CASE REPORT

STRUMA NODOSA NON TOXIC

Created By :

Aulia Putri Nurjannah 1110221053

Preceptor :

dr. W. Setiawan, SpB

SURGERY CLERKSHIP
PERIOD NOVEMBER 4th, 2013 - JANUARY 11th, 2014
FACULTY OF MEDICINE UPN VETERAN
Dr.MINTOHARDJO NAVAL HOSPITAL
JAKARTA
2013

SHEET ATTESTATION
Approved and presented
Day / Date : ..

Case Report

Struma Nodusa Non Toxic

Submitted for Surgery Clerkship
Naval Hospital Dr. Mintohardjo

Created By :
Aulia Putri Nurjannah 1110221053

Has been approved and endorsed by :

Preceptor

dr. W.Setiawan, SpB

EXAMINATION STATUS

I.

PATIENT IDENTITY
Name
: Mrs. S
Age
: 44 years old
Sex
: Female
Occupation
: House wife
Pendidikan
: Senior High School
Religion
: Muslim
Status
: Married
Race
: Javanese
Address
: Duri Kosambi
Medical Record No
: 238741
Come in
: November 18th, 2013

II.

ANAMNESIS
Autoanamnesis on November 19th, 2013 at 10.00 am in Operating Room Dr.
Mintohardjo Navy Hospital.
Chief Complaint
Mass in the front left neck since about 2 months ago.
Additional Complaint
None
History of Present Illness
Patient, 44 years old, come to the Departement of Surgical Dr. Mintohardjo Hospital
with chief complaint mass in the front left neck since about 2 months ago. At the first, the
mass was palpated in the size of a marble. But since a month ago, the mass got bigger until
the size of a quail egg. There are neither pain nor reddish area in the mass. The mass is
mobile, especially when patients eating. There are no other symptom like shortness of
breath, weight loss, palpitation, tremor, sweating and hoarseness. Normal urinating and
defecation.
Past Medical History

Hypertension : none

Diabetes Melitus

: none

Asthma

: none

Jantung

: none

Alergy

Malignancy

: none

Operation

: none

: none

Family History of Disease

Hypertension : none

Diabetes Melitus

: none

Asthma

: none

Jantung

: none

Alergy

Malignancy

: none

Operation

: none

: none

Habit
The patient uses non-iodium salt when cooking the foods.
III. PHYSICAL EXAMINATION
General State

: Moderate ill

Consciousness

: Composmentis

Weight

: 50 kg

Height

: 160 cm

BMI

: 19,53 (Normal)

Vital Sign

Blood Pressure

: 120/80 mmHg

Pulse

: 80x/menit

Respiration Rate

: 18x/menit

Temperature

: 36,8oC

Head
Forms

: Normocephali

Hair

: Black

Face

: Symmetric

Eyes
Palpebra

: Edema (-/-), Ptosis (-/-), Lagoftalmus (-/-)

Conjungtiva

: No anemic

Sclera

: No icteric

Pupil

: Isocor, diameter 2 mm, direct reflex and indirect reflex

(+/+)

Ears
Forms

: Normotia

Ear canal

: Field

Auricular pain

: (-/-)

Nose
Forms

: Normal, deformity (-)

Septum

: No deviation

Discharge

: (-/-)

Nasal mucosa

: Hyperemis (-/-)

Mouth
Lips

: Normal, pallor (-), cyanosis (-)

Teeth

: Missing teeth (-)

Oral mucosa

: Normal, hyperemis (-)

Throat
Tonsil

: T1-T1, hyperemis (-)

Pharynx

: Pharyngeal arch symmetric, uvula in the middle, hyperemis (-)

Neck ( Local Status)

Thorax
Pulmonal
Inspection

: Symmetrical, hemithoraks left during inspiration (-/-)

Palpation

: Vocal fremitus equally strong on both hemithoraks

Percussion

: Resonant to both hemithoraks

Auscultation

: Vesicular breath sound (+/+), ronkhi (-/-), wheezing (-/-)

Cor
Inspection

: Pulsation ictus cordis (-/-)

Palpation

: There pulsation ictus cordis on ICS V linea midclavicula

sinistra 1 cm medial

Percussion

: Right side : equal ICS III-V linea sternalis dextra

Left side : equal ICS V linea midclavicula sinistra
Upper side :equal ICS II linea parasternalis sinistra

Auscultation

: Heart sounds regular I-II, murmur (-), gallop (-)

Abdomen
Inspection

: Flat, mass (-), widening of the veins (-)

Auscultation

: Intestinal noice (+) 5-6 x/minute

Palpation

: Tenderness, pain (-), hepatospleenomegali (-)

Percussion

: Timpany

Ekstremity
Upper ekstremity

: warm, cyanosis (-/-), sweating (-/-), CRT < 2

Lower ekstremity

IV.

