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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.
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
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.
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 .
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:
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)