THYROID DISEASES

Anatomy of Thyroid Gland

Arterial supply Sup. thyroid artery
(branch of ext carotid artery)

Inf. thyroid artery

(branch of thyrocervical trunk)

Thyroidea ima (from

brachiocephalic artery/arch of aorta)

Anatomy of Thyroid Gland

Venous drainage Sup. Thyroid (drains into
internal jugular vein)

Middle thyroid (drains

into internal jugular vein)

Inf. thyroid (drain into left

brachiocephalic vein)

Ectopic Thyroid & Anomalies

Lingual

Median ectopic thyroid

Lateral aberrant thyroid Pyramidal lobe

Intrathoracic aberrant thyroid

Ectopic Thyroid & Anomalies

Lingual thyroid
Rounded swelling at back of tongue May cause dysphagia, impairment of speech, resp obstruction, hemorrhage

Median ectopic thyroid

Upper part of the neck Mistaken for thyroglossal cyst

Lat aberrant thyroid

normal thyroid laterally must be considered & treated as mets in cervical LN from occult papillary thyroid ca

Ectopic Thyroid & Anomalies

Thyroglossal cyst
Any part of thyroglossal tract Midline Move upward on protrusion of tongue >1cm, excised because prone for infection Infected cyst often mistaken for abcess & incised thyroglossal fistula

Ectopic Thyroid & Anomalies

Thyroglossal fistula
Infection/inadequate removal of throglossal cyst Cutaneous opening drawn upward on protussion of tounge Discharge mucus recurrent attack of inflammation

Classification of Thyroid Swelling

Simple goiter (euthyroid)
Diffuse hyperplastic
Physiological

Inflammatory
Autoimmune
Hashimotos ds Chronic lymphocytis thyroiditis

Multinodular

Toxic
Diffuse : Graves disease Multinodular Toxic adenoma

Granulomatous
De Quervains thyroiditis

Fibrosing
Riedels thyroiditis

Infective
Acute (bacterial & viral thyroiditis) Chronic (TB, syphilis)

Neoplastic
Benign Malignant

Other
amyloid

Simple Goiter
Aetiology Iodine deficiency Dyshormogenesis Goitrogens The natural history of simple goiter Persistent growth stimulation causes diffuse hyperplasia Mixed patterns develops with areas of active and inactive lobules as result of fluctuating stimulation Active lobules become more vascular and hyperplastic until haemorrhage occurs, causing central necrosis Necrotic lobules coalesce to form nodules filled with either iodine-free colloid or a mass of new but inactive follicles Continual repetition of these processes result in a nodular goitre

Diffuse Hyperplastic Goiter

Correspond to the 1st stages of natural history Childhood (endemic areas), puberty, pregnancy soft, diffuse and may become large enough to cause discomfort.

Nodular Goiter
Later stage of natural history of simple goitre Multiple multinodular goitre may be colloid or cellular cystic degeneration and haemorrhage is common Can develop retrosternal goitre
dyspnea, cough, stridor, SVC obstuction

Solitary Nodule
70% are clinically isolated, 30% dominant May have risk of neoplasia 15% isolated - malignant 30-40% - follicular adenomas Remainders non neoplastic, colloid degeneration, thyroiditis, cysts Ix
TFT autoAb titres Isotope scan
Hot/cold 80% cold & only 15% malignant

U/s : solid/cyst FNAC

Hypothyroidism
Autoimmune thyroiditis (Hashimotos ds, 1o myxodema) Iatrogenic Dyshormongenesis Goitrogens 2o to pituitary or hypothalamic disease Endemic cretinism

Signs & Symptoms

Hashimotos disease
destruction of thyroid cells by various celland Ab-mediated immune processes. Ab bind and blocking the TSH inadequate thyroid hormone production and secretion Middle age woman Uniformly enlarge & firm (occ asymmetrical & irregular) Thyroglobulin & microsomal Ab (90%)

Hashimotos disease
TFT
Low T4 & T3 High TSH

Treatment
levothyroxine sodium, usually for life. goal of therapy is to restore a clinically and biochemically euthyroid state. standard dose is 1.6-1.8 mcg/kg lean body weight per day

Hyperthyroidism
Diffuse toxic goitre (Graves disease) Toxic nodular goitre Acute thyroiditis Gestational thyrotoxicosis Exogenous iodine Drugs- amiodarone Thyrotoxicosis factitia TSH-secreting pituitary tumours Metastatic differentiated thyroid carcinoma Hcg-producing tumours Hyperfunctioning ovarian teratoma thyrotoxicosis factitia (rare)