LOCAL STATUS
Neck
Inspection
Palpation
Auscultation

V.

: warm, cyanosis (-/-), sweating (-/-), CRT < 2

: mass measuring 5 cm, mobile when patients eating

: palpable rubbery, mobile, no tenderness, no lymphadenopaty
: no vascular bruit

SUPPORT EXAMINATION

Laboratory
October 13th, 2013 at Dr. Mintohardjo Naval Hospital

Examination
Glucose
Fasting Blood
Glucose
2 hour PP Glucose
Hematologic
Leucosyte
Erithrocytes
Haemoglobin
Hematocrit
Platelets
BT
CT
Blood Chemistry
Triglycerides
Cholesterol
HDL Cholesterol
LDL Cholesterol
Total Protein
Albumin
Globulin
Total Bilirubin
Bilirubin Direct
Bilirubin Indirect
SGOT
SGPT
Uric acid
Ureum
Creatinin

Result

Reference Range

Information

106

70 - 115 mg%

Normal

132

< 140 mg%

Normal

5.200
4,37
11,7
38
242.000
200
1100

5000 - 10000/ul
3,6 - 5,2 juta/mm3
12 - 16 gr/dl
38 - 46 %
150.000 - 400.000
Menit 1-6
Menit 10-16

Normal
Normal
Down
Normal
Normal
Normal
Normal

77
258
74
169
6,7
4,0
2,7
0,49
0,12
0,37
17
34
2,8
32
0,9

< 170 mg/dl

< 200 mg/dl
> 40 mg/dl
< 130 mg/dl
6,6 - 8,8 gr/dl
3,5 - 5,2 gr/dl
2,6 - 3,4 gr/dl
0,1 - 1,2 mg/dl
< 0,2 mg/dl
< 0,9 mg/dl
< 31 u/l
< 31 u/l
2,3 - 6,1 mg/dl
17 - 43 mg/dl
0,6 - 1 mg/dl

Normal
High
High
High
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal

October 10th, 2013 at Parahita Diagnostic Center

Examination
TSH
Free-T3
Free-T4

Result
3,02
2,4
1,09

Reference Range
0,35 - 4,94ulU/ml
2,6 - 5,4 pg/ml
0,70 - 1,48 ng/dl

Information
Normal
Down
Normal

Thyroid USG
October 2nd, 2013 at Dr. Mintohardjo Naval Hospital

Impression:
Struma
Adenomatosa
Thyroid
Sinistra
VI.

RESU

ME
Patient,

years

44

old, with chief

complaint mass in the front left neck since about 2 months ago. At the first, the mass was
palpated in the size of a marble. But since a month ago, the mass got bigger until the size
of a quail egg. There are neither pain nor reddish area in the mass. The mass is mobile,
especially when patients eating. There are no other symptom like shortness of breath,
weight loss, palpitation, tremor, sweating and hoarseness. Normal urinating and defecation.
The patient uses non-iodium salt when cooking the foods.
On physical examination found general state moderate ill, consciousness
composmentis. Normal BMI and vital sign. At local status examination found, a mass
measuring 5 cm, mobile when patients eating, palpabre rubbery, no tenderness, no
lymphadenopaty, no vascular bruit. On the laboratory examination found anemia,
hyperlipidemia and decreased level of T3 and on Thyroid USG found struma adenomatosa
thyroid sinistra.
VII. Working Diagnosis
Struma Nodosa Non Toxic Sinistra
VIII. Differential Diagnosis
- Thyroiditis
- Ca thyroid
IX.

