THYROID GLAND
REDA FAWZY ABBAS, MD
H&N& Endocrine surgeon
Lecturer Of General Surgery
KFS UNIVERSITY

THYROTOXICOSIS

Toxic
goitre
Diffuse Nodular STN Recurrent

Graves’ disease
Etiology: TSI, LATS
Symptoms.
Signs: Local: Diffuse gland – inc. vasc.

Thyroid gland
diffuse enlargement, butterfly shape
uniform .smooth, rubbery, thrill can be felt

Symptoms
Metabolic
-progressive wt loss
- sweeting (hands , face)
-intolerance to heat
- warm hands
- Easy fatigability

CNS
Symptoms
- insomnia
- Nervousness, irritability,
- Nightmares
- Anxiety
Signs
- Pts looks tense
- Tremors (fingers tongue)
- Exaggerated reflexes.

CVS
Symptoms
palpitations, dyspnea, anginal pain
Signs
Tachycardia
Arrhythmia

Muscle
weakness, atrophy, quadriceps, shoulder
Skin
Worm, moist pigmentations, pretibial
myxedema

GIT
diarrhea
Genital
Females irregular menses, menorrhagia ,
amenorrhea
Males gynecomastia , abnormal libido

Signs: General
1. General appearance:
Eye signs
Hair falling
Thyroid acropathy ( skin thickening)
2. Body metabolism:
Excessive sweating
Loss of weight in spite of good appetite
Heat intolerance.

Signs: General
3. GIT:
Diarrhea
Distention
Increased glucose intolerance
4. Respiratory system:
Dyspnea on effort

Signs: General
5. CNS:
Fine tremors.
Irritability – nervousness – easy excitability
Headache – insomnia.
6. CVS:
Systolic HTN – wide pulse pressure.
Tachycardia.
Arrhythmias.
Thyrocardia.

Signs: General
7. Genitourinary:
Polyuria.
Menstrual disturbances.
Infertility with impotence & frigidity.
8. Musculoskeletal:
Pretibial myxedema.
Proximal myopathy.
Hypercalcemia & osteoporosis.

Eye
Symptoms
– Blurred vision.
– Diplopia
– Excessive tearing
– Pain and photophobia (corneal ulcers).
– . Swollen black eyelids.
– Bulging

9. Eye signs: opthalmopathy( exophthalmos)
Infrequent blinking
Lid retraction
Lid lag
Staring look
No forehead wrinkling
Lack of maintained convergence
Backer’s sign
Exophthalmos Vs Proptosis
Malignant exophthalmos

Investigations
1. Laboratory Tests:
FT3, FT4, & TSH.
Antibodies.
Protein bound iodine.
Serum cholesterol: It is decreased.
Creatinine: < 0.6 mg/dl excludes D.
2. Plain X-Ray: neck & chest.
3. Ultrasound.
4. Indirect laryngoscopy.

Differential Diagnosis
1. Anxiety neurosis.
2. Myasthenia gravis or other muscular
disorders.
3. Menopausal syndrome.
4. Pheochromocytoma.
5. Other causes of exophthalmos.
6. Thyrotoxic Factitia.

TREATMENT: MEDICAL
1. Physical and mental rest.
2. Diet.
3. Good sedation.
4. Anti-thyroid drugs:
– Propyl-thiouracil
– Neomercazole
– Lugol’s iodine
5. Beta-blockers.

TREATMENT: MEDICAL
Indications:
1. Small goiters.
2. Mild thyrotoxicosis.
3. Contraindication to anesthesia or
surgery.
4. High thyroid antibodies indicating
thyroiditis.
5. Treatment of Exophthalomos (refer
back).
6. Postoperative recurrence.

TREATMENT: MEDICAL
Indications:
7. Preoperative preparation in general &
especially in:
Pregnancy: followed by thyroidectomy in
the 2nd trimester.
Thyrocardiac patient.

TREATMENT: MEDICAL
Contraindications:
1. Retrosternal goiter.
2. As a definitive management for toxic nodular
goiter.
3. Development of side effects.

TREATMENT: MEDICAL
Advantages:
1. It avoids the hazards & complications of
surgery.
2. It avoids the hazards & side effects of
radio-active iodine (RAI).

TREATMENT: MEDICAL
Disadvantages:
1. It is expensive, has many side effects,
and requires observation for life
2. No guarantee for cure & relapses occur
in 50-70% of cases.
3. Drug resistance may occur.
4. Goitrogenic.

TREATMENT: RAI
Dose:
It differs according to the age, sex, body
weight & degree of toxicity.
It takes 3 months to give its effects.
During this period, one may depend on
ATD & inderal for control of symptoms

TREATMENT: RAI
Contraindications
Indications
1. Pregnancy & lactation
because it is teratogenic.
2. Large nodular goiter.
3. Tracheal narrowing.
4. Retrosternal extension.
5. Children
1. Toxic adenoma.
2. Contraindications to
operation.
3. Persons who refuse surgery
e.g. singers.
4. Postoperative recurrence.
5. If there is no evidence of
local pressure by the thyroid
swelling.