1o vs 2o hyperthyroidism
1o (Graves ds)
Enlargement of thyroid and toxic features appear simultaneously
Toxic features are usually severe Nervous manifestations young Exopthalmos and eye signs are common small, diffuse, smooth

2o
Goitre appears first, toxic features develope after an interval
Toxic features are mild Cvs manifestations elderly These are absent large, nodular, irregular

Signs & symptoms

Symptoms
Tiredness Emotional liability Heat intolerance LOW Excessive appetite Palpitations Myopathy Oligomenorrhea

Signs
Tachycardia Hot, moist palms Eye sign
Exopthalmos Lid lag/ retraction Dilated pupils Double vission

Agitation Thyroid goitre and bruit Fine tremor

Exophtalmos

Pretibial myxoedema

Diffuse Toxic Goiter (Graves ds)

autoimmune disease Abnormal TSH-Ab bind to TSH prolonged effect increase hormon Young women No preceding history of goiter Smoothy enlarged Eye signs

Toxic Nodular Goiter (2 )

o

Simple goiter present b4 hyperthyroidism Middle aged/elderly Many cases, nodule inactive but intranodular tissue is active Nodule activated hyperthyroidism

Investigations
Essential
Serum TSH (T3 and T4 if abnormal) Serum thyroid autoantibodies FNAC of all palpable discrete swellings

Optional
Calcium and albumin CXR and thoracic inlet if tracheal deviation/retrosternal Isotope scan if discrete swelling and toxicity coexist

Thyroid funtional state Euthyroid Thyrotoxic

TSH (0.3 3.3U -1)

Free T4 (10 30 nmol-1) Normal High

Free T3 (3.5 7.5 mol1) Normal High

Normal Undetectable

Myxoedema
Suppressive T4 therapy

High
Undetectable

Low
High

Low
High

T3 toxicity

Low/Undetectable

Normal

High

Treatment of thyrotoxicosis
Antithyroid drugs carbimazole -adrenergic blocking drugs Anti-thyroid drugs combined with subsequent thyroidectomy Radioactive iodine-131

Anti-thyroid Drugs
restore in euthyroid state and maintain for prolong period in hope of remission Carbimazole 10mg 8-hourly Continue for 12 months Aware of toxic symptoms within 2 weeks, if symptoms recur further 6 months treatment with surgery is advised High relapse rate (60%) after terminating the treatment (even in 2 or more years of tx) Medical tx alone usually confined to 1 hyperthyroidism in children and adolescents

 Side effects of carbimazole:

Drug rash Fever Arthropathy Lymphadenopathy Agranulocytosis (sore throat)

-adrenergic blocking drugs Propanolol induces rapid symptomatic improvement of cvs features in patients with severe hyperthyroidism

Surgery for thyrotoxicosis

Preoperative preparation
Anti-thyroid drugs -adrenergic blocking drugs (alternative)

Extent of resection
size of gland age of patient experience of surgeon need to minimise risk of recurrent toxicity

 Hemithyroidectomy, total thyroidectomy (depends) It cures by reducing mass of overactive tissue in diffuse toxic goitre and toxic nodular goitre Advantages: the goitre removed, cure is rapid and cure rate high if surgery adequate Disadvantages: recurrence in 5% of cases and risk of surgery complications

Procedures

While the patient is deep asleep and pain-free (general anesthesia), an incision is made in the front of the neck.

The thyroid gland is removed. Either one lobe of the thyroid gland, or the entire gland, is removed, depending on the disease process being treated

Complications of thyroidectomy
Hormonal disturbances
Tetany (parathyroid) Thyroid crisis Hypothyroidism (due to extensive removal of thyroid tissue) Late recurrence of hyperthyroidism (d2 inadequate operation in toxic gland)

Damage to related anatomical structures

Recurrent laryngeal nerve Injury to trachea Pneumothorax

Complications of any operation

Haemorrhage Sepsis Postoperative chest infection Hypertrophic scarring (keloid)

Radioactive Iodine
destroys thyroid cells reduces the mass of functioning thyroid tissue to below a critical level Swallow a glass of water containing radioiodine Useful in recurrence of hyperthyroidism after thyroidectomy (takes 2-3 months) high incidence of late hypothyroidism (75-80%) after 10 years Contraindicated in pregnant women (affecting infants thyroid) No evidence therapeutic radioiodine is carcinogenic or teratogenic

Neoplasms

Classification
Follicular epit diff Follicular benign adenoma

malign

1o

papillary (60%)
follicular (20%) Follicular epit undiff anaplastic (10%) Parafollicular cells medullary (5%) Lymphoid cells lymphoma (5%)

