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Thyroid GlandThyroid Gland
Prof. Dr. Mohamed Ahmed YehiaProf. Dr. Mohamed Ahmed Yehia
Professor of general surgeryProfesso...
Anatomy of thyroid glandAnatomy of thyroid gland
 Weight : 15 – 25 gmWeight : 15 – 25 gm
 Shape : Butterfly , consisting...
 Blood supply :Blood supply : It is high vascular organIt is high vascular organ
Arterial :Arterial : 55
 Superior thyro...
NervesNerves relatedrelated to the glandto the gland ::
1- The Superior laryngeal nerves.1- The Superior laryngeal nerves....
2-2- The Recurrent laryngeal nervesThe Recurrent laryngeal nerves :: ( branches of vagi )( branches of vagi )
 In the ear...
SoSo
 The Lt. one hooks around the aortic thenThe Lt. one hooks around the aortic then
ascendsascends
 The Rt. one hooks...
Surgical important pointsSurgical important points

Thyroid gland is one of sites ofThyroid gland is one of sites of occu...
 In unilateral recurrent nerve injury :In unilateral recurrent nerve injury :
vocal cord on that side becomes motionless ...
Development of thyroid glandDevelopment of thyroid gland
 The thyroid gland develops as a medianThe thyroid gland develop...
Thyroglossal CystThyroglossal Cyst
 It may occur at any site along the course of the thyroglossal duct.It may occur at an...
 It is never congenital , alwaysIt is never congenital , always acquiredacquired due to infection ordue to infection or
i...
 Ectopic thyroid tissue may occur anywhere along the course of theEctopic thyroid tissue may occur anywhere along the cou...
RetrosternalRetrosternal GoitreGoitre A very few retrosternal goitres arise from ectopic thyroid T. but , most arise from...
Struma ovariiStruma ovarii
 It is not ectopic , but port of an ovarian teratoma very rarelyIt is not ectopic , but port o...
GoitersGoiters
"" gutturguttur == throatthroat""
 definitiondefinition :: Any enlargement of thyroid glandAny enlargement...
Hormones of thyroid glands:Hormones of thyroid glands:
 Hormones secreted by the thyroid :Hormones secreted by the thyroi...
CLASSIFICATIONCLASSIFICATION
OFOF
GOITREGOITRE
Simple GoiterSimple Goiter
 It is due to stimulation of thyroid gland by the anterior pituitaryIt is due to stimulation o...
2.2. Defects in synthesis of thyroid hormones.Defects in synthesis of thyroid hormones.
 Enzyme deficiency within the thy...
Natural History of simple GoitreNatural History of simple Goitre::
"stages of goitre formation ""stages of goitre formatio...
Clinical types of S.N.G :Clinical types of S.N.G :
1. Diffuse hyperplastic goitre.1. Diffuse hyperplastic goitre.
2. Nodul...
1. Diffuse1. Diffuse hyperplastichyperplastic goitregoitre
(physiological and colloid(physiological and colloid goitregoit...
Frequently seen between 15 – 30 years , markedFrequently seen between 15 – 30 years , marked
enlargement of gland with smo...
22..Nodular GoiterNodular Goiter
As regards to natural history of S.N.G , persistAs regards to natural history of S.N.G , ...
 Diagnosis of S.N.G :Diagnosis of S.N.G : diagnosis of nodulardiagnosis of nodular
goiture is usually straightforward the...
Complication of nodular goitre :Complication of nodular goitre :
1.1. Toxic changeToxic change : In long standing cases in...
Indication for surgical removal of nodular goiter :Indication for surgical removal of nodular goiter :
1. Suspicion of mal...
Prevention and treatment of simple goitre :Prevention and treatment of simple goitre :
 All table salt should be iodised....
The problem of clinically solitary nodule andThe problem of clinically solitary nodule and
its evaluation :its evaluation ...
Causes of solitary nodule in thyroid:Causes of solitary nodule in thyroid:
1. solitary nodular goiter.1. solitary nodular ...
Adenoma of thyroid may be :Adenoma of thyroid may be :
 Embryonal adenomaEmbryonal adenoma
 Fetal or micro-follicular ad...
2. Investigations2. Investigations
A.A. is helpful in determining whether the lesion is singleis helpful in determining wh...
B. Ultrasound (echography)B. Ultrasound (echography)
• It is helpful to differentiate solitary from multipleIt is helpful ...
3. Treatment :3. Treatment :
A.A. Enucleation :Enucleation : Removal of the nodule from its capsule.Removal of the nodule ...
N.B.N.B.
 The term thyrotoxicosis is retained because hyperthyroidism i.e.The term thyrotoxicosis is retained because hyp...
Toxic GoitreToxic Goitre
Clinical Types :Clinical Types :
1. primary toxic goitre (Grave’s disease)1. primary toxic goitre...
I. Pathology :I. Pathology :
A. Gross appearance :A. Gross appearance :
 The gland : is moderately enlarged , brick red i...
II.II. Clinical FeaturesClinical Features ::
 Thyrotoxicosis affects all the systems of the body startingThyrotoxicosis a...
A) General FeaturesA) General Features
1. C.V.S1. C.V.S
a)a) Dyspnea on exertion , palpitation , tachycardia are early fea...
4. Gastro – intestinal :4. Gastro – intestinal :
 Polyphagia i.e. increased appetite, later there may be loss of appetite...
c)c) PretibialPretibial myxedemamyxedema
 It is thickening of skin by a mucin – like deposit. It isIt is thickening of sk...
B) Thyroid manifestationB) Thyroid manifestation
 Moderately, symmetrical enlargement of thyroid glandModerately, symmetr...
C) Eye ManifestationC) Eye Manifestation
Exopthalmos is commonly classified into 4 grades :Exopthalmos is commonly classif...
4.4. Malignant exophthalmos :Malignant exophthalmos :
It is a progressive form , which may increased afterIt is a progress...
 Stellwag’s sign :Stellwag’s sign : infrequency of blinking with ainfrequency of blinking with a
staring look.staring loo...
 N.B.N.B.
Other causes of exophthalmos :Other causes of exophthalmos :
1. A space – occupying lesion in orbit.1. A space ...
2. Secondary toxic goiter2. Secondary toxic goiter
 Here a simple nodular goitre is present for long time before the hype...
3. Toxic Nodule3. Toxic Nodule
It is solitary over active nodule (hot nodule)It is solitary over active nodule (hot nodule...
Investigations for thyrotoxicosisInvestigations for thyrotoxicosis
1. Clinical diagnosis by Wayne Diagnostic Index.1. Clin...
Thyroid function testsThyroid function tests
1. Measurements of thyroid hormone in serum1. Measurements of thyroid hormone...
4. Miscellaneous tests4. Miscellaneous tests
A.A. B.M.R N. -10% to +15% of the standardB.M.R N. -10% to +15% of the standa...
Protein bound iodine P.B.IProtein bound iodine P.B.I
 iodine containing hormones T3 and T4 are transported in theiodine c...
Total serum T3 - free Serum T4Total serum T3 - free Serum T4
 Both measured by Radio - Immuno assay, andBoth measured by ...
2- Measurement of free binding sites for thyroid hormones2- Measurement of free binding sites for thyroid hormones
in the ...
3. Uptake and discharge of radio active iodine :3. Uptake and discharge of radio active iodine :
A. Radio active iodine up...
B- T3 Resin uptake test :B- T3 Resin uptake test :
 By incubating iodine T3 (Radioactive T3) withBy incubating iodine T3 ...
C- T3 suppression test “Werner”.C- T3 suppression test “Werner”.
 Goitre due to iodine deficiency in endemic areasGoitre ...
D- Thyroid scanningD- Thyroid scanning
scanning of thyroid after a tracer dose of radioscanning of thyroid after a tracer ...
 D.D of thyrotoxicosisD.D of thyrotoxicosis
 Anxiety.Anxiety.
 Neurosis.Neurosis.
 HT disease.HT disease.
 Myasthenia...
 How do you differentiate between psychoneurosis andHow do you differentiate between psychoneurosis and
thyrotoxicosis ?t...
Treatment of Toxic GoitreTreatment of Toxic Goitre
1. Medical treatment1. Medical treatment
Indications :Indications :
 Mild cases.Mild cases.
 Thyrotoxicosis occuring dur...
Aim of treatment :Aim of treatment :
Inhibit the function of the gland without destroyingInhibit the function of the gland...
 Very rarely , there is a dangerous drug reactionVery rarely , there is a dangerous drug reaction
e.g.e.g. a granulocytos...
Drugs used :Drugs used :
Thiouracil.Thiouracil.
Methyl thiouracil 300 – 600 mg /day.Methyl thiouracil 300 – 600 mg /day....
 Scheme of treatment :Scheme of treatment :
 The patient is given forThe patient is given for one monthone month if ther...
The results of medical treatment :The results of medical treatment :
50%50% of cases are cured completely.of cases are cur...
22..Radio active iodineRadio active iodine
Indications :Indications : recurrent cases after surgery (overrecurrent cases a...
Disadvantages :Disadvantages :
1. No reliable method of estimating the exact dose1. No reliable method of estimating the e...
Dose of radio iodine for treatment :Dose of radio iodine for treatment :
 4 – 84 – 8 millicuries according to the size of...
3. Surgical treatment3. Surgical treatment
Indications :Indications :
 moderate and severe casesmoderate and severe cases...
Preoperative investigation :Preoperative investigation :
1. Indirect laryngoscope1. Indirect laryngoscope
2. Thyroid anti ...
7. Anti thyroid drug till B.M.R falls to normal7. Anti thyroid drug till B.M.R falls to normal
8.8. 15 days15 days before ...
Subtotal ThyroidectomySubtotal Thyroidectomy
 Anaesthesia :Anaesthesia : general endo – trachealgeneral endo – tracheal
...
 Anterior jugular veins are divided betweenAnterior jugular veins are divided between
ligaturesligatures
 Opening the in...
 They are divided near their upper end as theirThey are divided near their upper end as their
nerve supply comes from bel...
 Ligation ofLigation of inf. Thyroid arteryinf. Thyroid artery as far from theas far from the
gland as possible (away and...
 Closure leaving a drain on each sideClosure leaving a drain on each side
reaching the depth of wound behind thereaching ...
What are indications of tracheastomy afterWhat are indications of tracheastomy after
thyroidectomy ?thyroidectomy ?
1. Pos...
Complications of thyroidectomyComplications of thyroidectomy
Local complications :Local complications :
1. Hemorrhage1. He...
Endocrine :Endocrine :
1. Tetany1. Tetany
2. Thyrotoxic crisis2. Thyrotoxic crisis
3. Recurrent thyrotoxicosis3. Recurrent...
1. Tetany1. Tetany
-- It is due to removal of all parathyroidsIt is due to removal of all parathyroids
- It is rare but pe...
2. Thyroxic crisis2. Thyroxic crisis
-- It is due to flooding of the circulation withIt is due to flooding of the circulat...
Treatment :Treatment :
1. Sedation : morphia1. Sedation : morphia
2. anti-pyretic : cold compresses and largactil2. anti-p...
Cancer thyroidCancer thyroid
1. Precancerous conditions1. Precancerous conditions
2. Pathological types2. Pathological typ...
2. Pathological Types2. Pathological Types
PapillaryPapillary adenocarcinoma 85%adenocarcinoma 85%
- Occult.Occult.
- Intr...
It is characterized by :It is characterized by :
1. Low grade malignancy.1. Low grade malignancy.
2. Slow growth it may re...
Treatment :Treatment :
 Total thyroidectomy with unilateral orTotal thyroidectomy with unilateral or
bilateral block diss...
2. Follicular adenocarcinoma 10 %2. Follicular adenocarcinoma 10 %
 It is usually common in endemic nodular goitres met w...
3. Anaplastic Carcinoma 3%3. Anaplastic Carcinoma 3%
 It usually occurs in old age group.It usually occurs in old age gro...
4. Medullary Carcinoma 2 - 4%4. Medullary Carcinoma 2 - 4%
 It is rare tumors , a rise fromIt is rare tumors , a rise fro...
