1.
Management of goiters, simple and
toxic

2.
outline
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 Thyroid anatomy
 Thyroid physiology
 Evaluation of patients with thyroid diseases
 Management of simple goiters
 Management of toxic goiters
 References

3.
Thyroid anatomy
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 two lobes connected by an isthmus
 20 grams
 posterior to strap muscles in the anterior neck
 lobules that contain 20 to 40 follicles each
 3 million follicles exist in the adult male

4.
Anatomy
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5.
Thyroid physiology
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 Thyroid hormone synthesis
 Iodide trapping
 Oxidation of iodide & iodination of tyrosine by
thyroid peroxidase
 Coupling of MIT and DIT to form T4 and T3
 Hydrolysis of thyroglobulin to release free T3 and T4

6.
Thyroid hormone synthesis
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7.
Thyroid physiology cont…
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 All of T4 is produced in the thyroid while only 20%
of T3.
 T3&T4 are transported bound TBG,TBPA and TBA
 Hypothalamo – pituitary – thyroid axis controls
secretion

8.
Hypothalamo – pituitary – thyroid
axis
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9.
Effects of thyroid hormones
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 Affects almost every system in the body
 Fetal brain &skeletal development
 Increase O2 consumption,BMR& heat production
 Positive inotropic and chronotropic on heart
 Increased GI motility,etc.

10.
Evaluation of patients with thyroid
disease
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 TFT
 Serum TSH – most sensitive test for
diagnosis of hypo and hyperthyroidism
 Free T3&T4- for diagnosis of early
hyperthyroidism
 Total T3&T4-are not good for screening,
can be affected by factors other than
thyroid function
Calcitonin

11.
Evaluation cont…
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 TRH test-to asses pituitary TSH
secretion
 Thyroid antibodies(anti Tg,anti TPO and
TSI)
 elevated in autoimmune thyroid
d.(Graves d/Hashimoto’s thyroiditis)
Don’t indicate thyroid function
 Serum thyroglobulin
 for monitoring recurrent/metastatic
thyroid ca.

12.
Evaluation cont…
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 Thyroid imaging
 Radionuclide imaging
 Size, shape & function of gland assessed
 Increased uptake=“hot", less risk of
malignancy,<5%
 Decreased uptake=“cold" higher risk of
malignancy (15-20%)
 Ultrasound
 CT/ MRI good for assessment of
retrosternal extension

13.
RAI Scanning
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14.
Evaluation cont…
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 FNAC
The best investigative modality for
detecting malignancy
When guided by ultrasound has high
sensitivity and specificity
Reduced thyroidectomies by 50%
 Biopsy

15.
Simple goiters
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16.
Simple goiters cont…
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 Race = no racial predilection
 Sex= female to male ratio 4:1
 Spectrum of illness
Diffuse
Uninodular(Solitary Nodule)
Multinodular
Cystic enlargement

17.
Diagnosis
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 Most are asymptomatic
 If symptomatic
Neck mass
Compression symptoms mainly in
intrathoracic extension
Hoarseness of voice
 FNAC is important to exclude
malignancy

18.
Treatment of simple goiters
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I. Multinodular goiters
 no ideal treatment
Options are
A. Iodine supplementation-not
effective on nodular goiter,
abandoned
B.L thyroxine suppression therapy
15 – 40 % reduction in size in 3
months
 More effective on small diffuse
goiters

19.
Treatment cont…
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C . Surgery
The preferred modality
Indicated for:
-large goiters with compression
symptoms, -in suspicion of
malignancy &
-cosmosis
Advantages
 Significant goiter reduction with prompt relief of
symptoms
 Definitive tissue diagnosis

20.
Treatment cont…
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Disadvantages
 Many complications
 Recurrence in 15 – 40%
 Long term risk of
hypothyroidism(10-20%)
D.Radioiodine therapy(I131)
Not effective in larger goiters, with
higher recurrence
40- 60% reduction in size in 1 to 2
years
Small Goiters:-Recurrence is low(8%

21.
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II.Solitary nodule
A.Small sized(1-1.5 cm) no treatment,
followed regularly with FNAC(3-6% risk of
malignancy)
B.Solitary cold nodule
 T4 therapy – helps to shrink the nodule
 Surgery( lobectomy or isthmusectomy)
 In malignant or suspicious cytology
 Cosmetic
 Pressure symptoms
 Percutaneous ethanol injection therapy
Treatment cont…

22.
Treatment cont…
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III. Solitary cyst –accounts for 15-25% of
thyroid nodules
 FNAC needed always to exclude
malignancy
 If small (<2-3cm) and benign should be left
untreated
 If large(>2-3cm) – aspiration is effective
 Surgery –in suspicious or non diagnostic
cytology & recurrence after aspiration
 PEIT – good success(61-95% reduction in
size)

23.
Toxic goiters
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 Include
Toxic diffuse goiter (Grave’s disease)
Toxic multinodular goiter (TMNG)
Toxic solitary nodule(Plummer’s
disease)
Thyroiditis

24.
Toxic goiters cont…
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I . Grave’s disease
Most common cause of
hyperthyroidism
Prevalence of 3per 1000 in the USA
an autoimmune disease of unknown
etiology
M:F ratio 1:5 and peak age of 20 - 40
years
Mediated by thyroid stimulating
antibodies
The gland is diffusely & smoothly