Management
Have done Strumectomy on November 19th, 2013 at Dr. Mintohardjo Naval Hospital.
Surgical technique :
1. Patient lying supine in general anesthesia.
2. Aseptic and antiseptic has done.
3. A transverse incision on the neck.
4. The skin and the subcutaneous pulled up, tagle was attached above and below.
5. The tumor is removed, in toto, bleeding was treated.
6. Surgical wound was closed tightly layer by layer with leaving drain from handscoon.
7. Operation was done.
Instruction post surgery :
1. Supervise the blood pressure, pulse, temperature, respiratory rate and bleeding.
2. Intravenous line or RL : Glucose = 1 : 3, 20 drops/minute.
3. Drugs :
- Ceftriaxone 2x1 gr
- Tramadol 2x100 mg (2 days)
After that further :
- Cefadroxyl 2x500 mg
- Asam Mefenamat 2x500 mg
4. After conscious, the patient may eating as usual.
5. If the temperature is > 38C, report the doctor on duty.

6. Thank you.
Photo during operation :

X.

Prognosis
Ad vitam
Ad fungsionam
Ad sanationam

: ad bonam
: ad bonam
: dubia ad bonam

LITERATUR REVIEW
A.

Anatomy of Thyroid Gland

To understand disease and thyroid disorders, to remember back about the anatomy of
the thyroid. Anatomy and normal physiologic must be known and remembered back before
the change of anatomy and physiology that may progress to a disease or disorder.
The thyroid gland consists of three lobes, which dextra lobe, the left lobe and the
isthmus which lies in the middle. It can sometimes be found all four parts namely the
pyramidal lobe is located on the isthmus slightly to the left of the center line. This lobe is
residual thyroid tissue that remains embryonic.
The thyroid gland has a weight of about 25-30 grams and is located between the
thyroid and sixth tracheal rings. The entire thyroid tissue wrapped by a layer called the true
capsule.

Vascularity of the thyroid gland derived from:

Artery:

1. A. Superior thyroid which is a branch of A. Carotid externa

2. A. Inferior thyroid which is a branch of A. Subclavian
3. A. Ima thyroid which is a branch of the Arcus Aorta
Vein:
1.

V. thyroidea superior (empties intoV. jugularis interna).

2.

V. thyroidea medialis (empties into V. jugularis interna).

3.

V. thyroidea inferior (empties into V. anonyma kiri).

B.

Physiology of Thyroid
The thyroid gland is an endocrine gland that secretes hormones Thyroxine or T4,
triiodothyronine or T3 and calcitonin. In the blood of most of the T3 and T4 are bound by
plasma proteins are albumin, Thyroxin Binding Pre Albumin (TBPA) and Thyroxin
Binding Globulin (TGB). Fraction T3 and free T4 circulates in the blood and play a role in
regulating

the

secretion

of

StimulatingHormone (TSH)

TSH. Hormon

produced

by

thyroid

the

is

anterior

controlled

by

lobe

the gland and

of

Thyroid

release hypofise influenced by Thyrotropin Releasing Hormone (TRH). Thyroid glands

alsosecrete calcitonin of parafolicular cell, which can lower serum calcium affect bone.
Thyroid hormone function, among others:
1) Increase the metabolic rate
2) Cardiogenic effects
3) Simpatogenik
4) Growth and nervous system

C.

Classification
Enlargement of the thyroid gland or struma classified according to its physiological
effects clinical, and changes in shape that occur. Struma can be divided into:
1) Toxic struma, struma which raises the clinical symptoms in the body, based on
changes in shape can be subdivided into:
a. Diffusa, if the enlargement of the thyroid gland covering the entire lobe, like those
found in Grave's disease.
b. Nodosa, if the enlargement of the thyroid gland only on one lobe, like those found in
Plummer's disease.
2) Nontoxic struma, the struma that does not cause clinical symptoms in the body, based
on the change in shape can be subdivided into:

a. Diffusa, such as those found in endemic struma

b. Nodosa, such as those found in thyroid malignancy
Diffusa Toxic Struma
1)

Definition
Difusa toxic struma can be found in Grave's Disease. The disease is also called
Basedow. Trias Basedow include diffuse enlargement of the thyroid gland, and
eksoftalmus hipertiroidy. Disease is more common in younger people with symptoms
such as excessive sweating, hand tremors, decreased heat tolerance, weight loss,
emotional instability, menstrual disorders such as amenorrhea, and polidefekasi (often
defecation). Clinical often found in the thyroid gland enlargement, sometimes there is
also a manifestation of the eye and miopatia exophthalmus ekstrabulbi. Although the
etiology of Graves' disease is not known for sure, it seems there is a role of an
antibody that can be captured TSH receptor, leading to increased thyroid hormone
stimulus. The disease is also characterized by increased absorption of radioactive
iodine by the thyroid gland.

