Neck masses

thyroid disease
Supervised by: Dr. Mohammad Khammash
Presented by: Nurul Aina Khalid

Embryology
The first endocrine gland to develop in embryo .
The gland originates as a proliferation of
endodermal epithelial cells on the median surface of
the developing pharyngeal floor.
Descends in the neck anterior to the level hyoid
bone . Briefly remain connected to the tongue by the
thyroglossal duct which obliterates eventually leaving
proximal pit (foramen cecum ) in the tongue base .
the parafollicular C cells (calcitonin ),differentiate
from the neural crest cells that migrate from the
pharyngeal arches to the 4th pharyngeal pouch.

Anatomy
largest endocrine organ in the body approximately 2025 g in adult .
2 lobes encircles the anterolateral portion of the
trachea overlying the 2nd to 4th tracheal rings
,connected by isthmus (<4mm ).
A pyramidal lobe was found in 55% of individuals .
Extends from the isthmus and can reach the level of
the hyoid bone.
A fibrous tract may extends from the pyramidal lobe
to the hyoid bone and may harbor a
thyroglossal cyst.

Its bordered medially by the trachea and

esophagus, laterally by the carotid sheath,
anteriorly and laterally by The sternocleidomastoid
muscle and the three strap muscles and posteriorly
by the longus colli muscles.

Blood Supply & Drainage

Superior thyroid artery : a branch of The external
carotid artery .
o courses with the superior laryngeal nerve
( landmark ).

Inferior thyroid artery : a branch of the

thyrocervical trunk which arises from the subclavian
artery.
o The RLN may course anterior or posterior to the inferior
thyroid artery(landmark ).

Thyroidea ima artery : is found in approximately

3% of individuals and arises from the aortic arch,
courses to the inferior portion of the isthmus or
inferior thyroid poles.

Function
Produce Thyroid hormones which are critical
determinants of brain and somatic development in
infants and of metabolic activity in adults; they
also affect the function of virtually every organ
system.
The parafollicular cells (c cells) of thyroid gland
secrete calcitonin ( Ca2+ in blood ).

Physiology
Primary function of the thyroid gland is the
secretion of thyroid hormones:
T4 is primary released hormone
T3 at least 10 times more active
T4 is converted to T3 mostly peripherally.

Effects of Thyroid Hormone

Fetal brain and skeletal maturation.
Increase in basal metabolic rate.
Positive Inotropic and chronotropic effects
on heart.
Increases sensitivity to catecholamines.
Stimulates gut motility.
Increase bone turnover.
Increase in serum glucose, decrease in
serum cholesterol.

Approach
History.
Physical exam.
Investigations .
Treatment.

Symptoms of The Thyroid

Diseases

Local (mass or swelling).

Endocrine Activity of the Gland.

Local Symptoms (mass)

o History
A lump in the neck.
Rapid growth of the neck mass.
Discomfort During swallowing.
Dyspnea.
Pain.
Hoarseness.
childhood head and neck irradiation, total
body irradiation for bone marrow
transplantation,
Family history of thyroid cancer, or endocrine
ca (MEN)

Symptoms and Signs of Endocrine Dysfunction

Thyrotoxicosis:
anxiety, emotional lability, weakness, tremor, palpitations,
heat intolerance, increased perspiration, and weight loss
despite a normal or increased appetite
hyperdefecation (not diarrhea), urinary frequency,
oligomenorrhea or amenorrhea in women, and
gynecomastia and erectile dysfunction in men
Hypothyroidism:
Fatigue, Feeling cold , Poor memory and concentration
Constipation , Weight gain with poor appetite, Shortness
of breath . Hoarse voice , Menorrhagia(and
lateroligomenorrhea) Paresthesia Dry, coarse skin Cool
extremities Hair loss Peripheraledema Carpal tunnel
syndrome and Myxedema

Examination
Inspection
General look
Hands
Eyes
Neck

Palpation
Percussion
Auscultation.

Investigations

Investigations
TSH level
Free T4 level
Free T3 level
Thyroid antibodies (anti-thyroglobuline
antibodies, anti-peroxidase antibodies)
Thyroid ultrasound
Radio active iodine uptake
Thyroid biopsy (FNA)

Thyroid US
Give good anatomical images
of the thyroid and surrounding
structures but unfortunately
reveals more thyroid swelling
than are clinically relevant.
Cystic vs. Solid lesions
Reveal smaller nodules not
felt on exam .
The US will show the size,
shape, consistency of the
gland and whether its nodular
or not.

Isotope scanning

The uptake by the thyroid of a low dose of either:

Radiolabelled iodine ( I 123)
technetium (Tc 99).
Shows isotope uptake and distribution in the gland
which reflects its activity.
Main value in a toxic patient presented with a
nodule, it helps localize the overactivity whether a
toxic nodule or toxic multinodular goiter (small
nodules )

Fine needle aspiration

( cytology )
Is the investigation of choice for discrete
thyroid swelling.
It has excellent patient compliance, is simple
and quick to perform in outpatient clinic and
readily repeated.
Best done under US guidance.
The only diseases that cant be differentiated
by FNA is follicular carcinoma from follicular
adenoma.

