An Approach To A Thyroid SwellingDr Surendra Shah Lecturer, Dept of Surgery Patan Hospital, PAHS

y TWENTY TO 25 g y TWO LOBES y ISTHMUS (10% ABSENT) y PYRAMID LOBE (50% +) y C5 TO T1

Venous Drainage

Arterial Supply

Recurrent Laryngeal N.

Superior Laryngeal N.

II IA IB III V IV VI

TerminologyGOITREy GENERALISED ENLARGEMENT

SOLITARY THYROID NODULEy DISCRETE SWELLING IN ONE

LOBE WITH NO PALPABLE ABNORMALITY ELSEWHERE IN THE GLAND

TerminologyDOMINANT THYROID NODULEy DISCRETE SWELLING IN ONE LOBE WITH PALPABLE

ABNORMALITY ELSEWHERE IN THE GLAND INCIDENTALOMAy THE CLINICALLY NOT PALPABLE NODULES, FOUND

INCIDENTALLY DURING USG NECK FOR ANY OTHER REGIONy INCIDENCE OF MALIGNANCY: 3-6% SIMILAR TO 3-

PALPABLE NODULES (>1.5cm)

PresentationSWELLING IN THE NECK ASSOCIATED WITH THYROID DYSFUNCTION MASS EFFECT

Dealing with swelling Etiology of swelling should be in the mind

What should be in mindy Is there feature of thyroid dysfunction? y Is there pain over swelling? y Is there features of retrosternal goitre? y Is there sign of tracheal compression? y Is there h/o sudden increase in size? y Is there another swelling in the neck? y Is there recent change in voice or not?

Features of HypothyroidismCommon Man Come To Marry Common Women

Come Patan Hospital Directly Before Buying Drug

Features of HypothyroidismEnthusiasm In Patient With Hyper Thyroidism

Leading Too Hot Environment After Thyrotoxicosis

Physical ExaminationInspection y Size and shape y Locationsy One side y Midline y Both sides

y Bordersy SCM muscles y Suprasternal notch

Pizillos method

Physical ExaminationInspectiony Surfacey Smooth y Nodular y Bosselated

y Overlying skiny Redness/edema y Scar y Dilated veins y Sinuses

Physical ExaminationSwelling moves with deglutinationy Thyroid y Thyroglossal cyst y Pretracheal lymph nodes y Subhyoid bursa y Extrinsic carcinoma of larynx

Physical Examination

Physical Examination

Physical ExaminationPalpationy Location y Surfacey Smooth/Bosselated

y Consistencyy Soft: Colloid goitre y Firm: Multinodular goitre y Hard: Carcinoma, Reidels thyroiditis

y Retrosternal extension y Thrill and fixity

Physical ExaminationSigns of retrosternal extensiony Palpate tracheal ring at suprasternal notch y Dull on percussion over manubrium y Positive Pembertons sign y Dilated neck veins

Physical ExaminationSigns of metastasisy Palpable LN in the neck y Hard nodules on skull y Long bone metastasis y Nodular liver & ascitis y Chest effusion/consolidation

Physical Examinationy Eye signsy Dalrymples sign: lid

retractiony Stellwags sign:

infrequent and incomplete blinkingy Von graefes sign: lid lag

Physical ExaminationExophthalmos

Mobius sign Naffzigers method

Association of thyroid dysfunctionGoitre with hypothyroidismy Hashimotos thyroiditisMost common cause of hypothyroidism Thyroid microsomal antibodies are produced Infiltration of lymphocytes and fibrosis result decrease in number and efficiency of individual follicles

y De Quervains thyroiditis y Riedels thyroiditis

Association of thyroid dysfunctionGoitre with hyperthyroidismy Graves disease (primary thyrotoxicosis)

Diffuse and vascular goitre Appears at the same time as hyperthyroidism Common in younger women (20-40Yrs) Eye sign is common while cardiac sign is rare Severe form of hyperthyroidism

Association of thyroid dysfunctionGoitre with hyperthyroidismy Toxic nodular goitre-Toxic adenoma

Appears long time before hyperthyroidism Common in middle aged or elderly Cardiac sign is common, eye sign is very infrequent Nodules within an otherwise goitrous thyroid gland Nodules are inactive in many cases with overactive internodular tissue In toxic adenoma, nodules are overactive

