seminar presentation on multinodular goitre Ref: Bailey and love's short practice of surgery SRB Manual of surgery

1. MULTI NODULAR
GOITRE
L A Y A K P I L L A I

2. CONTENTS
• ANATOMY AND PHYSIOLOGY OF THYROID
• GOITRE
• CLASSIFICATION OF GOITRE
• MULTI NODULAR GOITRE
• AETIOPATHOGENESIS
• CLINICAL FEATURES
• INVESTIGATIONS
• TREATMENT
• EXAMINATION OF THYROID SWELLING

3. GOITRE ??

4. Goitre from latin word ‘guttur’ meaning the throat
Goitre is generalised enlargement of thyroid gland

5. ANATOMY

8. PHYSIOLOGY

9. CLASSIFICATION OF THYROID SWELLING
SIMPLE GOITRE DIFFUSE HYPERPLASTIC PHYSIOLOGICAL
PUBERTAL
PREGNANCY
MULTINODULAR GOITRE
TOXIC DIFFUSE(GRAVES DISEASE)
MULTINODULAR
TOXIC ADENOMA
NEOPLASTIC BENIGN
MALIGNANT
INFLAMMATORY AUTOIMMUNE CHRONIC LYMPHOCYTIC THYROIDITIS
HASHIMOTO’S DISEASE
GRANULOMATOUS De QUERVAIN’S THYROIDITIS
FIBROSING REIDEL’S THYROIDITIS
INFECTIVE ACUTE
CHRONIC

10. DIFFUSE HYPERPLASTIC GOITRE

11. MULTI NODULAR GOITRE

12. MNG
• There are multiple nodules in thyroid
• Progression from diffuse hyperplastic goiter
• Can weigh upto 2kg
• Mostly euthyroid
• More common in FEMALES
• They can be : NonToxic & Toxic
• Toxic MNG : a hyperfuntioning nodule may develop within a long
standing goiter resulting in hyperthyroidism . The condition called
PLUMMER SYNDROME

13. AETIOPATHOGENESIS
• Puberty , pregnancy : demand feedback in TSH level hypertrophy of gland
( physiological goiter)
• Endemic : iodine deficiency.
daily requirement : 0.1-0.15 mg
• Dyshormonogenesis: familial ; autosomal recessive condition with deficiency of
peroxidase or dehalogenase resulting in sporadic goiters.
• Goitrogens : such as cabbage, drugs like sulfonamides , iodides
• Previous irradiation to neck

14. GOITROGENS
• Environmental
– Cassava root (contains thiocyanate)
– Vegetables cruciferae family (cabbage, cauliflower, brussel sprouts)
– Milk from regions where goitrogens are present in grass
– Others
• Drugs
– Iodides
– Amiodarone, aminoglutethemide, Lithium
– Cobalt
– Diiodoquinone
– Ethionamide
– PAS

15. ENDEMIC GOITRE AREAS

17. STAGES IN GOITER FORMATION
STIMULATION DIFFUSE HYPERPLASTIC GOITRE
(reversible if stimulation ceases)
MIXED PATTERN with areas of active &
inactive lobules
(as a result of fluctuating stimulation)
Active lobules bcom more vascular &
hyperplastic until hemorrhage occurs,
causing central necrosis .
Necrotic lobules coalesce to
form nodules filled either
wih iodine free colloid or a
mass of new but inactive
follicles
Continual repetition of this
process results in a nodular
goitre

19. PATHOLOGY
• GROSS : multilobulated ; cut section has irregular nodule containing
amts of gelatinous colloid.
Regressive changes occur frequently in older lesion which
include areas of hemorrhage, fibrosis, calcification, and cyst changes
• MICROSCOPY : follicles of varying size.
area of hemorrhage, hemosiderin-laden macrophages
calcification

25. CLINICAL FEATURES
• Mass effects like dyspnea , dysphagia, hoarseness ,compression to
the great vessels (superior vene cava syndrome).
• Cosmetic effects
• Mostly euthyroid , may present with hyperthyroidism (toxic MNG)
• Hypothyroidic presentations in specific clinical settings.

34. INVESTIGATIONS
• Thyroid function tests
• Ultrasonography (USG)
• Fine needle aspiration cytology (FNAC)
• Complete blood picture (CBP)
• X-ray neck :AP & Lateral view
• CT scan : to look for retrosternal extension
• Thyroid scan-contains radioactive I
• Indirect laryngoscopy : to see vocal cord mobility

36. COMPLICATIONS
• Dyspnoea / dysphagia
• Secondary thyrotoxicosis
• Calcification of nodules
• Degeneration of nodules
• Hemorrhage into nodules
• Malignant transformation (follicular/papillary)- 5%
• Cosmetic disfigurement

37. TREATMENT
• In the early stages a hyperplastic goiter may regress if thyroxine is given in
a dose of 0.15-0.2 mg daily for few months.
• Although the nodular stage is irreversible , more than half of benign
nodules will regress in size over years.
• Most of the MNG are asymptomatic and do not require operation.
• Operation may be indicated on cosmetic grounds, for pressure symptoms,
or in response to patient anxiety.
• Retrosternal extension is an indication for thyroidectomy.

38. • When entire gland Is involved – total thyroidectomy is better
• Subtotal thyroidectomy is done depending on the amt of gland involved, location
8gms of thyroid tissue is retained in each lateral lobe
• often partial thyroidectomy or Harley dunhill operation (one lateral lobe + isthmus+ opp
side subtotal or partial)
• Reoperation for recurrent nodular goiter is more difficult and hazardous and for this
reason, total thyroidectomy is favoured in younger patients.
• Total lobectomy and total thyroidectomy have additional advantage of being therapeutic
for incidental carcinomas.
• There is some evidence that radioactive iodine may reduce size of recurrent nodular
goiter after previous subtotal resection and in some circumstances it is safer alternative
than reoperation.

39. • Incision : a gently curved skin crease incision made between the notch of thyroid
cartilage and suprasternal notch- KOCHERS
• Superior thyroid artery ligated
Inferior thyroid artery are not routinely ligated to
preserve Parathyroid blood supply.

40. POST OP COMPLICATIONS
• Bleeding
• infection
• Temporary permanent loss of voice
• Temppermanent hypocalcemia
• Vocal cord paralysis
• Need for life long thyroid supplements like L-thyroxine

41. PREVENTION
• Use of iodised salt
• At puberty : 0.1 mg or 0.2 mg thyroxine
• Reduce the use of goitrogens

43. EXAMINATION OF A THYROID SWELLING
• INSPECTION : by Pizillo’s method
size, shape and location and borders, surface
look for redness, scar, dialated vein pulsation, sinuses.
• Palpation : Lahey’s method for palpation of deep surface
Crile’s method for small nodules
measure size, shape, consistency, mobility
kochers test for stridor
berry’s sign for carotid pulse
• Percussion : Dull note if retrosternal extension
• Auscultation: bruit

44. Pizillo’s method
Crile’s method
Lahey’s method

45. Kocher’s test
PEMBERTON’S SIGN

46. THANK YOU