GOITRE

Syed Shahzil Ali Shah

 • The thyroid gland is composed of right and
left lobes positioned anterolateral to the
larynx and trachea.
• The two lobes are connected to each
other by the isthmus, which is present just
below the cricoid cartilage.
• The superior pole of each lobe lies lateral
to the inferior constrictor muscle of the
ANATOMY pharynx and posterior to the sternothyroid
muscle.
• The lower pole of each lobe extends till
the fifth or sixth tracheal rings.
• Important anatomical structures that lie in
close proximity to the thyroid gland
include recurrent laryngeal nerves,
superior laryngeal nerves and two pairs of
parathyroid glands.
 • Blood supply of the thyroid gland is
derived mainly from superior thyroid and
inferior thyroid artery on each side.
• Superior thyroid artery is a branch of
external carotid artery and runs along the
inferior constrictor muscle.
• Inferior thyroid artery is a branch of
thyrocervical trunk and enters into the
ANATOMY gland near its lower pole.
• Venous drainage is through superior,
middle and inferior thyroid veins.
• Lymphatic drainage occurs through upper,
middle and lower deep cervical,
supraclavicular, pretracheal, prelaryngeal
lymph nodes.
 Enlargement of the thyroid gland.
Comprises of a variety of conditions.
Classified into toxic and non-toxic, diffuse or nodular, and
solitary or multiple.
Classification
• Based on how it enlarges:
• Simple (diffuse) goitre: This type of goitre happens when your
entire thyroid gland swells and feels smooth to the touch.
• Nodular goitre: This type of goitre happens when a solid or
GOITRE fluid-filled lump called a nodule develops within your thyroid
and makes it feel lumpy.
• Multinodular goitre: This type of goitre happens when there
are many lumps (nodules) within your thyroid. The nodules
may be visible or only discovered through examination or
scans.
• Based on thyroid hormone levels include:
• Toxic goitre: This goitre happens when your thyroid is
enlarged and produces too much thyroid hormone.
• Nontoxic goitre: If you have an enlarged thyroid but normal
thyroid levels (euthyroid), it’s a nontoxic goitre. In other words,
you don’t have hyperthyroidism or hypothyroidism.
 Common etiological factors:

1. Iodine deficiency
2. Excessive use of goitrogens: substances that causes enlargement
of the thyroid gland.
3. Stimulation of TSH by pituitary tumours, pituitary thyroid hormone
resistance and thyroid-stimulating immunoglobulins.
4. Inborn errors of metabolism causing defects in biosynthesis of
5. thyroid hormones.
Etiology 6. Thyroid hormone resistance
7. Autoimmune thyroiditis (Hashimoto’s thyroiditis, post-partum
8. thyroiditis, subacute lymphocytic thyroiditis, Graves’ disease etc.)
9. Infectious thyroiditis including post-viral and bacterial thyroiditis
10.Granulomatous diseases
11.Fibrous or Riedel’s thyroiditis
12.Thyroid neoplasia
 • Dysphagia
• Dyspnea
• Hoarseness
• Neck swelling
• Signs and symptoms associated with hyperthyroidism and hypothyroidism
Signs &
Symptoms
 Detailed history taking
Physical Examination ( inspection, palpation, auscultation, and percussion)
Thyroid function test: includes serum TSH, T3 and T4 levels. Serum TSH
offers the most specific and sensitive means of defining euthyroidism.
Ultrasound imaging: to find out presence, number, consistency and size
Investigations of the nodules.
Fine Needle Aspiration Cytology (FNAC): to find out histopathology in
diagnosis of a suspicious nodule.
Thyroid scintigraphy: provides information about the functional status of
the nodule in relation with the surrounding thyroid tissues. A hyper-
functioning nodule will appear as ‘hot’ while a hypo-functioning nodule will
appear as ‘cold’.
 Chronically enlarged thyroid gland with multiple areas of nodularity.
Most common endocrine disorder worldwide.
Iodine deficiency is a common cause.