2) Pathophysiology
Grave's Disease is a disease caused by abnormalities in the body's immune
system, where there is a substance called Thyroid Receptor Antibodies. This substance

occupies TSH receptor in thyroid cells and stimulate them in berlebiham, so it can not
occupy the TSH receptor and thyroid hormone levels in the body is increased.

3) Clinical Symptoms
Symptoms and signs that arise is a manifestation of increased metabolism in all
body systems and organs that may be clinically apparent. Increased metabolism causes
increased caloric needs, and often intake (intake) insufficient caloric needs, causing
drastic weight loss.
Increased metabolism in the cardiovascular system visible in the form of an
increase in blood circulation, among others, with an increase in cardiac
output / cardiac output up to two-three times normal, and also in a resting
state. Rhythm pulse rise and pulse pressure increases, so be pulsus Celer; patients will
experience tachycardia and palpitations. Burden on myocardial, and autonomic nerve
stimulation can result in a heart rhythm disorder ekstrasistol, atrial fibrillation, and
ventricular fibrillation.
Gastrointestinal secretion and peristalsis increases often resulting polidefekasi
and diarrhea.
Hipermetabolisme nervous system usually causes tremors, sleeplessness
sufferers, often waking in the night. Patients experience emotional instability, anxiety,
thought disorder, and unwarranted fear that very disturbing.
In the airways, causing dyspnea and tachypnea hipermetabolisme are not too
distracting. Muscle weakness mainly proximal muscles, usually quite disturbing and
often appear suddenly. This is caused by electrolyte disturbances triggered by the
hipertiroidi.
Menstrual disorders can be secondary amenorrhoea or metrorhagia. Eye
disorders caused by an autoimmune reaction in the form of antibodies binding to
receptors on muscle and connective tissue in the eye socket ekstrabulbi. Connective
tissue and fat tissue to hyperplastic so eyeball pushed to the outer eye muscles and
pinched. The result is eksoftalmus which can cause eye damage due to keratitis.
Impaired muscle movement will cause strabismus.

Figure: Schematic pathogenesis of Graves' disease

4) Treatment
Graves disease therapy aimed at controlling the state tirotoksisitas / hipertiroidi
with

antithyroid

administration,

such

as

propyl-tiourasil

(PTU)

or

karbimazol. Definitive therapy can be selected between anti-thyroid medication longterm, detachments with radioactive iodine, or thyroidectomy. Surgery of the Thyroid
with hipertiroidi done especially if treatment with the thyroid gland fails
medikamentosa great.Surgery usually provides a good permanent cure although
sometimes encountered the hipotiroidi and minimal complications.
Nodosa Toxic Struma
1) Definition
Nodosa toxic struma is an enlarged thyroid gland on one lobe is accompanied by
signs of hyperthyroidism. Nodular enlargement occurs in young adulthood as a

nontoxic goiter. When untreated, in 15-20 years can be toxic. Was first distinguished
from Grave's disease by Plummer, then known as Plummer's disease.

2) Pathophysiology
The disease begins with the onset of nodular enlargement of the thyroid gland that
does not cause symptoms of toxicity, but if not treated immediately, within 15-20 years
can cause hyperthyroidism. The factors that affect the change of nontoxic be toxic
include these nodules turn out to be its own autonomous (associated with autoimmune
diseases), thyroid hormone from the outside, as the radioactive iodine treatment.
3)

Clinical Symptoms
When history, it is difficult to distinguish between Grave's disease with
Plummer's disease because both showed symptoms of hyperthyroidism. The difference
is when a physical examination at the time of palpation where we can feel the
enlargement affects only one lobe.

