1. BENIGN THYROID
Case 1

2. Chief Complaint: Anterior Neck Mass
36 F Pampanga
Chief Complaint: Anterior Neck Mass
Enlarging Left Anterior Neck Mass
7 Years PTA
Easy Fatigability
Palpitations
Weight Loss
Consulted a physician
Prescribed with medications
Provided symptom relief
1 Year PTA
ADMISSION

3. PHYSICAL EXAMINATION PR = 90/min RR = 20/min T = 37 C No Exophthalmos
Neck:
Multilobulated firm left mass
Moves with deglutition
12 x 10 cm

4. Salient Features PERTINENT POSITIVE PERTINENT NEGATIVE
Enlarging left anterior neck mass
Easy fatigability
Palpitations
Weight loss
Neck: - 12 x 10 cm
- left,firm,multilobulated
- moves with deglutition
No exophthalmos
No fever
Non tender neck mass
No weight gain
No cold intolerance
No memory impairment
No constipation
No underlying autoimmune disease
No history of intake of high iodine load
No history of hormone intake

5. DIFFERENTIAL DIAGNOSIS

6. Anterior neck mass GOITER HYPERTHYROIDISM GROWTH HYPOTHYROIDISM
(Non toxic Goiter)
HYPOTHYROIDISM

7. HYPERTHYROIDISM HYPOTHYROIDISM PATIENT
Nervousness
Irritability
Heat Intolerance
Palpitations
Tachycardia
Weightloss
Tremor
Easy fatigability
Alterations in appetite
Diarrhea
Dyspnea
Sleep disturbances (insomnia)
Thyroid enlargement (depending on the cause)
Pretibial myxedema
Exophthalmos
Weight gain
Cold intolerance
Constipation
Memory impairment
Bradycardia
Hypothermia
Loss of hair
Reflex delay
Thyroid enlargement
Weight loss

8. Anterior neck mass GOITER HYPERTHYROIDISM GROWTH HYPOTHYROIDISM
(Non toxic Goiter)
HYPOTHYROIDISM

9. HYPERTHYROIDISIM CAUSES: Diffuse toxic goiter (Grave’s disease)
Toxic multinodular goiter (Plummer’s disease)
Toxic adenoma
Jod Basedow hyperthyroidism – iodine induced
Subacute thyroiditis (De quervain’s thyroiditis)
Painless thyroiditis
Factitious hyperthyroidism (hormone induced)

10. TOXIC GOITER NODULAR DIFFUSE OTHERS -TOXIC MULTINODULAR GOITER
-TOXIC ADENOMA
-DIFFUSE TOXIC GOITER
OTHERS
-SUB ACUTE THYROIDITIS
-PAINLESS THYROIDITIS
-JOD BASEDOW HYPERTHYROIDISM
-FACTITIOUS HYPERTHYROIDISM

11. JOD -BASEDOW HYPERTHYROIDISM FACTITIOUS HYPERTHYROIDISM
SUB ACUTE THYROIDITIS
PAINLESS THYROIDITIS
JOD -BASEDOW HYPERTHYROIDISM
FACTITIOUS HYPERTHYROIDISM
Viral infection
History of URTI
Hyperthyroidism due to leakage
Self limiting
Tender enlarged thyroid gland
Fever
Patients with underlying autoimmune disease
Common among post partum women
Painless goiter
Occurs most often in older population
Iodine Induced
History of intake of high iodine load (medications, contrast agents)
History of hormone intake, bangkok pills
Elevated T3 and T4
Low TSH
Diminished RAI uptake
Diminshed RAI uptake
Very low or absent thyroglobulin level
No fever
Enlarged NON tender thyroid gland
No underlying autoimmune disease
No history of intake of high iodine load
No history hormone intake

12. TOXIC GOITER NODULAR DIFFUSE OTHERS -TOXIC MULTINODULAR GOITER
-TOXIC ADENOMA
-DIFFUSE TOXIC GOITER
OTHERS
-SUB ACUTE THYROIDITIS
-PAINLESS THYROIDITIS
-JOD BASEDOW HYPERTHYROIDISM
-FACTITIOUS HYPERTHYROIDISM