Thyroid Gland
Thyroid Gland
Thyroid Gland
Thyroid Gland
Thyroid Gland
Thyroid Gland
Thyroid Gland
Thyroid Gland
Thyroid Gland
Thyroid Gland
Thyroid Gland
Thyroid Gland
Thyroid Gland
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Thyroid Gland

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Property of Prof. Dr. Mohamed Ahmed Yehia, Department of General Surgery, Faculty of Medicine, University of Zagazig, Egypt

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Thyroid Gland

  1. 1. Thyroid GlandThyroid Gland Prof. Dr. Mohamed Ahmed YehiaProf. Dr. Mohamed Ahmed Yehia Professor of general surgeryProfessor of general surgery Zagazig Faculty Of MedicineZagazig Faculty Of Medicine
  2. 2. Anatomy of thyroid glandAnatomy of thyroid gland  Weight : 15 – 25 gmWeight : 15 – 25 gm  Shape : Butterfly , consisting of two lobes connected by an isthmus. TheShape : Butterfly , consisting of two lobes connected by an isthmus. The  pyramidal lobe is projection extends up wards from left border of thepyramidal lobe is projection extends up wards from left border of the  isthmusisthmus  Extension : - Upper pole which extends to the middle of thyroid cartilage .Extension : - Upper pole which extends to the middle of thyroid cartilage .  - Lower pole which extends to the 5th tracheal ring.- Lower pole which extends to the 5th tracheal ring.  Capsule : The thyroid gland has two capsules :Capsule : The thyroid gland has two capsules :  True capsule from condensation of its connective tissueTrue capsule from condensation of its connective tissue  False capsule from pretracheal fascia.False capsule from pretracheal fascia.  Relations :Relations :  Anteriorly :Anteriorly : Skin , SC. fat , platysma , deep cervical fascia,Skin , SC. fat , platysma , deep cervical fascia,  pretracheal muscles :-pretracheal muscles :-  Omo hyoid muscle .Omo hyoid muscle .  Sterno hyoid muscle.Sterno hyoid muscle.  Sterno thyroid muscle.Sterno thyroid muscle.  Its lower poles is overlapped by sterno mastoid muscle.Its lower poles is overlapped by sterno mastoid muscle.  Posteriorly :Posteriorly :  Two tubes ( trachea , esophagus)Two tubes ( trachea , esophagus)  Two cartilages ( thyroid , cricoid )Two cartilages ( thyroid , cricoid )  Two muscles (Cricothyroid , inf. Constrictor of the pharynx)Two muscles (Cricothyroid , inf. Constrictor of the pharynx)  Two nerves ( recurrent – external laryngeal )Two nerves ( recurrent – external laryngeal )
  3. 3.  Blood supply :Blood supply : It is high vascular organIt is high vascular organ Arterial :Arterial : 55  Superior thyroid artery from external carotid arterySuperior thyroid artery from external carotid artery  Inferior thyroid artery from thyrocervical trunk ofInferior thyroid artery from thyrocervical trunk of subclavian artery.subclavian artery.  Thyrodima artery from innominateThyrodima artery from innominate Venous :Venous : 66  Sup. thyroid veinSup. thyroid vein  Drain into internal jugular vein.Drain into internal jugular vein.  Middle thyroid veinMiddle thyroid vein  Inferior thyroid vein Drains into innominate vein.Inferior thyroid vein Drains into innominate vein. → →
  4. 4. NervesNerves relatedrelated to the glandto the gland :: 1- The Superior laryngeal nerves.1- The Superior laryngeal nerves. 2- The Recurrent laryngeal nerves.2- The Recurrent laryngeal nerves. 1- The Superior laryngeal nerves :1- The Superior laryngeal nerves : (branch. of the vagus)(branch. of the vagus)  Divides into two branches :Divides into two branches : a) Internal laryngeal nerve, which pierces (with sup.a) Internal laryngeal nerve, which pierces (with sup. laryngeal art.) the thyrohyoid membrane to thelaryngeal art.) the thyrohyoid membrane to the larynx.larynx. It is sensory to larynx above the level of vocal cordsIt is sensory to larynx above the level of vocal cords b) The external laryngeal nerve, which descends withb) The external laryngeal nerve, which descends with the sup. thyroid art.the sup. thyroid art.  It is motor to the cricothyroid muscle.It is motor to the cricothyroid muscle.
  5. 5. 2-2- The Recurrent laryngeal nervesThe Recurrent laryngeal nerves :: ( branches of vagi )( branches of vagi )  In the early fetus the neck is divided into 6 branchialIn the early fetus the neck is divided into 6 branchial arches each contains anarches each contains an aortic arch.aortic arch.  the recurrent laryngeal nerve is the nerve of the 6ththe recurrent laryngeal nerve is the nerve of the 6th branchial arch which gives rise to the developingbranchial arch which gives rise to the developing larynx.larynx.  As the neck elongates and the heart descends, theAs the neck elongates and the heart descends, the recurrent laryngeal nerves are dragged downward byrecurrent laryngeal nerves are dragged downward by the descending aortic arches.the descending aortic arches.  On the Rt. side the 5th & 6th arches disappearOn the Rt. side the 5th & 6th arches disappear leaving the Rt. R.L.N. to hook around the 4th archleaving the Rt. R.L.N. to hook around the 4th arch =Rt. subclavian artery.=Rt. subclavian artery.  On the Lt. side R.L.N. remains hooking around theOn the Lt. side R.L.N. remains hooking around the 6th arch, which doesn`t disappear but forms the6th arch, which doesn`t disappear but forms the ductus arterious which later gives ligamentum.ductus arterious which later gives ligamentum. Arteriouses which is overlapped by the aortic arch.Arteriouses which is overlapped by the aortic arch.
  6. 6. SoSo  The Lt. one hooks around the aortic thenThe Lt. one hooks around the aortic then ascendsascends  The Rt. one hooks around the Rt. subclavianThe Rt. one hooks around the Rt. subclavian art. then ascends.art. then ascends.  Both of them ascends in the trachea-esophagealBoth of them ascends in the trachea-esophageal groove to enter larynx JUST behind thegroove to enter larynx JUST behind the suspensory ligament of berry ( anatomicalsuspensory ligament of berry ( anatomical landmark for recurrent laryngeal nerve )landmark for recurrent laryngeal nerve )  The recurrent nerves are motor to all intrinsicThe recurrent nerves are motor to all intrinsic muscles of larynx and sensory to the larynxmuscles of larynx and sensory to the larynx below the level of vocal cords.below the level of vocal cords.  Lymphatics :Lymphatics : Into the near by deep cervicalInto the near by deep cervical lymph nodeslymph nodes
  7. 7. Surgical important pointsSurgical important points  Thyroid gland is one of sites ofThyroid gland is one of sites of occultoccult carcinoma in the bodycarcinoma in the body  The thyroid gland moves up and down during deglutition because it isThe thyroid gland moves up and down during deglutition because it is enclosed in the pretracheal fascia "enclosed in the pretracheal fascia "false capsulefalse capsule""""surgical capsulesurgical capsule"which is"which is attached to the ligament of berry " suspensory ligament" which attached toattached to the ligament of berry " suspensory ligament" which attached to the tracheal and thyroid cartilage.the tracheal and thyroid cartilage.  The middle thyroid veinThe middle thyroid vein must be ligated first, as it`s easily rupturesmust be ligated first, as it`s easily ruptures with massive hemorrhage which may be mask the surgical field.with massive hemorrhage which may be mask the surgical field.  TheThe Superior Thyroid ArterySuperior Thyroid Artery must be ligated within the gland tomust be ligated within the gland to avoid injury ofavoid injury of superior laryngeal nervesuperior laryngeal nerve which leads to :which leads to : - Choking : due to loss of sensation above level of vocal cords. (I.L.N)- Choking : due to loss of sensation above level of vocal cords. (I.L.N) - Loss of high pitched voice due to paralysis of erico-thyroid M. (E.L.N)- Loss of high pitched voice due to paralysis of erico-thyroid M. (E.L.N)  The Inferior Thyroid ArteryThe Inferior Thyroid Artery must be ligated away and lateral to themust be ligated away and lateral to the gland to avoid injury of recurrent nerve and parathyroid glandsgland to avoid injury of recurrent nerve and parathyroid glands  The infrahyoid musclesThe infrahyoid muscles must be divided ( in thyrodectomy for big ormust be divided ( in thyrodectomy for big or malignant gland) near their upper end to avoid injury of its nerves whichmalignant gland) near their upper end to avoid injury of its nerves which comes from below ( from ansacervicalis)comes from below ( from ansacervicalis)  InIn Near Total ThyroidectomyNear Total Thyroidectomy we must leave post medial part of thewe must leave post medial part of the gland to avoid injury of parathyroid glands and recurrent nerves.gland to avoid injury of parathyroid glands and recurrent nerves.  In thyroidectomyIn thyroidectomy we have to put a drain before closure of the skin towe have to put a drain before closure of the skin to avoid post operative hematoma.avoid post operative hematoma.
  8. 8.  In unilateral recurrent nerve injury :In unilateral recurrent nerve injury : vocal cord on that side becomes motionless sovocal cord on that side becomes motionless so the voice is weak and hoarseness is usuallythe voice is weak and hoarseness is usually improve within weeksimprove within weeks  In bilateral recurrent injuryIn bilateral recurrent injury :: IncompleteIncomplete :: Leads to adduction of cords and suffocationLeads to adduction of cords and suffocation so, tracheostomy must be done immediately.so, tracheostomy must be done immediately. CompleteComplete :: Leads to aphonia as the cord lie mid wayLeads to aphonia as the cord lie mid way between adduction and abduction inbetween adduction and abduction in cadaveric position.cadaveric position.  Complete removal or devascularization of the fourComplete removal or devascularization of the four parathyroidparathyroid glands leading toglands leading to TetanyTetany
  9. 9. Development of thyroid glandDevelopment of thyroid gland  The thyroid gland develops as a medianThe thyroid gland develops as a median downgrowth of a column of cells from thedowngrowth of a column of cells from the pharyngeal floor between the 1st and the 2ndpharyngeal floor between the 1st and the 2nd pharyngeal pouch (subsequently marked bypharyngeal pouch (subsequently marked by thethe foramen caecumforamen caecum of the tongue). Theof the tongue). The canalized column becomes the thyroglossalcanalized column becomes the thyroglossal duct. The thyroglossal duct forms theduct. The thyroglossal duct forms the pyramidal lobe, the isthmus and most ofpyramidal lobe, the isthmus and most of lateral lobes of the thyroid. Its remnant maylateral lobes of the thyroid. Its remnant may appear in adult as :appear in adult as :  Thyroglossal cystThyroglossal cyst oror thyroglossal fistulathyroglossal fistula oror ectopic thyroid.ectopic thyroid.
  10. 10. Thyroglossal CystThyroglossal Cyst  It may occur at any site along the course of the thyroglossal duct.It may occur at any site along the course of the thyroglossal duct. It is considered to be one type of tubulodermoids. It may occurIt is considered to be one type of tubulodermoids. It may occur above the hyoid bone (suprahyoid) but it is more commonlyabove the hyoid bone (suprahyoid) but it is more commonly found below it (infrahyoid).found below it (infrahyoid).  It has the following characters :It has the following characters :  Exactly in the middle line (in 25% of cases it may be shifted to oneExactly in the middle line (in 25% of cases it may be shifted to one side , usually to the left) - Shapeside , usually to the left) - Shape globular .globular .  - Surface- Surface smooth .smooth .  - Consistency- Consistency firm .firm .  Moves with deglutition and protrusion of the tongue.Moves with deglutition and protrusion of the tongue.  A fibrous band can usually be felt extending from the cystA fibrous band can usually be felt extending from the cyst upwards towards the tongue.upwards towards the tongue.  Attached to deep structures but not to the skin unless infectionAttached to deep structures but not to the skin unless infection has occurred.has occurred.  TreatmentTreatment :: Excision and dissection of the tractExcision and dissection of the tract “Sistrunk’s“Sistrunk’s operationoperation”. The thyroglossal cyst must be excised because”. The thyroglossal cyst must be excised because infection is inevitable due to fact that the wall contains nodules ofinfection is inevitable due to fact that the wall contains nodules of lymphatic tissue which communicate by lymphatics of lymphlymphatic tissue which communicate by lymphatics of lymph nodes of the neck.nodes of the neck. → → →
  11. 11.  It is never congenital , alwaysIt is never congenital , always acquiredacquired due to infection ordue to infection or incision of pre-existing cyst. It appears as a tiny opening inincision of pre-existing cyst. It appears as a tiny opening in the middle line of the neck discharging serous fluid orthe middle line of the neck discharging serous fluid or purulent mucoid material. The opening moves up withpurulent mucoid material. The opening moves up with deglutition and protrusion of the tongue and becomesdeglutition and protrusion of the tongue and becomes inverted inwardinverted inward due to uneven rates of growth of the neckdue to uneven rates of growth of the neck as a whole and that of the thyroglossal tract. The tract canas a whole and that of the thyroglossal tract. The tract can be felt as a fibrous band extending upwards from the fistula.be felt as a fibrous band extending upwards from the fistula. It is adherent to hyoid bone and may even pass through it.It is adherent to hyoid bone and may even pass through it.  TreatmentTreatment :: excision of the whole tract up to the base of theexcision of the whole tract up to the base of the tongue. In order to avoid the recurrence the middle portiontongue. In order to avoid the recurrence the middle portion of hyoid bone must be excised.of hyoid bone must be excised.  Multiple transverse incisions in the neck the first enclosingMultiple transverse incisions in the neck the first enclosing the opening of the fistula and dissection proceeds upwardsthe opening of the fistula and dissection proceeds upwards as for as possible. Another incision may done following theas for as possible. Another incision may done following the tract upwards “tract upwards “Sistrunk’s operationSistrunk’s operation”. Unless the fistula is”. Unless the fistula is completely removed recurrence is inevitable.completely removed recurrence is inevitable. ThyroglossalThyroglossal Fistula " Sinus"Fistula " Sinus"
  12. 12.  Ectopic thyroid tissue may occur anywhere along the course of theEctopic thyroid tissue may occur anywhere along the course of the thyroglossal tact. The comment site is the point of origin of thethyroglossal tact. The comment site is the point of origin of the thyroid at the base of tongue or foramen cecum (lingual , cervicalthyroid at the base of tongue or foramen cecum (lingual , cervical intro thoracic)intro thoracic)  The lingual thyroid appears as a firm nodule dating from birthThe lingual thyroid appears as a firm nodule dating from birth and may increase in size during menstruation If it is big it mayand may increase in size during menstruation If it is big it may interfere with swallowing , speaking and breathing. Ulcerationinterfere with swallowing , speaking and breathing. Ulceration and bleeding may be caused by traumaand bleeding may be caused by trauma  TreatmentTreatment ::excision ,excision , butbut , before excision one must be sure of, before excision one must be sure of the presence of the normal thyroid in the neck thyroid tissuethe presence of the normal thyroid in the neck thyroid tissue present in the body this can be achieved by :present in the body this can be achieved by :  Radio – active iodine uptake.Radio – active iodine uptake.  Surgical exploration of the neck.Surgical exploration of the neck. The lateral aberrant thyroidThe lateral aberrant thyroid  Thyroid tissue to be ectopic in nature but it is nowThyroid tissue to be ectopic in nature but it is now considered to be secondaries in the lymph gland from aconsidered to be secondaries in the lymph gland from a small papillferous cacinoma of the thyroid.small papillferous cacinoma of the thyroid. Ectopic Thyroid
  13. 13. RetrosternalRetrosternal GoitreGoitre A very few retrosternal goitres arise from ectopic thyroid T. but , most arise fromA very few retrosternal goitres arise from ectopic thyroid T. but , most arise from the lower pole of nodular goitre. If the neck is short and pretracheal muscles arethe lower pole of nodular goitre. If the neck is short and pretracheal muscles are strong as in men , intrathoracil pressure tends to draw these nodules into superiorstrong as in men , intrathoracil pressure tends to draw these nodules into superior mediastinum.mediastinum. The degree of descent :The degree of descent : Substernal type :Substernal type : when nodule is palpable.when nodule is palpable. plunging type :plunging type : when intrathoracic goitre is forced into the neck by increased intrawhen intrathoracic goitre is forced into the neck by increased intra thoracic pressure.thoracic pressure. Intra thoracic type :Intra thoracic type : Clinical FeaturesClinical Features It may be symptomless or produce severe obstructive symptoms :It may be symptomless or produce severe obstructive symptoms :  Dyspnea particularly at night / cough "brassy cough" which is spasmodicDyspnea particularly at night / cough "brassy cough" which is spasmodic with stridor.with stridor.  Engorgement of neck veins : in severe cases sup. veins on chest wall.Engorgement of neck veins : in severe cases sup. veins on chest wall.  Dysphagia rare (Recurrent N. paralysis)Dysphagia rare (Recurrent N. paralysis)  It also may be malignant or toxic.It also may be malignant or toxic. InvestigationInvestigation  X.Ray (AP and lat. View) : soft T. shadow in the sup. mediastinum ,sometimes withX.Ray (AP and lat. View) : soft T. shadow in the sup. mediastinum ,sometimes with calcification, Deviation or compression of trachea.calcification, Deviation or compression of trachea.  I3 scan : may help to distinguish a retrosternal goitre from a mediastinal tumor.I3 scan : may help to distinguish a retrosternal goitre from a mediastinal tumor. Treatment :Treatment : if obstructive symptoms are present, it is unwise to treat a retrosternalif obstructive symptoms are present, it is unwise to treat a retrosternal goitre with anti-thyroid drugs or radio iodine as these may enlarge the goitre sogoitre with anti-thyroid drugs or radio iodine as these may enlarge the goitre so resection must done and carried out from the neck.resection must done and carried out from the neck.
  14. 14. Struma ovariiStruma ovarii  It is not ectopic , but port of an ovarian teratoma very rarelyIt is not ectopic , but port of an ovarian teratoma very rarely carcinogenic change occurs or hyperthyroidism develops.carcinogenic change occurs or hyperthyroidism develops.  It is a congenital deficiency of thyroid function which mayIt is a congenital deficiency of thyroid function which may be associated with aplasia of the thyroid or with a goitrousbe associated with aplasia of the thyroid or with a goitrous gland cretinoid goitre.gland cretinoid goitre.  ClinicallyClinically The child is sluggish , constipated, puffy face, thick lips ,The child is sluggish , constipated, puffy face, thick lips , flattened nose, protruding tongue , short neck and thickflattened nose, protruding tongue , short neck and thick short hand (spade shaped hands). He rare cries , and learnshort hand (spade shaped hands). He rare cries , and learn to suck , walk, talk and control of the sphincters much laterto suck , walk, talk and control of the sphincters much later than normal.than normal. In adolescence , the pat is dwarfed and mentally retardedIn adolescence , the pat is dwarfed and mentally retarded with dry wrinkled skin , supraclavicular pads of fat delayedwith dry wrinkled skin , supraclavicular pads of fat delayed epiphyseal ossification and very low B.M.R.epiphyseal ossification and very low B.M.R.  Treatment :Treatment : Thyroid extract should be given for life. In continued goitreThyroid extract should be given for life. In continued goitre partial thyroidectomy is indicated to reduce the size of thepartial thyroidectomy is indicated to reduce the size of the swelling.swelling. CretinismCretinism
  15. 15. GoitersGoiters "" gutturguttur == throatthroat""  definitiondefinition :: Any enlargement of thyroid glandAny enlargement of thyroid gland  clinical diagnosesclinical diagnoses :: mass in the anatomical site of thyroid glandmass in the anatomical site of thyroid gland and moves up and down with deglutition.and moves up and down with deglutition. PhysiologyPhysiology  - The circulating inorganic iodine is picked up to the thyroid cells and- The circulating inorganic iodine is picked up to the thyroid cells and oxidation occurs by peroxidase enzyme forming oxidized iodineoxidation occurs by peroxidase enzyme forming oxidized iodine  - This oxidized iodine bind to tyrosine forming mono and- This oxidized iodine bind to tyrosine forming mono and di-iodotyrosine by the iodonase enzyme.di-iodotyrosine by the iodonase enzyme.  - Coupling of mono iodotyrosine and di-iodotyrosine occurs forming- Coupling of mono iodotyrosine and di-iodotyrosine occurs forming tri-iodotyrosine T3 and two molecules of di-iodotyrosine formingtri-iodotyrosine T3 and two molecules of di-iodotyrosine forming tetra-iodotyrosine T4 which stored in the thyroid follicles .tetra-iodotyrosine T4 which stored in the thyroid follicles .  - When T3 and T4 are required ,the protease enzyme acted on- When T3 and T4 are required ,the protease enzyme acted on thyroglobulin to release the free T3 and T4 into the circulation .thyroglobulin to release the free T3 and T4 into the circulation .  - The thyroid hormones in the blood are bound to serum protein (thyroid- The thyroid hormones in the blood are bound to serum protein (thyroid binding globulin) and only very small part of it are free in the serum .binding globulin) and only very small part of it are free in the serum . This free fraction of the thyroid hormones is the biological active part .This free fraction of the thyroid hormones is the biological active part .  - T3 is more rapid and more potent in its action than T4 .- T3 is more rapid and more potent in its action than T4 .
  16. 16. Hormones of thyroid glands:Hormones of thyroid glands:  Hormones secreted by the thyroid :Hormones secreted by the thyroid :  Tetraiodothyronine (T4) or thyroxine.Tetraiodothyronine (T4) or thyroxine.  Tri-iodothyronine (T3)Tri-iodothyronine (T3)  Thyrocalcitonine, which regulates calcium metabolism .Thyrocalcitonine, which regulates calcium metabolism . its increase leads to hypocalcemia and vice-versa.its increase leads to hypocalcemia and vice-versa.  Hormones acting on the thyroid :Hormones acting on the thyroid :  Thyroid stimulating hormone (T.S.H). it is secreted by theThyroid stimulating hormone (T.S.H). it is secreted by the anterior pituitary to regulate the thyroid function. Its level risesanterior pituitary to regulate the thyroid function. Its level rises in cases of stress and according to a feed-back mechanismin cases of stress and according to a feed-back mechanism whenever thyroid hormones (T3 and T4) are diminished T.S.H.whenever thyroid hormones (T3 and T4) are diminished T.S.H. increase the vascularity of the gland.increase the vascularity of the gland.  Long Acting Thyroid Stimulator (L.A.T.S). This is an Lg foundLong Acting Thyroid Stimulator (L.A.T.S). This is an Lg found in 85% of cases of thyrotoxicosis and may be cause ofin 85% of cases of thyrotoxicosis and may be cause of exophthalmos.exophthalmos.  Exophthalmos Producing Substance (E.P.S). This is supposedExophthalmos Producing Substance (E.P.S). This is supposed to to produce infiltrative changes in the orbit in cases ofto to produce infiltrative changes in the orbit in cases of exophthalmos and its level drops after hypophysectomy.exophthalmos and its level drops after hypophysectomy.
  17. 17. CLASSIFICATIONCLASSIFICATION OFOF GOITREGOITRE
  18. 18. Simple GoiterSimple Goiter  It is due to stimulation of thyroid gland by the anterior pituitaryIt is due to stimulation of thyroid gland by the anterior pituitary i.e. by increased levels of circulating T.S.H. secretion is increasedi.e. by increased levels of circulating T.S.H. secretion is increased by low levels of circulating thyroid hormones. Any factor ,by low levels of circulating thyroid hormones. Any factor , therefore that maintains a persistently low level of circulatingtherefore that maintains a persistently low level of circulating thyroid hormones can be responsible for a simple goitre. The mostthyroid hormones can be responsible for a simple goitre. The most important factor is iodine deficiency but , defects in hormoneimportant factor is iodine deficiency but , defects in hormone synthesis may be responsible.synthesis may be responsible. 1. Iodine deficiency :1. Iodine deficiency : one mg/kg/body wt/dailyone mg/kg/body wt/daily - Daily requirement- Daily requirement of iodine is aboutof iodine is about 100 – 125 mg100 – 125 mg. In endemic areas there is very low. In endemic areas there is very low iodide content in the water and food. The endemic areas are rockyiodide content in the water and food. The endemic areas are rocky mountains , the alps and the Himalayas. In England it is found inmountains , the alps and the Himalayas. In England it is found in Mendips , Chilterns and Cotswolds. Endemic goitres is also foundMendips , Chilterns and Cotswolds. Endemic goitres is also found in low land areas where the water supply comes from far awayin low land areas where the water supply comes from far away mountain areas e.g. great lakes of North America , the Nile Valleymountain areas e.g. great lakes of North America , the Nile Valley and the Congo although iodides in food and water may beand the Congo although iodides in food and water may be adequate , failure of intestinal absorption may produce iodineadequate , failure of intestinal absorption may produce iodine deficiency .deficiency .
  19. 19. 2.2. Defects in synthesis of thyroid hormones.Defects in synthesis of thyroid hormones.  Enzyme deficiency within the thyroid gland.Enzyme deficiency within the thyroid gland.  Goitrogens :Goitrogens :  Vegetables of the brassica family (cabbage , kale andVegetables of the brassica family (cabbage , kale and cauliflower) contains thiocynate.cauliflower) contains thiocynate.  P.A.S / Anti thyroid / cyanides / cyanates sulphurP.A.S / Anti thyroid / cyanides / cyanates sulphur containing drugs.containing drugs.  Iodides in large quantities are goitrogenic as theyIodides in large quantities are goitrogenic as they inhibit the organic binding of iodine and give andinhibit the organic binding of iodine and give and iodide goitre which is usually seen in asthmatics whoiodide goitre which is usually seen in asthmatics who have taken proprietary preparations containing iodideshave taken proprietary preparations containing iodides over a prolonged period.over a prolonged period.  Genetic enzymatic deficiencies , the condition mayGenetic enzymatic deficiencies , the condition may be associated with congenital hypothyroidism.be associated with congenital hypothyroidism.
  20. 20. Natural History of simple GoitreNatural History of simple Goitre:: "stages of goitre formation ""stages of goitre formation "  Persistent T.S.H stimulation causes diffuse hyperplasia allPersistent T.S.H stimulation causes diffuse hyperplasia all lobules are composed of active follicles and iodine uptakes islobules are composed of active follicles and iodine uptakes is uniform. This is a diffuse hyperplastic goitre which mayuniform. This is a diffuse hyperplastic goitre which may persist for along time but , is reversible if T.S.H stimulationpersist for along time but , is reversible if T.S.H stimulation stop.stop.  Later , as result of fluctuating T.S.H levels mixed patternLater , as result of fluctuating T.S.H levels mixed pattern develops with in area of active lobules and areas of inactivedevelops with in area of active lobules and areas of inactive lobules.lobules.  Active lobules become more vascular and hyperplastic tillActive lobules become more vascular and hyperplastic till hemorrhage occurs causing central necrosis and leaving onlyhemorrhage occurs causing central necrosis and leaving only a surrounding rind of active follicles.a surrounding rind of active follicles.  Necrotic nodules coalesce to form nodules filled either withNecrotic nodules coalesce to form nodules filled either with iodine free colloid or a mass of new but inactive follicles.iodine free colloid or a mass of new but inactive follicles. Continual repetition of this process result in a nodularContinual repetition of this process result in a nodular goitre.goitre.
