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Thyroid- Benign swellings
The document discusses various thyroid conditions, particularly focusing on thyrotoxicosis, its causes, symptoms, and treatment options including Graves' disease, toxic nodular goiter, and toxic adenoma. Treatments such as anti-thyroid drugs, radioactive iodine ablation, and surgical interventions are outlined, alongside their indications, mechanisms, and potential complications. It emphasizes the necessity of careful management in cases such as thyroid storm and during pregnancy.
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Thyroid- Benign swellings
- 1. THYROID- BENIGN SWELLINGS DR.B.SELVARAJ MS;MCH;FICS MMMC;MALAYSIA
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- 4. DEFINITIONS • GOITER:any enlargement of thyroid gland • Thyrotoxicosis : Symptoms of thyroid hormone excess due to increased synthesis or release due to destruction of thyroid follicles or exogenous thyroid hormone supplementation. • Hyperthyroidism : Features of thyroid hormone excess due to increased synthesis of thyroid hormone by the gland.
- 5. CONDITIONS CAUSING THYROTOXICOSIS • Diffuse toxic goitre (Grave’s disease) • Toxic nodular goitre (Toxic MNG)- Plummer’s disease • Toxic nodule (Toxic adenoma)- Goetsch’s disease • Thyrotoxicosis factitia (Due to excess exogenous thyroid hormone supplementation) • Jod-Basedow thyrotoxicosis (Iodide induced) • Thyroiditis • Malignancies of thyroid. • Trophoblastic tumor (Due to thyroid stimulating action of HCG produced by this tumor) • Ectopic thyroid tissue (Struma ovarii)
- 6. Primary thyrotoxicosis Secondarythyrotoxicosis Age Younger patients Middle age and elderly Onset Goitre and Hyperthyroidism appear simultaneously Goitre present for many years prior to hyperthyroidism Symptoms Calorigenic (weight loss,heat intolerance) and nervous manifestations common Cardiovascular manifestations more common Signs All eye signs present. Diffuse goitre,highly vascular (bruit+) Only limited eye signs present (spastic)-lid spasm and lid lag. Nodular goitre complications Obstructive symptoms uncommon Obstructive symptoms commoner Treatment Start with anti thyroid drugs.Subsequent surgery or radio-iodine if needed Definite role for surgery
- 7. GRAVE’S DISEASE •Described by Irish physician Dr.Robert Graves in 1835 • Common in females • Age : 20-40 years • Pathogenesis: • Thyroid stimulating immunoglobulins (TSI) of IgG class produced by lymphocytes stimulate TSH receptor. • Ophthalmopathy: Fibroblast proliferation and increased glycosaminoglycans production induced by TSI (?antigenic similarity between orbital tissues and thyroid.)
- 8. CLINICAL FEATURES -SYMPTOMS • Calorigenic : Increased appetite,weight loss,heat intolerance, increased sweating, tiredness • Nervous : Tremors,anxiety,nervousness,increased activity • CVS: Dyspnoea, palpitations, pedal edema (due to CCF) • Ocular : Diplopia, pain and increased lacrimation (due to corneal ulcer)
- 9. CLINICAL FEATURES- SYMPTOMS • Menstrual : Amenorrhoea/ oligomenorrhoea • Miscellaneous: Loose stools.
- 10. THYROTOXICOSIS- SIGNS •Thyroid :Diffuse enlargement with bruit and visible pulsations CVS • Pulse : Increased sleeping pulse rate with wide pulse pressure. • Stages of development of thyrotoxic arrhythmias : Multiple extra systoles → Paroxysmal atrial tachycardia → Paroxysmal atrial >brilla?on → Persistent AF not responding to digoxin.
- 11. EYE SIGNS Seenin both Primary and secondary thyrotoxicosis (due to increased thyroid hormone levels which sensitizes the Muller's muscle to sympathetic system) • Von Graefe’s sign (lid lag) • Stellwag’s sign (characteristic stare with infrequent blinking) • Dalrymple’s sign (widened palpebral fissure)
- 12. EYE SIGNS •Naffziger’s sign : For proptosis • Moebius sign : Loss of convergence (Due to ophthalmoplegia) • Joffroy’s sign: Absence of wrinkling of forehead on looking up.