4) Treatment
Therapy given to Plummer's Disease Grave's also the same as that aimed at
controlling the state tirotoksisitas / hipertiroidi with antithyroid administration, such as
propyl-tiourasil (PTU) or karbimazol. Definitive therapy can be selected between antithyroid

medication

long-term,

detachments

with

radioactive

iodine,

or

thyroidectomy. Surgery of the Thyroid with hipertiroidi done especially if treatment

with the thyroid gland fails medikamentosa great. Surgery usually provides a good
permanent cure although sometimes encountered the hipotiroidi and minimal
complications.
Diffusa Nontoxic Struma
1) Definition
Endemic goitre endemic goitre is a disease that i signed with ti roid gland
enlargement that occurs in a population, and is expected to relate to deficiencies in the
daily diet. Endemic goiter epidemiology is estimated there are approximately 5% in a

population of primary school children / preadolescent (6-12 years), as is evident from

several studies. Endemic goitre occurs due to deficiency of iodine in the diet. Frequent
incidence of endemic goiter in derah pegnungan, such as in the Himalayas, alpens,
areas with the availability of natural iodine and iodine additional coverage has not
done well.
2) Pathophysiology
Generally,

the

mechanism

of

occurrence

of

goiter

caused

by

deficiency intake iodine by the body. In addition, goiter can also be caused by
congenital abnormalities of thyroid hormone synthesis or goitrogen (goiter-causing
agents such as intake Excessive calcium and Brassica family vegetables). Lack of
iodine causes a lack of thyroid hormone can be synthesized. This will lead to an
increase in the release of TSH (thyroid-stimulating hormone) into the blood as
kompensatoriknya effect. The effect causes hypertrophy and hyperplasia of thyroid
follicular cells, resulting in enlargement of the thyroid macroscopically. This
enlargement can normalize body of work, because on the kompensatorik effects of
thyroid hormone needs are met. However, in some cases, such as iodine deficiency is
endemic, this enlargement will not be able to compensate for the existing disease. The
condition known as goiter hypothyroidism. The degree of enlargement of the thyroid
following levels and duration of thyroid hormone deficiency that occurs in a person.
Diffuse Goiter
Diffuse Goiter is a form like piece that forms a visible enlargement without
forming nodules. Form is usually found with non-toxic properties (normal thyroid
function), hence this form is also called simple goiter. Can also be referred to as
colloid goiter due to an enlarged follicle cells are generally met by colloidal
proficiency level. This disorder appears in endemic and sporadic goiter.
Endemic goiter appeared in a soil, water, and food supply contains less iodine,
so the iodine deficiency is widespread in the area teresebut. Examples region is
mountainous Alps, the Andes or Himalayas.

Meanwhile, sporadic goiter appeared less frequently and can be caused by many
things, the consumption of which inhibit the synthesis of thyroid hormones or enzymes
for impaired thyroid hormone synthesis dropped hereditary.
On simple goiter, there are two phases of evolution, namely hyperplastic and
colloid involution. In the hyperplastic phase, the thyroid gland is diffusely enlarged
and symmetrical, although not too large magnifying power (up to 100-150
grams). Follicle-folikelnya

coated

by

columnar

cells

are

numerous

and

crowded. Accumulation of these cells is not the same in the whole gland. If after the
consumption of iodine the body needs increased or decreased thyroid hormone, follicle
epithelial cell involution occurs, forming large follicles filled with colloid. Thyroid
would normally macroscopically visible brown and translucent, while histologically
will be seen that the follicles filled with colloid and epitelnya flattened and cuboidal
cells.
3) Clinical Symptoms
Most of the clinical manifestations associated with enlargement of the thyroid
gland. Most patients remained euthyroid state shows, but some circumstances having
hypothyroidism. Hypothyroidism is more common in children with biosynthetic defect
as the cause, including defects in the transfer of iodine.
4)

Procedures
The goal of treatment is to shrink the goitre endemic goitre and hypothyroidism
resolve possible, namely by giving SoL Lugoli for 4-6 months. If there is
improvement, treatment was continued until a year and then tapering off in 4
weeks. When the 6 months after treatment of goitre is not also shrink the medical
treatment is not successful and should be operative action.

Nodosa Nontoxic Struma

1)

Definition
Goitre nodosa is non toxic ti roid gland enlargement to the clinically palpable
nodules without one or more signs hypertiroidisme. The term struma nodosa indicates

the existence of a process, either physiological or pathological cause asymmetrical

enlargement of the thyroid gland. Because it is not accompanied by signs of toxicity in
the body, it is referred to as asymmetric enlargement nodosa nontoxic goiter.This
disorder is very common everyday, and to watch out for signs of possible malignancy.

