2. classification of goitre

CLASSIFICATION OF THYROID SWELLING

1. BY- DEBALINA BHATTACHARJEE CLINICAL FEATURES AND PATHOPHYSIOLOGY

2. CLASSIFICATION OF GOITRE Simple Goitre( Euthyroid ) Diffuse hyperplastic - physiological pubertal pregnancy Multinodular goitre Toxic- Diffuse(graves disease) multinodular Toxic adenoma Neoplastic - Benign Malignant Inflammatory- Autoimmune granulomatous fibrosing infective other

3. The natural history of simple goitre Stages in goitre formation are: Persistent growth stimulation causes diffuse hyperplasia; all lobules are composed of active follicles and iodine uptake is uniform. This is a diffuse hyperplastic goitre , which may persist for a long time but is reversible if stimulation ceases. Later, as a result of fluctuating stimulation, a mixed pattern develops with areas of active lobules and areas of inactive lobules. Active lobules become more vascular and hyperplastic until hemorrhage occurs, causing central necrosis and leaving only a surrounding rind of active follicles. Necrotic lobules coalesce to form nodules filled either with iodine-free colloid or a mass of new but inactive follicles. Continual repetition of this process results in a nodular goitre . Most nodules are inactive, and active follicles are present only in the internodular

4. Types of simple goitre Diffuse hyperplastic goiter Diffuse hyperplasia corresponds to the first stages of the natural history. The goitre appears in childhood in endemic areas but, in sporadic cases, it usually occurs at puberty when metabolic demands are high. If TSH stimulation ceases, the goitre may regress, but tends to recur later at times of stress, such as pregnancy. The goitre is soft, diffuse and may become large enough to cause discomfort. A colloid goitre is a late stage of diffuse hyperplasia when TSH stimulation has fallen off and when many follicles are inactive and full of colloid. Nodular goiter Nodules are usually multiple, forming a multinodular goitre . Occasionally, only one macroscopic nodule is found, but microscopic changes will be present throughout the gland; this is one form of a clinically solitary nodule. Nodules may be colloid or cellular, and cystic degeneration and hemorrhage are common, as is subsequent calcification. Nodules appear early in endemic goitre and later (between 20 and 30 years) in sporadic goitre , although the patient may be unaware of the goitre until his or her late 40s or 50s. All types of simple goitre are more common in the female than in the male owing to the presence of estrogen receptors in thyroid tissue.

5. Pathophysiology of multinodular goitre

6. Stages of MNG formation Stage of hyperplasia and hypertrophy Stage of fluctuation in TSH Stage of formation of nodules(inactive)

7. Clinical features of MNG Common in middle aged women Slowly progressive disease with many years of history Multiple nodules of different sizes are formed in both lobes, also in isthmus, which is firm, non tender, nodular, moves with deglutition Recent increase in size signifies malignant transformation 0r haemorhage

8. Solitary thyroid nodule It is a single palpable nodule in thyroid on clinical examination in an otherwise normal gland. TYPES- toxic solitary nodule Nontoxic solitary nodule- Hot- Means autonomous toxic nodule. Normal surrounding tissue is inactive so will not take up isotope. nodule is overactive Warm- nodule and surrounding tissue will tale up isotope Cold- nonfunctioning nodule, nodule will not tae up isotope.

9. Clinical features Single nodule palpable in one or other lobes of the thyroid gland is usually smooth and firm Lahey’s test does not show any other nodules in posterior part of gland Thyroid nodule in children and elderly can be malignant Tracheal deviation towards opposite side is common, confirmed by trail sign, 3 finger test, auscultation, and X ray neck Commonest site of a nodule is at the junction of isthmus with one of the lateral lobes

10. clinical manifestations The symptoms are- Gastrointestinal system- weight loss diarrhoea Cardiovascular system- palpitations shortness of breath at rest or on minimal exertion angina irregularity in heart rate cardiac failure in elderly Neuromuscuar system- undue fatigue and muscle weakness tremor

11. Integument- hairloss , gynaecomastia pruritus palmar erythema Psychiatry- irritability nervousness insomnia Sympathetic overactivity - causes dyspnoea, palpitation, tiredness, heat intolerance, nervousness,increase in appetite, decrease in weight Because of increased catabolism, they have increased appetite, decreased weight and increased creatinine level which signifies myopathy

12. Signs of thyrotoxicosis EYE SIGNS- exopthalmos Lid retraction Stellwag’s sign (staring look) Von graefe’s sign (lid lag sign) Joffroy’s sign Moebius sign CARDIAC SIGNS- Tachycardia is common MYOPATHY- Weakness of proximal muscles occurs- front thigh muscles, arm muscles Weakness is more when muscle contracts isometrically

13. PERITIBIAL MYXOEDEMA- Usually bilateral, symmetrical, shiny, red thicened hard sin with coarse hair in feet and ankles Due to deposition of myxoematous tissues in sin and subcutaneous planes Might or might not regress completely after treatment for toxicity