- 13. THYROTOXICOSIS- SIGNS •Dermopathy : Pretibial myxedema due to increased mucopolysaccharide deposition. • Thyroid acropachy : Dermopathy associated with clubbing of toes • Tremors: Outstretched hands,tongue • Grave’s disease is diagnosed when features of thyrotoxicosis is associated with ophthalmopathy +/- dermopathy
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- 15. DIAGNOSIS • Mostcases can be diagnosed clinically. • Thyroid function test : Raised T3,T4 with decreased TSH. • Thyroid scan : I123 scan-Diffuse increased uptake. • FNAC : Relative contraindication in the presence of thyrotoxicosis.
- 16. HISTOPATHOLOGY OF GRAVE’SDISEASE-FOLLICULAR HYPERTROPHY WITH SCANTY COLLOID
- 19. TREATMENT OPTIONS •Medical • Radio-Iodine • Surgery
- 20. MEDICAL TREATMENT –DRUGSUSED • Anti thyroid drugs : Carbimazole and propylthiouracil • Mechanism of action : Inhibit thyroid peroxidase and thereby interfere with iodination of tyrosine residues in thyroglobulin and coupling of iodotyrosine residues to form T3 and T4. • Dose : Start with high dose (Carbimazole 10mg TDS ) once control is achieved dose is reduced (5 mg BD or TDS) • Alternatively block and replacement regimen is used – Continue with high dose of antithyroid drugs with thyroxine supplementation (0.1 mg OD) . Decreased risk of iatrogenic hypothyroidism . • Adverse effects : Agranulocytosis less common but serious adverse effect. Needs monitoring of counts.
- 21. MEDICAL TREATMENT-ADVANTAGES: •C an be used even in children and young adults. • Hypothyroidism if induced is reversible • No complications associated with surgery. Disadvantages: • Prolonged treatment is required since relapse rate is high. • Drug toxicity
- 22. BETA BLOCKERS •Propranolol most commonly used Indications : • For symptomatic control • When antithyroid drugs are initiated till biochemical control is achieved • Thyroid storm • Along with iodide for preop preparation. • Dose : 20-40 mg QID (Max dose – 600mg/day)
- 23. IODIDES • Lugol’siodine most commonly used preparation (5% iodine in 10% potassium iodide solution). Mechanism of action : • Inhibition of thyroid hormone release (Thyroid constipation) • Decreases vascularity of the gland Uses: • Preop preparation : 10-14 days prior to surgery • Thyroid storm :iodinated contrast agents (sodium ipodate ) given i.v. Dose : Lugol’s iodine 5 drops TDS in milk.
- 24. RADIOACTIVE IODINE ABLATION • I131 most commonly used Indications : • Patients with small to moderate enlargement of gland and antithyroid drugs have clearly not worked. • Patients not willing for surgery or for whom surgery is contraindicated. • Recurrence after surgical or medical therapy.
- 25. RADIOACTIVE IODINE ABLATION Euthyroid state achieved by using antithyroid drugs for 3-4weeks before treatment. Interruption of antithyroid drugs for 3-4 days before and after Iodine treatment to permit adequate accumulation and retention of administered iodine. Pretreatment radioiodine scan done (25-100 micro curie of I131 given) to calculate therapeutic dose. Therapeutic dose of radio-iodine given (usually 8-12 milli curie) orally.
- 26. RADIOACTIVE IODINE ABLATION • Patient rendered euthyroid by 8-12 weeks after treatment. Disadvantages : • Hypothyroidism : incidence 10-15% by 1 year which increases by 3% in each succeeding year. • Exacerbation of cardiac arrhythmias in elderly • Fetal damage-hence contraindicated in pregnant and lactating women • Worsening of ophthalmopathy – avoided by using prophylactic steroids • Can induce Thyroid storm if patients are not rendered euthyroid before radio-iodine administration.
- 27. RADIOACTIVE IODINE ABLATION • Carcinogenic effect of radio-iodine has been ruled out and hence radio-iodine can be safely used in all individuals over 25 years i.e when development is complete.