  21. 21. Clinical types of S.N.G :Clinical types of S.N.G : 1. Diffuse hyperplastic goitre.1. Diffuse hyperplastic goitre. 2. Nodular goitre.2. Nodular goitre. 3. Solitary nodule.3. Solitary nodule. 4. Retrosternal goitre.4. Retrosternal goitre.
  22. 22. 1. Diffuse1. Diffuse hyperplastichyperplastic goitregoitre (physiological and colloid(physiological and colloid goitregoitre)) The diffuse hyperplastic goiter corresponds to the firstThe diffuse hyperplastic goiter corresponds to the first stages of the natural history of simple goitre.stages of the natural history of simple goitre. PhysiologicalPhysiological goitregoitre :: It occurs usually in female during puberty, menstruationIt occurs usually in female during puberty, menstruation and lactation where the metabolic demands are high. Ifand lactation where the metabolic demands are high. If T.S.H stimulation stop , the goitre may regress but , tendsT.S.H stimulation stop , the goitre may regress but , tends to recur later at times of stress such as pregnancy, theto recur later at times of stress such as pregnancy, the gland isgland is symmetricallysymmetrically enlargedenlarged soft , smooth surface , notsoft , smooth surface , not associated with general or local manifestation.associated with general or local manifestation. Cut sectionCut section the gland is fleshy and pale , the cells liningthe gland is fleshy and pale , the cells lining the acini arethe acini are columnarcolumnar with minimal colloid.with minimal colloid. Treatment :Treatment :  Prophylactic : Iodized table saltProphylactic : Iodized table salt  Curative : - Reassurance of the patient and her parentsCurative : - Reassurance of the patient and her parents - L. thyroxin- L. thyroxin
  23. 23. Frequently seen between 15 – 30 years , markedFrequently seen between 15 – 30 years , marked enlargement of gland with smooth surface , softenlargement of gland with smooth surface , soft consistency , rarely produces local pressure effectsconsistency , rarely produces local pressure effects by its size.by its size. Microscopically :Microscopically :the acini are distended withthe acini are distended with abundantabundant colloidcolloid and lined withand lined with squamoussquamous cells.cells. Colloid goitre is a late stage of diffuse hyper plasticColloid goitre is a late stage of diffuse hyper plastic type of goitre when T.S.H stimulation has fallen offtype of goitre when T.S.H stimulation has fallen off and when many follicles are inactive and full ofand when many follicles are inactive and full of colloid.colloid. TreatmentTreatment :: - Early: L thyroxin- Early: L thyroxin - Late : Subtotal thyroidectomy for huge goiter- Late : Subtotal thyroidectomy for huge goiter ColloidColloid goitregoitre ::
  24. 24. 22..Nodular GoiterNodular Goiter As regards to natural history of S.N.G , persistAs regards to natural history of S.N.G , persist fluctuating T.S.H stimulation results inevitably influctuating T.S.H stimulation results inevitably in progressive nodule formation nodules are usuallyprogressive nodule formation nodules are usually multiple forming a multinodular goitre nodules maymultiple forming a multinodular goitre nodules may be colloid or cellular and cystic degeneration andbe colloid or cellular and cystic degeneration and hemorrhage are common , as is subsequenthemorrhage are common , as is subsequent calcification when epithelial hyperplasia is marked ,calcification when epithelial hyperplasia is marked , it may be associated with hyperthyroidism andit may be associated with hyperthyroidism and condition is then referred to as 2ry toxic goitre. Allcondition is then referred to as 2ry toxic goitre. All types of S.G are more common in the female than intypes of S.G are more common in the female than in male.male. Clinically :Clinically : the gland is variable in its enlargement notthe gland is variable in its enlargement not symmetrical , nodular surface , its consistency maysymmetrical , nodular surface , its consistency may be firm , soft or cystic.be firm , soft or cystic.
  25. 25.  Diagnosis of S.N.G :Diagnosis of S.N.G : diagnosis of nodulardiagnosis of nodular goiture is usually straightforward the pat isgoiture is usually straightforward the pat is euthyroid , nodules are palpable and ofteneuthyroid , nodules are palpable and often visible , they are usuallyvisible , they are usually smoothsmooth ,, firmfirm ,, notnot hardhard painlesspainless moves with swallowingmoves with swallowing.. Investigation of S.N.G:Investigation of S.N.G:  Thyroid function test to exclude mild hyperThyroid function test to exclude mild hyper thyroidism.thyroidism.  Estimation of titres of thyroid antibodies toEstimation of titres of thyroid antibodies to differentiate from lymphadenoid goitre.differentiate from lymphadenoid goitre.  Plain X-Ray : may show calcification,Plain X-Ray : may show calcification, tracheal deviation or compression ,tracheal deviation or compression , pulmonary metastases, retrosternol goitre.pulmonary metastases, retrosternol goitre.
  26. 26. Complication of nodular goitre :Complication of nodular goitre : 1.1. Toxic changeToxic change : In long standing cases in about 30%.: In long standing cases in about 30%. 2.2. HageHage into cystinto cyst : This cause rapid distension of the cyst.: This cause rapid distension of the cyst. 3.3. Malig. ChangeMalig. Change : In about 4 – 8 % cases commoner with: In about 4 – 8 % cases commoner with solitary type.solitary type. 4. Calcification4. Calcification : Hard nodule.: Hard nodule. 5.5. Pressure effectPressure effect : Dyspnea / dysphagia/ hoarseness of: Dyspnea / dysphagia/ hoarseness of voice.voice. 6.6. DisfigurementDisfigurement : when it is big .: when it is big . 7.7. TracheomalaciaTracheomalacia : Rare due to long standing goitre: Rare due to long standing goitre pressing on trachea for long time ending into softpressing on trachea for long time ending into soft trachea so after operation , collapsing occurs leadingtrachea so after operation , collapsing occurs leading to suffocation.to suffocation.
  27. 27. Indication for surgical removal of nodular goiter :Indication for surgical removal of nodular goiter : 1. Suspicion of malignancy1. Suspicion of malignancy 2. Symptoms of pressure2. Symptoms of pressure 3. Hyper thyrodism3. Hyper thyrodism 4. Substernal extension4. Substernal extension 5. Cosmetic deformity5. Cosmetic deformity 6. Solitary nodule that are cold on radio – iodine6. Solitary nodule that are cold on radio – iodine scan and solid by ultrasound should be removed.scan and solid by ultrasound should be removed. Non operative treatment is indicated inNon operative treatment is indicated in Hashimoto’s diseaseHashimoto’s disease
  28. 28. Prevention and treatment of simple goitre :Prevention and treatment of simple goitre :  All table salt should be iodised.All table salt should be iodised.  In endemic areas , the incidence has been reduced byIn endemic areas , the incidence has been reduced by this prophylaxis.this prophylaxis.  In early stages a hyper plastic goitre is reversible if 1In early stages a hyper plastic goitre is reversible if 1 thyroxine is given in maximum doses 0.3 mg daily forthyroxine is given in maximum doses 0.3 mg daily for several months and then very slowly reduction to 0.1several months and then very slowly reduction to 0.1 mg daily for many years. If regression does not occur .mg daily for many years. If regression does not occur .  Thyroidectomy may be indicated for cosmetic reasonsThyroidectomy may be indicated for cosmetic reasons or pressure symptoms.or pressure symptoms.  Nodular stage of S.G is irreversible so subtotalNodular stage of S.G is irreversible so subtotal thyroidectomy is indicated. The rule is to leave athyroidectomy is indicated. The rule is to leave a portion equal to one normal thyroid lobe , on eachportion equal to one normal thyroid lobe , on each side.side.
  29. 29. The problem of clinically solitary nodule andThe problem of clinically solitary nodule and its evaluation :its evaluation : Clinically only one macroscopic nodule isClinically only one macroscopic nodule is found , but microscopic changes will befound , but microscopic changes will be present throughout the gland. This is one formpresent throughout the gland. This is one form of clinically solitary nodule which is referredof clinically solitary nodule which is referred to asto as cystadenoma of the thyroidcystadenoma of the thyroid and itsand its commonest site is at junction of the isthmuscommonest site is at junction of the isthmus with one lobe , and although it appearswith one lobe , and although it appears solitary multiple small adenomata aresolitary multiple small adenomata are scattered around it. When there is a solitaryscattered around it. When there is a solitary nodule of thyroid it is must be differentiatednodule of thyroid it is must be differentiated from true adenoma.from true adenoma.
  30. 30. Causes of solitary nodule in thyroid:Causes of solitary nodule in thyroid: 1. solitary nodular goiter.1. solitary nodular goiter. 2. Toxic nodular goiter.2. Toxic nodular goiter. 3. Malignant nodule (medullary adenoma)3. Malignant nodule (medullary adenoma) 4. True adenoma of thyroid.4. True adenoma of thyroid.
  31. 31. Adenoma of thyroid may be :Adenoma of thyroid may be :  Embryonal adenomaEmbryonal adenoma  Fetal or micro-follicular adenomaFetal or micro-follicular adenoma  Colloid or macro-follicular adenomaColloid or macro-follicular adenoma  Hurthle-cell adenoma with acidophilic cytoplasmHurthle-cell adenoma with acidophilic cytoplasm  Papillary cystadenoma highly suspicious of being malignant.Papillary cystadenoma highly suspicious of being malignant. Diagnoses of solitary nodule in thyroidDiagnoses of solitary nodule in thyroid 1. Clinically1. Clinically  Many cases are asymptomaticMany cases are asymptomatic  The solitary nodule in thyroid is more likely be malignant thanThe solitary nodule in thyroid is more likely be malignant than multi nodular goitre.multi nodular goitre.  A thyroid nodule is more likely to be cancer in man than inA thyroid nodule is more likely to be cancer in man than in woman.woman.  Patient with thyroid nodules who received X-Ray treatment to thePatient with thyroid nodules who received X-Ray treatment to the head and neck in infancy and childhood have 35 – 50 % chance ofhead and neck in infancy and childhood have 35 – 50 % chance of having thyroid cancer.having thyroid cancer.  cystic lesions less than 10 Cm in diameter are almost never cancer.cystic lesions less than 10 Cm in diameter are almost never cancer.  Toxic manifestation in toxic noduleToxic manifestation in toxic nodule  Malignant features in malignant noduleMalignant features in malignant nodule
  32. 32. 2. Investigations2. Investigations A.A. is helpful in determining whether the lesion is singleis helpful in determining whether the lesion is single or multiple and whether it is functioning (hot) or non functioningor multiple and whether it is functioning (hot) or non functioning (cold).(cold).  Hot noduleHot nodule = overactive nodule= overactive nodule Takes up isotope , while the surrounding tissue does not , here , theTakes up isotope , while the surrounding tissue does not , here , the surrounding. T. is inactive because the nodule is producing such highsurrounding. T. is inactive because the nodule is producing such high levels of thyroid hormones that T.S.H is suppressed.levels of thyroid hormones that T.S.H is suppressed.  Worm noduleWorm nodule = active nodule= active nodule Takes up isotope and so does normal surrounding tissue about it.Takes up isotope and so does normal surrounding tissue about it.  Cold noduleCold nodule = inactive nodule Takes up no isotope= inactive nodule Takes up no isotope D.D of cold nodule : degenerative cyst, calcification, haemorrhage,D.D of cold nodule : degenerative cyst, calcification, haemorrhage, abscess or hydatid cyst.abscess or hydatid cyst. N.B.N.B. The fluorescent scanning using a collimated source of radiationThe fluorescent scanning using a collimated source of radiation is now used to differentiate benign from malignant thyroidis now used to differentiate benign from malignant thyroid nodules. This procedure has advantage that no radio – activenodules. This procedure has advantage that no radio – active materials are introduced into the body.materials are introduced into the body. Thyroid scanThyroid scan ::
  33. 33. B. Ultrasound (echography)B. Ultrasound (echography) • It is helpful to differentiate solitary from multipleIt is helpful to differentiate solitary from multiple nodulesnodules • It is also used for differentiating solid from cysticIt is also used for differentiating solid from cystic lesions .lesions . C. BiopsyC. Biopsy • FNAC or Trucut or Excisional biopsy.FNAC or Trucut or Excisional biopsy. N.B.N.B. Percutaneous needle biopsy is helpful if goodPercutaneous needle biopsy is helpful if good endocrine cytologists are available , needle biopsyendocrine cytologists are available , needle biopsy should not performed in patients with history ofshould not performed in patients with history of irradiation to the neck, because radiation – inducedirradiation to the neck, because radiation – induced tumors are often multi focal and –ve biopsy maytumors are often multi focal and –ve biopsy may therefore be unreliable.therefore be unreliable.
  34. 34. 3. Treatment :3. Treatment : A.A. Enucleation :Enucleation : Removal of the nodule from its capsule.Removal of the nodule from its capsule. But it is not recommended because recurrenceBut it is not recommended because recurrence is the rule as the nodule is never solitary.is the rule as the nodule is never solitary. B. Resection Enucleation :B. Resection Enucleation : Excision of the nodule with theExcision of the nodule with the surrounding thyroid tissue.surrounding thyroid tissue. It is the recommended operation asIt is the recommended operation as we remove the scattered small noduleswe remove the scattered small nodules around the clinical solitary nodule.around the clinical solitary nodule. C. Hemithyroidectomy :C. Hemithyroidectomy : Removal of the affected lobe togetherRemoval of the affected lobe together with the isthmus and pyramidal lobe.with the isthmus and pyramidal lobe. The specimen must be sent for biopsy.The specimen must be sent for biopsy. It is the operation of choice.It is the operation of choice.