25.
Toxic goiters (Grave’s) cont…
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 Clinical presentations
 Triad:-
Goiter,thyrotoxicosis,exophthalmos
Symptoms and signs of increased
thyroid hormone activity
Some specific manifestations
Graves ophtalmopaty (50%)
Dermopathy (1-2%)
Acropathy
Gynecomastia in men

26.
Toxic goiters (Grave’s) cont…
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 Diagnosis
Decreased TSH
with or without
increased free
T3&T4
Diffuse increase
in RAI uptake
Increased
TsAb,TSH
receptor Ab

27.
Toxic goiters (Grave’s) cont…
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 Treatment –focuses on hyperthyroidism,
not the autoimmunity
Antithyroid drugs
 radioiodine ablation
Surgery
 Choice depends on
Age, previous therapy,cost,size of
goiter,asscociated
ophtalmopathy,availability,patients
preference etc…

28.
Toxic goiters (Grave’s) cont…
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A . Antithyroid drugs
PTU and methimazole are used
Both act by inhibiting thyroid
peroxidase enzyme
First line treatment in children,
adolescents
In preparation for radiotherapy and
surgery

29.
Toxic goiters (Grave’s) cont…
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Disadvantages
Both cross the placenta
Side effects e.g. agranulocytosis
Associated with high relapse rate(40-
80% in 2 years)
Most patients improve in 2 weeks
,become euthyroid in 6 weeks
 β blockers can be used together

30.
Toxic goiters (Grave’s) cont…
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B . Radioiodine therapy (I 131)
 Is the mainstay of therapy in the developed
world
 Advantages
 Avoidance of surgery and it’s risks
 Reduced cost and ease of treatment
 Disadvantages
 High chance of hypothyroidism(70% at 11
years)
 Progression of ophtalmopathy (33%)
 Fetal damage

31.
Toxic goiters (Grave’s) cont…
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Indications
Older patients with small or moderate
sized goiters
Relapse after medical or surgical
treatment
Patients with contraindication for
drugs and surgery
Contraindications
Pregnancy and breast feeding
Young patients
Patients with ophtalmopathy

32.
Toxic goiters (Grave’s) cont…
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C . Surgery
Goal is complete and permanent
control
Indications
Young patients
Patients with cancer or suspicious
nodule
Allergy to antithyroid drugs
Large goiters
Pregnant and those with desire to
conceive soon

33.
Toxic goiters (Grave’s) cont…
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 Preoperatively
Patient should be rendered euthyroid
Lugol’s iodine (for 10 days,3 drops
BID) to decease vascularity of the
gland
 Extent of surgery
Depend on desired outcome
(recurrence vs. euthyroidism) and
surgeons experience

34.
Toxic goiters (Grave’s) cont…
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 Options
Total or near total thyroidectomy
Coexisting cancer
Refusal to RAI
Severe ophtalmopathy
Severe reaction to drugs
Subtotal thyroidectomy
For all the remaining patients

35.
Toxic goiters (Grave’s) cont…
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 If recurrence occurs =RAI
 Patients need long term follow up with
yearly TSH measurement

36.
Toxic goiters cont…
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II.Toxic MNG
Has slow onset and subtle symptoms,
with no extra thyroidal manifestations
Usually in older age(>50 years) ,with
previous non toxic MNG, because of
autonomous nodules
Diagnosis =similar to graves
RAI-multiple nodules with increased
uptake

37.
Scan in a patient with a toxic
multinodular goiter
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38.
Toxic goiters (TMNG) cont…
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 Treatment
Surgery (subtotal thyroidectomy)
Is the preferred mode of treatment
RAI
Larger doses are needed
High recurrence rate
Only for elderly poor operative risks
Provided no cancer or airway
compression exists

39.
Toxic goiters (TMNG) cont…
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Antithyroid drugs
As preparation for surgery or
radiotherapy
Not effective as long term therapy
High recurrence rate

40.
Toxic goiters cont…
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III.Toxic adenoma (Plummer's disease)
Is hyperthyroidism from a single hyper-
functioning nodule( at least 3 cm
diameter )
Mainly in young patients
Thyrotoxicosis is usually mild
Diagnosis
Palpable nodule and symptoms of
thyrotoxicosis
RAI = hot nodule

41.
Iodine (I 123) scan in a patient with a
palpable nodule
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42.
Toxic goiters cont…
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 Treatment
Antithyroid drugs as preparation for
RAI or surgery
RAI effective for small nodules
Surgery( lobectomy and
isthmusectomy)
Good for larger nodules
PEIT (ethanol injection)

43.
Post operative Complications
 Recurrent Laryngeal nerve injury
 Hypoparathyroidism
 Bleeding
 External Laryngeal nerve injury
 Hypothyroidism
 Recurrence
 Others
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44.
References
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 Stephanie L Lee, e medicine, July 2006
 John L Floyd ,e medicine, march 2006
 Schwartz’s ,principles of surgery,8th ed,2005
 Laszlo Hegedus ,NEJM.2004;351;1764-1771
 Laszlo Hegedus et al,Endocrine
reviews.2003; 24(1):102-132
 Ad R.Hermus,NEJM.1998,338;1438-1447

45.
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Thank you