GOITRE
AP DR Daw Htike Htike Aye
Roll No – 76,77,78
Presenter – 76,77
Thyroid Enlargement
Definitions
Goitre
generalized enlargement of the thyroid gland.
Isolated or solitary swelling
discrete swelling with no palpable abnormality elsewhere.
Dominant
discrete swellings with evidence of abnormality elsewhere
Classification of thyroid swellings
Simple goitre (euthyroid)
Simple diffuse hyperplastic goitre.
Physiological
Pubertal
Pregnancy
Simple multinodular goitre.
Toxic goitre
Toxic diffuse goitre.
Graves’ disease
Toxic multinodular goitre.
Toxic adenoma.
Neoplastic goitre
Benign
Malignant
Inflammatory goitre
Autoimmune - Chronic lymphocytic thyroiditis
- Hashimoto’s disease.
Granulomatous - De Quervain’s thyroiditis.
Fibrosing - Riedel’s thyroiditis.
Infective
Acute (bacterial thyroiditis, viral thyroiditis, subacute thyroiditis)
Chronic (tuberculous, syphilitic).
Other
Amyloid.
Simple Goitre.
Aetiology
Simple goiter may developed as a result of stimulation of the
thyroid gland by TSH in response to chronically low level of
circulating thyroid hormones
Dietary deficiency of iodine is the most important factor in
endemic goitres.
Defective hormone synthesis in sporadic goitres.
Other stimuli to the gland follicular cell proliferation by growth
factors including immunoglobulin
Goitrogens - vegetables of brassica family {cabbage, kale and
rape}, which contain thiocyanate, drugs such as PAS and
antithyroid drugs, iodides in large quantities are goitorgenics
The natural history of simple goitre
Persistent growth stimulation causes diffuse hyperplasia. All lobules are
composed of active follicles and iodine uptake is uniform. (diffuse
hyperplastic goitre, which may persist for a long time but is reversible if
stimulation ceases.)
As a result of fluctuating stimulation, a mixed pattern develops with area
of active lobules and areas of inactive lobules.
Active lobules become more vascular and hyperplastic until haemorrhage
occurs, causing central necrosis.
Necrotic lobules coalesce to form nodules filled either with colloid or a
mass of inactive follicles.
Continual repetition of the above process results in multinodular goitre.
(Most nodules are inactive, and active follicles are present only in the
internodular tissue.)
Diffuse hyperplastic goitre
It corresponds to the first stages of the natural history.
Appears in childhood in endemic areas.
In puberty in sporadic cases.
The goitre is soft, diffuse and may be very large.
A colloid goitre is a late stage of diffuse hyperplastic goitre when
TSH stimulation has fallen off and when many follicles are
inactive and full of colloid.
Nodular goitre
Nodules are usually multiple.
Sometimes only one macroscopic nodule is found but
microscopic changes will be present throughout the gland {one
form of clinically solitary nodule}
All types of simple goitre is more common in females than in
males due to the presence of oestrogen receptors in thyroid
tissue.
Diagnosis – is usually straight forwards.
Investigations
Thyroid function test
to exclude mild hyperthyroidism.
Thyroid antibodies
to exclude autoimmune thyroiditis.
X-ray chest and thoracic inlet may show calcification and
tracheal deviation or compression.
Complications.
Tracheal obstruction due to gross lateral displacement or
compression by retrosternal goitre.
Acute respiratory obstruction due to haemorrhage into a thyroid
nodule.
Secondary thyrotoxicosis.
Carcinoma – follicular carcinoma
Prevention and treatment of
simple goitre
In endemic areas the incidence of goitre can be reduced by use of
iodized salt.
In early stage, hyperplastic goitre may regress if thyroxine is
given 0.15 – 0.2 mg daily.
Indications for operation: -
Nodular goiter
Cosmetic reason
Pressure symptoms
Patient’s anxiety.
Retrosternal extension with tracheal compression.
Presence of dominant nodule – as it may be neoplastic
Choice of operation
Total thyroidectomy with immediate and life-long thyroxin
replacement.
Subtotal thyroidectomy which remove the bulk of the gland
leaving up to 8 gm of relatively normal thyroid tissue in each
remnant
Hemithyroidectomy – Lobectomy (total lobectomy) on the more
affected side and subtotal resection or no intervention on the less
affected side.
After subtotal thyroidectomy it is customary to give thyroxine to
suppress TSH secretion to prevent recurrence.
Radioactive iodine may reduce the size of recurrent nodular goitre.
Multinodular goiter
Indications for operation
Cosmesis
Pressure symptoms
Patients wish
Retrosternal extension with actual or incipient tracheal
compression
Dominant area of enlargement that may be neoplastic
Treatment
If asymmetrical
total lobectomy in the more affected side with subtotal or no
intervention to the less affected side
postoperative thyroxine to suppress thyroxine
Total thyroidectomy to prevent recurrence
Clinically Discrete swellings
(Solitary Thyroid Nodule)
Definition
Isolated or solitary
A discrete swelling in an otherwise impalpable gland
True incidence is less than 70%
Dominant.
When there is clinical evidence of generalized abnormality
(30%)
The importance of discrete swelling lies in the risk of neoplasia.
About 15% of isolated swellings are malignant and an additional
30% are follicular adenomas.
Causes
Non-neoplastic
Areas of colloid degeneration
Thyroiditis
Cyst
Neoplastic
Adenocarcinoma
Carcinoma
Investigations
Thyroid function tests.
Serum TSH and thyroid hormones levels should be
determined.
If hyperthyroid, it indicated toxic adenoma or a manifestation
of toxic multinodular goitre.
Autoantibodiy titres
If present, may indicate chronic lymphocytic thyroiditis.
Its presence may increase the risk of thyroid failure after
lobectomy.
Isotope scan.
Swellings are characterized as ‘hot’(over active), ‘warm’ (active)
or ‘cold’ (under active)
About 80% of discrete swellings are cold, but only 15% is
malignant.
Therefore the use of this criterion as an indication for operation
lacks discrimination.
Routine thyroid scanning is abandoned except when toxicity is
associated with nodularity.
Ultrasonography.
It can demonstrate subclinical nodularity and cyst formation.
Fine Needle Aspiration Cytology.
FNAC is the investigation of choice in discrete thyroid swelling.
FNAC has excellent patient compliance, is simple and quick to
perform and is readily repeated.
FNAC can diagnose
Colloid nodules.
Thyroiditis.
Papillary carcinoma.
Medullary carcinoma.
Anaplastic carcinoma and
Lymphoma.
FNAC cannot distinguish between a benign follicular and
follicular carcinoma (needs demonstration of capsular and
vascular invasion)
Radiology
CXR and thoracic inlet x-ray are necessary when there is
clinical evidence of tracheal deviation or compression.
Other scans e.g. CT and MRI.
They are useful in assessing retrosternal and recurrent
swellings.
Indirect laryngoscopy
Done pre-operatively to determine the mobility of vocal cords
from medico-legal point.
Large bore needle (Tru-cut) biopsy.
It has high accuracy but low patient compliance and is
associated with complications such as pain, bleeding,
recurrent laryngeal nerve or tracheal injury.
Indications For Operation In Isolated Or Dominant Thyroid
Swelling
Neoplasia (FNAC positive, clinically suspicious)
Age above 50 years
Male sex
Hard texture.
Fixity.
Recurrent laryngeal nerve palsy.
Lymphadenopathy.
Recurrent cyst.
Toxic adenoma.
Pressure symptoms.
Cosmesis.
Patient’s wishes.
Treatment
Lobectomy - for benign condition of uncertain condition
Near total or total thyroidectomy – for papillary, follicular and
medullary carcinoma
Hyperthyroidism
Clinical types are
Diffuse toxic goitre (Graves’ disease)
Toxic nodular goitre.
Toxic nodule.
Hyperthyroidism due to rarer causes
Pathology
Diffuse toxic goitre (Graves’ disease)
Young women
Frequently associated with eye signs
50% family history of autoimmune endocrine disease
The whole gland is involved with hypertrophy and hyperplasia
due to abnormal thyroid stimulating antibodies that bind to
TSH receptor sites and produce a disproportionate and
prolonged effect.
Diffuse vascular goiter appearing at the same time as
hyperthyroidism
Toxic nodular goitre.
Appear as secondary change in long standing nodular goiter
Usually, middle age or elderly
Infrequently associated with eye signs
Cardiac symptoms predominate (thyro-cardiacs)
The nodules are inactive and only the internodular tissues are
overactive
In some, one or more nodules are over active like in toxic
adenoma
Toxic nodule
A solitary overactive nodule (toxic adenoma) which may be
part of generalized nodularity or a true toxic nodule
It is autonomous and its hyperplasia and hyperactivity is not
due to TSH-RAb.
