September 13, 2022 Dr.

Montenegro
THYROID SGD

A 48 year old female came in for consult because of anterior neck mass. She noted the mass to be
enlarging since 2019. There are no associated symptoms such as hoarseness, dysphagia or difficulty
breathing. No consultation was done in Benguet province.

PPE: BP 120/80, PR 86, RR 21 T 36.5

Pink palpebral conjunctivae, anicteric sclerae
A round, doughy, non-tender, moveable mass is seen and palpated in the anterior
neck area measuring 7x8cm. No palpable cervical lymph nodes
*The rest of the physical examination are normal

Patient Profile Subjective (+) Objective (+)

48 y/o F Enlarging since 2019 Round, doughy, non-tender,

Benguet Province → Iodine moveable mass
deficiency 7x8 cm size

CC Subjective (-) Objective (-)

Anterior Neck Mass No hoarseness BP 120/80 PR 86

No dysphagia RR 21
No difficulty breathing T 36.5

Normal thyroid gland - not palpable

Diffuse – symmetrically enlarged, no nodules
Nodular – with nodules
Majority of nodules are BENIGN – >90%, euthyroid (normal thyroid function)
Thyroid UTZ, TFT, FNAB, Thyroid scan
- Depends on clinical diagnosis
- Diffuse nontoxic goiter
- TFT (TSH, T3 T4) confirm
- UTZ - to confirm if there are no nodules
 - RAI (thyroid scan)
- No malignancy in diffuse goiter only in nodular goiter
- Solitary nodule in the R lobe
- TFT – hyper or hypo; in the event that the patient is to be operated, usually euthyroid
- FNAB UTZ – single most important to request; may be malignant
- Multinodular - guidance if small, to select which of the nodules is the most
suspicious (large)
- RAI – hyper or same or cold (more malignant)

1. What information will you ask the patient that would help arrive at a clinical diagnosis?
Discuss.

HPI
● Ask symptoms related to hyper- and hypothyroidism to narrow down possible causes of thyroid
enlargement
○ Hyperthyroidism
■ Palpitations, tremors, fatigue/weakness, heat intolerance, increase in sweating,
hair thinning/loss, weight loss, diarrhea, anxiety
○ Hypothyroidism
■ Cold intolerance, weight gain, brittle hair, constipation, dry skin, mood changes
such as depression or forgetfulness, puffiness in the face
● Ask symptoms that may attribute it to a possible malignancy (although it has been enlarging for
some time already, most likely it is benign)
○ Pain
○ Any swelling felt in the neck (palpable lymph nodes)

Secondary Hx
● ROS
○ If the patient is exhibiting other pulmonary symptoms such as DOB
○ If there is any symptom of bone pain
■ These are the two most common areas (Bone and Lungs) where thyroid
cancers could metastasize and if the said symptoms are present, then we may
consider a malignancy in the thyroid gland.
○ Hoarseness, progressive dysphagia

Tertiary
● Past history
○ Birth and developmental history
○ Childhood illness
○ Adults illness
○ History of transfusion
○ Surgical procedures
○ Injuries
○ Allergies
○ Obstetric history and Gynecological history
■ It is important to ask the patient if she has any history of thyroid disorders that
was diagnosed from childhood to adulthood. In addition to this, the gynecologic
history of the patient should be asked because this would help us rule out
other differential diagnoses such as postpartum thyroiditis. Also we would want
to know if our patient is already in menopause. Furthermore, we would want to
know any history of cancer if we are considering a malignancy that may have
metastasized to the thyroid gland.
2. Describe the physical findings? What other essential data regarding the physical exam would
you ask?

Describe the physical findings:

● round, doughy, non-tender, moveable mass is seen and palpated in the anterior neck area
measuring 7x8cm.
● might not suspect malignancy

PE: What other essential data regarding the physical exam would you ask?
PE (What other essential data re: the PE would you ask) hillary
​ - Important landmark if thyroid gland examination - cricoid cartilage
​ - Suspect malignancy if nodule is hard, gritty or nodules fixed to surrounding structures
such as trachea and strap muscles
​ - Examine cervical lymph nodes and posterior triangle nodes (lymphadenopathy)

Check for (+) Pemberton’s Sign

● This would indicate obstruction of venous return at the thoracic inlet from a substernal
goiter, in which the abnormal enlargement of the goiter would extend down to the chest
● When both arms are raised, it causes accentuation of SVC syndrome with some facial
congestion and marked neck vein distention
● Here, you check if the patient’s neck veins would become more distended or if the
patient would exhibit facial plethora, cyanosis, or inability to swallow, or if dyspnea or
stridor would appear
● Maneuver (if asked): hold patient’s arms vertically above the head for 60 sec.

