Goitres
- Abnormal enlargement of the thyroid gland
Classification
- Neoplastic
- Benign
- Malignant
- Thyroid function
- Hypothyroid – Hashmimoto’s
- Euthyroid
- Toxic – Graves’
- Mass/size
- Solitary – adenoma, cyst
- Multinodular
- Diffuse – Graves, Hashimoto’s
Clinical features
- Patients are commonly asymptomatic
- Altered hormone metabolism – features of hypo/hyperthyroidism
- Obstructive symptoms
- Compression of trachea – dyspnea, stridor, wheezing
- Compression of oesophagus – dysphagia
Investigations
- Palpation of thyroid gland – classify according to WHO grading
- Laboratory tests
- TSH levels, antibody screen
- Calcitonin if medullary carcinoma suspected
- Imaging – US, CT, MRI
- to see size, nodularity, consistency
- Interventions – FNAC
Treatment
- Non toxic – no treatment if asymptomatic
- Large goitre – surgery and/or radioiodine therapy
- Iodine deficiency – iodine supplement
Riedel’s Thyroiditis
- Rare disease involving fibrosis of thyroid gland – this fibrous tissue infiltrates the capsule, surrounding muscles, paratracheal tissues and carotid sheath
- Associated with retroperitoneal and mediastinal fibrosis and sclerosing cholangitis
- Also affects parathyroid and recurrent laryngeal nerve
Clinical features
- Swelling with irregular surface
- Stony hard consistency
- Stridor
- Positive Berry sign – impalpable carotid pulse
Investigations
- T3/T4 decrease due to hypothyroidism
- Radioscan does NOT show any uptake
- FNAC – to rule out carcinoma
Treatment
- Isthmectomy to relieve compression on airway
- Levothyroxine to treat hypothyroidism
- High dose steroid
- Thyroidectomy not necessary
De Quervain’s Thyroiditis
- Subacute granulomatous thyroiditis
- Due to viruses – mumps, coxsackie
- Causes an inflammatory response, with infiltration of lymphocytes, neutrophils and multi-nucleated giant cells
- More common in young females
Clinical features
- Painful diffuse swelling in thyroid which is tender
- Fever
- Initially transient hyperthyroidism with elevated T3/T4, but poor radioiodine uptake
- Self-limiting disease
Stages – within 6 months
- 1. Thyroid gland becomes acutely congested, swollen, mildly tender (thyrotoxicosis)
- 2. Gland remains enlarged, but not tender (euthyroid)
- 3. Patient returns to hypothyroid stage (hypothyroid)
- 4. Remission or recovery (euthyroid)
Investigations
- High ESR
- Anemia
- Low TSH, high T3/T4
- FNAC
Treatment
- Prednisolone 30mg for 7 days
- Salicylates and B-blockers
- Propanolol inhibits conversion of T3 to T4
Hashimoto’s Thyroiditis
- Painless diffuse goitre
- Autoimmune disease – antibodies to TPO + TBG receptors
- More common in females 30-50 years old
- Genetic predisposition
- Initially there is hyperplasia, then fibrosis and eventually infiltration with plasma and lymphyocytic cells
Clinical features
- Painless diffuse enlargement of both lobes – firm, rubbery, tender, smooth
- Initially toxic, later presents with features of hypothyroidism
- Hyperplasia –hashitoxicosis
- Fibrosis – hypothyroid
Investigations
- High TSH, decreased T4
- Antibodies – anti-TPO and anti-TBG
Treatment
- Levothyroxine
- Steroid therapy
- Subtotal thyroidectomy