1. Thyroid gland diseases 2.
M . Alhashash MD

2. Toxic goiter
Thyroid enlargement with increased thyroid function.

3. Toxic goiter Etiology and Types
Primary thyrotoxicosis (Grave’s dz)
Diffuse vascular goiter appearing hand by hand with toxic manifestation
Young age, more in females & with eye signs.
The only autoimmune dz with hyperfunction (females , familial, remission and relapse).
The responsible Ab is TSAb.
Secondary thyrotoxicosis (Plummer’s dz)
Hyperfunction occurs on top of simple nodular goiter i.e goiter then hyperfunction. 2 types.
First types : internodular tissue is active (autonomus) and the nodules are inactive.
Second type : one nodule is active (autonomus) and the rest of the gland is inactive called toxic nodule.

4. Toxic goiter Etiology and Types
3. Toxic adenoma
the rest of the gland is not nodular(normal gland).
autonomous hyperactive adenoma.
4. Rare types as:
thyrotoxicosis factitia from excess L-troxine.
Neonatal from the toxic mother.
Struma overii
Pituitary adenoma.
Ectopic thyroid

5. Toxic goiter Clinical picture
The gland
Primary  diffuse enlargement , uniform ,smooth ,rubbery , thrill. ( in this type toxic manifestation may present without goiter)
Secondary diffuse or localized ,nodular surface , firm consistency.

6. Clinical picture Increased metabolism
CNS: Sympathetic overactivity
Insomnia.
Nervousness
Anxiety
Tremors
Exaggerated reflexes.

7. Toxic goiter Clinical picture
General
Progressive weight loss inspite of good appetite.
Hotness intolerance.
Glucose intolerance.
Easy fatigue.

8. Toxic goiter Clinical picture
Cardiovascular :
Tachycardia
Palpitation
Arrhythmia
Cardiomyopathy
Skeletal weakness
GIT: diarrhea.
Genital : impotence , menorrhagia.

9. Toxic goiter Clinical picture
Warm , wet skin.
Eye :exophthalmos
Stairing look = infrequent blinking.
Lid lag
Lid retraction
Redness, pain ,
Dermopathy :
Non pitting pretibial edema (myxedema only in Grave’s dz)

10. Toxic goiter Clinical picture
Cardinal signs :
Tremors
tachycardia
Thyroid bruit
Exophthalmos
Moist skin

11. HYPERTHYROIDISM GRAVE’S Disease (Diffuse Thyroid Goiter) Triad: Other:
diffuse goiter
thyrotoxicosis
exopthalmos
Other:
hair loss
pretibial myxedema

12. Toxic goiter Investigations
Lab :
T3 , T4 , TSH.
TS Ab.
Radiological :
Plain X-ray
U/S
Radioactive iodine uptake RAIU
CT or MRI.
Biopsy.
Laryngoscopy and sleeping pulse.

13. Hyperthyroidism—uptake
A. Normal
B. Graves’ Dz
C. Toxic Multinodular Goiter
D. Toxic Adenoma
E. Thyroiditis

14. Toxic goiter Diagnosis:
Autonomous thyroid function
Low TSH
Elevated T3 / T4
Thyroid scan ---> diffuse elevated iodine uptake

15. Toxic goiter Treatment
Choices:
Antithyroid drugs
Radioactive iodine therapy
Surgery
Choice depends on:
Age
Severity of the disease
Size of the gland
Coexistent pathology (Ophthalmoplegia)
Other factors:
Patient’s preference
Pregnancy

16. Toxic goiter Medical treatment.
Antithyroid Drugs:
Propyl thiouracil (PTU) = mg TID
Methimazole (Tapazole) = TID
Carbimazole = 40mg
Lugol’s iodine. 10 drops TDS
Beta blockers : Inderal.
Tranquillizers.

17. Toxic goiter Indications of medical treatment.
Small
Mild toxicity
Young age
Primary type
Preparation to surgery
Contraindication to surgery
Recurrence after surgery
Marked eye manifestations.

18. Toxic goiter Disadvantage of these drugs.
Crosses the placenta --> inhibits fetal thyroid function
Excreted in breast milk
Side effects:
Skin rashes
Fever
Peripheral neuritis
Polyartheritis
Granulocytopenia (reversible)
Agranulocytosis / aplastic anemia (poor prognosis)
Goitrogenic

19. Toxic goiter Radioactive Iodine Therapy:
Advantages:
Avoidance of surgery (no injury to nerve / parathyroid gland)
Reduce cost & ease of treatment
Disadvantages:
Lifelong thyroxin replacement therapy
Slower correction of hyperthyroidism
Higher relapse rate
Adverse effect of ophthalmopathy
Suitable treatment:
Small or moderate size goiter
Relapse after medical and surgical therapy
Antithyroid drug and surgery are contraindicated
Contraindicated:
Pregnant / breast feeding
Ophthalmopathy (progression of eye signs)
Isolated nodular goiter or toxic nodular goiter
Young age (children/adolescence ----> Infertility / carcinoma

20. Toxic goiter Thyroid Surgery:
Indicated to:
Young patient
With Grave’s ophthalmopathy
Pregnant
With suspicious thyroid nodule in Grave’s gland
Large nodular toxic goiter with low level of radioactive iodine uptake.
Placed patient to euthyroid state prior to thyroid surgery:
Antithyroid drugs
Lugol’s iodine solution (3 drops BID)
Propranolol

21. Toxic goiter Thyroid Surgery:
Thyroidectomy:
Bilateral subtotal thyroidectomy .
Total lobectomy & subtotal lobectomy contra-lateral.
Total thyroidectomy.
Advantages over RAI:
Immediate cure of the disease
Low incidence of hypothyroidism
Potential removal of coexisting thyroid carcinoma
Disadvantages:
Complication ---> nerve injury (1%) and hypoparathyroidism (13% transient/ 1% permanent).
Hematoma
Hypertrophic scar formation

22. Treatment of HYPERTHYROIDISM
Grave’s disease: medical treatment if failed surgery.
Recurrent thyrotoxicosis after surgery---> RAI
Exopthalmos:
Tape eyelids at night
Wear eyeglasses
Steroid eye drop / systemic steroid (60mg prednisone OD) alleviate chemosis.
Lateral tarsorrhaphy to oppose eyelids
Radio-orbital radiation or orbital decompression

23. Treatment of HYPERTHYROIDISM
Toxic Nodular Goiter (Plummers’ disease):
No extrathyroidal manifestation
Milder than Grave’s disease
Treatment:
Propranolol as preparation.
Thyroidectomy (lobectomy with isthmectomy)
Toxic nodule:
Surgery.
Toxic adenoma
Radioactive iodine

24. Thyroiditis classification
Autoimmune
Focal
Diffuse
With goiter = Hashimoto’s dz.
Without goiter =primary myxedema.
Granulomatous = De Quervain’s thyroiditis.
Fibrosing = Riedel’ thyroiditis.
Infective
Acute ( bacterial or viral ).
Chronic (tuberculosis or syphilis).

25. Thyroiditis clinical picture:
Fever
Malaise.
Thyroid function
Early may be hyperthyroidism.
Late hypothyroidism.
Goiter. Hard gland.
Pressure symptoms.
+ or – LN
Suspect malignancy.

26. Thyroiditis treatment:
L –troxine for replacement.
Corticosteroids for inflammation.
Surgery.
Mass.
Pressure manifestation.
Suspicion of malignancy.

27. Next : Neoplasms
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