2) Pathophysiology
SNNT can also be referred to as sporadic goiter. If endemic goitre occurs 10% of
the population in areas with iodine deficiency, the sporadic goiter occurs in someone
who does not live in an area endemic low iodine. The cause is as yet unknown, there
can be interference enzyme important in the synthesis of thyroid hormones or
consumption of drugs containing lithium, propiltiourasil, fenilbutazone, or
aminoglutatimid.
3) Clinical Symptoms
In general, non-toxic struma nodosa had no complaints because there was no
hypo-or hyperthyroidism. SNNT diagnosis is important in the absence of toxic
symptoms caused by changes in thyroid hormone levels, and felt on palpation of the
enlarged thyroid gland on one lobe. Usually thyroid began to swell at a young age and
developed into multinodular in adulthood. Due to gradual growth, goitre may be
asymptomatic unless large lump in the neck. majority of patients with struma nodosa
can

live

with

strumanya

without

complaint.

Although most of struma nodosa does not interfere with breathing due to jut
forward,

others

can

cause

narrowing

of

the

trachea

when

bilateral

enlargement. Goitre nodosa unilateral stimulation can lead the way into contra
lateral

direction. Thus

may

not

lead

to

the

promotion

of

respiratory

disorders. Significant narrowing cause respiratory until finally happened with stridor
inspiratoar

dispnea.

Complaints that there is a sense of weight in the neck. Trachea during swallowing to

cover up the larynx and epiglottis so heavy because fixed to the trachea.
4)

Treatment
Operative action is still the main option on SNNT. Various techniques of
operations include:
a. Lobectomy, which is the lobe lift, when the gland is left subtotal weighing 3 grams
b. Isthmolobektomi, the removal of one lobe followed by the isthmus
c. Total thyroidectomy, which is removal of the entire thyroid gland
d. Bilateral subtotal thyroidectomy, the partial removal of the right lobe and the left
part, the rest of the network in the posterior 2-4 grams taken to prevent damage to
the parathyroid glands or N.Recurrent Laryngeus

Carcinoma of the Thyroid

1)

Definition
Thyroid carcinoma is a malignancy (uncontrolled growth of cells) that occur in
the thyroid gland. Cancer is a depressing thyroid malignancy in thyroid which has 4
types: papillary, follicular, medullary and anaplastic. Thyroid cancer rarely causes
enlargement of the gland, often causing small growth (nodule) in the gland. The
majority of thyroid nodules are benign, thyroid cancer usually can be cured
Thyroid Cancer often limit the ability to absorb iodine and limit the ability to
produce thyroid hormone, but sometimes produce enough thyroid hormone, causing
hyperthyroidism.

2)

Classification of thyroid carcinoma

a. Papillary carcinoma, This carcinomas derived from thyroid cells and is the most
common type of thyroid carcinoma. More often found in children and young
adults and is more common in females. Exposed to radiation during childhood
helped to cause this malignancy. First appeared in the form of a palpable lump in
the thyroid gland as enlarged lymph nodes or neck area. Metastases may occur via
a.

the lymph to other areas in the thyroid or, in some cases, to the lungs.
Follicular carcinoma, carcinoma is derived from follicular cells and is 20-25% of
thyroid carcinoma. Follicular carcinoma primarily affects on age above 40

tahun.Karsinoma follicular also attacked 2 women up to 3 times more often

than men. Exposure to X-rays during childhood increases the risk of this type of
b.

malignancy. This type is more invasive than the papillary type.

Anaplastic carcinoma, This highly malignant carcinoma and constitute 10% of
thyroid

cancers. Slightly

more

often

in

women

than

men. Metastasis

occurs in rapid, early around it and then other parts of the body. At first people
were just complaining about the presence of thyroid tumor area. With this cancer
infiltration around, arising hoarseness, stridor, and difficulty swallowing. Life
c.

expectancy after diagnosis is established, usually only a few months.

Parafolikular carcinoma, carcinoma parafolikular or medul l er is unique among
thyroid cancer. This carcinoma more commonly in women than men and is most
often over 50 years. Carcinoma is rapidly metastasize, often to the place much like
the lungs, bones, and liver. His trademark is his ability to secrete calcitonin
because of origin. Carcinoma is often said to be hereditary.