- 28. SURGERY Indications : • Failure of medical/radioiodine treatment • Younger patients particularly adolescents • Pregnant patients • Patients with suspicious masses contained within the large thyroid. • Patients with severe cosmetic deformities or tracheal compression causing discomfort.
- 29. SURGERY • Extentof surgery : Subtotal or total thyroidectomy Advantage of total thyroidectomy : • Recurrence is avoided • Patients with ophthalmopathy are stabilized most successfully by total thyroidectomy.(Due to removal of entire antigenic focus) • Patients should be rendered euthyroid before surgery to avoid thyroid storm.
- 30. THYROID STORM-TREATMENT •Supportive measures : Correction of dehydration with I.v fluids and hyperpyrexia with cooling blankets • Antithyroid drugs : Propylthiouracil preferred.Given through Ryle’s tube if patient can’t take orally.(Parenteral forms not available). • Iodinated contrast agents (sodium ipodate)-1gm given I.v • Propranolol 2mg I.v with ECG monitoring (if patient cannot take orally) or 40-80mg Q6h • Large doses of dexamethasone : 2mg Q6h (inhibit hormone release,peripheral conversion of T4toT3 and provide adrenal support. • Life threatening circumstances : Peritoneal or hemodialysis to lower T3 andT4 levels.
- 31. OPHTHALMOPATHY-TREATMENT • Milddisease – Conservative measures: Elevating the head at night ,Protection of eye ball and avoiding corneal drying by applying 1%methylcellulose eye drops or plastic shields. • Severe cases –large doses of prednisolone (100-120 mg/day) • Malignant exopthalmos : Orbital decompression.
- 32. THYROTOXICOSIS IN PREGNANCY • Radio-Iodine : Contraindicated. • Surgery : Can be done in second trimester • Chance of miscarriage present with surgery. • Antithyroid drugs : Propylthiouracil preferred (Placental transfer less) • Can cause fetal goitre. • Avoided by keeping antithyroid drug dosage to minimum to prevent rise in TSH.
- 33. TOXIC MULTINODULAR GOITER-PLUMMER’S DISEASE • Seen in long standing goitre when one or more nodules become autonomous. • Cardiovascular symptoms predominate • Radionuclide scan: Can demonstrate autonomous nodules. • Treatment : • Antithyroid drugs : Can control symptoms but relapse invariably occurs with discontinuation of medications. • Propranolol can be used for symptomatic control. • Radio-iodine : Effective.But larger doses are required 20-30 milli curie)
- 34. TOXIC MULTINODULAR GOITER-PLUMMER’S DISEASE • Chance of hypothyroidism with radio-iodine is less compared to grave’s disease due to variable activity of different portion of the gland allowing previously quiescent area to function in place of those destroyed by I131. • Surgery : Preferred treatment (Subtotal thyroidectomy)
- 35. TOXIC ADENOMA- GOETSCH’S DISEASE
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- 37. ROUTINE INVESTIGATIONS BEFORE THYROID SURGERY • X-ray soft tissue neck – AP and lateral view • Indirect laryngoscopy • Serum calcium : Baseline value to detect post-op hypocalcemia due to hypoparathyroidism (Optional)
- 38. TYPES • Hemithyroidectomy • Subtotal thyroidectomy • Near total/total thyroidectomy
- 39. TECHNIQUE • Anaesthesia: GA with ET tube • Position : Supine with table tilted up by 15 degree to reduce venous engorgement • Neck extended by placing sandbags under shoulder. • Incision : Skin crease incision about 2 finger breadths above suprasternal notch.
- 40. TECHNIQUE • Flapsof skin,subcutaneous tissue and platysma raised upwards to superior thyroid notch and downwards to the suprasternal notch. • Deep cervical fascia is divided in the midline between the sternothyroid muscles down to the plane of thyroid capsule.
- 41. THE THYROID LOBEIS EXPOSED BY MOBILIZING THE STRAP MUSCLES AWAY FROM THE LOBE BY MEANS OF LATERAL RETRACTION ON THE MUSCLES THE MIDDLE THYROID VEIN IS EXPOSED, DIVIDED, AND LIGATED.