Check for signs of hypo or hyperthyroidism

● Listen for thyroid bruit - a sign of increased thyroid blood flow that may indicate presence of
hyperthyroidism
● Examine the quality of the patient’s pulse
● Check the patient’s skin and hair
● Examine the eyes
● Examine the reflexes

Check for lymph node enlargement

● Palpate for the cervical lymph nodes, check for lymph node enlargement in case of
malignant infiltration (Refer to image below)

3. Discuss your clinical impression.

Endemic Goiter
● Patient lives in Benguet province
○ It is probably also important to mention that the patient lives in Benguet province,
which is a mountainous region and we know that soils in mountains have low salt
iodination hence, it is possible that grown crops are also low in iodine
○ We could also then infer that through high intake of goitrogens such as cabbage and
cauliflower, which are the major crops of the mentioned province, could probably have
aggravated her iodine deficiency since in itself, these goitrogens has to be eaten raw
and in very very high amounts to be able to take effect
● Goiter is the most obvious manifestation of iodine deficiency. Low iodine intake leads to
reduced T4 and T3 production, which results in increased thyroid-stimulating hormone (TSH)
secretion in an attempt to restore T4 and T3 production to normal. TSH also stimulates thyroid
growth; thus, goiter occurs as part of the compensatory response to iodine deficiency.
○ [The goiter is initially diffuse but eventually becomes nodular because the cells in some
thyroid follicles proliferate more than others, and over time, nodules can enlarge and
undergo cystic degeneration, hemorrhage, and calcification. Therefore, in regions of
iodine deficiency, children and adolescents generally have diffuse goiters, while adults
who lived in conditions of longstanding iodine deficiency have nodular goiter. ]

Differential Diagnosis:
● The differential diagnosis in a patient presenting with a neck mass is extensive and varies with
the age of the patient at presentation.
● Neck masses that are not goiter may be congenital, inflammatory, or neoplastic disorders.
● Congenital neck masses are usually present at birth but may present at any age inflammatory
neck masses are most commonly due to infection, typically reactive viral
lymphadenopathy
● Neck masses that result from metastatic disease are predominantly related to metastatic
squamous cell carcinoma arising from the aerodigestive tract but may be due to
metastatic skin cancer
● Most important in differentiating nontoxic goiter from other causes of goiter is to exclude
Malignancy
○ This means thyroid cancers such as follicular thyroid carcinoma, medullary thyroid
carcinoma, papillary thyroid carcinoma, and thyroid lymphoma should be excluded
● Other cause of goiter that must be differentiated from nontoxic goiter include inflammatory
goiter
○ Hashimoto thyroiditis, De Quervain thyroiditis, and Riedle thyroiditis are important
inflammatory goiters that should be differentiated from nontoxic goiters.

4. Discuss the significant laboratory and ancillary tests that should be requested.

Thyroid function tests:

● TSH
○ Serum TSH levels reflect the ability of the anterior pituitary to detect free T4 levels.
There is an inverse relationship between the free T4 level and the logarithm of the TSH
concentration—small changes in free T4 lead to a large shift in TSH levels.
● Free T3 and T4
○ These radioimmunoassay-based tests are a sensitive and accurate measurement of
biologically active thyroid hormone. Free T3 is most useful in confirming the diagnosis
of early hyperthyroidism, in which levels of free T4 and free T3 rise before total T4 and
T3. Free T4 is also important in the detection of early hyperthyroidism in cases when
Total T4 is still normal and Free T4 is already increased.

No single test can determine the complete thyroid function. It is therefore important to correlate each
finding with the patient’s clinical manifestations. According to Schwartz, in most patients that clinically
appear to be euthyroid, TSH is the only test necessary.

Severe iodine deficiency causes hypothyroidism. Mild and moderate iodine deficiencies
cause multifocal autonomous growth of thyroid, which results in hyperthyroidism.