TSH secretion is suppressed by the high level of circulating
thyroid hormones and the normal thyroid tissue surrounding
the nodule is suppressed and inactive.
Clinical Features
Female : male – 8:1
Symptoms are: -
Tiredness.
Emotional labiality.
Heat intolerance. Recent preference to cold.
Weight loss.
Excessive appetite.
Palpitations.
Diarrhoea
Signs are: -
Tachycardia and or arrhythmias, cardiac failure.
Hot, moist palms.
Exophthalmos.
Lid lag/ lid retraction.
Agitation.
Thyroid swelling and bruit
Myopathy.
Manifestation not due to hyperthyroidism per se is seen in
primary thyrotoxicosis. i.e. orbital proptosis, ophthalmoplegia
and pretibial myxoedema.
Cardiac rhythm
A fast heart rate which persists during sleep is
characteristic.
Cardiac arrhythmias are more common in older patients and
include: -
Multiple extrasystoles.
Paroxysmal atrial tachycardia.
Paroxysmal atrial fibrillation.
Persistent atrial fibrillation, not responsive to digoxin.
Myopathy
Weakness of the proximal limb muscles is common.
Eye Signs
Exophthalmos
Due to infiltration of the retrobulbar tissues with fluid and round cells.
Lid lag - Spasm the levator palpebrae superioris muscle
Oedema of the eyelids, conjunctival injection and chemosis
Due to compression of the ophthalmic vein.
Weakness of the extraocular muscles results in diplopia
In severe cases
Malignant Exophthalmos and the eye may be destroyed
It is an autoimmune disease with antibody-mediated effect on the ocular
muscles.
Treatment
Tends to improve with time.
Sleeping propped up and lateral tarsorrhaphy – protect the eye.
Hypothyroidism increases proptosis and should be avoided.
Massive doses of prednisolone causes some improvement.
If the eye is in danger, orbital decompression should be done
Diagnosis of thyrotoxicosis.
Most cases are diagnosed clinically.
Thyroid function test will help
Raised T3 & T4 with very low TSH levels.
T3 thyrotoxicosis is diagnosed by estimation of the free
T3.
Thyroid scan is requires to differentiate an autonomous toxic
nodule from a dominant swelling in toxic multinodular goitre.
Thyrotoxicosis should always be considered in: -
Children with growth spurt, behaviour problems or myopathy.
Tachycardia or arrhythmias in elderly.
Unexplained diarrhoea.
Loss of weight.
Principles of treatment of thyrotoxicosis.
Non-specific measures – rest and sedation
Specific measures – anti-thyroid drugs, surgery and radio-
iodine.
Anti-thyroid drugs.
carbimazole and propylthiouracil.
B blockers may also be use to control the symptoms. They are not
antithyroid drugs.
Iodides reduce the vascularity of the gland and should only be
used in the immediate preoperative preparation (10 days before
surgery). Prolonged used will result in escape phenomenon with
exacerbation of thyrotoxicosis.
Dose – 10 mg of carbimazole 6 – 8 hourly to bring to the
euthyroid state. Latent interval is about 10 – 14 days.
Maintenance dose is 5 mg 2 – 3 times a day.
Some doctors use high dose regimen with thyroxine replacement
(block and replacement therapy)
Aim
They are used to restore the patient to an euthyroid state and
to maintain this for a prolonged period of time in the hope that
permanent remission will occur.
Anti-thyroid drugs cannot cure a toxic nodule.
Advantages.
No surgery.
No use of radioactive material.
Disadvantages
Treatment is prolonged (mild case – 6 months, severe cases –
one year)
Failure rate is at least 50%
Relapse rate is high, around 60%
Impossible to predict which patient is likely to go into
permanent remission.
Some goiter enlarge and become very vascular during
treatment
Dangerous drug reaction – agranulocytosis, aplastic anaemia
Special indications
Childhood
Mild thyrotoxicosis in adolescents.
Recurrence after operation, as an alternative to radio-iodine.
Thyrocardiacs require carbimazole in combination with
digoxin, diuretics and radio-iodine.
Pregnancy.
Radioactive iodine.
Destroys thyroid cells and reduces the mass of functioning
thyroid tissue
Advantages
Simply given as a drink.
No surgery - Avoids the risk of operation in unfit or unwilling
patients.
No prolonged drug therapy -Avoids the risks of long-term
antithyroid drug therapy.
Disadvantages.
Isotope facilities must be available
Hypothyroidism always develops with time.
Theoreticalrisks of genetic defects and carcinogenesis in
young females.
Indications
Adults over 40 years of age especially women.
Recurrent thyrotoxicosis after operation.
Severely affected thyrocardiacs.
Surgery
Subtotal thyroidectomy in diffuse toxic goiter and toxic
nodular goiter
Total lobectomy in autonomous toxic nodule
Advantage
Rapidly effective.
Low incidence of recurrence.
Disadvantages
Even in skilled hands it is a technically demanding
procedure.
Dangerous in unskilled hands.
If mild thyrotoxicosis persists unrecognized beforehand
operation can precipitate thyroid crisis.
Indications
Large toxic goitre.
Toxic nodular goitre.
Intrathoracic goitre.
Failure of antithyroid treatment.
Social, economic and other factors when the patient is unable
or unwilling to undergo long-term drug therapy and
supervision
Failure of treatment with antithyroid drugs or radioiodine.
Surgery or thyroid ablation with 123I is appropriate.
Special problems in the treatment
Pregnancy –
Radio-iodine is contraindicated.
The danger of surgery is miscarriage
The danger of drugs is inducing hypothyroidism in mother
and baby. (goitre and obstructed labour).
The risk of either surgery in the second trimester or careful
antithyroid drug therapy is very small and the choice is as in
the uncomplicated cases.
Post-partum hyperthyroidism.
It is usually treated with drugs.
Children.
Radio-iodine is contraindicated.
Antithyroid drugs are usually given in children and
adolescence.
The Thyrocardiacs.
Radioiodine is the treatment of choice together with
antithyroid drugs started either before or after and continued
until the radioiodine has taken effect. (6 weeks)
High titres of thyroid antibodies.
They are best treated with anti-thyroid drugs but if the
treatment fails definitive treatment by operation or radio-
iodine is not contraindicated.
Proptosis of recent onset.
Treat the patient with antithyroid drugs until the proptosis is
stable for 6 months and then the choice is as in uncomplicated
cases.
Surgery for thyrotoxicosis
Preoperative preparations
Thyroid function tests.
Medical treatment to control thyrotoxicosis – keep in
Euthyroid
Indirect laryngoscopy.
Thyroid antibodies.
Serum calcium estimation
An isotope scan is necessary in patients with toxic nodular
goitre if total thyroidectomy is not planned. The surgeon
should know which nodules are autonomous and active in
order to ensure their resection.
Complications of thyroidectomy.
Local Complications.
Haemorrhage.
It is reactionary and occurs within 12 hours of operation
Blood collects beneath the deep fascia and cause venous
congestion and secondary laryngeal oedema leading to
hypoxia and death.
Clinically there is tachycardia, tachypnoea, pallor or cyanosis,
stridor and agitation.
Treatment - In the ward the dressings are taken down and skin
sutures are removed and the strap muscles are separated to
evacuate the clot. Then the patient is returned to OT for
exploration under general anaesthesia and haemostasis. IF
there is tracheal narrowing tracheostomy should be done.
Wound infection
Due to infection of the haematoma. It needs antibiotics and
drainage.
Laryngo-tracheitis.
Simple analgesia and steam inhalation is indicated.
Pneumothorax
Due to pleural damage during removal of retrosternal goitre.
It needs intercostal drainage.
Air embolism
Due to damage to the great veins of the neck. Any injury to
the major vein should be recognized, clamped and sutured
immediately.
Special complications
Glottic oedema.
Previous recurrent laryngeal nerve injury and
Over treatment with antithyroid drugs
may induce thickening of the vocal cords and glottic
narrowing
Tracheal collapse.
Due to softening of trachea from prolonged pressure by a
large goitre.
Intubation or tracheostomy may be needed.
Nerve injuries
Recurrent laryngeal nerves
Hoarseness of the voice in unilateral lesion and stridor if bilateral.
Tracheostomy may then be necessary.
External laryngeal branch of superior laryngeal
Injured during dissection of the upper pole.
It cause loss of high pitch sound and choking.
Cervical sympathetic chain
Horner’s syndrome – meiosis, enophthalmos, partial ptosis and
anhydrosis.