13. DIFFUSE TOXIC GOITER NODULAR THYROID ENLARGEMENT NO EXOPHTHALMOS
Aka GRAVES’ DISEASE
Autoimmune disorder whereby the thyroid gland is overstimulated by antibodies directed to TSH receptor on thyroid follicular cells
TRIAD:
Diffusely enlarged thyroid gland
Hyperthyroidism
Exophthalmos
NODULAR THYROID ENLARGEMENT
NO EXOPHTHALMOS
Low TSH
Elevated T3 and T4
RAI – high or normal
Uptake on RAI is diffuse and homogenous

14. TOXIC GOITER NODULAR DIFFUSE OTHERS -TOXIC MULTINODULAR GOITER
-TOXIC ADENOMA
-DIFFUSE TOXIC GOITER
OTHERS
-SUB ACUTE THYROIDITIS
-PAINLESS THYROIDITIS
-JOD BASEDOW HYPERTHYROIDISM
-FACTITIOUS HYPERTHYROIDISM

15. TOXIC NODULAR GOITER SOLITARY MULTINODULAR
-TOXIC ADENOMA
-TOXIC MULTINODULAR GOITER
variably enlarged and composed of multiple nodules

16. Clinical Impression: Toxic Multinodular Goiter

17. Work Ups: TSH level – low
T4 level may be normal or minimally increased
T3 is often elevated to a greater degree than T4
Radionuclide Scanning – heterogenous uptake with multiple regions of increased and decreased uptake
FNAB

18. Medications
Anti-thyroid drugs like Methimazole and Propylthiouracil. Methimazole, which is the drug of choice, inhibits the addition of iodine to thyroglobulin by the enzyme thyroperoxidase, a necessary step in the synthesis of triiodothyronine (T3) and thyroxine (T4).

19. A non-cardioselective beta-blocker, propanolol, is given for the adrenergic symptoms of the patient such as the palpitations and easy fatigability.
The thyrotoxic patient’s response to catecholamines is exaggerated. To counter this, propanolol, a non-cardioselective beta-blocker is given.

20. Management
Thyroidectomy may be the only option for the patient because of the large size of the mass. It progressed in size and also began to compress her airway which makes the patient a candidate for surgery.
There is a risk for hypothyroidism post-op.
Special precaution should be taken with regards to the superior and recurrent laryngeal nerves. If accidentally severed they may cause stridor, vocal fatigue and hoarseness.

21. Thyroidectomy

22. Prospective Study of Postoperative Complications After Total Thyroidectomy for Multinodular Goiters by Surgeons With Experience in Endocrine Surgery
Rios-Zambudio, Rodriguez, Riquelme, et. al.
Annals of Surgery
Volume 240, 1; July 2004

23. Background of Study
Subtotal thyroidectomy resulted in a high rate of recurrences (10-30%)
Total thyroidectomy involves a greater risk of complications

24. Goals
To demonstrate that total thyroidectomy for multinodular goiters can be performed with a permanent complication rate of 1% or less
To analyze the risk factors for complications with total thyroidectomy performed by surgeons with experience in endocrine surgery

25. Patient Population 268 women, 33 men Mean age 48 +/- 14 years
Selection criteria:
Bilateral multinodular goiter
No prior cervical surgery
No associated parathyroid pathology
No initial thoracic approach

26. Methods
Prospective study of 301 patients diagnosed and surgically treated for multinodular goiter between January 1996 – January 2001
2 surgeons with experience in endocrine surgery
X2 test; regression analysis

27. Risk Factors Age Duration of surgery Sex Weight of excised specimen
Time of evolution
Associated thyroid carcinoma
Symptoms
Cervical goiter grade
Intrathoracic component

28. Patient Procedures CBC Thyroid hormone study CXR Thyroid sonography
Thyroid gammagraphy for 69 toxic goiters
Cervical CT for 70 goiters with intrathoracic component
FNA of dominant nodule for 132 patients
Laryngoscopy in 5 patients with dysphonia
142 patients initially controlled with medications

32. Results Overall complication rate 21%
Definitive postoperative complications in 3 patients (1%)
2 hypoparathyroidism
1 RLN injury

33. Discussion
TT is the definitive surgery of choice for multinodular goiter
Prevents recurrences
Treatment in cases of malignancy
Greater risks of complications does not occur in centers with experience.

34. Discussion Main independent risk factors: Hyperthyroidism
Goiter size: intrathoracic component, goiter grade, weight of excised thyroid