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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
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