2o

Mets local infiltrate

Benign Follicular Adenoma

Clinically, solitary nodules F:M = 4:1 HPE to differentiate adenoma and carcinoma (in adenoma there is no invasion of capsule or of pericapsular blood vessels) Tx: wide excision (lobectomy)

Thyroid carcinoma
F:M = 3:1 (incidence 3.7 in 100 000) Arising in pre-existing goitres Reported following radiation of the neck in childhood Clinical features
Goiter LN (papillary ca) recurrent laryngeal nerve paralysis (locally advanced dis.) usually euthyroid

Anaplastic hard, irregular, infiltrating

Papillary carcinoma
Commonest (60%) Young adults, adolescents or children Slow growing tumour Spread
lymphatic (late and common) Blood-born (uncommon)

Occult carcinoma- enlarged lymph node in the jugular chain with no palpable abnormality of thyroid (good prognosis) Tx
combination of surgery (total lobectomy or thyroidectomy), thyroid suppression by T4 and radioiodine

numerous papillae having a fibrovascular stalk covered by a single to multiple layers of cuboidal epithelial cells

Follicular carcinoma
Young and middle-aged adults Common in area of endemic goiter Spreads
Blood stream (common)
worsen the prognosis mortality rate twice fr papillary ca

Lymphatic rare

Tx: same as papillary ca

Invasion of capsule and the vascular spaces in the capsular region in follicular carcinoma.

Papillary vs. Follicular ca

Papillary (%) Follicular (%)

Male incidence LN mets Blood vessel invasion Recurrence Mortality rate Distant mets Nodal mets

22 35 40 19 11 45 34

35 13 60 29 24 75 12

Prognosis : PAPILLARY > follicular

Medullary carcinoma
Arises from parafollicular C cells may secrete calcitonin (tumour marker) any age F=M associated with other cancers in MEN syndrome (type II) Deposits of amyloid between the nests of tumour cells Lymph node and blood-borne involvement are common Tx: total thyroidectomy and lymph node clearance (if involved)

Characteristic cell balls and amyloid in medullary carcinoma

Anaplastic carcinoma
elderly Rapid local spread takes place with compression and invasion of the trachea Early dissemination to the regional lymphatics and blood-stream spread to the lung, skeleton and brain Tx
radical thyroidectomy palliative radiotherapy temporary relieve (tracheostomy for obstructed airway)

TNM staging
Primary tumor (T) TX: Primary tumor cannot be assessed T0: No evidence of primary tumor T1: Tumor 1 cm or less in greatest dimension limited to the thyroid T2: Tumor more than 1 cm but not more than 4 cm in greatest dimension limited to the thyroid T3: Tumor more than 4 cm in greatest dimension limited to the thyroid T4: Tumor of any size extending beyond the thyroid capsule

Regional lymph nodes (N) NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Regional lymph node metastasis
N1a: Metastasis in ipsilateral cervical lymph node(s) N1b: Metastasis in bilateral, midline, or contralateral cervical or mediastinal lymph node(s)

Distant metastases (M) MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis

Prognosis
Well differentiated tumours
Long survival even with presence of LN deposits

Anaplastic tumours
Pt dead within a year (due to local invasion or widespread dissemination)

Thyroiditis

Chronic lymphocytic (autoimmune) thyroiditis

Raised titer of thyroid Ab Family history of autoimmune disease goitre (diffuse or nodular) with characteristic bosselated feel Common in menopause women any age mild hyperthyroidism initially and later hypothyroidism Dx: raised serum level of thyroid antibodies, FNAC, biochemical test of thyroid fx if hypothyroidism is present Tx: replacement with thyroxine (hypothyroidism), thyroidectomy maybe necessary if goitre is large

Granulomatous thyroiditis
subacute thyroiditis, de Quervains thyroiditis virus infection Features pain in the neck Fever Malaise firm, irregular enlargement of one or both thyroid lobes Raised ESR absent thyroid antibodies serum T4 is high or slightly raised radioiodine uptake of gland is low Self limiting, goitre subsides in few months Dx - confirmed by FNAC & radioactive iodine uptake - rapid symptomatic response to prednisolone in acute case of severe pain

Riedels thyroiditis
Rare slightly enlarged but is woody hard with infiltration of adjacent tissues represent late stage of Hashimotos disease or inflammatory origin Mistaken for thyroid ca (histologically gland is replaced by
fibrous tissue containing chronic inflammatory cells)

a/w other conditions such as retroperitoneal fibrosis, sclerosing cholangitis, and fibrosing mediastinitis Wedge resection of portion of gland if tracheal compression symptoms develop