GOITRE

Dr Echebiri, Promise State House Medical Centre, Aso Rock, Abuja. 5th December,2011.

CONTENTS
Definition Overview Background Pathophysiology Classification Presentation Investigations Differential Diagnoses Treatment Prognosis

DEFINITION
An enlarged thyroid gland.

-Clinically palpable gland. -Gland enlargement more than twice of the normal size.

OVERVIEW
Geography: Worldwide, the most common cause of goiter is iodine deficiency. Approximately 800million people subsist on iodine-deficient diet. In industrialized countries,goiter is more often due to Hashimotos thyroiditis.

OVERVIEW
Sex: The female-to-male ratio is 4:1. Thyroid nodules are more likely to be malignant in men The frequency of goiters decreases with advancing age. although the incidence of thyroid nodules increases with advancing age. Race: No racial predilection exists.

BACKGROUND
Thyroid gland surface marking

BACKGROUND
Hypothalamo-Pituitary-Thyroid Axis

BACKGROUND
Thyroid anatomy

BACKGROUND
Thyroid physiology

BACKGROUND
TRH:Produced by Hypothalamus. Release is pulsatile,circadian. Downregulated only by T3. Travels through portal venous system to adenohypophysis. Stimulates TSH formation. TSH: Produced by Adenohypophysis Thyrotrophs.Up
regulated by TRH .Down regulated by T4, T3.

BACKGROUND
Travels through portal venous system to cavernous sinus, then thyroid gland. Stimulates several processes Iodine uptake Colloid endocytosis Growth of thyroid gland.

Thyroid Hormone: Majority of circulating hormone is T4 98.5% T4 1.5% T3

BACKGROUND
Total Hormone load is influenced by serum binding proteins Albumin 15% Thyroid Binding Globulin 70% Transthyretin 10% Regulation is based on the free component of thyroid hormone

BACKGROUND
Hormonal interplay

TRH TSH

T4,T3

PATHOPHYSIOLOGY

CLASSSIFICATIONS
Based on growth pattern

Goitre

Nodular

Diffuse

Uninodular:
Cysts Benign thyroid neoplasms Thyroid cancers

Multinodular:
Iodine deficiency Thyroiditis Sarcoidosis

Hypothalamic disease

Pituitary disease
Iodine deficiency(endemic, sporadic) Graves disease Thyroid hormone insensitivity

CLASSIFICATIONS
Based on size of gland

Grade III GradeII Grade I

Invisible Palpable

Visible Palpable

Visible Palpable Retrosternal extension

CLASSIFICATIONS
Based on activity of gland

Hyperthyroid (toxic)

Hypothyroid

PRESENTATION

PRESENTATION History:
Anterior neck swelling Pain: Haemorrhage, inflammation, necrosis, or Malignant transformation Compressive symptoms: Dysphagia, dyspnea, stridor, plethora or hoarseness Symptoms of hyperthyroidism or hypothyroidism

PRESENTATION Physical Examination

Characterisation of thyroid swelling Check for signs of hyperthyroidism/hypothyroidism Check for signs of compression(Pemberton manoeuvre). Check for signs of malignancy

PRESENTATION
Hyperthyroidism versus Hypothyroidism

INVESTIGATIONS
Laboratory Studies: TRH TSH Total T3, T4 Free T3, T4 RAIU Thyroglobulin Antibodies: Anti-TPO, Anti-TSHr

INVESTIGATIONS
Imaging Studies: Ultrasonography:Evaluate goiter size, consistency, and nodularity. Localize nodules for ultrasonographically guided biopsy. X Rays:Usually AP and Lateral with thoracic inlet.Retrosternal goitre extension.Presence of calcification.

INVESTIGATIONS
Computed tomography (CT) scanning: Delineate the relationship of the thyroid gland to nearby structures.CT-guided biopsies. Radionuclide isotope scanning are used to assess thyroid function and anatomy in hyperthyroidism, as shown below.

INVESTIGATIONS

INVESTIGATIONS
Spirometry: The flow-volume loop is useful in determining the functional significance of compressive goiters.

Histology:fine needle aspiration or core biopsy.

DIFFERENTIAL DIAGNOSES
Pseudogoitre Thyroglossal cyst Sublingual dermoid Lymphadenopathy(bulls neck). Thyroid lipomas Thyroid lymphomas

TREATMENT
Observation Small goiter Euthyroid Asymptomatic Medications: Hypothyroidism: Thyroid hormone replacement with levothyroxine. Hyperthyroidism:May require medications to normalize hormone levels for example propylthiouacil,Methimazole Inflamed thyroid gland, aspirin or a corticosteroid

TREATMENT
Surgery: Removing all or part of the thyroid gland-Thyroidectomy. Large goiters with compression Malignancy When other forms of therapy are not practical or ineffective Radioactive iodine: Treatment results in diminished size of goiter, but eventually may also cause a hypothyroid state.

TREATMENT
Minimally-invasive modalities Endoscopic subtotal thyroidectomy Embolization of thyroid arteries Plasmaphoresis Percutaneous ethanol injection into toxic nodule L-Carnitine supplementation may improve symptoms and may prevent bone loss

PROGNOSIS
Complications of thyroidectomy: Thyrotoxic storm Bleeding Infection Hypoparathyroidism Injury to recurrent laryngeal nerve Injury to superior laryngeal nerve Hypothyroidism

PROGNOSIS
A small percentage of multinodular goiters do lead to hyperthyroidism. Benign goiters have a good prognosis,furthermore,the risk of malignant transformation is low.

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