1. GOITER…

2. ANATOMY

3. Anatomy:
• It consist of 2 lobes, each lobe is pear in
shaped measure 2.4-4 cm length 1.5-2 cm in
width 1-1.5 cm in thickness.
• both lobes are connected by isthmus.
•The weight in adult is approximately 10-20
gm.
•The isthmus of the thyroid gland is located
midway between apex of thyroid cartilage and
suprasternal notch.
•Located anteriorly in the lower neck,
extending from the level of the fifth cervical
vertebra down to the first thoracic
•Second to fourth tracheal rings

5. * The thyroid gland is the largest endocrine organ in the
body.
* Highly vascularized; rich blood supply, venous drainage
and lymphatics.
* The blood flow to the thyroid gland is about 5ml/g/min.
* Its function to secrete sufficient amount of thyroid
hormone.
Thyroid hormone promote normal growth and development
and regulate energy and heat production.
*The parafollicular cells of thyroid gland secrete calcitonin.

7. Physiology:
* Primary function of the thyroid gland is the secretion of
thyroid hormones
- T4 (thyroxine) is primary released hormone
- T3 (triiodothyronine) at least 10 times more active
-T4 is converted to T3 peripherally
* 100% of T4 is synthesized in the thyroid gland.
* Only 25-30% of T3 is synthesized in thyroid gland and
remaining 70-75% are coming from conversion (deiodination)
of T4 into T3 in peripheral tissues.

8. •Thyroid hormone regulated by thyroid stimulating
hormone (TSH) from the anterior pituitary gland.
•The anterior portion of pituitary gland in turn is
controlled by thyrotropin releasing hormone (TRH)
from hypothalamus.

10. Effects of thyroid hormone:
*Fetal brain and skeletal maturation.
*Increase in basal metabolic rate.
*Inotropic and chronotropic effects on heart.
*Increases sensitivity to catecholamines.
*Stimulates gut motility.
*Increase bone turnover.
*Increase in serum glucose, decrease in serum
cholesterol.

11. The endocrine disorders in general can be manifested
by either excess or deficiency in the secreting
hormones..
Common problem related with thyroid
1)Thyrotoxicosis
2) Hypothyroidism
3)Thyroiditis
4) Goiter
5) Thyroid neoplasia

12. Leading cause of anterior neck masses.
Children:
- Most common neoplastic condition
- Male predominance
- Higher incidence of malignancy
Adults
- Female predominance
- Mostly benign

13. History.
 Physical exam.
Investigation of
thyroid.
Treatment.

14. Investigation of thyroid disease:
• TSH level
• Free T4 level
• Free T3 level
• Thyroid antibodies (anti-thyroglobuline antibodies, anti-
peroxidase antibodies)
• Thyroid ultrasound (U/S neck)
• Radio active iodine uptake
• Thyroid biopsy (FNA)

15. TSH
LOW
< 0.5mU/L
Hyperthyroid
NORMAL
0.5- 5.0mU/L
Euthyroid
HIGH
>0.5mU/L
Hypothyroid

16. Fine needle aspiration cytology (FNAC):
* For discrete thyroid swelling.
* Best done under US guidance.
* The only disease that cant be diagnosed by FNA is
follicular carcinoma.

17. Isotope scanning:
The uptake by the thyroid of a
low dose of either:
-Radiolabelled iodine ( I 123)
- technetium (Tc 99)
will demonstrate distribution of
activity in the whole gland.

18. Goiter
-Non specific term to indicate
diffuse enlargement of
thyroid gland.
- Its only enlargement.
- The most common
presentation of a goiter case is
painless mass in the neck.

19. Classification of Goitres
Simple goiter:
- No hormonal
abnormalities
and therefore no
systemic effects.
-Either diffuse
or nodular.
Simple
Toxic goiter:
-Increased in
production of
thyroid hormones.
-Either diffuse
(graves dis.) or
nodular (single
nodule or on the top
of multinodular
goiter.
Neoplastic
goiter:
Either benign
(adenoma) or
malignant
Inflammatory
goiter:
As many thyroiditis
presentation:
-Subacute
granulomatous
-Autoimmune
(hashimot’s)
-Reidel
-Acute supporative

20. Clinical assessment of simple goiter:
- Benign disease, colloid goiter, euthyroid , female (3rd
-5th
decade )
-Presented as mild enlargement of the gland, most of the time
asymptomatic.
-Complication might develop due to mass effect like tracheal
compression or voice changes, but mostly asymptomatic.
-Acute development—Hemorrhage or cyst >> acute pain
** investigation :
1.TFT
2.neck & chest x-ray
3. dx invest :US & FNAC
4.ISOTOPE SCAN

21. Prevention and treatment:
1) Iodine uptake: Iodination of salt
Food
2) T4 administration.
3) Thyroidectomy

22. Toxic multinodular goiter:
- Results from disorganized response of the gland to
stimulation and contains areas of hyperplasia and
hypoplasia side by side.
These nodules are usually necrotic and hemorrhagic.
- The commonest presentation is solitary nodule.
- 20% risk of malignancy

23. Thyroid Uptake Scans
(Technetium 99) –Scintigraphy
(A)Normal
(B) Graves disease: diffuse
increased uptake in both thyroid
lobes.
(C) Toxic multinodulargoiter
(TMNG): “hot”and “cold”areas of
uneven uptake.
(D) Toxic adenoma: increased
uptake in a single nodule with
suppression of the surrounding
thyroid.
(E) Thyroiditis: decreased or
absent uptake.

24. Surgical treatment:
* Unilateral total
lobectomy
* Frozen section
examination
* Surgery for
multinodular goiter:
Subtotal vs total
thyroidectomy.

