BENIGN THYROID Case 1
Dec 27, 2015
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