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Similar to approach to a patient with thyroid swelling (EMCH)
approach to a patient with thyroid swelling (EMCH)
- 1. Approach To A PatientWith Thyroid Swelling Dr.Al Tarique Registrar Medicine, EMCH
- 2. Anatomy of thyroidgland • The thyroid is a butterfly-shaped gland that lies inferior to the cricoid cartilage , approximately 4 cm below the superior notch of the thyroid cartilage. • It is comprised of a central isthmus (covering the 2nd to 4th tracheal ring) and two lateral lobes.
- 3. Histology of thyroidgland
- 5. Differential diagnosis ofanterior midline neck swelling Ludwig’s angina Enlarged submental lymph nodes Sublingual dermoid Lipoma in the submental region Thyroglossal cyst Goitre of the thyroid isthmus & pyramidal lobe Retrosternal goitre
- 6. • Diseases ofthe thyroid gland invariably leads to enlargement of the gland. • The term GOITER is applied to any enlargement of the thyroid gland regardless of the cause.
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- 12. Benign Follicular adenoma,papillary adenoma Malignant thyroid tumors Types of tumor Frequ ency (%) Age at presentation (years) 10- years survival (%) Follicular cells Differentiated carcinoma Papillary Follicular Anaplastic Parafollicular C cells Medullary carcinoma Lymphocytes Lymphoma 75-85 10-20 <5 20-40 40-60 >60 98 94 9 5-8 >40 78 <5 >60 45
- 13. Most patientswith goitre are Euthyroid, But goitre may be associated with thyroid dysfunction (Thyrotoxicosis or Hypothyroidism). To examine the thyroid status we must have to know the features of toxicosis and features of hypothyroidism.
- 14. Clinical features ofthyrotoxicosis Symptoms Signs Weight loss despite normal or increased appetite Heat intolerance, sweating Palpitations, tremor Dyspnoea, fatigue Irritability, emotional lability Weight loss Tremor Palmar erythema Sinus tachycardia Lid retraction, lid lag Common
- 15. Clinical features ofthyrotoxicosis Symptoms Signs Amenorrhoea Spontaneous abortion Osteoporosis Diarrhoea, steatorrhoea Anxiety, psychosis Muscle weakness Angina Ankle swelling Goitre with bruit Atrial fibrillation Systolic hypertension increased pulse pressure Cardiac failure Hyper reflexia Proximal myopathy Less Common
- 16. Clinical features ofhypothyroidism Symptoms Signs Weight gain Cold intolerance Dry skin Dry hair Fatigue, somnolence Menorrhagia Weight gain Common
- 17. Clinical features ofhypothyroidism Symptoms Signs Constipation Hoarseness Depression Deafness Infertility Muscle stiffness Alopecia Aches and pains Hoarse voice Loss of lateral eyebrows Anaemia Carotenaemia Delayed relaxation of reflexes Dermal myxedema Bradycardia hypertension Less Common
- 18. Clinical features ofthyroid neoplasm • Solitary thyroid nodule • Cervical lymphadenopathy • Rapidly enlarging goitre • Pain in the neck • Stridor due to tracheal compression • Dysphagia due to esophageal compression • Hoarseness due to vocal cord palsy
- 19. Approach to apatient with thyroid swelling
- 20. History To seethe thyroid status of the patient we must have to ask about the History suggesting thyrotoxicosis or hypothyroidism.
- 21. Past medical, drug,family and social history Prior neck irradiation Recent pregnancy Drug therapy Family history of thyroid or other autoimmune disease.
- 22. Residence inan area of iodine deficiency,in bangladesh certain northern districts, particularly rangpur, gaibandha, nilphamari, and dinajpur are considered as goiter-prone areas. Smoking (increases the risk of graves’ opthalmopathy)
- 23. The physical examinationin general
- 24. Observe thefacial appearance, noting signs of dry or coarse hair and periorbital puffiness. Inspect the hands for vitiligo, thyroid acropachy, onycholysis and palmar erythema. Assess pulse (tachycardia, atrial fibrillation, bradycardia) and blood pressure.
- 25. Auscultate theheart for a mid systolic flow murmur(hyperthyroidism). Inspect the limbs for coarse, dry skin and pretibial myxedema. Assess proximal muscle power and deep tendon (ankle) reflexes.
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- 31. Inspection Inspect theneck from the front; note the position, diffuse or localised nature of swelling, extent, shape, size, overlying skin (dilated veins, thyroidectomy scar, local signs of inflammation) of the swelling.