  35. 35. N.B.N.B.  The term thyrotoxicosis is retained because hyperthyroidism i.e.The term thyrotoxicosis is retained because hyperthyroidism i.e. symptoms due to a raised level of circulating thyroid hormonessymptoms due to a raised level of circulating thyroid hormones are not responsible for all manifestations of the disease.are not responsible for all manifestations of the disease.
  36. 36. Toxic GoitreToxic Goitre Clinical Types :Clinical Types : 1. primary toxic goitre (Grave’s disease)1. primary toxic goitre (Grave’s disease) 2. Toxic nodular goitre (2ry toxic)2. Toxic nodular goitre (2ry toxic) 3. Toxic nodule3. Toxic nodule 4. Hyper thyrodism due to rare cases.4. Hyper thyrodism due to rare cases. 1.1. Primary ToxicPrimary Toxic GoitreGoitre : (Greave’s disease): (Greave’s disease)  It is a diffuse vascular goitre appearing at the same time as the hyperIt is a diffuse vascular goitre appearing at the same time as the hyper thyroidism usually in the younger woman than man (8 times), andthyroidism usually in the younger woman than man (8 times), and frequently associated with eye signs.frequently associated with eye signs.  The onset is usually insidious with insomnia , irritability and wt loss.The onset is usually insidious with insomnia , irritability and wt loss. Sometimes the onset is acute and the course may be progressive orSometimes the onset is acute and the course may be progressive or intermittent.intermittent.  The whole of the functioning thyroid tissue isThe whole of the functioning thyroid tissue is involved and the hypertrophy and hyperplasia are due to abnormalinvolved and the hypertrophy and hyperplasia are due to abnormal thyroid stimulators such as L.A.T.S which is an immunoglobulin ,thyroid stimulators such as L.A.T.S which is an immunoglobulin , found in 85% of cases of thyrotoxicosis.found in 85% of cases of thyrotoxicosis.  Grave`s disease is considered now an auto immune disease in whichGrave`s disease is considered now an auto immune disease in which antibodies binding to T.S.H receptors leading to release of thyroxine.antibodies binding to T.S.H receptors leading to release of thyroxine.
  37. 37. I. Pathology :I. Pathology : A. Gross appearance :A. Gross appearance :  The gland : is moderately enlarged , brick red inThe gland : is moderately enlarged , brick red in colour and highly vascular, fleshy in consistencycolour and highly vascular, fleshy in consistency with an opaque meaty appearance. In some cases nowith an opaque meaty appearance. In some cases no enlargement is detected clinically and even atenlargement is detected clinically and even at operation the gland may not enlarged at all. Theoperation the gland may not enlarged at all. The enlargement is characteristically diffuse althoughenlargement is characteristically diffuse although one lobe may be more affected than the other.one lobe may be more affected than the other. B. Microscopically :B. Microscopically :  Marked hyperplasia of the cells , which becomeMarked hyperplasia of the cells , which become arranged in several layers.arranged in several layers.  Marked diminution of the lumen of the acini.Marked diminution of the lumen of the acini.  Disappearance of the colloid from the lumenDisappearance of the colloid from the lumen..  Marked lymphocytic infiltrationMarked lymphocytic infiltration
  38. 38. II.II. Clinical FeaturesClinical Features ::  Thyrotoxicosis affects all the systems of the body startingThyrotoxicosis affects all the systems of the body starting with excitation and ending with failure or depressionwith excitation and ending with failure or depression  Wayne’s clinical diagnostic index gives all the importantWayne’s clinical diagnostic index gives all the important symptoms and signs of thyrotoxicosis and indicates by their scoresymptoms and signs of thyrotoxicosis and indicates by their score the relative importance of each.the relative importance of each. Cardinal signs of thyrotoxicasis are : E + 3TCardinal signs of thyrotoxicasis are : E + 3T 1. Eye manifestation.1. Eye manifestation. 2. Tremors2. Tremors 3. Tachycardia.3. Tachycardia. 4. Tumors4. Tumors Cardinal symptoms of thyrotoxicasis are : HLPCardinal symptoms of thyrotoxicasis are : HLP 1. Heat intolerance.1. Heat intolerance. 2. Loss of weight in-spite of good appetite.2. Loss of weight in-spite of good appetite. 3. Palpitation.3. Palpitation.
  39. 39. A) General FeaturesA) General Features 1. C.V.S1. C.V.S a)a) Dyspnea on exertion , palpitation , tachycardia are early featuresDyspnea on exertion , palpitation , tachycardia are early features b)b) Slight elevation of systolic pressure. with decrease ofSlight elevation of systolic pressure. with decrease of diastolic pressure so that , the pulse pressure is increased. Thediastolic pressure so that , the pulse pressure is increased. The pulse is easily felt at the wrist (water hammer pulse).pulse is easily felt at the wrist (water hammer pulse). c)c) Auricular fibrillation and heart failure may occur but , this isAuricular fibrillation and heart failure may occur but , this is more usual in 2ry toxic goitre.more usual in 2ry toxic goitre. 2. C.N.S2. C.N.S a)a) Insomnia, occurs early in the course of the disease.Insomnia, occurs early in the course of the disease. b)b) Irritability , anxiety and tremors of out stetted hands andIrritability , anxiety and tremors of out stetted hands and protruding tongue are common features.protruding tongue are common features. c)c) In severe cases , mania may be present.In severe cases , mania may be present. 3. Metabolic disturbances :3. Metabolic disturbances : a)a) Loss of weight in-spite of good appetite.Loss of weight in-spite of good appetite. b)b) Sweating especially of the palms of hands , which feel worm.Sweating especially of the palms of hands , which feel worm. c)c) Intolerance to heat the patient can tolerate cold weather well.Intolerance to heat the patient can tolerate cold weather well. d)d) Flushing and feeling of hotness.Flushing and feeling of hotness.
  40. 40. 4. Gastro – intestinal :4. Gastro – intestinal :  Polyphagia i.e. increased appetite, later there may be loss of appetite.Polyphagia i.e. increased appetite, later there may be loss of appetite.  Abdominal pains.Abdominal pains.  Looseness of stools or even diarrhea.Looseness of stools or even diarrhea. 5. Sexual system.5. Sexual system. a)a) Menorrhagia, dysmenorrhea or amenorrhea.Menorrhagia, dysmenorrhea or amenorrhea. b)b) In male , at first there is increase sexual desire, later the patient mayIn male , at first there is increase sexual desire, later the patient may become impotent.become impotent. 6. Muscle – skeletal system6. Muscle – skeletal system a)a) Bone pains due to osteoporosisBone pains due to osteoporosis b)b) Muscle weakness (thyrotoxic myopathy or myasthenia)Muscle weakness (thyrotoxic myopathy or myasthenia) 7. Urinary system7. Urinary system a)a) PolyuriaPolyuria b)b) GlycosuriaGlycosuria 8. Skin8. Skin a)a) FlushingFlushing b)b) Abdominal pigmentationAbdominal pigmentation
  41. 41. c)c) PretibialPretibial myxedemamyxedema  It is thickening of skin by a mucin – like deposit. It isIt is thickening of skin by a mucin – like deposit. It is rare sign of thyrotoxicosis but may occur at any stage ofrare sign of thyrotoxicosis but may occur at any stage of the disease it is usually follows thyroidectomy , Iodinthe disease it is usually follows thyroidectomy , Iodin therapy or prolonged antithyroid ttherapy or prolonged antithyroid treatment .reatment .  It is usually associated with progressive exophthalmos.It is usually associated with progressive exophthalmos.  It starts as bilateral symmetrical pitting edema with red andIt starts as bilateral symmetrical pitting edema with red and then deep purple colour.then deep purple colour.  In severe cases , whole leg below its knee is involvedIn severe cases , whole leg below its knee is involved “thyroid acropachy”. Although it is resistant to treatment .“thyroid acropachy”. Although it is resistant to treatment . it tends to subside spontaneously.it tends to subside spontaneously.
  42. 42. B) Thyroid manifestationB) Thyroid manifestation  Moderately, symmetrical enlargement of thyroid glandModerately, symmetrical enlargement of thyroid gland with smooth surface and firm or rubbery in consistencywith smooth surface and firm or rubbery in consistency associated with increased vascularity.associated with increased vascularity. Evidence of increased vascularity :Evidence of increased vascularity : 1.1. Dilated vein on the skinDilated vein on the skin 2.2. Hot sensationHot sensation 3.3. Bruit may be feltBruit may be felt 4.4. Murmur may be heard.Murmur may be heard.  Sometimes the enlargement is very small or noSometimes the enlargement is very small or no enlargement at all, this type occurs in old patientsenlargement at all, this type occurs in old patients who present with weight loss and myasthenia overwho present with weight loss and myasthenia over a long period, the eye manifestation in that cases isa long period, the eye manifestation in that cases is absent and the heart is mainly affected so it may beabsent and the heart is mainly affected so it may be pass into heart failure while the original causes arepass into heart failure while the original causes are over locked .over locked .
  43. 43. C) Eye ManifestationC) Eye Manifestation Exopthalmos is commonly classified into 4 grades :Exopthalmos is commonly classified into 4 grades : 1.1. Mild :Mild : consists of widening of the palpepral fissure due toconsists of widening of the palpepral fissure due to retraction of the upper eyelids without any bulging ofretraction of the upper eyelids without any bulging of the eyes.the eyes. SteStellllwag’s sign and Von Graefe’s sign are positive.wag’s sign and Von Graefe’s sign are positive. 2.2. Moderate :Moderate : due to actual bulging of eyeballs from increaseddue to actual bulging of eyeballs from increased compositions of retrobulbar fat.compositions of retrobulbar fat. Darlymple and Joffroy’s signs are positive.Darlymple and Joffroy’s signs are positive. 3.3. Severe :Severe : due to intra – orbital oedema and congestion ,due to intra – orbital oedema and congestion , marked protrusion of the eye balls is associated with wateringmarked protrusion of the eye balls is associated with watering of the eyes , dilatation of conjunctival vessels and muscleof the eyes , dilatation of conjunctival vessels and muscle paresis.paresis.  Limitation of movement in an upwards and outwardsLimitation of movement in an upwards and outwards directions, also downwards and inwards directions must bedirections, also downwards and inwards directions must be tested.tested. Moebius signs is positiveMoebius signs is positive
  44. 44. 4.4. Malignant exophthalmos :Malignant exophthalmos : It is a progressive form , which may increased afterIt is a progressive form , which may increased after otherwise successful treatment of thyrotoxicosisotherwise successful treatment of thyrotoxicosis particularly by thyrodectomy increasing exophthalmos isparticularly by thyrodectomy increasing exophthalmos is associated with chemosis of conjunctiva impairment ofassociated with chemosis of conjunctiva impairment of corneal sensibility and paralysis of the eye muscles withcorneal sensibility and paralysis of the eye muscles with grave risks of corneal ulceration, panophthalmitis and lossgrave risks of corneal ulceration, panophthalmitis and loss of vision.of vision. Exophthalmos of graves disease is probably due toExophthalmos of graves disease is probably due to infiltration of retrobulbar tissues with fluid and roundinfiltration of retrobulbar tissues with fluid and round cells with varying degree of retraction or spasm of uppercells with varying degree of retraction or spasm of upper eyelid the cause is unknown but it is not due to an increaseeyelid the cause is unknown but it is not due to an increase of T.S.H as it is not found in mxyedema where TSH is atof T.S.H as it is not found in mxyedema where TSH is at its highest level.its highest level. L.A.T.S or E.P.S may be responsible.L.A.T.S or E.P.S may be responsible. The condition is usually bilateral but unilateral mayThe condition is usually bilateral but unilateral may occur in rare cases.occur in rare cases.