- 42. BABCOCK CLAMPS AREAPPLIED TO INFERIOR AND SUPERIOR (NOT SHOWN) ASPECTS OF THE THYROID LOBE TO FACILITATE MEDIAL RETRACTION ON THE GLAND.
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- 44. DOWNWARD TRACTION ONTHE SUPERIOR BABCOCK CLAMP EXPOSES THE SUPERIOR POLE VESSELS, INCLUDING THE BRANCHES OF THE SUPERIOR THYROID ARTERY. THE EXTERNAL LARYNGEAL NERVE COURSES ALONG THE CRICOTHYROID MUSCLE JUST MEDIAL TO THE SUPERIOR POLE VESSELS. TO AVOID INJURY TO THIS NERVE, THE SUPERIOR POLE VESSELS ARE DIVIDED INDIVIDUALLY AS CLOSE AS POSSIBLE TO THE POINT WHERE THEY ENTER THE THYROID GLAND.
- 45. AS THE THYROIDIS RETRACTED MEDIALLY, GENTLE DISSECTION IS USED TO EXPOSE THE PARATHYROID GLANDS, INFERIOR THYROID ARTERY, AND RECURRENT LARYNGEAL NERVE.
- 46. TO PERFORM TOTALLOBECTOMY, THE BRANCHES OF THE INFERIOR THYROID ARTERY ARE DIVIDED AT THE SURFACE OF THE THYROID GLAND. THE INFERIOR THYROID VEINS CAN NOW BE LIGATED AND DIVIDED. SUPERIORLY, THE CONNECTIVE TISSUE (LIGAMENT OF BERRY), WHICH BINDS THE THYROID TO THE TRACHEAL RINGS, IS CAREFULLY DIVIDED. THERE ARE USUALLY SEVERAL SMALL ACCOMPANYING VESSELS, AND THE RECURRENT NERVE IS CLOSEST TO THE THYROID AND MOST VULNERABLE AT THIS POINT.
- 47. THE DISSECTION OFTHE THYROID FROM THE TRACHEA CAN BE PERFORMED WITH THE CAUTERY BY DIVISION OF THE LOOSE CONNECTIVE TISSUE BETWEEN THESE STRUCTURES. DISSECTION IS EXTENDED UNDER THE ISTHMUS, AND THE SPECIMEN IS DIVIDED SO THAT THE ISTHMUS IS INCLUDED WITH THE RESECTED LOBE.
- 48. SUBTOTAL LOBECTOMY NECESSITATESIDENTIFICATION OF THE PARATHYROID GLANDS, INFERIOR THYROID ARTERY, AND RECURRENT LARYNGEAL NERVE, AS PREVIOUSLY DESCRIBED. THE LINE OF RESECTION IS SELECTED TO PRESERVE THE PARATHYROID GLANDS AND THEIR BLOOD SUPPLY AND TO PROTECT THE RECURRENT LARYNGEAL NERVE. IT SHOULD BE BASED ON THE INFERIOR THYROID ARTERY OR ITS MAJOR BRANCHES.
- 49. CLAMPS ARE PLACEDALONG THE LINE OF RESECTION AND THE THYROID GLAND IS DIVIDED. THE DIVIDED TISSUE IS LIGATED OR SUTURE-LIGATED WITH 3-0 SILK SUTURES.
- 50. DURING THYROIDECTOMY, THERECURRENT LARYNGEAL NERVE IS AT GREATEST RISK FOR INJURY (1) AT THE LIGAMENT OF BERRY, (2) DURING LIGATION OF BRANCHES OF THE INFERIOR THYROID ARTERY, AND (3) AT THE THORACIC INLET.
- 52. POST-OP COMPLICATIONS •Hemorrhage : Tension hematoma deep to cervical fascia usually result from slipping of ligature on the superior thyroid artery.Requires emergency re-exploration. • Respiratory Obstruction : Due to tension hematoma or Tracheomalacia. • Thyroid insufficiency- hypothyroidism • Recurrent laryngeal nerve paralysis • Superior laryngeal nerve paralysis • Parathyroid insufficiency- hypocalcemia • Wound infection • Hypertrophic scar