Goiter

Goiter

Is a non specific term to indicate diffuse

enlargement of thyroid gland.

The most common presentation of a goiter is

painless mass in the neck

Patient may be hyper , hypo, euthyroid .

Diffuse ,solitary nodule , multinodular goiter

Classification of Goiter
Simple

Toxic

Inflammatory

Neoplasti
c

Autoimmune

Diffuse
hyperplastic
goiter
Physiological
Pubertal
Pregnancy

Multinodular
goiter

Diffuse
Graves
disease
Multinodular

Toxic
adenoma

Chronic
lymphocytic
thyroiditis
Hashimotos
disease

Granulomatous
De Quervains
thyroiditis

Fibrosing
Infective

Benign
Malignant

Simple Goiter
Etiology

Iodine deficiency : Appears in childhood in

endemic areas .

Dyshormonogenesis : Enzyme deficiency in

sporadic cases , appears in puberty ( increased
metabolic demand )

Goitrogens : Cabbage , kale (contain

thiocyanate )

Simple Goiter

Because of Persistent
growth stimulation by
(TSH) due to low (TH)
leading to diffuse
hyperplasia .

1. As a result of fluctuating
stimulation a mixed pattern of
areas of active lobules and
areas of inactive lobules
develops .

Low (TH) Mostly due to

iodine deficiency.

2. Active lobules become more

vascular and hyperplastic
until hemorrhage , causing
central necrosis .

Stimulation increase in
puberty and pregnancy .
May persist for a long time
but its reversible if
stimulation stops early .

3. Necrotic lobules coalesce to

form nodules ( colloid or
cellular )

Presentation
Painless Goiter (diffuse or palpable nodules)
Euthyroid.
More common in females.
Complications of Neck masses.
Acute development (size or pain )Hemorrhage

Investigations
TFT
Thyriod antibodies
to differentiate from autoimmune thyroiditis

Neck & chest x-ray.

US
FNAC

Treatment
Iodine uptake: iodised salt
Thyroxin administration
(in hyperplastic stage )

Thyroidectomy
(tracheal compression , cosmatic ,
neoplastic )

Toxic diffuse goiter

Graves Disease
Diffuse goiter
Hyperthyroidism
Eye signs (exophthalmos )
Myxedema (later on)

Cause : thyroid stimulating antibodies (TSHRAbs)that bind to TSH receptors site and produce a
prolonged effect .

Diagnosis
High T3, T4.

Low TSH
thyroid stimulating antibodies.
Diffuse increased uptake in Isotope scan

Treatment
Medical : carbamazole or propylthiouracil
+propranolol (agranulocytosis)
Radioiodine ablation.
Surgical resection.

Toxic Multinodular Goiter

(Plummer's disease)
Its the second most common cause of
hyperthyroidism (afterGraves' disease) in the
developed world and in areas of endemic iodine
deficiency.
Ranges from a single hyperfunctioning nodule within
a multinodular thyroid to multiple areas of
hyperfunction.
this may progress to hemorrhage and degeneration,
followed by healing and fibrosis, Calcification.

Presentation
Neck masses.
Hyperthyroidism

Diagnosis & Treatment

TFT

Thyroid isotope Scans

Treatment

subtotal or total thyroidectomy

Thyroid carcinoma
Majority present as lump in the neck , mostly euthyroid.
Rare: Less than 1% of all malignancies ,If treated
appropriately high survival rate

Types :

Follicular epithelium
Differentiated
Papillary

Follicular

Undifferentiated
Anaplastic
Not follicular

Medullary

Lymphoma

Rare secondary

When to suspect ca ?
History:
Extreme age
Neck radiation.
Family Hx. (thyroid CA or MEN-II)
Symptoms:
Voice changes.
Neck mass
Lymph node enlargement
Dysphagia.

When to suspect ca ?
Signs:
Single Nodule.
Cold nodule.
Increase calcitonin level.
Lymphadenopathy
Hard, Immobile.

Investigations
FNA
TSH
US , CT
Calcium level
CXR

Treatment
Differentiated: (papillary &follicular):
1. Total Thyroidectomy
2. Radioactive iodine.
3. Thyroxin replacement

Undifferentiated: (Anaplastic):

total thyroidectomy

. Radiotherapy (palliation)

Pre-operative preparation
1. the patient should be euthyroid (to decrease the
risk of thyroid storm)
2. Give carbimazole or beta-blocker
(propranolol )before surgery
3. Check the vocal cords.
4. Patient should be warned for possible nerve
damage intraoperatively .

Postoperative
assessment
Thyroxin T4

Thyroglobulin
Sensitive indicator for residual or
recurrent tumor

Thyroid scan after 3-4 weeks to check that there

is no remnant after total thyroidectomy
Serum calcium

Complication of
thyroidectomy

Hemorrhage

Laryngeal edema

Nerve damage---- recurrent laryngeal nerve,

superior laryngeal nerve (may be reversible
or irreversible according to the cut)

Hypocalcaemia (after 4 weeks )

wound infection

Signs of hypocalcaemia
perioral numbness (1st)
Chvostek sign: It refers to an abnormal reaction
to the stimulation of thefacial nerve
Trousseau sign (when taking blood pressure)
Carpal spasm

References

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