  45. 45.  Stellwag’s sign :Stellwag’s sign : infrequency of blinking with ainfrequency of blinking with a staring look.staring look.  Von graefe’s sign :Von graefe’s sign : upper lid lays behind the eyeupper lid lays behind the eye ball as the patient looks down without movingball as the patient looks down without moving the head.the head.  Dalrymple‘s sign :Dalrymple‘s sign : a rim of white sclera betweena rim of white sclera between the upper eye lid and upper edge of cornea due tothe upper eye lid and upper edge of cornea due to retraction of upper lid and protrusion of the eyeretraction of upper lid and protrusion of the eye ball.ball.  Joffroy’s sign :Joffroy’s sign : lack of wrinkling of the foreheadlack of wrinkling of the forehead on looking upwards without moving the head.on looking upwards without moving the head.  Moebius sign :Moebius sign : imperfect convergence on lookingimperfect convergence on looking at a near object due to muscular paresis (medialat a near object due to muscular paresis (medial recti muscles)recti muscles)
  46. 46.  N.B.N.B. Other causes of exophthalmos :Other causes of exophthalmos : 1. A space – occupying lesion in orbit.1. A space – occupying lesion in orbit. 2. Cavernous sinus thrombosis.2. Cavernous sinus thrombosis. Treatment of exophthalmos :Treatment of exophthalmos : I.I. Mild casesMild cases ( most common ) :( most common ) : It is usually self limiting and may even regressIt is usually self limiting and may even regress treatment of thyrotoxicosis will improve the eye signs.treatment of thyrotoxicosis will improve the eye signs. lid retraction disappears in 2/3 of cases.lid retraction disappears in 2/3 of cases. II. Severe casesII. Severe cases ( rare ):( rare ): The proptosis can be measured with an exophthalmometer.The proptosis can be measured with an exophthalmometer. 1.1. Protection of eye (wind – dust – sun)Protection of eye (wind – dust – sun) 2.2. Sleep sitting to decrease venous pressure.Sleep sitting to decrease venous pressure. 3.3. Lateral tarsorrhaphy may be needed.Lateral tarsorrhaphy may be needed. 4.4. Prednisone with massive doses + metronidazole (flagyl)Prednisone with massive doses + metronidazole (flagyl) 5.5. Irradiation of retro orbital Tissue may be necessary.Irradiation of retro orbital Tissue may be necessary. • Pituitary :Pituitary : irradiationirradiation stalk sectionstalk section cryo surgerycryo surgery • Orbital decompression (trans-frontal and trans-antral)Orbital decompression (trans-frontal and trans-antral)
  47. 47. 2. Secondary toxic goiter2. Secondary toxic goiter  Here a simple nodular goitre is present for long time before the hyperthyroidism.Here a simple nodular goitre is present for long time before the hyperthyroidism.  In many cases of toxic nodular goitre ,the nodules are inactive and it is theIn many cases of toxic nodular goitre ,the nodules are inactive and it is the internodular thyroid tissue that is over active , here the hyperthyroidism is due tointernodular thyroid tissue that is over active , here the hyperthyroidism is due to abnormal thyroid stimulators such as L.A.T.S.abnormal thyroid stimulators such as L.A.T.S.  In some toxic nodular goitre one or more nodules are overactive and here theIn some toxic nodular goitre one or more nodules are overactive and here the hyperthyroidism is due to autonomous thyroid tissue as in toxic nodule.hyperthyroidism is due to autonomous thyroid tissue as in toxic nodule. The 2ry toxic goitre differs from Grave’s diseases in the following :The 2ry toxic goitre differs from Grave’s diseases in the following :  The thyroid gland is nodular either prior to toxic manifestation or nodularity andThe thyroid gland is nodular either prior to toxic manifestation or nodularity and toxicity started together.toxicity started together.  C.V. manifestations are prominent and nervous manifestation are less marked thanC.V. manifestations are prominent and nervous manifestation are less marked than in Grave’s disease.in Grave’s disease.  Proptosis is usually absent.Proptosis is usually absent.  Medical treatment is less effective and has to be given for long periods to obtain aMedical treatment is less effective and has to be given for long periods to obtain a response.response.  Recurrence of symptoms after thyroidectomy : for 2ry toxic goitre is rare (1% orRecurrence of symptoms after thyroidectomy : for 2ry toxic goitre is rare (1% or less) where as in grave’s disease the incidence of recurrence is from 10 to 20less) where as in grave’s disease the incidence of recurrence is from 10 to 20 percent.percent.  Post operative myxedema is extremely rare in 2ry toxic goitre but it is frequent inPost operative myxedema is extremely rare in 2ry toxic goitre but it is frequent in graves’s disease.graves’s disease.  2ry toxic goitre occurs in an older age group it is better treated surgically because2ry toxic goitre occurs in an older age group it is better treated surgically because the other lines of treatment usually fail to control it.the other lines of treatment usually fail to control it.  More ever the cardiac affection which is commonly associated with it responds toMore ever the cardiac affection which is commonly associated with it responds to surgical removal of the goitre.surgical removal of the goitre.
  48. 48. 3. Toxic Nodule3. Toxic Nodule It is solitary over active nodule (hot nodule)It is solitary over active nodule (hot nodule) 4. Thyrotoxicosis due to other causes4. Thyrotoxicosis due to other causes 1.1. Thyrotoxicosis fastitiaThyrotoxicosis fastitia Patients whose given thyroxine as tonic.Patients whose given thyroxine as tonic. 2. Jod-basedow thyrotoxicosis2. Jod-basedow thyrotoxicosis when large doses of iodide were given for an endemic goitre.when large doses of iodide were given for an endemic goitre. 3.3. Neonatal thyrotoxicosisNeonatal thyrotoxicosis It occurs in babies who were born from hyperthyroid mothers.It occurs in babies who were born from hyperthyroid mothers. L.A.T.S titres in both mother and child will be high.L.A.T.S titres in both mother and child will be high. Hyperthyroidism manifestation will be gradually subsides inHyperthyroidism manifestation will be gradually subsides in 3 or 4 weeks3 or 4 weeks
  49. 49. Investigations for thyrotoxicosisInvestigations for thyrotoxicosis 1. Clinical diagnosis by Wayne Diagnostic Index.1. Clinical diagnosis by Wayne Diagnostic Index. 2. Sleeping pulse.2. Sleeping pulse. 3. Thyroid function tests3. Thyroid function tests Sleeping pulseSleeping pulse It is very important in grading the severity ofIt is very important in grading the severity of thyrotoxicosisthyrotoxicosis 80 – 90 Mild case80 – 90 Mild case 90 – 110 Moderate case90 – 110 Moderate case Above 110 Severe caseAbove 110 Severe case
  50. 50. Thyroid function testsThyroid function tests 1. Measurements of thyroid hormone in serum1. Measurements of thyroid hormone in serum A. Serum protein bound iodine ( P.B.I. )A. Serum protein bound iodine ( P.B.I. ) B. Total serum thyroxine ( T4 )B. Total serum thyroxine ( T4 ) C. Total serum T3C. Total serum T3 D. Free serum T4D. Free serum T4 E. Thyroid indexE. Thyroid index 2. Measurements of free binding sites for thyroid hormones2. Measurements of free binding sites for thyroid hormones 3. Uptake and discharge of radio active iodine3. Uptake and discharge of radio active iodine A. Radio active iodine uptake.A. Radio active iodine uptake. B. T3 resin uptake test .B. T3 resin uptake test . C. T3 suppression test “ werner “.C. T3 suppression test “ werner “. D. Thyroid scanning.D. Thyroid scanning. E. Iodine clearance test.E. Iodine clearance test.
  51. 51. 4. Miscellaneous tests4. Miscellaneous tests A.A. B.M.R N. -10% to +15% of the standardB.M.R N. -10% to +15% of the standard ( 40 cal. / square meter / surface area / hour )( 40 cal. / square meter / surface area / hour ) False results in : neurosis / pregnancy / fever.False results in : neurosis / pregnancy / fever. B. Serum cholesterol : normal 150 – 250 mg%B. Serum cholesterol : normal 150 – 250 mg% It is decreased in thyrotoxicosis & Increased inIt is decreased in thyrotoxicosis & Increased in myxedema.myxedema. False result in : hypercholesteremia.False result in : hypercholesteremia. C. Serum creatinine : normal 0.6 mg/100 mlC. Serum creatinine : normal 0.6 mg/100 ml It increased in thyrotoxicosisIt increased in thyrotoxicosis False increase in renal failure.False increase in renal failure. D. E.C.G.D. E.C.G.
  52. 52. Protein bound iodine P.B.IProtein bound iodine P.B.I  iodine containing hormones T3 and T4 are transported in theiodine containing hormones T3 and T4 are transported in the plasma mainly by specific binding proteins (thyroxineplasma mainly by specific binding proteins (thyroxine binding globulin) (T.B.G). As only a very small amount of T3binding globulin) (T.B.G). As only a very small amount of T3 and T4 are free in the blood, The P.B.I effectively representsand T4 are free in the blood, The P.B.I effectively represents total circulation Thyroid hormones.total circulation Thyroid hormones.  The euthyroid rangThe euthyroid rang 4 – 8 Mg/100ml4 – 8 Mg/100ml False low results in :False low results in :  hereditary decrease of T.B.Ghereditary decrease of T.B.G  Nephrotic syndrome.Nephrotic syndrome. False high results in:False high results in:  X-ray contrast media containing Iodine biligrafinX-ray contrast media containing Iodine biligrafin  Expectorants containing Iodine, Lugol’s IodineExpectorants containing Iodine, Lugol’s Iodine  PregnancyPregnancy  Oral contraceptivesOral contraceptives  Estrogen administrationEstrogen administration  Early hepatitisEarly hepatitis
  53. 53. Total serum T3 - free Serum T4Total serum T3 - free Serum T4  Both measured by Radio - Immuno assay, andBoth measured by Radio - Immuno assay, and are available in special laboratories, but, they willare available in special laboratories, but, they will eventually become routine tests, for theeventually become routine tests, for the twotwo reasonsreasons 1- Some cases of hyper thyroidism are due to1- Some cases of hyper thyroidism are due to excessive production of T3 without anyexcessive production of T3 without any accompanying rise in level of serum P.B.I or totalaccompanying rise in level of serum P.B.I or total serum T4serum T4 2- Free serum T4 ( which not protein bound) is far2- Free serum T4 ( which not protein bound) is far more representative of the level of hormonemore representative of the level of hormone available to the individual thyroid cell than is theavailable to the individual thyroid cell than is the total serum T4.total serum T4.
  54. 54. 2- Measurement of free binding sites for thyroid hormones2- Measurement of free binding sites for thyroid hormones in the blood :in the blood :  Radio active T3 is incubated with patient’s serum so that itRadio active T3 is incubated with patient’s serum so that it becomes fixed to any thyroid binding protein not alreadybecomes fixed to any thyroid binding protein not already carrying T3 or T4.carrying T3 or T4.  The amount so fixed can be measured and from this can beThe amount so fixed can be measured and from this can be estimated the number of binding sites in the serum which areestimated the number of binding sites in the serum which are un occupied.un occupied.  In the hyperthyroidism, the number of free binding sites isIn the hyperthyroidism, the number of free binding sites is low because a few are not already carrying hormonelow because a few are not already carrying hormone  In hypothyroidism and myxedema, the number of free sitesIn hypothyroidism and myxedema, the number of free sites are high.are high.  This is not accurate test in itself , but in conjunction with theThis is not accurate test in itself , but in conjunction with the total serum T4 or serum P.B.Itotal serum T4 or serum P.B.I  the free thyroxinthe free thyroxin indexindex can be calculated from the formula:can be calculated from the formula:  FTIFTI = serum T4 or (B.P.I) × T3 uptake percent= serum T4 or (B.P.I) × T3 uptake percent  euthyroid range of FTI 2.5 – 7.0euthyroid range of FTI 2.5 – 7.0
  55. 55. 3. Uptake and discharge of radio active iodine :3. Uptake and discharge of radio active iodine : A. Radio active iodine uptake.A. Radio active iodine uptake. normal thyroid uptake isnormal thyroid uptake is 15 – 55 %15 – 55 % of the given dose inof the given dose in thyrotoxicosis the uptake increase above 55% inthyrotoxicosis the uptake increase above 55% in hypothyrodism it decrease belowhypothyrodism it decrease below 10%10% technique.technique. 1- No drugs or materials containing iodine are allowed for1- No drugs or materials containing iodine are allowed for the previous 3 weeks.the previous 3 weeks. 2-2- 5 Micro curies5 Micro curies of radio active iodine are given by mouthof radio active iodine are given by mouth in a small amount of water or milk it is rapidlyin a small amount of water or milk it is rapidly absorbed from the small bowel into blood and theabsorbed from the small bowel into blood and the thyroid and kidneys compete for it in hyper thyroidismthyroid and kidneys compete for it in hyper thyroidism the thyroid uptake is rapid and little is excreted in thethe thyroid uptake is rapid and little is excreted in the urine.urine. 3-3- After 24h the uptake is measured over the thyroid byAfter 24h the uptake is measured over the thyroid by Geiger Muller Counter.Geiger Muller Counter.
  56. 56. B- T3 Resin uptake test :B- T3 Resin uptake test :  By incubating iodine T3 (Radioactive T3) withBy incubating iodine T3 (Radioactive T3) with patient’s serum. Part of T3 is fixed by plasmapatient’s serum. Part of T3 is fixed by plasma protein and the part which is not fixed isprotein and the part which is not fixed is precipitated by resinprecipitated by resin and estimated.and estimated. In the hyperthyroidism , the proteins are alreadyIn the hyperthyroidism , the proteins are already saturated with thyroxine and the resin uptake issaturated with thyroxine and the resin uptake is highhigh in the hypothyroidism the resin uptake is low.in the hypothyroidism the resin uptake is low. This is another vitro test through which hazardsThis is another vitro test through which hazards of irradiation are thus avoided.of irradiation are thus avoided.
  57. 57. C- T3 suppression test “Werner”.C- T3 suppression test “Werner”.  Goitre due to iodine deficiency in endemic areasGoitre due to iodine deficiency in endemic areas has a rapid radio active iodine uptake , buthas a rapid radio active iodine uptake , but simple goitre is under T.S.H control so thatsimple goitre is under T.S.H control so that uptake can be diminished by suppressing T.S.Huptake can be diminished by suppressing T.S.H that is done by giving 40 Mg every 8 hourly forthat is done by giving 40 Mg every 8 hourly for 7 days.7 days.  In a toxic goitreIn a toxic goitre 10 – 20 %10 – 20 % reduction in uptakereduction in uptake by suppression whole in simple goitreby suppression whole in simple goitre 50 – 80%50 – 80% reduction.reduction.