MULTI-
NODULAR
GOITRE
(MNG)
 • Iodine deficiency causes decreased formation of thyroid
hormone.
• Stimulates secretion of increased TSH from the anterior
pituitary gland.
• TSH stimulates the growth of thyroid gland tissue.
• Initially, there is diffuse hyperplasia that is later on followed by
Pathology colloid storage, where the follicles of various sizes are
present, giving a nodular appearance.
• These follicles are morphologically and functionally identical
to normal thyroid tissue.
• Growth of thyroid tissue continues and sometimes areas of
increased functioning may progress to hyperthyroidism or
toxic MNG.
• Genetic influences also play a role in formation of MNG.
 Obvious neck swelling on the anterior aspect of the neck.
Signs and symptoms of hyperthyroidism or
hypothyroidism.
Clinical Large and long-standing MNG may produce compression
symptoms at upper aerodigestive system causing:
Features 1. Dysphagia
2. Dyspnea
3. Hoarseness of voice
 Thyroid function test: includes serum TSH, T3 and T4 levels. Serum TSH
offers the most specific and sensitive means of defining euthyroidism.
Ultrasound imaging: to find out presence, number, consistency and size of
the nodules.
Investigations Fine Needle Aspiration Cytology (FNAC): to find out histopathology in
diagnosis of a suspicious nodule.
Thyroid scintigraphy: provides information about the functional status of the
nodule in relation with the surrounding thyroid tissues. A hyper-functioning
nodule will appear as ‘hot’ while a hypo-functioning nodule will appear as
‘cold’.
 Medical treatment of MNG in the form of suppression therapy
with thyroxine to suppress TSH has a very limited role
The mainstay of treatment is surgical removal of the gland in
the form of total, near total or subtotal thyroidectomy.