25. Solitary thyroid nodule:
Are common, being a feature of
many different thyroid diseases
The essential clinical problem,
particularly when the lesion is
Solitary, is to distinguish between
Benign and Malignant disease
(nodule).

26. Assessment of the thyroid nodule
- A nodule in hyperthyroid patient is highly unlikely
to be malignant.
- Dominant nodule in MNG : Malignancy rate may
approach that of solitary nodule 20%
Size ,pain ,age ,previous neck radiation
Voice changes
Pressure symptoms
Consistency of the nodule(hard ,fixed)
Lymphadenopathy 26

27. Investigations:
Hormones: T4 , T3 , TSH
Neck & Chest X-ray
Diagnostic investigations:
Needle biopsy and FNAC
Ultrasonography
Isotope scanning
27

28. Treatment
Hormone administration Very little evidence to affect
benign nodule
Indications for surgery
Clinical features and suspicious or definite FNAC
result.
If continue enlarge despite TSH suppression
Mechanical symptoms
Cosmetic
28

29. Thyroid Cancer
Rare: Less than 1% of all malignancies
Wide spectrum of biological behavior
If treated appropriately there is high survival rate
Types :
Papillary
Follicular
Anaplastic
Medullary
Lymphoma
Rare secondary
29

30. Papillary Carcinoma
The Commonest
Iodine rich areas
Affects children and young adults more, F>M.
Previous neck irradiation
It has lymphatic spread more than blood
(the cervical lymph glands may be palpable long before the
primary lesion in the thyroid become palpable)
It could be intra, extra thyroid or multicentric.
Clinical presentation: nodule with or without cervical
lymphoadenopathy, voice changes, airway obstruction if
enlarged.
Dx: clinical assessment and FNAC
30

31. Follicular Carcinoma
Higher incidence in iodine deficient areas
Low association with radiation.
Female to male ratio 3:1
Affects older age group
Stimulated by TSH
The cells in this tumor retain their normal follicular
configuration, encapsulated and solitary.
Spreads by blood stream to the brain, bone, lung..
It is not diagnosed by FNA
Dx: frozen section
Tt: total thyroidectomy. 31

32. Anaplastic carcinoma
This is the worst type being poorly differentiated and
highly invasive.
Peak incidence 60-80 years
Females more than males
Rapid local tissue infiltration
Rapid blood metastasis
-Long standing goiter-rapid changes in voice and
breathing
FNAC is diagnostic
Surgery, radiotherapy, chemotherapy
32

33. Treatment of differentiated thyroid carcinoma:
*Total Thyroidectomy is the treatment of choice.
*Treatment objectives:
Eradicate the primary tumor
Reduce the incidence of metastasis
Facilitate treatment of metastasis
Minimal morbidity
33

34. Post operative treatment
Thyroxin T4
 Replacement
 Suppress TSH
Thyroglobuline
• Sensitive indicator for residual or recurrent tumor
Radioactive Iodine
• Detect metastatic disease
• Ablation
34

35. Thyroidectomy
Indication:
- Suspected or proven malignancy.
- Thyrotoxicosis.
- Tracheal/ esophageal compression
- Cosmetic.
- Cold nodule for Graves’ Disease
- When I131 is contraindicated (pregnancy)
- Large Goiters less likely to respond to ATD or I131.

36. Pre-operative preparation:
1) the patient should be euthyroid to decrease the risk of
arrythmia.
(Give PTU +/- beta-blocker before surgery. PTU is better
pre-surgical prophylaxis because it additionally blocks
peripheral conversion of T4 to T3).
2) Vocal cords should be checked
3) Patient should be warned for post op complication
4) stable (cold) iodine treatment to decrease gland
vascularity (usually administer 10 to 14 days before
surgery)
5) beta-blocker therapy
Generally, antithyroid drug therapy should be
administered until thyroid functions normalize (4-8 wk).

37. Operations:
•Solitary benign nodule requires lobectomy
•Cancer requires total thyroidectomy
•Thyrotoxicosis or large multinodular goiter
requires subtotal or total thyroidectomy

38. 1- hemorrhage
2- laryngeal edema
3- nerve damage
*recurrent laryngeal nerve
*superior laryngeal nerve
4- thyroid storm
5- hypocalcaemia
6- wound infection
7-recurrent thyrotoxicosis or hypothyroidism
Complications of Thyroidectomy:

39. 1. hemorrhage
Rapid expanding of neck swelling
(hematoma)
Caused airway compromised
Incident 0.3 - 1%
Features: sudden difficulty in breathing

40. Nerve damage
Recurrent laryngeal nerve injury
Mechanism: partial/ complete transection /
burn/ compromised blood supply
Features: true vocal cord paresis/
paralysis
Hoarseness of voice / difficulty in
breathing
Prevention: identification intra operatively

41. Thyroid storm
Acute life threatening, hypermotabolic
state
Caused by excessive release of thyroid
hormones
Features: fever, tachycardia,
hypertension,
neurological, GI disturbance

42. hypoparathyroidism
Function of PTH
- increases serum calcium ( bone
resorption, increasing renal absorption of
calcium, and stimulating the synthesis of
the biologically active form of vitamin D
(1,25-dihydroxy vitamin D)
- increases renal excretion of phosphorous.
- Lead to hypocalcemia

43. Hypocalcemia ( transient or permanent)
Direct trauma to the parathyroid glands,
devascularization of the glands, or
removal of the glands during surgery.

44. Follow up
Review symptoms and thyroid function test
every 4 to 6 week until thyroid levels are
stabilized on a low dose of antithyroid
medication.
thyroid function at least every 3 months for the
first year. After 12-18 months, stop antithyroid
medication or decrease it in patients with Graves
hyperthyroidism to determine if the patient has
gone into remission.

45. THANK YOU