  58. 58. D- Thyroid scanningD- Thyroid scanning scanning of thyroid after a tracer dose of radioscanning of thyroid after a tracer dose of radio active iodine shows which parts of the gland areactive iodine shows which parts of the gland are functioning or functionless (Hot or Cold) : whilstfunctioning or functionless (Hot or Cold) : whilst scanning is sometimes helpful in cases of thyroidscanning is sometimes helpful in cases of thyroid carcinoma its principle value is in the diagnosis ofcarcinoma its principle value is in the diagnosis of toxic nodule either as solitary or as a part of toxictoxic nodule either as solitary or as a part of toxic multinodular goitre.multinodular goitre. E- Iondine clearance test :E- Iondine clearance test : in thyrotoxicosis most of isotope is taken byin thyrotoxicosis most of isotope is taken by thyroid and there fore there is less excretion ofthyroid and there fore there is less excretion of radio active iodine by the kidney. The normalradio active iodine by the kidney. The normal range of excretion in 48h isrange of excretion in 48h is 30 – 70%30 – 70% of given doseof given dose lower valueslower values are suggestive of thyrotoxicosis.are suggestive of thyrotoxicosis.
  59. 59.  D.D of thyrotoxicosisD.D of thyrotoxicosis  Anxiety.Anxiety.  Neurosis.Neurosis.  HT disease.HT disease.  Myasthenia.Myasthenia.  T.B.T.B.  Pheochromocytoma.Pheochromocytoma.  Menopausal syndromeMenopausal syndrome  Other causes of exophthalmos.Other causes of exophthalmos.
  60. 60.  How do you differentiate between psychoneurosis andHow do you differentiate between psychoneurosis and thyrotoxicosis ?thyrotoxicosis ?  Anorexia is an invariable presentation inAnorexia is an invariable presentation in psychoneurosis while polyphagia is always presentpsychoneurosis while polyphagia is always present in thyrotoxicosis taking notice ,in thyrotoxicosis taking notice , in both , there is loss of weight.in both , there is loss of weight.  Sleeping pulse normal in psychoneurosis.Sleeping pulse normal in psychoneurosis.  Although the hands show tremors and sweating inAlthough the hands show tremors and sweating in both conditions , but the hand is hot inboth conditions , but the hand is hot in thyrotoxicosis and cold in psychoneurosis.thyrotoxicosis and cold in psychoneurosis.  Thyroid function tests are normal inThyroid function tests are normal in psychoneurosis.psychoneurosis.
  61. 61. Treatment of Toxic GoitreTreatment of Toxic Goitre
  62. 62. 1. Medical treatment1. Medical treatment Indications :Indications :  Mild cases.Mild cases.  Thyrotoxicosis occuring during periods ofThyrotoxicosis occuring during periods of stress. As puberty , pregnancy and lactation.stress. As puberty , pregnancy and lactation. Anti thyroid drugs are given in accurate doesAnti thyroid drugs are given in accurate does and it is better to be on under dose side. Theyand it is better to be on under dose side. They are stopped one month before delivery andare stopped one month before delivery and lugol’s iodine given instead.lugol’s iodine given instead.  Recurrent cases after operation specially 2ndRecurrent cases after operation specially 2nd recurrence for fear of injuring the recurrentrecurrence for fear of injuring the recurrent laryngeal nerves. (Patient under 45y).laryngeal nerves. (Patient under 45y).  Bad general conditions as HT failure.Bad general conditions as HT failure.  Progressive exophthalmos.Progressive exophthalmos.
  63. 63. Aim of treatment :Aim of treatment : Inhibit the function of the gland without destroyingInhibit the function of the gland without destroying it.it. Advantages :Advantages :  No surgery.No surgery.  No use of radio active materials.No use of radio active materials. Disadvantages :Disadvantages :  The treatment isThe treatment is prolongedprolonged and the failure rateand the failure rate after course of 1.5 or 2 years is at least 50 %after course of 1.5 or 2 years is at least 50 %  It isIt is impossible to predictimpossible to predict which patient iswhich patient is likely to go into a remission.likely to go into a remission.  Some goitres enlarge and becomeSome goitres enlarge and become very vascularvery vascular during treatment leading toduring treatment leading to pressure symptomspressure symptoms and making the surgery is difficult .and making the surgery is difficult .
  64. 64.  Very rarely , there is a dangerous drug reactionVery rarely , there is a dangerous drug reaction e.g.e.g. a granulocytosisa granulocytosis (0.1 – 0,4%). The drug is(0.1 – 0,4%). The drug is stopped if sore throat develops or white countstopped if sore throat develops or white count drops and the patient is given penicillin anddrops and the patient is given penicillin and streptomycin as a guard against infection.streptomycin as a guard against infection.  AllergicAllergic manifestation as itching – vomitingmanifestation as itching – vomiting and rashes.and rashes.  Persistent tachycardiaPersistent tachycardia due to markeddue to marked vascularity this may mislead the physician tovascularity this may mislead the physician to increase the dose of anti thyroids to degree ofincrease the dose of anti thyroids to degree of producing myxoedema. Thickening of vocalproducing myxoedema. Thickening of vocal cords and aedema of the glottis may occur andcords and aedema of the glottis may occur and may necessitate tracheostomy.may necessitate tracheostomy.  Myxoedema.Myxoedema.
  65. 65. Drugs used :Drugs used : Thiouracil.Thiouracil. Methyl thiouracil 300 – 600 mg /day.Methyl thiouracil 300 – 600 mg /day. Propyl thiouracil 200 – 300 mg/dayPropyl thiouracil 200 – 300 mg/day Neomercazol 5 – 15 mg/T.D.SNeomercazol 5 – 15 mg/T.D.S Potassium Perchlorate 200 – 800Potassium Perchlorate 200 – 800 mg/daymg/day
  66. 66.  Scheme of treatment :Scheme of treatment :  The patient is given forThe patient is given for one monthone month if there isif there is improvement it is continued for upimprovement it is continued for up 3 months3 months then thethen the dose isdose is halved for another 3 monthshalved for another 3 months.. After 6 months oneAfter 6 months one fourth of the original dosefourth of the original dose is given for anotheris given for another one yearone year on the whole the course takes abouton the whole the course takes about 1.5 year1.5 year..  It is most important to maintain high concentration ofIt is most important to maintain high concentration of the drug through out 24 h by spacing the doses at threethe drug through out 24 h by spacing the doses at three times daily.times daily.  IfIf there is no improvement after thethere is no improvement after the first monthfirst month , it is, it is better to shift to surgical treatment because furtherbetter to shift to surgical treatment because further medical treatment will be ineffective and will increase themedical treatment will be ineffective and will increase the vascularity of the gland markedly so that the operationvascularity of the gland markedly so that the operation will be very difficult.will be very difficult.
  67. 67. The results of medical treatment :The results of medical treatment : 50%50% of cases are cured completely.of cases are cured completely. 50%50% of cases will go into relapse , these areof cases will go into relapse , these are treated either by surgery or radio active iodine.treated either by surgery or radio active iodine. With anti-thyroid drugs, the following isWith anti-thyroid drugs, the following is essential :essential : 1. Rest physically and mentally1. Rest physically and mentally 2. Sedation by luminal2. Sedation by luminal 3. Diet and fluids 3000 cal/daily3. Diet and fluids 3000 cal/daily 4. Inderal.4. Inderal. This measures make your mild cases withoutThis measures make your mild cases without any anti-thyroid drugsany anti-thyroid drugs
  68. 68. 22..Radio active iodineRadio active iodine Indications :Indications : recurrent cases after surgery (overrecurrent cases after surgery (over 45y) bad risky cases due to age or disease.45y) bad risky cases due to age or disease.  Aim of treatment its modification :Aim of treatment its modification : radio iodineradio iodine destroys thyroid cell and as in thyroidectomy ,destroys thyroid cell and as in thyroidectomy , reduces the mass of functioning thyroid tissue toreduces the mass of functioning thyroid tissue to below a critical level.below a critical level. Advantages :Advantages :  Safe , simpleSafe , simple  Less expensive than operationLess expensive than operation  No prolonged drug therapy.No prolonged drug therapy.
  69. 69. Disadvantages :Disadvantages : 1. No reliable method of estimating the exact dose1. No reliable method of estimating the exact dose 2. Complication of irradiation to the working physicians.2. Complication of irradiation to the working physicians. 3. Delayed action :3. Delayed action : As its effect appears after 2 – 3 months , therefore if theAs its effect appears after 2 – 3 months , therefore if the symptoms are severe anti thyroid drugs are given duringsymptoms are severe anti thyroid drugs are given during this periodthis period 4. Incidence of thyroid insufficiency may reach 75% after 104. Incidence of thyroid insufficiency may reach 75% after 10 years.years. Contraindication :Contraindication :  Patient below 40y because of its potential carcinogenicPatient below 40y because of its potential carcinogenic effect (20y or more later).effect (20y or more later).  Pregnancy as it may lead to cretinismPregnancy as it may lead to cretinism  Lactation as it is excreted in milk.Lactation as it is excreted in milk.
  70. 70. Dose of radio iodine for treatment :Dose of radio iodine for treatment :  4 – 84 – 8 millicuries according to the size of themillicuries according to the size of the gland given in a small amount of water orgland given in a small amount of water or milk. The dose can be repeated once aftermilk. The dose can be repeated once after 3 months.3 months. N.B.N.B. Microcurie = 1/1000,000 of curieMicrocurie = 1/1000,000 of curie MillicurieMillicurie = 1/1000 of curie= 1/1000 of curie
  71. 71. 3. Surgical treatment3. Surgical treatment Indications :Indications :  moderate and severe casesmoderate and severe cases  pressure symptomspressure symptoms  2ry toxic goitre2ry toxic goitre  suspicion of malignancysuspicion of malignancy  failure of medical treatment or relapse after itfailure of medical treatment or relapse after it  retrosternal as medical treatment will increase theretrosternal as medical treatment will increase the size of gland and cause more pressure symptoms.size of gland and cause more pressure symptoms. Advantage :Advantage : rapid cure , low incidence of recurrencerapid cure , low incidence of recurrence Disadvantage :Disadvantage :  Recurrence of thyrotoxicosis in about 5% of cases.Recurrence of thyrotoxicosis in about 5% of cases.  Complication of the operation.Complication of the operation.
  72. 72. Preoperative investigation :Preoperative investigation : 1. Indirect laryngoscope1. Indirect laryngoscope 2. Thyroid anti body titres2. Thyroid anti body titres 3. x-ray chest ( retrosternal extension –3. x-ray chest ( retrosternal extension – calcification deviation of trachea ).calcification deviation of trachea ). 4. Scanning4. Scanning 5. Complete rest physically and mentally5. Complete rest physically and mentally 6. Sedation by luminal6. Sedation by luminal
  73. 73. 7. Anti thyroid drug till B.M.R falls to normal7. Anti thyroid drug till B.M.R falls to normal 8.8. 15 days15 days before operation anti thyroidbefore operation anti thyroid are stopped instead we give lugol’s iodineare stopped instead we give lugol’s iodine 10 drops T.D.S to vascularity and make the10 drops T.D.S to vascularity and make the gland tough.gland tough. Lugol`s Iodine =Lugol`s Iodine = 5%5% iodine iniodine in 10%10% KIsolutionKIsolution 9. Inderal may be used as B. adrenergic9. Inderal may be used as B. adrenergic blockers for severe tachycardia .blockers for severe tachycardia .
  74. 74. Subtotal ThyroidectomySubtotal Thyroidectomy  Anaesthesia :Anaesthesia : general endo – trachealgeneral endo – tracheal  Position :Position : supine with sand bag behind the shoulderssupine with sand bag behind the shoulders to extent the neckto extent the neck  Incision :Incision : kocher’skocher’s ((collarcollar) incision in one of the) incision in one of the lower creases of the neck it extends from thelower creases of the neck it extends from the posterior border of one sternomastoid to the post.posterior border of one sternomastoid to the post. Border of the other.Border of the other.  Incision divides the skin and superficial fasciaIncision divides the skin and superficial fascia containing the platysma some prefer to divide thecontaining the platysma some prefer to divide the platysma at a slightly higher level than the skin toplatysma at a slightly higher level than the skin to obtain a good scarobtain a good scar  mobilization of the skin flaps:mobilization of the skin flaps: The upper to the levelThe upper to the level of upper border of thyroid cartilage and the lower toof upper border of thyroid cartilage and the lower to level of manubrium.level of manubrium.
  75. 75.  Anterior jugular veins are divided betweenAnterior jugular veins are divided between ligaturesligatures  Opening the investing layer of deep fascia inOpening the investing layer of deep fascia in midline vertically.midline vertically.  Incising the sheath of pretracheal fascia in theIncising the sheath of pretracheal fascia in the midlinemidline  As a rule the larger lobe is dealt with first.As a rule the larger lobe is dealt with first.  Separation or division of infrahyoid Ms.Separation or division of infrahyoid Ms. In order to expose the thyroid the muscles areIn order to expose the thyroid the muscles are divided in cases of :divided in cases of : A. Big nodular goitre.A. Big nodular goitre. B. Toxic goitre to minimize manipulation.B. Toxic goitre to minimize manipulation. C. Malignant goitre.C. Malignant goitre.
