Goitre
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GOITRE
Dr Echebiri, PromiseState House Medical Centre, Aso Rock, Abuja.
5th December,2011.
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CONTENTS• Definition• Overview• Background• Pathophysiology• Classification• Presentation• Investigations• Differential Diagnoses• Treatment• Prognosis
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DEFINITION
An enlarged thyroid gland.
-Clinically palpable gland.-Gland enlargement more than twice of the
normal size.
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OVERVIEW
• Geography: Worldwide, the most common cause of goiter is iodine deficiency.
Approximately 800million people subsist on iodine-deficient diet.
In industrialized countries,goiter is more often due to Hashimoto’s thyroiditis.
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OVERVIEW
• Sex: The female-to-male ratio is 4:1. Thyroid nodules are more likely to be
malignant in menThe frequency of goiters decreases with
advancing age. although the incidence of thyroid nodules increases with advancing age.
• Race: No racial predilection exists.
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BACKGROUNDThyroid gland surface marking
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BACKGROUNDHypothalamo-Pituitary-Thyroid Axis
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BACKGROUNDThyroid anatomy
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BACKGROUNDThyroid physiology
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BACKGROUND
• TRH:Produced by Hypothalamus. Release is pulsatile,circadian. Downregulated only by T3.
Travels through portal venous system to adenohypophysis. Stimulates TSH formation.
• TSH: Produced by Adenohypophysis Thyrotrophs.Up regulated by TRH .Down regulated by T4, T3.
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BACKGROUND
Travels through portal venous system to cavernous sinus, then thyroid gland. Stimulates several processesIodine uptakeColloid endocytosisGrowth of thyroid gland.
• Thyroid Hormone: Majority of circulating hormone is T4 98.5% T4 1.5% T3
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BACKGROUND
Total Hormone load is influenced by serum binding proteins
Albumin 15% Thyroid Binding Globulin 70% Transthyretin 10%
Regulation is based on the free component of thyroid hormone
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BACKGROUNDHormonal interplay
T4,T3
TSH
TRH
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PATHOPHYSIOLOGY
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CLASSSIFICATIONSBased on growth pattern
Goitre
Nodular
Uninodular:Cysts
Benign thyroid neoplasms
Thyroid cancers
Multinodular:Iodine deficiency
ThyroiditisSarcoidosis
Diffuse
Hypothalamic diseasePituitary disease
Iodine deficiency(endemic, sporadic)Grave’s disease
Thyroid hormone insensitivity
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CLASSIFICATIONSBased on size of gland
Grade III
• Invisible
• Palpable
GradeII
• Visible
• Palpable
Grade I
• Visible
• Palpable
• Retrosternal extension
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CLASSIFICATIONSBased on activity of gland
Hyperthyroid(toxic)
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PRESENTATION
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PRESENTATION
• History:Anterior neck swellingPain: Haemorrhage, inflammation, necrosis, or
Malignant transformationCompressive symptoms: Dysphagia, dyspnea,
stridor, plethora or hoarsenessSymptoms of hyperthyroidism or
hypothyroidism
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PRESENTATION
• Physical ExaminationCharacterisation of thyroid swellingCheck for signs of
hyperthyroidism/hypothyroidismCheck for signs of compression(Pemberton
manoeuvre).Check for signs of malignancy
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PRESENTATIONHyperthyroidism versus Hypothyroidism
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INVESTIGATIONS
• Laboratory Studies: TRH TSH Total T3, T4
Free T3, T4
RAIU Thyroglobulin Antibodies: Anti-TPO, Anti-TSHr
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INVESTIGATIONS
• Imaging Studies:Ultrasonography:Evaluate goiter size,
consistency, and nodularity. Localize nodules for ultrasonographically guided biopsy.
X Rays:Usually AP and Lateral with thoracic inlet.Retrosternal goitre extension.Presence of calcification.
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INVESTIGATIONS
Computed tomography (CT) scanning: Delineate the relationship of the thyroid gland to nearby structures.CT-guided biopsies.
Radionuclide isotope scanning are used to assess thyroid function and anatomy in hyperthyroidism, as shown below.
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INVESTIGATIONS
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INVESTIGATIONS
Spirometry: The flow-volume loop is useful in determining the functional significance of compressive goiters.
Histology:fine needle aspiration or core biopsy.
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DIFFERENTIAL DIAGNOSES
• Pseudogoitre• Thyroglossal cyst• Sublingual dermoid• Lymphadenopathy(bull’s neck).• Thyroid lipomas• Thyroid lymphomas
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TREATMENT
• Observation Small goiter Euthyroid Asymptomatic• Medications: Hypothyroidism: Thyroid hormone replacement with
levothyroxine. Hyperthyroidism:May require medications to normalize
hormone levels for example propylthiouacil,Methimazole Inflamed thyroid gland, aspirin or a corticosteroid
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TREATMENT
• Surgery: Removing all or part of the thyroid gland-Thyroidectomy.
Large goiters with compressionMalignancyWhen other forms of therapy are not practical
or ineffective• Radioactive iodine: Treatment results in
diminished size of goiter, but eventually may also cause a hypothyroid state.
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TREATMENT
• Minimally-invasive modalitiesEndoscopic subtotal thyroidectomyEmbolization of thyroid arteries PlasmaphoresisPercutaneous ethanol injection into toxic
noduleL-Carnitine supplementation may improve
symptoms and may prevent bone loss
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PROGNOSIS
• Complications of thyroidectomy:• Thyrotoxic storm• Bleeding• Infection• Hypoparathyroidism• Injury to recurrent laryngeal nerve• Injury to superior laryngeal nerve• Hypothyroidism
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PROGNOSIS
• A small percentage of multinodular goiters do lead to hyperthyroidism.
• Benign goiters have a good prognosis,furthermore,the risk of malignant transformation is low.
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THANK YOU