- 32. Inspect thethyroid from the side with the patient’s neck slightly extended.
- 33. Give thepatient a glass of water and ask them to take a sip and then swallow. As Thyroid swelling moves upwards on swallowing, look for the inferior border as soon as the gland moves up.
- 34. Palpation At first,palpation of the thyroid gland should always be done from the behind on a sitting patient by using both hands with slight flexion of the neck ( to relax the sterno mastoid muscles) and thumbs placed over the nape of the neck.
- 35. Ask thepatient to swallow again and feel the gland as it moves upward. Note the size, shape, surface, mobility, tenderness and consistency of any goitre and feel for any thrill. Palpate the cervical lymph nodes.
- 36. a) Size –small or large b) Shape – localised or diffuse swelling, nodular (single or multiple) or not. c) Surface – smooth or irregular d) Consistency - • Soft – normal gland, Cystic swelling, graves disease. • Firm – simple goitre • Hard – carcinoma of thyroid • Woody feel – reidel’s thyroiditis
- 37. e) Mobility –fixed or mobile. Mobility is lost in carcinoma of thyroid with infiltration. f) Tenderness – tender (thyroiditis, malignancy, bleeding within cyst) or non tender g) Thrill – present in graves disease due to increased vascularity.
- 38. Percussion Percussion ofthe sternum may be done to detect the presence of retrosternal goitre.
- 39. Auscultation A thyroidbruit indicates abnormally high blood flow and is most commonly associated with Graves’ disease.
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- 41. Investigation Indication/comment Biochemistry Thyroid functiontest To assess thyroid status Immunology Antithyroid peroxidase antibodies Non-specific, high in autoimmune thyroid disease Antithyroid stimulating hormone receptor antibodies Specific for graves disease
- 42. Investigation Indication/comment Imaging Ultrasound Thyroid scintigraphy Computedtomography Goitre, nodule To assess areas of hyper- /hypoactivity To assess goitre size and aid surgical planning Invasive / other Respiratory flow volume loop Thyroid nodule Fine needle aspiration cytoloogy To assess tracheal compression from a large goitre
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- 44. THYROTOXICOSIS Toxic Multinodular goitre Toxic adenoma 1. Drugs– Carbimazole And Propylthiouracil. 2. Radioiodine therapy 3. Surgery 1. Beta blocker 2.Radio iodine therapy 3.Surgery (occasionally necessary, if there is large goitre) Radio iodine therapy or surgery
- 45. Paillary Carcinoma And Follicular Carcinoma Anaplasticor undifferentiated carcinoma Medullary carcinoma 1. Total thyroidectomy followed by high dose Radio Iodine Therapy 2. Life long T4 (to suppress TSH,if it is TSH dependent) There is no effective treatment for anaplastic carcinoma,although surgery and radiotherapy may be considered in some circumstances. Total thyroidectomy with removal of affected lymph nodes and T4 therapy. External radiotherapy may be given after surgery.
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Editor's Notes
- #4 It has outer false capsule derived from pretracheal fascia, and inner true capsule of loose connective tissue. True capsule extend septa which divide it into many lobule. Each lobule contain numerous thyroid follicle lined by simple cuboidal to columnar cell. Parafollicular cell found between follicular cells.
- #5 Production of T3 and T4 in the thyroid is stimulated by thyroid stimulating hormone which is released from the thyrotroph cells of the anterior pituitary in response to the hypothalamic tripeptide, thyrotrophin releasing hormone. There is a negative feedback of thyroid hormone on the hypothalamus and pituitary – TSH secretion is suppressed when plasma concentration of T3 and T4 are raised.
- #6 There is a broad differential diagnosis of anterior mid line neck swellings, which includes lymphadenopathy, dermoid cyst, Thyroglossal duct cyst.
- #8 There are numerous causes of thyroid swelling, but broadly speaking, a thyroid swelling is either a solitary nodule, a multinodular goitre, or a diffuse goitre.
- #11 Patients with thyroid tumors usually present with a solitary nodule. Only 5-10% of thyroid nodules are malignant. A solitary nodule presenting in childhood or adolescence or one presenting in the elderly should heighten suspicion of a primary thyroid malignancy.