3) Differences Benign and Malignant Thyroid Nodules

Approximately 5% had malignant struma nodosa. In the clinic should be
differentiated thyroid nodules are benign and malignant nodules that have these
characteristics:
1. Consistency hard on some parts or the whole nodules and hard-driven, although
malignant nodules may undergo cystic degeneration and then become soft.
2. In contrast to the consistency of soft nodules more often benign, although calcified
nodules can be found in adenomatous hyperplasia longstanding.
3. Infiltration into the surrounding tissue nodules merupaka sign of malignancy,
although not always malignant nodules infiltrating. If found ptosis, miosis, and
enoftalmus a sign of infiltration into surrounding tissue
4. 20% are malignant solitary nodules whereas multiple nodules are rarely malignant.
5. Nodules that appear suddenly or rapidly growing needs, especially malignant
suspicion that is not accompanied by pain. Or nodules old suddenly enlarged
progressively.
6. Suspected malignant nodules when accompanied by regional lymph node
enlargement or change in voice became hoarse.

7. Carotid artery pulsation is palpable from the rear edge of the sternocleidomastoid
muscular enlargement due to pressure nodules (Berry's Sign).

D.

Etiology
Enlargement of the thyroid gland can be caused by:
1) Hyperplasia and hypertrophy
Each organ is triggered when the work will have to compensate by increasing the
number of cells and multiply. Likewise, when the thyroid gland will be encouraged to
work produce the hormone thyroxine and will have m embesar, such as puberty and
pregnancy.
2)

Inflammation or infection
Processes such as inflammation of the thyroid gland in acute thyroiditis, subacute
thyroiditis (de Quervain) and chronic thyroiditis (Hashimoto)

3)

Neoplasms
Benign and malignant
Struma cause clinical symptoms caused by changes in thyroid hormone levels in
the blood. The thyroid gland can result in excessive levels of thyroid hormone or
commonly called hyperthyroidism and in levels of normal or less than normal is called
hypothyroidism.
Symptoms in hyperthyroidism are:
Increased appetite and weight loss
Can not stand the heat and hyperhidrosis
Palpitations, high systolic and diastolic pressure is low resulting in a high pulse
(pulsus celler) and in the long term could be atrial fibrillation
Tremor
Diarrhea
Infertility, amenorrhae in women and testicular atrophy in men
Exophtalmus

Symptoms in hypothyroidism is the opposite of hyperthyroidism:

Decreased appetite and weight gain
Can not stand the cold and dry scaly skin
Bradycardia, low systolic pressure and pulse pressure are weak
Gestures become sluggish and edema of the face, eyelids and limbs
E.

Enforcement Measures Diagnosis Struma

1) Anamnesis
On history, major complaints expressed by the patient may be a lump in the neck
that has lasted a long time, and the symptoms of hyperthyroidism or hipotiroidnya. If
the patient complained of a lump in the neck, then it should be further explored whether
or progressive enlargement occurs very slowly, accompanied with swallowing disorders,
impaired breathing and voice changes. After that asked whether or not there symptoms
of hyper and hypofunction of thyroid kelenjer. Need a place to stay were also asked
patients and salt intake to see if there are trends towards endemic goitre. Conversely, if
patients present with symptoms towards hyper or hypofunction of the thyroid, should be
explored further to hyper or hypo and whether there is a lump in the neck.
2) Physical Examination
On physical examination localist status at the anterior region coli, the most first
carried out an inspection, symmetrical enlargement seen whether or not, arise
respiratory signs or not, part moves while swallowing or not.
On palpation it is important to determine whether the right is bejolan thyroid
gland or lymph nodes. The difference was at the time the patient is asked to swallow. If
true then enlarged thyroid lumps will also move when swallowing, while if not moving
then to think about the possibility of enlarged cervical lymph nodes. Palpable
enlargement

should

Location

right

Size

in

be
lobe,
centimeters,

left

described:
lobe,
length

isthmus
diameter

The number of nodules: one (uninodosa) or more than one (multinodosa)

Consistency :
there

pain

: no or no attachment to the trachea, muscular sternokleidomastoidea

the

not

thyroid:

at

the
no

time

hard

Mobility

around

or

chewy,

:
nodes

is

soft,

Pain
Lymph
F.