  76. 76.  They are divided near their upper end as theirThey are divided near their upper end as their nerve supply comes from below (fromnerve supply comes from below (from ansacervicalis)ansacervicalis) Devascularization :Devascularization :  Ligation ofLigation of middle thyroid veinmiddle thyroid vein (easily rupture(easily rupture with more bleeding) its division makeswith more bleeding) its division makes mobilization of the gland easier.mobilization of the gland easier.  Ligation ofLigation of sup. Thyroid artery and veinsup. Thyroid artery and vein as near toas near to the gland as possible to avoid sup. Laryngeal n.the gland as possible to avoid sup. Laryngeal n.
  77. 77.  Ligation ofLigation of inf. Thyroid arteryinf. Thyroid artery as far from theas far from the gland as possible (away and laterally) to avoid thegland as possible (away and laterally) to avoid the recurrent laryngeal n.recurrent laryngeal n.  Legation ofLegation of inf. Thyroid veininf. Thyroid vein in front of trachea.in front of trachea.  Removal of required portion of gland leaving postRemoval of required portion of gland leaving post medial part to protect parathyroid and recurrentmedial part to protect parathyroid and recurrent nerves.nerves.  In case ofIn case of simple goitresimple goitre , it is advisable to leave, it is advisable to leave about equal to normal lobe on each side but , inabout equal to normal lobe on each side but , in toxic goitretoxic goitre there are general tendency to leavethere are general tendency to leave very little thyroid tissue since the risk of recurrentvery little thyroid tissue since the risk of recurrent thyrotoxicosis is greater than that of myxaedemathyrotoxicosis is greater than that of myxaedema the amount suggested is that which equals onethe amount suggested is that which equals one third of normal lobe.third of normal lobe.
  78. 78.  Closure leaving a drain on each sideClosure leaving a drain on each side reaching the depth of wound behind thereaching the depth of wound behind the infrahyoid muscles.infrahyoid muscles.  The platysma is closed with plain cat gut asThe platysma is closed with plain cat gut as a separate layer in order to allow removal ofa separate layer in order to allow removal of the stitches of skin early. Skin is closed withthe stitches of skin early. Skin is closed with interrupted silk suture or with metal clips.interrupted silk suture or with metal clips.  The stitches or clips are removed after 3 – 4The stitches or clips are removed after 3 – 4 days.days.
  79. 79. What are indications of tracheastomy afterWhat are indications of tracheastomy after thyroidectomy ?thyroidectomy ? 1. Post operative oedema of glottis.1. Post operative oedema of glottis. 2. Post operative deep haemorrhage beneath2. Post operative deep haemorrhage beneath pre-tracheal M and not relieved by re-pre-tracheal M and not relieved by re- opening of the wound.opening of the wound. 3. Bilateral injury of recurrent.3. Bilateral injury of recurrent. 4. Tracheomalacia .4. Tracheomalacia .
  80. 80. Complications of thyroidectomyComplications of thyroidectomy Local complications :Local complications : 1. Hemorrhage1. Hemorrhage 2. Liquefying hematoma2. Liquefying hematoma 3. Wound infection (uncommon)3. Wound infection (uncommon) 4. Tracheitis4. Tracheitis 5. Phemothorax and mediastinal emphysema5. Phemothorax and mediastinal emphysema 6. Air embolism6. Air embolism 7. Unsightly scar7. Unsightly scar 8. Glottic oedema8. Glottic oedema 9. Tracheal collapse9. Tracheal collapse 10. N. injuries :10. N. injuries :  R. laryngeal n.R. laryngeal n.  Sup. Laryngeal n.Sup. Laryngeal n.  Cervical sympathetics ( Horner’s syndrome).Cervical sympathetics ( Horner’s syndrome).
  81. 81. Endocrine :Endocrine : 1. Tetany1. Tetany 2. Thyrotoxic crisis2. Thyrotoxic crisis 3. Recurrent thyrotoxicosis3. Recurrent thyrotoxicosis 4. Progressive exophthalmos4. Progressive exophthalmos 5. Myxaedema5. Myxaedema
  82. 82. 1. Tetany1. Tetany -- It is due to removal of all parathyroidsIt is due to removal of all parathyroids - It is rare but permanent.- It is rare but permanent. - It is frequently due to scheme resulting from- It is frequently due to scheme resulting from ligation of all vessels of the thyroid and isligation of all vessels of the thyroid and is temporary because the parathyroids regain newtemporary because the parathyroids regain new blood supply from the neighboring vesselsblood supply from the neighboring vessels Treatment :Treatment : -- Calcium gluconate 10 cc 10% daily untilCalcium gluconate 10 cc 10% daily until improvement occurs.improvement occurs. - In permanent cases oral long therapy is given .- In permanent cases oral long therapy is given .
  83. 83. 2. Thyroxic crisis2. Thyroxic crisis -- It is due to flooding of the circulation withIt is due to flooding of the circulation with thyroxin after operation.thyroxin after operation. - Usually in adequate preoperative preparation and- Usually in adequate preoperative preparation and excessive manipulation during the operation areexcessive manipulation during the operation are the cause of this crisisthe cause of this crisis It is characterized by :It is characterized by : 1. Marked irritability1. Marked irritability 2. Marked sweating.2. Marked sweating. 3. Severe tachycardia.3. Severe tachycardia. 4. Hyperthermia4. Hyperthermia 5. Heart failure in neglected cases5. Heart failure in neglected cases
  84. 84. Treatment :Treatment : 1. Sedation : morphia1. Sedation : morphia 2. anti-pyretic : cold compresses and largactil2. anti-pyretic : cold compresses and largactil 3. Glucose 5% I.V for increased metabolic rate3. Glucose 5% I.V for increased metabolic rate 4. 5 c.c. Lugol`s iodine in one bottle of glucose I.V4. 5 c.c. Lugol`s iodine in one bottle of glucose I.V 5. A.C.T.H and cortisone may needed in severe5. A.C.T.H and cortisone may needed in severe cases.cases. 6. Anti thyroid drugs should be given in big doses6. Anti thyroid drugs should be given in big doses 7. Inderal is given to control tachycardia7. Inderal is given to control tachycardia
  85. 85. Cancer thyroidCancer thyroid 1. Precancerous conditions1. Precancerous conditions 2. Pathological types2. Pathological types 3. Clinical features.3. Clinical features. 4. Investigations4. Investigations 5. Treatment5. Treatment 1. Precancerous conditions1. Precancerous conditions 1.1. AdenomaAdenoma of the thyroidof the thyroid 2.2. NodularNodular goitre specially in endemic areas (solitary nodular isgoitre specially in endemic areas (solitary nodular is more liable to undergo malig.) usually givesmore liable to undergo malig.) usually gives follicularfollicular type.type. 3. Previous3. Previous irradiationirradiation of the neck in children (never in adult) ofof the neck in children (never in adult) of enlarged thymus or T.B lymphadenitis usually givesenlarged thymus or T.B lymphadenitis usually gives papillarypapillary type.type. 4.4. Genetic factorsGenetic factors : sometimes: sometimes medullarymedullary carcinoma run incarcinoma run in families.families. 5. Carcinoma of thyroid is extremely rare with5. Carcinoma of thyroid is extremely rare with toxictoxic goitregoitre..
  86. 86. 2. Pathological Types2. Pathological Types PapillaryPapillary adenocarcinoma 85%adenocarcinoma 85% - Occult.Occult. - Intra-thyroidal.Intra-thyroidal. - Extra-thyroidal.Extra-thyroidal.  It is commonest type , met with any age , commonIt is commonest type , met with any age , common in children specially with previous irradiation of thein children specially with previous irradiation of the neck. It is usually has good prognosis. It is formedneck. It is usually has good prognosis. It is formed of delicate branching C.T covered by one or severalof delicate branching C.T covered by one or several layers of cuboidal cells small calcified areas , calledlayers of cuboidal cells small calcified areas , called “Psammoma bodies” are seen and may help in“Psammoma bodies” are seen and may help in differentiation from benign.differentiation from benign.
  87. 87. It is characterized by :It is characterized by : 1. Low grade malignancy.1. Low grade malignancy. 2. Slow growth it may remain stationary with or2. Slow growth it may remain stationary with or without metastases for many years.without metastases for many years. 3. Early lymphatic spread to deep cervical L.N.3. Early lymphatic spread to deep cervical L.N. 4. The affected L.N reach a big size while the4. The affected L.N reach a big size while the primary is small “lat aberrant thyroid T.”primary is small “lat aberrant thyroid T.” 5. The papillary T. has a small or no radio-iodine5. The papillary T. has a small or no radio-iodine uptake.uptake.
  88. 88. Treatment :Treatment :  Total thyroidectomy with unilateral orTotal thyroidectomy with unilateral or bilateral block dissection of Lymph Nodes.bilateral block dissection of Lymph Nodes.  Thyroid extract is given post operatively inThyroid extract is given post operatively in big doses as replacement therapy tobig doses as replacement therapy to suppress the T.S.H in trial to inhibit furthersuppress the T.S.H in trial to inhibit further of the glandof the gland..
  89. 89. 2. Follicular adenocarcinoma 10 %2. Follicular adenocarcinoma 10 %  It is usually common in endemic nodular goitres met with anyIt is usually common in endemic nodular goitres met with any age usually between 40 – 60 years. It forms grey , nonage usually between 40 – 60 years. It forms grey , non encapsulated mass with varying degree of differentiation. Theencapsulated mass with varying degree of differentiation. The well differentiated type is usually referred as “malignantwell differentiated type is usually referred as “malignant adenoma” , and may remain without metastases for many years.adenoma” , and may remain without metastases for many years. While , the undifferentiated tumors grow more rapidly in size ,While , the undifferentiated tumors grow more rapidly in size , spread mainly by BI. But lymphatic is also common.spread mainly by BI. But lymphatic is also common.  The follicular tumors in which invasion is minimal are termedThe follicular tumors in which invasion is minimal are termed “non-invasive“non-invasive” and those in which invasion is moderate or” and those in which invasion is moderate or marked are termed “marked are termed “invasiveinvasive”.”.  The follicular T. has a large radio-iodine uptake.The follicular T. has a large radio-iodine uptake. Treatment :Treatment :  Total thyroidectomy with block dissection.Total thyroidectomy with block dissection. In case of 2ryies scanning for it with radio active iodine.In case of 2ryies scanning for it with radio active iodine.  If active : radio active iodine ablationIf active : radio active iodine ablation  If inactive deep x-ray therapy.If inactive deep x-ray therapy.
  90. 90. 3. Anaplastic Carcinoma 3%3. Anaplastic Carcinoma 3%  It usually occurs in old age group.It usually occurs in old age group.  It grows very rapidly to infiltrate the thyroid and theIt grows very rapidly to infiltrate the thyroid and the surrounding T.surrounding T.  two types are recognised : the small cell and giant celltwo types are recognised : the small cell and giant cell types.types.  TheThe small cellsmall cell type may be mistaken for atype may be mistaken for a lymphosarcemalymphosarcema , while the, while the giant cellgiant cell type simulate ontype simulate on anaplasticanaplastic fibrosarcomafibrosarcoma..  The tumor spreads rapidly by the blood and lymph andThe tumor spreads rapidly by the blood and lymph and kills the patient in a short time.kills the patient in a short time.  It is of bad prognosesIt is of bad prognoses 90% of patient are dead within 1 year.90% of patient are dead within 1 year. 10 % of patient are dead within 3 years10 % of patient are dead within 3 years TreatmentTreatment  Surgery has little or no place , but deep x-ray therapySurgery has little or no place , but deep x-ray therapy chemotherapy, tracheostomy may be needed.chemotherapy, tracheostomy may be needed.
  91. 91. 4. Medullary Carcinoma 2 - 4%4. Medullary Carcinoma 2 - 4%  It is rare tumors , a rise fromIt is rare tumors , a rise from para-follicularpara-follicular cells “cells “CC”” cells which secretecells which secrete calcitonincalcitonin..  The malignant cells contains amyloid.The malignant cells contains amyloid.  The tumors are solid , hard , not hormone dependentThe tumors are solid , hard , not hormone dependent and do not take up radio-iodineand do not take up radio-iodine  High level of serum calcitonin are produced by manyHigh level of serum calcitonin are produced by many medullary carcinoma.medullary carcinoma.  DiarrheaDiarrhea is a feature of 30% of cases , this is may due tois a feature of 30% of cases , this is may due to 5 HT produced by malignant cells.5 HT produced by malignant cells.  The tumors present usually in 50 – 70 age group butThe tumors present usually in 50 – 70 age group but there is younger group which presents in childhood orthere is younger group which presents in childhood or before 30 years with family history and is associatedbefore 30 years with family history and is associated withwith hyperparathyroidismhyperparathyroidism andand pheochromocytomapheochromocytoma , a, a combination known ascombination known as Sipple’s SyndromeSipple’s Syndrome..  The prognosis depends upon the absence or presenceThe prognosis depends upon the absence or presence of L.N. metastases.of L.N. metastases.

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