- #13 Most thyroid tumors are benign , called follicular adenoma or papillary adenoma. A few of these called toxic adenoma, which secret excess thyroid hormone. Malignant tumors of thyroid can be classified according to the cell type of origin. 1.Papillary carcinoma is slowly growing tumor , arises from follicular cells of thyroid. Young adults are affected more, in between 20-40 years of age Females are 3 times more affected than Male Papillary carcinoma Consist 75 - 85% of total thyroid malignancy Lymphatic spread is common(level 3-7), patient may present with cervical lymphadenopathy. 2.Follicular Carcinoma is always a single encapsulated lesion. common in middle aged, between 40 to 60 years . Blood born metastases are common ,usually to bones, brain and lungs . 3.Patients with anaplastic carcinoma and lymphoma are usually over 60 years of age and present with rapid thyroid enlargement over 2-3 months. Anaplastic carcinoma is Locally infiltrative & invade surrounding structure ,Spread by lymphatic's and by blood stream . The goitre is hard and there may be stridor due to tracheal compression and hoarseness due to recurrent laryngeal nerve palsy. In older patients with anaplastic carcinoma median survival is only 7 month. Most lymphoma Occur against a background of lymphocytic thyroiditis. High grade Non –Hodgkin’s B-cell lymphoma are common type. 4.Medullary carcinoma arises from parafollicular C cells of the thyroid. Patient usually present in middle age with a firm thyroid mass. Cervical lymph node involvement is common but distant metastases are rare initially.
- #15 thyroid swelling patient may present with features of thyrotoxicosis. Common presenting symptoms of thyrotoxicosis include….. Most common signs in patient with thyrotoxicosis include…….
- #17 thyroid swelling patient may present with features of hypothyroidism. Common presenting symptoms of hypothyroidism include….. Most common signs in patient with hypothyroidism include…….
- #18 thyroid swelling patient may present with features of hypothyroidism. Common presenting symptoms of hypothyroidism include….. Most common signs in patient with hypothyroidism include…….
- #22 Ask about….. Ask about Prior neck irradiation which is a risk factor for thyroid malignancy Ask about Recent pregnancy as postpartum thyroiditis usually occurs in the first 12 months History of drug therapy is important as anti thyroid drugs or radio iodine therapy ; amiodarone and lithium can cause thyroid dysfunction. Family history of thyroid or other autoimmune disease.
- #27 Picture shows a patient with overactive thyroid,There is bilateral exophthalmos. Patient looks anxious and restless.
- #28 Picture shows a hypothyroid patient whose thyroid gland is enlarged and his appearance is immobile and uninterested.
- #29 This picture shows Thyroid acropachy which is present only in graves disease.
- #30 Patient with thyrotoxicosis may present with onycholysis.
- #33 Extending the neck will cause the thyroid to rise by a few centimeters and may make the gland more apparent.
- #34 To confirm the neck swelling as goitre give…..
- #39 Changing the percussion note from resonant to dull indicates the possibility of retrosternal goitre.
- #40 Ask the patient to hold his breath and then auscultate. Search for systolic bruit over the lateral lobes of the thyroid gland.
- #42 To assess thyroid status Free T3 and free T4, Thyroid stimulating Hormone(TSH) are now measured. Antibody against TSH receptor presents in Graves‘ Disease.
- #43 Ulltrasonography of the Thyroid gland : High sensitivity for determining the physical characteristics of the thyroid swelling and demonstrate sub-clinical nodularity and cyst formation But low specificity for the differentiation between benign and malignant lesion. Isotope scan Uptake scanning is done by either by radiolabelled I123 or by the technetium (99mTc).Routine isotope scanning is unnecessary. It’s principle value is in the toxic patient with a nodule. One scanning - swelling are categorized as Hot (overacting) Warm (active) or Cold (underactive) CT scan and MRI Not use as a routine or First line investigations. Reserved for the assessment of known Malignancy, to assess the extension of retrosternal and recurrent goitre & nodal metastases. Fine needle aspiration Cytology(FNAC) Provide most direct and specific information about the pathology of thyroid nodules. Ultrasonography guided FNAC give more accurate results. It’s sensitivity 65-90% and specificity is 72-100%. FNAC has excellent patient compliance, is simple and quick to perform in out patient department .
- #45 Three modes of treatment of thyrotoxicosis : drugs, radioiodine therapy, surgery. Indication of surgery in thyrotoxicosis is large goitre with pressure effect, relapse or no response to drugs, cosmetic purpose and suspicion of malignancy. Anti thyroid drugs are given for short time in toxic Multinodular goitre. Long term treatment with anti thyroid drugs is not helpful, as many nodules are autonomous and relapse is invariable after withdrawal of the drug. Betablocker is given to reduce the heart rate.radio iodine therapy is the treatment of choice. Surgery is oaccasionally needed.