cystic,

of

enlargement

palpation
or

not

Examination Support
Laboratory tests used in the diagnosis of thyroid disease is divided into:
1) Examination to measure thyroid function. Examination to determine levels of T3 and
T4 and TSH most often using radioimmunoassay technique (RIA) and ELISA in serum
or blood plasma. Normal levels of total T4 in adults is 50-120 ng / dl. Normal levels of
T3 in adults is 0.65 to 1.7 ng /dl.
2) Examination to indicate the cause of thyroid disorders. Antibodies to various thyroid
antigens found ing the serum of patients with autoimmune thyroid disease. Such as
thyroglobulin antibodies and thyroid stimulating hormone antibodies.
3) Radiological examination
X-rays can clarify the deviation of the trachea or retrosternal goitre enlargement is
generally clinically was to be expected. X-ray neck AP and lateral position is usually
an option.
Thyroid ultrasound is useful to determine the number of nodules, differentiate
between solid and cystic lesions, detect the presence of cancerous tissue that does not
capture iodine and can be seen by scanning the thyroid.
Thyroid scanning is essentially a presentation of I 131 uptake thyroid
distributed. Uptake can be determined from the impression the size, shape and location
of the main parts is thyroid function (distribution within the gland). Normal uptake of
15-40% within 24 hours. From the results of thyroid scanning can distinguish three
forms, namely cold nodule uptake when nil or less than normal compared with the
surrounding region, this suggests that the function of low and often occurs in
neoplasms. The second form is when uptakenya warm nodule with surrounding,
showing the function of the thyroid nodule with other parts. If the latter is the hot
nodule uptake more than normal, meaning excessive activity and rarely in neoplasms.

4) FNAB. Histopathologic examination of 80% accuracy. It is worth remembering that not

to determine the only definitive therapy based on the results of FNAB alone.
G.

Measures Surgery
Indications operations on goitre is:
1. Toxic diffuse goiter who fail to medical therapy
2. Struma uni or multinodosa with the possibility of malignancy
3. Struma with compression disorders
4. Cosmetics
Contraindicated in goiter surgery:
1. Struma toksika that have not prepared in advance
2. Goitre with cardiac decompensation and other systemic diseases that have not been
controlled
3. Large goitre which cling tightly to the neck tissues that are normally difficult to move
because of carcinoma. Such carcinomas are usually of poor prognosis anaplastic
type. Attachment to the trachea or larynx or trachea may well dilakukanreseksi
laringektomi, but attachment with extensive soft tissue neck excision is difficult to do
well.
First clinical examination whether the suspected malignant thyroid nodules or
suspected to be benign. When the suspected malignant nodules, it is distinguished whether
the case is operable or inoperable.
When the case at hand is inoperable then performed an act of incisional biopsy for
histopathological examination purposes. Debulking followed by action and external
radiation or chemoradiotherapy. When suspected malignant thyroid nodules or suspected
benign operable can be taken isthmolobektomi or lobectomy. If after the PA results prove
that the lesion is benign then the operation is complete, but if malignant it must be
determined beforehand which type of carcinoma occurred.
Complications of thyroid surgery:

1. Bleeding from A. Superior thyroid

2. Dispneu
3. Paralysis N. Recurrent Laryngeus. Consequently oto-laryngeal muscle weakness occurs
4. Paralysis N. Laryngeus Superior. As a result, patients become lenih sound weak and
difficult to control the high pitch sound, due to the shortening of the vocal cords due to
relaxation of M. Cricothyroid. Possibility terligasi nerve during surgery.

REFERENCES

1. Widjosono, Garitno, Endocrine System: Textbook of Surgery. Editor Syamsul Hidayat

R.Jong WB, Revised Edition, EGC, Jakarta, 1997: 925-952.
2. Kariadi KS Sri Hartini, Sumual A., Struma Nodosa Non Toxic & Hyperthyroidism:
Textbook of Penyakit In, Keiga Edition, Publisher Faculty of Medicine, Jakarta, 1996:
757-778.
3. Schteingert David E., Thyroid Disease, Pathophysiology, Fourth Edition, Book Two,
EGC, Jakarta, 1995: 1071-1078.
4. Liberty Kim H, Thyroid Glands: Textbook of Surgery, Volume One, Publisher Binarupa
script, Jakarta, 1997: 15-19.