Endocrine changes.
Hypoparathyroidism –
Due to excision, bruising or devascularization of the
parathyroid glands.
Postoperatively it presents with paraesthesia, and
neuromuscular irritability (Trousseau’s and Chvostek’s
signs).
Serum calcium should be measured on the 4th
postoperative day.
Prevention
avoid damage during operation.
tie the inferior thyroid artery not in the main trunk but
the branches close to the gland.
Treatment – calcium and Vitamin D supplement.
Hypothyroidism
Recurrent hyperthyroidism
Progressive exophthalmos - to prevent by T4 treatment
post-operatively to suppress TSH secretion.
a. Thyroid crisis
Postoperative agitation, tachycardia, tachypnoea, fever
and mental disturbances are danger signs. Immediate
management includes serum estimation of thyroid
hormones, intravenous beta blockers plus sedation with
chlorpromazine and diazepam and large quantities of
intravenous fluids.
Thyroid Neoplasms.
Classification of thyroid neoplasms
Benign
Follicular adenoma.
Malignant
Primary
Follicular epithelium – differentiated
Follicular carcinoma
Papillary carcinoma
Follicular epithelium – undifferentiated
Anaplastic carcinoma.
Parafollicular cells.
Medullary carcinoma.
Lymphoid cells
Lymphoma
Secondary
Metastatic
Local infiltration.
Blood borne
Clinical features of thyroid neoplasms.
Incidence 3.7/ 100,000 population.
Male : female 1:3
Thyroid swelling.
Anaplastic growth are hard, irregular and infiltrating
Differentiated carcinoma may be suspiciously firm and
irregular
Small papillary tumour may be impalpable (occult) even
when lymphatic metastases are present
Enlarged cervical lymph nodes in papillary carcinoma.
Recurrent laryngeal nerve palsy in advanced disease.
Pain often referred to ear
absence of carotid artery pulsation (Berry’s sign)
Occult tumors present as enlarged lymph nodes in the
jugular chain with no palpable abnormality of the thyroid.
The primary is less than 1.5 cm in diameter. These have an
excellent prognosis and are regarded as of little clinical
significance.
Papillary carcinoma
Multiple foci may occur in the same or in both lobes may be
due to lymphatic spread or multicentric growth
Spread to regional lymph nodes is common
Blood borne metastases are uncommon
Follicular carcinoma
Microscopic invasion of the capsule and vascular spaces
Multiple foci is rare
Lymphatic spread is uncommon
Blood borne metastases are common
Aaplastic (undifferentiated) carcinoma
Elderly women
Local infiltration is an early feature but lymphatic and blood
borne spread also occur
Survive only months
Usually presents with tracheal obstruction and treated by
tracheal decompression by isthmusectomy
Complete resection is possible only in minority of patients
Radiotherapy sometimes gives worthwhile palliation
Medullary carcinoma
Tumours of parafollicular C cells derived from neural crest
The progress of the disease is very slow and spread mainly to
the lymph nodes
Total thyroidectomy and resection of involved lymph nodes
with either radical or modified radical neck dissection.
Malignant Lymphoma.
Response to irradiation is good
Radical surgery is unnecessary if diagnosis can be established
by biopsy.
Diagnosis
Is obvious on clinical examination in most cases.
Thyroid scans
A cold nodules
Characteristics of almost all thyroid carcinomas
Only very rarely well differentiated carcinoma take up
radioactive iodine)
Degenerating nodules
All forms of thyroiditis
FNAC –
can diagnose all neoplasms except follicular carcinoma as it
cannot demonstrate capsular and vascular invasion.
Thyroid antibody titres are often raised in carcinoma
Incisional biopsy will cause seeding of cells and local recurrence
and is not advisable.
Treatment
Differentiated carcinoma
Total lobectomy and isthmusectomy
Total thyroidectomy (bilateral disease)
Total thyroidectomy (staged procedure)
Additional measures
Thyroxine to suppress TSH in papillary carcinoma
Radioiodine – if metastases take up radioiodine they can be
detected by scanning and treated with large dose of
radioiodine
Undifferentiated anaplastic carcinoma
Complete resection is possible only in minority of cases
Radiotherapy should be given in all cases for palliation
Medullary carcinoma
Total thyroidectomy and resection of involved lymph nodes
Reference
Bailey & loves’s Short Practice of Surgery, 28 th
Edition