Other ancillary tests:

● Thyroid Antibodies
○ Includes anti- Tg, anti-microsomal, or anti-TPO and thyroid stimulating hormone (TSI).
○ These do not determine thyroid function however, this could diagnose an autoimmune
type of thyroiditis.
○ About 80% of patients with Hashimoto’s thyroiditis have elevated thyroid antibody
levels; however, levels may also be increased in patients with Graves’ disease,
multinodular goiter, and occasionally, thyroid neoplasms
● Serum Thyroglobulin
○ Thyroglobulin is made by both normal and abnormal thyroid tissue. It is normally not
released into the circulation but may increase in destructive processes of the thyroid
gland. This includes conditions such as Graves’ disease, and Hashimoto Thyroiditis.
○ Its most important role however is in monitoring patients with differentiated thyroid
cancer for recurrence, particularly after total thyroidectomy and RAI ablation.
● Serum Calcitonin
○ Functions to lower calcium levels,
○ Sensitive marker for Medullary Thyroid Carcinoma

CT scan
● Not routinely requested and usually indicated in obstructive/compressive symptoms,
extrathyroidal involvement, substernal extension and it serves as road map prior to operative
surgery
● Useful in large, fixed substernal goiters
● Used to delineate size and goiter extent
● Helpful in evaluating the extent of retrosternal extension and airway compression
● In diffuse and multinodular nontoxic goiter there is (+) retrosternal extension and in uninodular
nontoxic goiter retrosternal extension is unusual
FNAB
● Presence of nodule suspicious of cancer
● Preferably ultrasound guided
● Ultrasound parameters suggestive of malignancy in thyroid nodules (table)
5. How would you manage the case? What are possible complications of the procedure and how
should these be managed?

Near total or total thyroidectomy

● For goiters that are very large or >80-100 mL or goiters that continue to grow
○ Active treatment is preferred rather than monitoring
○ Concern of potential continuous growth and possible development of thyroid autonomy.
○ May also potentially cause obstructive signs
○ Recommended for cosmetic concerns
● Treatment of choice; preferred over subtotal thyroidectomy
● Complications:
○ Requires lifelong T4 Therapy
○ Tracheomalacia
■ pressure-induced destruction of tracheal rings by the goiter, causing airway to
collapse during the postoperative period
○ Recurrent laryngeal nerve (RLN) injury occurs in less than 5% of patients.
■ Of those with injury, approximately 10% are permanent.
■ Causes vocal cord paralysis
● Unilateral injury
○ Paramedian - normal but weak voice, able to breath
○ Median - hoarse voice, ineffective cough
● Bilateral injury - airway obstruction, loss of voice
○ Thyrotoxic storm
■ Unusual complication that may result from manipulation of thethyroid gland
during surgery in patients with hyperthyroidism. It can develop preoperatively,
intraoperatively, or postoperatively.
■ Signs and symptoms of thyrotoxic storm are as follows:
● Anesthetized patients: Evidence of increased sympathetic output (eg,
tachycardia hyperthermia)
● Awake patients: Nausea, tremor, and altered mental status
● Cardiac arrhythmias may also occur
● Progression to coma in untreated patients
Doctor’s Notes:

● Physical exam of a normal thyroid gland (1)

○ NON palpable
○ Goiter is defined as enlargement of thyroid gland and a normal thyroid has to be NON
PALPABLE THIS ONE PLS
● Moves with deglutition → thyroid goiter
● Palpable only are the tracheal rings
● Nodular goiter - with multiple nodules
● Diffuse goiter - symmetrically enlarged without nodules (2)
● Asymmetrical but no nodules (e.g. L lobe lang malaki) → still nodular goiter
● Majority of nodules are BENIGN - >90% (3)
● Majority of nodular goiters are euthyroid - normal thyroid gland function (4)
● Thyroid cancers occur with nodular goiter (5)
● Most commonly requested exam is T4, T3, TSH (thyroid function tests) (6)
○ Thyroid scan, ultrasound, FNAB
○ Depends on the clinical diagnosis - diffuse/nodular

1. 30 yo female w/ diffuse goiter

- Dx: Diffuse nontoxic goiter
- Request for thyroid function tests 1st
- Next request for ultrasound - check if it is
- To check if really diffuse (may be nodular, mali lang yung PE)
- Check for thyroid scan -
- NO Malignancy w/ diffuse goiter - no need FNAB
- You don’t know where to put the needle since it’s diffuse

2. 20 yo male with solitary nodule on R lobe

- Request for TSH - Majority are euthyroid
- FNAB - Single most important thing to request for Nodular goiter since baka cancer
- Ultrasound is more pertinent if multinodular
- Which is most suspicious
- To check if cystic or solid
- W/ MALIGNANCY
- What will a RAI - scan tell you? Know how ready the nodule wants to take in iodine
- Thyroid scan
- Iodine uptake
- Cold (20% risk of malignancy)
- Hot(<4% risk) nodule

On thyroid scan:
● In 10 cold nodules → 1-2 malignant (20%)
● In 10 cancer - thyroid scan - how many will have a cold nodule - 8-9 cold nodules

Remembar da 5 omahgah
Ayaw niya proper noun
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