Association of thyroid dysfunctionPrimary thyrotoxicosisy Eye sign y Tremor

Secondary thyrotoxicosisy Cardiac signy Tachycardia y Cardiomegaly y Atrial fibrillation y CCF

Association of thyroid dysfunctionGoitre without dysfunctiony Physiological goitre

Diffuse hyperplasia No pain Smooth, bilateral, symmetrical Below teens, Often females who are menstruating, lactating or pregnant

Association of thyroid dysfunctionGoitre without dysfunctiony Multinodular goitre

Patient from endemic area Multiple nodules of long standing Soft to firm (sometimes calcified) No fixity or pressure effect

Physical ExaminationPoints in favor of benign diseasey SN with feature of hypo/hyperthyroidism y F/H/O benign thyroid nodule y Diffuse enlargement of thyroid y Soft, smooth, mobile noduleSOFT NODULE MAY BE PTC AND FIRM TO HARD NODULE WITH IRREGULAR SURFACE MAY BE DUE TO CHRONIC THYROIDITIS

ABOUT 15-30% PATIENT WITH SN HAVE 2ND NODULE IN THE SAME OR OPOSITE LOBE AT IMAGING INVESTIGATION LIKE USG

Physical ExaminationFeature S/O malignant disease y Hoarseness of voice y Persistent unexplained diarrhea y Enlarge LN at the level 3,4,5 y H/O irradiation, F/H/O MEN Type 2 y Nodules of short duration y Increase in size and pain y Firm, hard and nodular surface y Restriction of movement y Dimpling of skin during deglutination

Prognostic risk classification for patients with thyroid carcinoma (AMES OR AGES)Low risk < 40 Yrs Female No local extension Intrathyroidal No capsular invasion None 40 Yrs Male Extrathyroidal Capsular invasion Regional/Distant >4 cm Poorly differentiated

Age Sex Extent

Metastasis Size Grade

Investigationy Serum thyroid hormone y Thyroid autoantibody y Ultrasound/CT scan y FNAC y Isotope-scanning Isotopey Thoracic inlet X-ray Xy Indirect laryngoscope

InvestigationThyroid function testTSH Normal No further study High Free T4 TPOAb Low T3, T4, TRAb

Raise TPOAb: hashimotos thyroiditis

Diff. Graves disease from toxic nodular goitre

InvestigationUltrasoundy Size of the nodule y Multicentricity y Solid or cystic y Cervical nodes y For follow up y Guide for FNAFeature of malignancyy Irregular margin y Micro-calcification Microy Hypo-echodencity Hypoy Predominantly solid

componenty Intranodular vascularity y Regional lymphadenopathy y Invasive growth

Though benign appearance-FNAC is mandatory

InvestigationUSG WITH COLOR DOPPLERy ECHOGRAPHY

ADVANTAGES OF USG: EASY AVAILABILITY LOW COST LIMITED DISCOMFORT NON-IONISING NATURE NON-

DELINEATES INTERNAL MORPHOLOGYy COLOR DOPPLER:

OUTLINE THE VASCULAR PATTERN

InvestigationULTRASOUND WITH COLOR DOPPLERy

FOUR PATTERNS:1. TOTALLY SONOLUSCENT UNILOCULAR LESION:

CYST (~10%)2. A SONOLUSCENT CYST WITH INTERNAL ECHOES,

SEPTASE, AND/OR ECHOGENIC (SOLID TISSUE) PROJECTIONS FROM THE WALL (~15%)3. A NODULE WITH HOMOGENOUS ECHOGENICITY

(HYPER/HYPO) (~15%)

InvestigationWHOLLY SONOLUSCENT (CYSTIC):

USG WITH COLOR DOPPLERy

UNLIKELY TO BE MALIGNANT

FOUR PATTERNS:4. NODULES WITH

ECHOGENIC PROJECTION FROM WALL, SOLID NUBBINS ESPECIALLY IF VASCULAR: POSSIBILITY OF PCT

MIXED SONOLUSCENCY AND ECHOGENICITY (~60%)

AS THE ECHOGENIC COMPONENT IN NODULE OR VASCULARITY INCREASES: CHANCES OF TUMOR OR MALIGNANCY INCREASES

InvestigationFNACIndications y All palpable symptomatic nodules y Nodule >1cm y Nodule