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A CASE PRESENTATION ON

MULTINODULAR GOITRE
Clinical Features
45 year old lady, Diabetic on Oral med
Swelling in anterior part of neck -1 year
Patient had no history of weight loss/
breathing difficulty/ palpitation
No similar family history
Clinical Features
Anterior neck swelling both sides Rt > Lt
Moves with swallowing not with protusion of
tongue
Nodulocystic firm non tender swelling in
thyroid gland 5 x 4 cm Rt and 3 x 2 cm Lt
Lower pole of Rt lobe not palpable
USG Diffuse thyroid enlagement, multiple cystic
nodules. Rt lobe lower pole substernal extension.
D/D-Hashimoto Thyroiditis, Multinodular Goitre.
FNAC - s/o multi nodular goitre
T3-92 ng/dl (4.6-12),
T4-5.3ug/dl (80-180),
TSH-2 Uu/ml (0.5-6)
FBS - 168mg/dl, PPBS - 237 mg/dl
Other routine blood investigation are normal
Patient worked up and posted for near
total/sub total thyroidectomy
ANATOMY OF THYROID GLAND
The arterial supply to the thyroid
gland
1-Superior thyroid artery and superior
laryngeal nerve:
The superior thyroid artery is the first anterior branch
of the external carotid artery. In rare cases, it may
arise from the common carotid artery just before
its bifurcation.
the external branch of the superior laryngeal nerve
runs with the superior thyroid artery.

2-Inferior thyroid artery and recurrent


laryngeal nerve
The inferior thyroid artery arises from the
thyrocervical trunk, a branch of the subclavian
artery.
is closely associated with the recurrent laryngeal
nerve.

3-The thyroidea ima, if present:


May arise from the brachiocephalic artery or the arch
of the aorta to supply the isthmus.
Venous Drainage
1-The superior thyroid vein:
ascends along the superior thyroid artery and
becomes a tributary of the internal jugular
vein.
2- The middle thyroid vein:
follows a direct course laterally to the internal
jugular vein.
3- The inferior thyroid veins :
follow different paths on each side. The right
passes anterior to the innominate artery
to the right brachiocephalic vein or
anterior to the trachea to the left
brachiocephalic vein. On the left side,
drainage is to the left brachiocephalic
vein. Occasionally, both inferior veins form
a common trunk called the thyroid ima
vein, which empties into the left
brachiocephalic vein.
Lymphatic drainage
The lymph from the thyroid gland drains mainly
laterally into the deep cervical lymph nodes.
A few lymph vessels descend to
the paratracheal
nodes.
innervation of the thyroid gland :
derives from the autonomic nervous system. Parasympathetic fibers come from the
vagus nerves, and sympathetic fibers are distributed from the superior, middle,
and inferior ganglia of the sympathetic trunk
Physiology
The thyroid follicles secretes tri-iodothyronine(T3)and thyroxin(T4)synthesis involves
combination of iodine with tyrosine group to form mono and di-iodotyrosine
which are coupled to form T3 andT4.

The hormones are stored in follicles bound to thyrogobulin .


When hormones released in the blood they are bound to plasma proteins and small
amount remain free in the plasma .

The metabolic effect of thyroid hormones are due to free (unbound)T3 and T4.
90%of secreted hormones is T4 but T3is the active hormone so, T4is converted to T3
peripherally.
Physiological control of secretion

Synthesis and libration of T3 and T4 is controlled by thyroid stimulating


hormone(TSH)secreted by anterior pituitary gland.

TSH release is in turn controlled by thyrotropin releasing hormone (TRH)from


hypothalamus .

Circulating T3and T4 exert ve feedback mechanism on hypothalamus and


anterior pituitary gland .

So, in hyperthyroidism where hormone level in blood is high ,TSH production


is suppressed and vice versa.
Clinical presentation of specific
condition
HYPOTHYRODISM;

Hypothyroidism is the disease state in humans and animals caused by insufficient


production of thyroid hormone by the thyroid gland.

Fatigue
Depression
Modest weight gain
Cold intolerance
Excessive sleepiness
Dry, coarse hair
Constipation
Dry skin
Muscle cramps
Increased cholesterol levels
Decreased concentration
Swelling of the legs
Clinical presentation of specific
condition
Hyperthyroidism;
Hyperthyroidism is a condition caused by the effects of too much thyroid hormone on tissues of
the body. Although there are several different causes of hyperthyroidism, most of the
symptoms that patients experience are the same regardless of the cause.

Increase appetite ,weight loss


Palpitations
Heat intolerance
Nervousness
Insomnia
Breathlessness
Increased bowel movements
Light or absent menstrual periods
Fatigue
Eye: lid retraction,
lid lag,
exophthalmos ,
ophthalmoplegia,chemosis.
Clinical presentation of specific
condition
3-Silent Thyroiditis. Silent Thyroiditis is the third and least
common type of thyroiditis..