Treatment The extent of surgery, either total thyroidectomy or subtotal

thyroidectomy depends on the situation where normal thyroid
tissue can be left behind or not.
For surgery, patient must be euthyroid before surgery.
In case of hyperthyroidism or toxic MNG, first medical
treatment in the form of antithyroid drugs is recommended
until the patient is euthyroid.
 Thyroid nodule is a common clinical condition.
SOLITARY Prevalence of clinically palpable thyroid
nodule is estimated to be around 1% to 7%.
THYROID
Whether the detected nodule is malignant or
NODULE not always remains critical.
Classified into benign and malignant.
 Most solitary thyroid nodules are benign and include:
Thyroid adenoma: further classified into follicular and papillary
type. Follicular adenoma is much more common than
papillary type.
Colloid nodule
Thyroid cyst: often caused by cystic degeneration of thyroid
Benign tissues, haemorrhage or trauma.
Infectious nodule
Granulomatous or lymphocytic nodule
Hyperplastic nodule
 The various types of malignant thyroid tumors are:
Papillary carcinoma
Follicular carcinoma
Hurthle cell carcinoma
Medullary carcinoma
Malignant Anaplastic carcinoma
Thyroid lymphoma
Squamous cell carcinoma
Sarcoma
 Most common type of thyroid cancer.
Has the best prognosis among all
thyroid cancers.
Females are more commonly affected.
Average age at the time of diagnosis is
Papillary around 40 years.
carcinoma Arises from the follicular cells.
Characterised by a papillary growth
pattern which exhibits distinctive
nuclear features.
Lymphatic metastasis to the regional
lymph nodes is very common.
 Exhibits a pattern of growth that resembles normal
thyroid follicles.
Invasion through the fibrous capsule helps distinguish
follicular carcinoma from the benign follicular
adenoma.
Follicular Follicles of a hyperplastic adenoma are
indistinguishable from those of follicular carcinoma.
carcinoma Presence or absence of invasiveness determines the
malignant potential of a follicular neoplasm.
Regional lymph node metastasis is less common.
Distant hematogenous metastasis is much more
common.
 Also called as ‘oncocytic carcinoma’.
Characterized by the presence of Hurthle cells (oncocytes), which
are large, polygonal cells with abundant cytoplasm and
mitochondria.
Hurthle cell Behavior of Hurthle cell carcinoma is highly variable and depends
carcinoma on the histological features of the tumour.
 Rare malignant tumour.
Arises from parafollicular C cells of the thyroid gland.
Comes in the category of neuroendocrine neoplasia.
Biochemically active neoplasm that secretes calcitonin.
Medullary
carcinoma
 Uncommon malignant tumour.
Anaplastic Shows aggressive and rapid growth with local tissue invasion.
carcinoma Commonly seen in elderly patients.
 Although thyroid gland does not contain native lymphoid tissues, but
they may be acquired through pathological conditions.
Thyroid Majority are of B cell origin but T cell lymphoma may also occur in the
lymphoma thyroid gland.
 Asymptomatic mass in the neck.
Symptoms of compression or invasion may be present.
Neck mass moves on swallowing but not on tongue protrusion.
Factors that increase the suspicion of malignancy include:
Clinical Rapid growth of the nodule
Features Extremes of age
Previous radiation therapy in head and neck region
Symptoms of compression or invasion
Family history of thyroid cancer
 Thyroid function test.
Ultrasound imaging: can detect a nodule of few millimetres in size and can
also differentiate between a solid or a cystic nodule. It is also helpful in
assessing nodal metastasis in the neck nodes.
Fine Needle Aspiration Cytology (FNAC): gold standard in evaluation of
a thyroid nodule.
Thyroid scintigraphy
Investigations
CT scan or MRI: CT scan is helpful in assessing neck nodes and for
assessing extension and invasion of the thyroid cancer into the surrounding
tissues.
Serum thyroglobulin: serum thyroglobulin level is used in follow- up cases
of thyroid cancers after surgery and it is raised in cases of tumor
recurrence.
Serum calcitonin: done in cases where medullary carcinoma of the thyroid
is suspected.
 Treatment of a thyroid nodule depends on the results of FNAC and
other investigations.
In small and benign thyroid nodules, suppression therapy with
thyroxine may reduce the size of the nodule.
Nodules that are not responding to treatment or are increasing in size,
suspicious nodules and malignant nodules are treated by surgery.
Treatment Benign and suspicious nodules are treated by lobectomy and
isthmusectomy.
Post-operative specimen is sent for histopathology.
If histopathology shows malignant tumor, complete thyroidectomy with
or without neck dissection is done.
In cases of malignant disease on FNAC, total thyroidectomy with or
without neck dissection is advised.
 • Autoimmune disease characterised by hyperthyroidism due to
circulating thyroid stimulating autoantibodies.
• These thyroid-stimulating immunoglobulins (TSIs) bind to and
activate thyrotropin receptors in the thyroid gland.
GRAVES’ • Causes the gland to grow and increases synthesis of thyroid
hormone.
DISEASE • Increased levels of circulating T3 and T4 have a negative
feedback effect causing decrease in secretion of TSH.
• Classically occurs in women of childbearing age (20-40 years).
• Most common cause of hyperthyroidism.
 Hyperthyroidism and thyrotoxicosis:
Weight loss, fatigue, weakness, increased appetite, heat
intolerance, restlessness, anxiety, irritability, insomnia,
palpitation, increased heart rate, increased sweating,
warm and moist skin, increased bowel movements,
menstrual irregularity, fine tremors etc.

Clinical Eye changes (ophthalmopathy):

Exophthalmos
Features Lid retraction
Lid lag
Restricted eye movements
Skin changes (dermopathy):
Pretibial myxedema
 • Thyroid function test: raised levels of free T3 and T4 and
decreased level of TSH
• Ultrasonography: diffuse enlargement of the thyroid gland with
increased vascularity.
• Thyroid scintigraphy: to rule out presence of functioning
Investigations adenoma (hot nodule) in the thyroid gland.
• Thyroid stimulating immunoglobulin assay: raised, diagnostic
test for Graves’ disease.
• Other thyroid antibodies assay: anti-thyroglobulin antibodies
and anti-thyroidal peroxidase antibodies are sometimes raised.
 • Beta blocker drugs for adrenergic hyperfunction.
• Anti-thyroid drugs like carbamizole.
• Radioactive iodine ablation.
Treatment • Thyroidectomy.
• Glucocorticoids (especially if Graves’ disease is associated with
• other autoimmune disorders).
 Q: Which of the following vessel gives rise to the superior
thyroid artery?
A: External carotid artery
Quiz B: Facial artery
C: Subclavian artery
D: Thyrocervical trunk
 Q: A 42-year-old male patient was diagnosed with
multinodular goitre. What is the most sensitive and specific
serum test for assessment of his thyroid functional status
whether he is euthyroid or not?
A: Free T4

Quiz B: Serum T3
C: Serum T4
D: Serum TSH
THANK YOU
For bearing this presentation