cm - left,firm,multilobulated - moves with deglutition

•No exophthalmos•No fever•Non tender neck mass•No weight gain•No cold intolerance•No memory impairment•No constipation•No underlying autoimmune disease•No history of intake of high iodine load•No history of hormone intake

DIFFERENTIAL DIAGNOSIS

Anterior neck mass

GOITER

HYPERTHYROIDISM

HYPOTHYROIDISM

GROWTH(Non toxic Goiter)

HYPERTHYROIDISM HYPOTHYROIDISM PATIENT

•Nervousness•Irritability•Heat Intolerance•Palpitations•Tachycardia•Weightloss•Tremor•Easy fatigability•Alterations in appetite•Diarrhea•Dyspnea•Sleep disturbances (insomnia)•Thyroid enlargement (depending on the cause)•Pretibial myxedema•Exophthalmos

•Weight gain•Cold intolerance•Constipation•Memory impairment•Bradycardia•Hypothermia•Loss of hair•Easy fatigability•Reflex delay•Thyroid enlargement

•Thyroid enlargement•Easy fatigability•Palpitations•Weight loss

Anterior neck mass

GOITER

HYPERTHYROIDISM

HYPOTHYROIDISM

GROWTH(Non toxic Goiter)

HYPERTHYROIDISIM

• CAUSES:– Diffuse toxic goiter (Grave’s disease)– Toxic multinodular goiter (Plummer’s disease)– Toxic adenoma– Jod Basedow hyperthyroidism – iodine induced– Subacute thyroiditis (De quervain’s thyroiditis)– Painless thyroiditis– Factitious hyperthyroidism (hormone induced)

TOXIC GOITER

DIFFUSE NODULAR

OTHERS

-DIFFUSE TOXIC GOITER -TOXIC MULTINODULAR GOITER-TOXIC ADENOMA

-SUB ACUTE THYROIDITIS-PAINLESS THYROIDITIS-JOD BASEDOW HYPERTHYROIDISM-FACTITIOUS HYPERTHYROIDISM

SUB ACUTE THYROIDITIS

PAINLESS THYROIDITIS

JOD -BASEDOW HYPERTHYROIDISM

FACTITIOUS HYPERTHYROIDISM

•Viral infection•History of URTI•Hyperthyroidism due to leakage•Self limiting•Tender enlarged thyroid gland•Fever

•Patients with underlying autoimmune disease•Common among post partum women•Painless goiter

•Occurs most often in older population•Iodine Induced•History of intake of high iodine load (medications, contrast agents)

•History of hormone intake, bangkok pills

•Elevated T3 and T4•Low TSH•Diminished RAI uptake

•Elevated T3 and T4•Low TSH•Diminshed RAI uptake

•Diminished RAI uptake •Very low or absent thyroglobulin level

•No fever•Enlarged NON tender thyroid gland•No underlying autoimmune disease•No history of intake of high iodine load•No history hormone intake

TOXIC GOITER

DIFFUSE NODULAR

OTHERS

-DIFFUSE TOXIC GOITER -TOXIC MULTINODULAR GOITER-TOXIC ADENOMA

-SUB ACUTE THYROIDITIS-PAINLESS THYROIDITIS-JOD BASEDOW HYPERTHYROIDISM-FACTITIOUS HYPERTHYROIDISM

DIFFUSE TOXIC GOITER• Aka GRAVES’ DISEASE• Autoimmune disorder whereby the thyroid gland is

overstimulated by antibodies directed to TSH receptor on thyroid follicular cells

• TRIAD:– Diffusely enlarged thyroid gland– Hyperthyroidism– Exophthalmos

•Low TSH•Elevated T3 and T4•RAI – high or normal•Uptake on RAI is diffuse and homogenous

•NODULAR THYROID ENLARGEMENT•NO EXOPHTHALMOS

TOXIC GOITER

DIFFUSE NODULAR

OTHERS

-DIFFUSE TOXIC GOITER -TOXIC MULTINODULAR GOITER-TOXIC ADENOMA

-SUB ACUTE THYROIDITIS-PAINLESS THYROIDITIS-JOD BASEDOW HYPERTHYROIDISM-FACTITIOUS HYPERTHYROIDISM

TOXIC NODULAR GOITER

SOLITARY MULTINODULAR

-TOXIC MULTINODULAR GOITER

-TOXIC ADENOMA

variably enlarged and composed of multiple nodules

Clinical Impression: Toxic Multinodular Goiter

Work Ups:

• TSH level – low• T4 level may be normal or minimally increased• T3 is often elevated to a greater degree than

T4• Radionuclide Scanning – heterogenous

uptake with multiple regions of increased and decreased uptake

• FNAB

Medications

• Anti-thyroid drugs like Methimazole and Propylthiouracil. Methimazole, which is the drug of choice, inhibits the addition of iodine to thyroglobulin by the enzyme thyroperoxidase, a necessary step in the synthesis of triiodothyronine (T3) and thyroxine (T4).

• A non-cardioselective beta-blocker, propanolol, is given for the adrenergic symptoms of the patient such as the palpitations and easy fatigability.

• The thyrotoxic patient’s response to catecholamines is exaggerated. To counter this, propanolol, a non-cardioselective beta-blocker is given.

Management

• Thyroidectomy may be the only option for the patient because of the large size of the mass. It progressed in size and also began to compress her airway which makes the patient a candidate for surgery.

• There is a risk for hypothyroidism post-op.• Special precaution should be taken with regards to

the superior and recurrent laryngeal nerves. If accidentally severed they may cause stridor, vocal fatigue and hoarseness.

Thyroidectomy

Prospective Study of Postoperative Complications After Total

Thyroidectomy for Multinodular Goiters by Surgeons With

Experience in Endocrine Surgery

Rios-Zambudio, Rodriguez, Riquelme, et. al.Annals of SurgeryVolume 240, 1; July 2004

Background of Study

• Subtotal thyroidectomy resulted in a high rate of recurrences (10-30%)

• Total thyroidectomy involves a greater risk of complications

Goals

• To demonstrate that total thyroidectomy for multinodular goiters can be performed with a permanent complication rate of 1% or less

• To analyze the risk factors for complications with total thyroidectomy performed by surgeons with experience in endocrine surgery

Patient Population

• 268 women, 33 men• Mean age 48 +/- 14 years• Selection criteria:

– Bilateral multinodular goiter– No prior cervical surgery– No associated parathyroid pathology– No initial thoracic approach

Methods

• Prospective study of 301 patients diagnosed and surgically treated for multinodular goiter between January 1996 – January 2001

• 2 surgeons with experience in endocrine surgery

• X2 test; regression analysis

Risk Factors

Patient Procedures• CBC• Thyroid hormone study• CXR• Thyroid sonography• Thyroid gammagraphy for 69 toxic goiters• Cervical CT for 70 goiters with intrathoracic

component• FNA of dominant nodule for 132 patients• Laryngoscopy in 5 patients with dysphonia• 142 patients initially controlled with medications

Results

• Overall complication rate 21%• Definitive postoperative complications in 3

patients (1%)– 2 hypoparathyroidism– 1 RLN injury

Discussion

• TT is the definitive surgery of choice for multinodular goiter– Prevents recurrences– Treatment in cases of malignancy

• Greater risks of complications does not occur in centers with experience.

Discussion

• Main independent risk factors:– Hyperthyroidism– Goiter size: intrathoracic component, goiter

grade, weight of excised thyroid