Silent thyroiditis features a small goiter without tenderness and, like the
other types of resolving thyroiditis, tends to have a phase of
hyperthyroidism followed by a phase of hypothyroidism then a return to
euthyroidism. The time span of each phase is not concrete, but the hypo-
phase usually lasts 2-3 months.
Clinical presentation of specific condition
THYROIDITIS:
Thyroiditis is an inflammation (not an infection) of the thyroid gland. Several types of thyroiditis exist .

1-Hashimoto's Thyroiditis. Hashimoto's Thyroiditis (also called autoimmune


or chronic lymphocytic thyroiditis) is the most common type of thyroiditis.
Fatigue-Depression-Modest weight gain--Cold intolerance-Excessive sleepiness-Dry, coarse hair-Constipation-
Dry skin-Muscle cramps-Increased cholesterol levels-Decreased concentration-Vague aches and pains-
Swelling of the legs

2-De Quervain's Thyroiditis. (also called subacute or granulomatous


thyroiditis). The thyroid gland generally swells rapidly and is very painful
and tender.]
Patients will experience a hyperthyroid period as the cellular lining of colloid spaces fails, allowing abundant
colloid into the circulation, with neck pain and fever. Patients typically then become hypothyroid as the
pituitary reduces TSH production and the inappropriately released colloid is depleted before resolving to
euthyroid. The symptoms are those of hyperthyroidism and hypothyroidism. In addition, patients may
suffer from painful dysphagia. There are multi-nucleated giant cells on histology.Thyroid antibodies can be
present in some cases.There is decreased uptake on isotope scan.
Simple (non-toxic) goitre

simple hyperplastic goitre (colloid goiter)


Cause: -physiological in pregnancy, puberty
-iodine deficiency.
Appearance: Large, smooth firm, non-tender
goitre
Effect: eythyroid & pressure effect.

Multinodular goitre.
Cause: presence of areas of hyperplasia & areas
of hypoplasia in gland.
Appearance: Large, irregular, nodular goiter
Effect: eythyroid & pressure effect.
Toxic goitre
Graves disease
Cause: Autoimmune disease characterizeby
presence of antibodies stimulate TSH
receptors in gland.
Appearance: Diffuce, nodular, hyperemic gland.
Effect: hyperthyroidism.
Toxic Multinodular goiter
(plummers disease)
Cause: Toxic effect of MNG
Appearance: Large, irregular, nodular goiter.
Effect: hyperthyroidism
Inflammatory goitre
Rediels thyroditis
Cause: Fibrosis of thyroid
Appearance: Enlarged stony hard thyroid
Effect: Pressure effect

De quervains thyroiditis
Cause: Viral infection
Appearance: Diffuse, firm, tender swelling
Effect: Mild hyperthyroidism

Hashimotos thyroiditis
Cause: Autoantibody against thyroid gland.
Appearance: Diffuse, enlarged, non-tender goitre
Effect: Hypothyroidism
Neoplastic goitre
-benign: adenoma
-malignant: papillary, follicular, anaplastic, medullary and
lymphoma
Cause: -complication of MNG.
-radiation
Appearance: Enlarged goiter associated with
lymphadenopathy
Effect: -pressure effect.
-euthyroid.
-invasive effect
Investigation:
Laboratory investigation:
-serum T3, T4.
-serum TSH.
-serum LATS:
in graves disease
-thyroid antibodies:
in hashimotos disease.
-serum cholesterol
increase cholesterol level in hypothyroidism
Endoscopic investigation:
-bronchoscopy: show compression and
infiltration of trachea by tumer
Biopsy:
-fine needle aspiration biopsy.
-true-cut biopsy.
Radiological investigation:

-chest and neck x-ray:


Show descend of thyroid gland to thorax
and mediastanal shifting in retrosternal
goitre.
-iodine isotopes
By i.v injection of I131. Then, use gama rays
to show hot and cold nodules.
-CT scan
Show thyroid size and if there is
compression to trachea
Medical Treatment
Antithyroid drugs:
e.g: carbimazole, propylthiouracil.
It use to treat hyperthyroidism
Mechanism:
Inhibit thyroid hormones synthesis by block iodine organification
and also PTU inhibit conversation of T4 toT3
Side effect:
Drug rash
Lymphadenopathy
N/V
Agranulocytosis
Beta-adernergic blockers:
e.g: propranolol
it is control sympathetic over activty to control cardiovascular
feature.
Radioactive iodine:
Taken orally in solution
Given for 8-12 wks.
Use for recurrent hyperthyroidism
Contraindication:
Pregnant women
Nursing mothers.
Surgical treatment:

Indication:
Failure of medical treatment.
Drug sensitivity in young patients.
Large goiter with compression symptoms.
Malignancy.
Complication of operation
Hemorrhage
Recurrent laryngeal nerve damage.
Superior laryngeal nerve damage
Hypoparathyrodism
Hypothyroidism
Sepsis
Postoperative infection
Hypertrophic scaring (keloid)

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