TREATMENT: RAI
Disadvantages &
Complications
Advantages
1.Slow in producing its effects &
often a long treatment period is
required.
2.Associated with a higher degree
of worsened eye manifestations
than after surgery.
1.It is a simple method, given
orally.
2.Cheap & effective.
3.It avoids the hazards &
complications of surgery.
4.It avoids the hazards & side
effects of ATDs.

TREATMENT: Surgery
Preoperative preparation.
TTx then replacement therapy for life.
Indications:
1. Large goiter with pressure
manifestations.
2. Retro-sternal goiter.
3. Failure or contraindications to medical
treatment
4. Patients who wish to become pregnant
within one year of treatment.

TREATMENT: Surgery
Contraindications:
1. High risk patients with a contraindication
to anesthesia or surgery.
2. Hyperthyroidism with high titre of thyroid
antibodies indicating thyroiditis

TREATMENT: Surgery
Advantages:
1. Rapid effect with low incidence of
hypothyroidism.
2. Low recurrence rate.

Toxic nodular goiter
2ry Thyrotoxicosis
1ry Thyrotoxicosis
Point of
Difference
> 35 years (older).
Start after gland
enlargement
Asymmetrical, may be
unilateral, firm &
nodular surface
More marked
Less marked
Less marked
Less marked
Less marked
Surgery only (after
preparation).
Rare
Progressive
< 35 years
Start with gland
enlargement
Symmetrical, bilateral,
fleshy & smooth
surface
Not marked
More marked
More marked
More marked
More marked
ATD, RAI or surgery
Not uncommon
Remission & relapses
Age:
Onset of S/S:
The gland:
CVS :
CNS :
GIT :
Eye :
BMR , T3, T4:
Treatment:
Recurrence:
Course:

Special situations
In pregnancy.
Thyrotoxic crisis.

Special situations
Hyperthyroidism due to rare causes:
1. Thyrotoxicosis factitia: due to over intake
of T4.
2. Jod-Basedow’s disease.
3. Thyroiditis.
4. Neonatal thyrotoxicosis.
5. Massive metastasis from a
normofunctioning follicular carcinoma.
6. T3 toxicosis with normal T4 levels.

Thyroiditis
Acute thyroiditis.
Subacute thyroiditis (De Quervain’s).
Chronic thyroiditis:
Specific – non specific
Hashimoto’s Vs Riedle’s

2. Riedle’s Disease
1. Hashimoto’s Disease
Criteria
Woody thyroiditis.
Lymphadenoid goiter
Synonyms
Most probably, a collagen
disease.
Autoimmune
Etiology
The gland becomes a mass of
dense F.T.
1.The gland is enlarged with a
slightly lobulated surface.
2.Thickened non-adherent
capsule.
NEA:
1.The epithelial elements are
replaced by a dense fibrous
tissue in which a few distorted
atrophic acini are widely
scattered.
2.Evidence of hyperplasia of
epithelial elements in the less
affected portions of the gland.
1.Interfollicular lymphocytic &
plasma cell infiltration.
2.Epithelial changes (from
destruction to hyperplasia).
3.Tendency to eventual fibrosis.
4.Askanazy cells.
MP:

1.Sex: Both males and
females.
2.Age: young adults.
3.Complaints:
•Neck swelling
•Profound
hypothyroidism.
•Profound pressure
symptoms.
1.Sex: More in females
(20:1).
2.Age: older (menopausal).
3.Complaints:
•Neck swelling.
•Patient is initially
euthyroid, with
superimposed
hashitoxicosis, then
eventually she is
hypothyroid.
•Little or no pressure
symptoms.
History-
Taking:

1.Goiter: Not uniformly
enlarged, woody hard,
fixed, irregular surface,
and ill-defined edges.
2.Signs of
hypothyroidism.
1.Goiter: Uniform
enlargement, usually
bilateral, firm, mobile with
deglutition, smooth
surface, butterfly shaped
and well-defined edges.
2.Signs of hypothyroidism.
3.No palpable lymph
nodes.
Examina
tion:
Thyroid cancer
Thyroid cancer
DD:

1.Thyroid function
tests show
hypothyroidism.
2.Antibodies are not
diagnostic.
3.US & plain X-ray
chest & neck may
help
4.Needle biopsy.
1.Thyroid function
tests show
hypothyroidism.
2.Highly raised titers
of thyroid antibodies.
3.US: may help.
4.Needle biopsy.
Investigati
ons

El-troxin for
replacement.
For diagnosis & to
relief pressure effects
by isthmectomy
(thyroidectomy may
be impossible).
It is ineffective.
El-troxin for
replacement &
cortisone
(autoimmune).
To rule out
malignancy & to
relief pressure effects.
Contraindicated
because it causes
severe myxedema.
Treatment
a)
Medical:
b)
Surgical:
c) RAI: