CCP 2 Thyroid

OUTLINE
01 Case Discussion 05 Diagnostic Modalities

02 Main Impression 06 Management

03 Differential Diagnosis 07 Indications for Surgery

04 Pathophysiology 08 Surgical Complications

Case Discussion 01
GENERAL DATA:
43 years old, female

CHIEF COMPLAINT:
Right anterior neck mass

HISTORY OF PRESENT ILLNESS:

3 yrs. PTA - palpable anterior neck mass follow up after 6
months - failed to comply

4 months PTA - difficulty of breathing

- neck ultrasound - calcified lesion (right) and
solid nodule (left)
PAST MEDICAL AND SURGICAL
HISTORY:
(+) Hypertension, losartan, simvastatin OD
(+) DM, metformin BID
(+) Allergy
(-) CA
(+) S/P Lap Chole 2016
FAMILY MEDICAL HISTORY:
(+) Hypertension
(+) Diabetes Mellitus
(+) Malignancy (breast, thyroid)
(-) Allergy
PERSONAL AND SOCIAL HISTORY:
Nonsmoker
Non alcoholic beverage drinker
No history of illicit drug use
OB/Gyne HISTORY:
LMP: 1/16/2017
G2P1 (1101)
 REVIEW OF SYSTEMS:
GENERAL (-) Chills (-) Weight Change (-) Body weakness
INTEGUMENTARY (-) Color change (-) Lesion (-) Pruritus
HEAD AND NECK (-) Hearing Loss (-) Eye Pain (-) Diplopia (-) Periorbital
swelling (-) Vertigo (-) Ear discharge (-) Ear Pain (-) Tinnitus (-) Nasal
Congestion (-) Epistaxis (-) Hearing loss (-) Sore throat (-) Taste disturbance
(-) Blurring vision (-) Colds (-) Hoarseness
CARDIOVASCULAR (-) PND (-) Easy Fatigability
 REVIEW OF SYSTEMS:

PULMONARY (-) Chest pain (-) Chest pain (-) hemoptysis

GENITOURINARY (-) Dysuria (-) Anuria (-) Polyuria (-) Hematuria (-)
Incontinence (-) Discharges (-) Flank/suprapubic Pain (-) Dribbling (-) Urinary
Frequency

HEMATOLOGIC (-) Pallor (-) Easy Bruisability (-) Easy Fatigability

ENDOCRINE (-) Weight Change (-) Heat or cold intolerance (-) Polydipsia (-)
Polyphagia (-) Abnormal growth

MUSCULOSKELETAL (-) Muscle Pain (-) Atrophy (-) Joint Pains (-) Back Pains
 PHYSICAL EXAMINATION:
GENERAL SURVEY: The patient is conscious, coherent, with the
following vital signs:
BP: 130/70mmhg PR: 89 RR: 20 Temp: 36.6
SKIN: fair, moist, good skin turgor
HEENT: anicteric sclera, pink palpebral conjunctiva, no nasoaural
discharge, no cervico- lymphadenopathy, (+) firm, movable, nontender,
2x2 mass on L thyroid, moves with deglutition
 PHYSICAL EXAMINATION:

CHEST AND LUNGS: Symmetrical chest expansion, no retractions, no

lagging, clear breath sounds,
HEART: Adynamic precordium, tachycardia, no murmur.
ABDOMEN: Flabby, normoactive bowel sounds, soft, nontender
EXTREMITIES: Grossly normal extremities, no cyanosis, no edema,
full and equal pulses on both upper and lower extremities.
Normal values
CBG 140 80-120 mg/dL
FBS 6.29 3.9-5.5 mmol/L
Hba1C 5.98 below 5.7
 Thyroid function test
Chest X-ray: NORMAL CHEST FINDINGS
Normal values
ECG: NORMAL ECG FINDINGS
TSH 1.7 0.27 – 4.20

FT3 2.78 2.02 – 4.43

Ultrasound of the Neck:
FT4 1.20 0.93 – 1.71
Right thyroid gland - 4.7x1.2x2.0 cm

Left thyroid gland - 4.2 x 1.1 x 2.2 cm

Both thyroid glands slightly enlarged with diffuse parenchymal

echo pattern

Right lobe - solid nodule with calcification - 0.40x0.54cm

Left lobe - solid nodules - 0.16 x 0.18 cm and 0.22 x 0.34 cm

Isthmus - not thickened - 0.36cm.

Questions to Ask:
- patient’s diet (iodine, goitrogens)
- family history (goiter, hormonal dysgenesis)
- medication history (amiodarone, lithium)
- presence of other symptoms (dysphagia)
- history of head and neck radiation exposure
Main Impression 02
Main Impression

Non-Toxic Multinodular Goiter

Image source: https://www.healthline.com/health/goiter-simple

 Main Impression:
Non-toxic Multinodular Goiter
Basis for Diagnosis:
➢ Multinodular
○ 1 solid nodule on the right
○ 2 solid nodules on the left
➢ Asymmetrically enlarged thyroid glands
○ Right gland = 4.7x1.2x2.0 cm
○ Left gland = 4.2 x 1.1 x 2.2 cm
➢ Having dominant lobe
○ Right thyroid gland
➢ Compressive symptoms
○ Episode of DOB
➢ Euthyroid state
○ Thyroid function test = normal values
➢ Areas of calcification
○ Right thyroid gland = solid nodule
with 0.40x0.54cm area of Image source: https://www.mayoclinic.org/diseases-conditions/goiter/symptoms-causes/syc-20351829
calcification
ETIOLOGY
 Image sources: http://courses.washington.edu/pbio376/thyroid-disorders/thyroid-376.html
https://www.amtec.edu/diffuse-and-nodular-goiter-k.html

CAUSED BY:

1. Iodine Deficiency
2. Goitrogens
a. Drugs - Propylthiouracil, lithium,
phenylbutazone, aminoglutethimide,
iodine-containing expectorants
b. Environmental agents - Phenolic and
phthalate ester derivatives and resorcinol
found downstream of coal and shale
mines
c. Foods - Vegetables of the genus Brassica
(eg, cabbage, turnips, brussels sprouts,
rutabagas), seaweed, millet, cassava, and
goitrin in grass and weeds
3. Excessive radiation exposure
4. Dyshormogenesis
Differential Diagnosis 03
 Differential Diagnosis
Rule In Rule Out

Papillary Thyroid Carcinoma ❖ Age Incidence: <50 ❖ (+) Lymph node

years old metastases
❖ Usually Multinodular ❖ (+) Fixed nodule
❖ Family history of 1st ❖ (+) Hoarseness/Vocal
degree increases the risk cord paralysis
to 10-fold
❖ Long Standing Goiter
❖ Compressive symptoms
❖ (eg. Dyspnea)
❖ Ultrasound findings:
Punctuate
Microcalcifications
 Differential Diagnosis
Follicular Thyroid Carcinoma
Rule In
❖ Women predilection
❖ Common in older population
(peaks in 40-60 y/o)
❖ Family history of thyroid CA
❖ Enlargement of thyroid gland
❖ (-) or uncommon pain
❖ (-) cervical lymphadenopathy
❖ (+) solid hypoechoic nodules
with microcalcification
❖ (+) dyspnea
❖ Long standing goiter
Rule Out
❖ Thyrotoxicosis
❖ Usually solitary thyroid
nodules
❖ (+) Lymph node metastases
❖ (+) Fixed Nodule
❖ Mean age 50 y/o
❖ (+) hoarseness of voice
 Differential Diagnosis
Rule In Rule Out

Thyroid Cyst ❖ Asymptomatic ❖ (+) Hoarseness

❖ Palpable thyroid nodule ❖ (+) Solid nodules with
❖ Difficulty swallowing or calcifications
breathing
❖ Rapidly growing nodule
❖ Pain or discomfort in the
neck
❖ Family history of thyroid
cancer and/or radiation
exposure
PATHOPHYSIOLOGY 0
Diagnostic Modalities 04
 Diagnostic Modalities

- FNAB (right lobe)

- Post operative biopsy
Management 06
Treatment method
Surgery (nodules suspicious
for malignancy, tracheal
compression)
Radioiodine therapy (age
>40-60 years, goiter volume
>60 mL, contraindications to
surgery; not commonly used)
Percutaneous ethanol
injections (subtoxic nodules,
simple cysts; not commonly
used)
Disadvantages Advantages
Surgical complications; Total removal of nodule;
hospitalization required complete resolution of
symptoms; histologic
diagnosis
Slow reduction in the goiter Minor side effects; 40%
volume; hypothyroidism (10% in 5 reduction in goiter
years); radiation-induced thyroiditis volume in 2 years
(1%-2%); effective contraception
required
Difficult evaluation of subsequent Does not cause
cytology; repeated injections hypothyroidism
necessary; ineffective in large
nodules; painful procedure;
transient dysphonia (1%-2%)
Indications for Surgery 05
 Indications

● Compressive symptoms
● Increase in size
● Substernal extension
● Suspicion of malignancy
● Cosmetically deforming
Surgical Complications 06
 Thyroid
Potential major complications of thyroid
surgery:
● Postoperative Bleeding
● Nerve damage:
○ Recurrent laryngeal nerve - hoarseness
○ Spinal accessory nerve - shoulder weakness
○ Superior laryngeal nerve - change in voice
capability
○ Vagus nerve - permanent hoarseness
● Hypoparathyroidism
● Hypothyroidism
● Thyrotoxic storm
● Infection
 Postoperative Bleeding

The incidence of bleeding after thyroid

surgery is low (0.3-1%), but an unrecognized
or rapidly expanding hematoma can cause
airway compromise and asphyxiation.

Patients present with neck swelling, neck

pain, and/or signs and symptoms of airway
obstruction (eg, dyspnea, stridor, hypoxia).
 Postoperative Bleeding Prevention
● Avoid traumatizing the thyroid tissue
during the procedure
● Provide good intraoperative
hemostasis
● Avoid the use of neck dressings, as
dressing that covers the wound may
mask hematoma formation
● No definitive evidence suggests that
drains prevent hematoma or seroma
formation
 Injury to the recurrent laryngeal nerve
Recurrent laryngeal nerve (RLN) injury results
in true vocal-fold paresis or paralysis.

● In unilateral vocal cord paralysis,

hoarseness or breathiness may not
manifest for days to weeks; other
potential sequelae are dysphagia and
aspiration
● Bilateral vocal-fold paralysis usually
manifests immediately after extubation;
patients may present with biphasic
stridor, respiratory distress, or both
 Injury to the recurrent laryngeal nerve Treatment

● In unilateral vocal cord paralysis, ● In bilateral vocal cord paralysis,

corrective procedures may be
delayed for at least 6 months to
allow time for improvement in a
reversible injury, unless the
nerve was definitely transected
during surgery; surgical
treatment options are
medialization (most common)
and reinnervation
emergency tracheotomy may be
required, but if possible, first
perform endotracheal intubation;
cordotomy and arytenoidectomy,
the most commonly performed
surgical procedures, enlarge the
airway and may permit
decannulation of a tracheostomy
 Injury to superior laryngeal nerve

The external branch of the superior

laryngeal nerve (SLN) is probably the
nerve most commonly injured in thyroid
surgery

Trauma to the nerve results in an inability

to lengthen a vocal fold and, thus,
inability to create a high-pitched sound
 Hypoparathyroidism
Can result from direct trauma to the parathyroid glands,
devascularization of the glands, or removal of the glands
during surgery.

Postoperative hypoparathyroidism, and the resulting

hypocalcemia, may be permanent or transient.

Evaluation of parathyroid function is performed in either

of the following ways:
● Follow ionized calcium (or total calcium and
albumin) levels perioperatively
● Measure PTH postoperatively; a normal level
accurately predicts normocalcemia
 Hypoparathyroidism Treatment
● Asymptomatic hypocalcemia in the early
postoperative period should not be treated with
supplemental calcium
● In symptomatic patients, replace calcium with IV
calcium gluconate
● Typically, patients who begin to have symptoms
can be started on oral calcium and vitamin D
● In 1-2 months, an attempt to wean the patient off
oral calcium may be made
● Dependence on calcium supplementation for
longer than 6 months usually indicates
permanent hypoparathyroidism
 Hypothyroidism

An expected sequela of total

thyroidectomy.

Measurement of TSH levels is

the most useful laboratory test
for detecting or monitoring of
hypothyroidism in these
patients.
 Hypothyroidism

An expected sequela of total

thyroidectomy.

Measurement of TSH levels is

the most useful laboratory test
for detecting or monitoring of
hypothyroidism in these
patients.
 Thyrotoxic Storm
Unusual complication that may result from
manipulation of the thyroid gland during
surgery in patients with hyperthyroidism.

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
Burch-Wartofsky Point Scale for the Diagnosis of Thyroid patients
Storm
 Infection
Presentation
● Cellulitis typically presents as
erythema, warmth, and
tenderness of neck skin
around the incision
● A superficial abscess
produces fluctuance and
tenderness
● A deep neck abscess may
manifest subtly but can
produce fever, pain,
leukocytosis, and tachycardia
Evaluation
● Send purulence expressed from the
wound or drained from an abscess for
Gram stain and culture
● CT imaging is useful when a deep neck
abscess is thought to be possible
● To exclude esophageal perforation in
patients with a deep neck abscess, an
esophageal swallow study performed
with sodium amidotrizoate and
meglumine amidotrizoate solution
(Gastrografin) may be useful
 Infection
Treatment
● Treat cellulitis with antibiotics that provide good
coverage against gram-positive organisms (eg,
staphylococci and streptococci)
● Drain abscesses, and direct antibiotic coverage
according to culture findings
● For deep neck abscesses, begin with broad-spectrum
antibiotics (eg, cefuroxime, clindamycin, ampicillin-
sulbactam) until definitive culture results are available
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 Microanatomy

Mission Vision
Saturn is a gas giant with Neptune is the farthest planet
beautiful rings from the Sun
 Thyroid hormones

Mercury Venus Jupiter

Mercury is the Venus has a beautiful Jupiter is the biggest
smallest planet name planet
 Hormone production

Mars Mercury
Mars is a very Mercury is a
cold place small planet

Saturn Jupiter
Saturn is a Jupiter is the
gas giant biggest planet
 Protein expression

Mercury Venus Mars

Mercury is the Venus is the hottest Mars is full of iron
smallest planet planet oxide dust

Saturn Neptune Jupiter

Saturn is the planet Neptune is far Jupiter is the
with rings away from us biggest planet
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9h 37m 23s 333,000
Is Jupiter's rotation period Earths is the Sun’s mass

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 Clinical stats of the disease

25% 50% 75%

Mars Jupiter Saturn

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1 2 3 4

Mercury Saturn Mars Jupiter

Mercury is a Only Saturn has Mars is full of Jupiter is the
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 Process of thyroid disease
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Mars is full of iron
oxide dust
Venus Saturn
Venus has high Saturn is the planet
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Mercury is a small Jupiter is the
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 Principal nodules

Mass Diameter Surface gravity

(earths) (earths) (earths)

Mercury 0.06 0.38 0.38

Mars 0.11 0.53 0.38

Saturn 95.2 9.4 1.16

Hyperthyroidism 02
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 Medical calendar
Mon Tue Wed Thu Fri Sat Sun Day 23

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21 22 23 24 25 26 27 ● Neptune is an ice giant

28 29 30 31 ● The Sun is our star

Congenital effects

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 Gene and protein expression

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temperatures with rings

Mercury Jupiter
Mercury is the Jupiter is the
smallest planet biggest planet
 Symptoms of thyroid problems
Fatigue
Mercury is the smallest planet of the
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Venus has a beautiful name and
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Despite being red, Mars is actually a
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