Goitres

Goitre

1. GOITRE
PRESENTERS:
HAMISI MKINDI,MD5
SHIJA CHARLES,MD5
THERESIA LUFYO,MD5
MODERATORS
Dr.FASSIL G.
Dr.MAYOKA R.
Dr.Fr.GINGO

2. Learning objectives
Definition
Surgical anatomy
and embryology of
thyroid gland
Etiology
Classification
Pathophysiology
Clinical
presentation
Workup
Treatment
Complications
Prevention

3. DEFINITION
Goiter can be
defined as
enlargement of
the thyroid
gland
irrespective of its
pathology

4. THYROID
Derives its name from thyroid cartilage
Anterior part of neck
20-25gm
Functional unit=lobule
Each lobule =24-40 follicles

5. SURGICAL ANATOMY

7. BLOOD SUPPLY

8. NERVE SUPPLY

9. ARTERIES AND NERVES

10. EMBRYOLOGY
Dv from TGD(median bud of pharynx)which
passes from foramen caecum at base of the
tongue to thyroid isthmus
First of the body's endocrine glands to
develop, on approximately the 24th day of
gestation.
2 main structures: the primitive pharynx and
the neural crest.

11. EMBRYOLOGY
The inferior parathyroid glands arise from
the dorsal wing of the third pharyngeal
pouch.
The initial descent of the thyroid gland
follows the primitive heart and occurs
anterior to the pharyngeal gut. At this point,
the thyroid is still connected to the tongue
via the thyroglossal duct.

13. PHYSIOLOGY

14. THYROID HORMONES
Mental growth and development
Physical growth
BMR
Sensitivity to catecholamines

15. ETIOLOGY OF GOITRE
Factors associated with goiter formation
can be classified as follows:-
Hereditary factors
Hormonal factors
Dietary factors
Pharmacological factors
Physiological factors
Environmental factors
Pathological factors

16. Hereditary factors
Inherited defect of thyroid hormone
synthesis
Enzymatic defect deficiency
Dyshormonogenesis
®Familial goitre

17. Hormonal factors
Thyroid hormone dysfunction
Hyperthyroidism (overproduction of thyroid
hormones)
Hypothyroidism (underproduction of thyroid
hormones)

18. Dietary factors
Dietary iodine deficiency
Goitrogens:-
Cabbage
® endemic goitre

19. Pharmacological factors
Use of goitrogen drugs like para-
aminosalicylic acid (PAS),
thiocyanate and antithyroid drugs
[e.g. thiouracil, carbimazole] ®
hypothyroidism

20. Physiological factors
Increased metabolic demand of
thyroid hormones e.g. during
pregnancy or puberty ®
physiological goitre

21. Environmental factors
Exposure to radiations ® Thyroid cancer
® Hypothyroidism

22. Pathological factors
Intrinsic thyroid gland diseases
Inflammatory goitres
Neoplastic goitres
-Benign adenoma(follicular adenoma)
-Malignant
A.Primary
Well differentiated, Poorly
differentiated, Arising from
parafollicular cells
B.Secondary

23. CLASSIFICATION
Etiological classification
Epidemiological classification
Anatomical classification
Pathological classification
Functional classification
Morphological classification

24. Etiological classification
Physiological goitre
Goitres resulting from increased metabolic
demand of thyroid hormones e.g. during
pregnancy or puberty
Pathological goitre
Goitres resulting from diseases affecting the
thyroid gland e.g. Neoplastic or
inflammatory conditions

25. Epidemiological classification
Familial goitres
goitres that run in families as a result of
Inherited defect of thyroid hormone
synthesis
Endemic goitres
defined as thyroid enlargement affecting a
significant number of inhabitants of a
particular locality
Sporadic goitres
goitres that run sporadically

26. Anatomical classification
Cervical goitre
Goitre situated on the anterior aspect of the
neck
Retrosternal goitre
Goitre extends downward and get situated
behind the sternum
Intrathoracic goitre
The type of goitre which extends into thoracic
cavity

27. Pathological classification
Simple goitres
Toxic goitres
Neoplastic goitres
Inflammatory goitres
Miscellaneous (Other rare types)

28. Functional classification
Toxic goitre
Type of goitre associated with thyroid
hyperfunction (hyperthyroidism)
Non-toxic
Type of goitre associated with thyroid
hypofunction (hypothyroidism) or normal
thyroid function (Euthyroid)

29. Morphological classification
According to the texture of the
gland
Diffuse goitre
Nodular goitre
Solitary nodular goitre
Multinodular goitre

30. PATHOPHYSIOLOGY
The pathophysiological
consequences of goitres results from
one of the following:-
The effect of thyroid hormone
dysfunction
The effect of enlarged thyroid gland
The effect of primary disease causing
goitre

31. Effect of thyroid hormone
dysfunction
Thyroid hyperfunction (hyperthyroidism)
®Features of hyperthyroidism
Thyroid hypofunction (hypothyroidism)
® Features of hypothyroidism

32. Effect of enlarged thyroid
gland
Effect on the trachea® dyspnea
Effect on the esophagus
®dysphagia
Effect on the superior venacava ®
distended neck veins
Effect on the recurrent laryngeal
nerve ® horsiness of voice

33. Effect of primary disease
causing goitre
The effect depends on the
underlying disease

34. CLINICAL PRESENTATION
History (Symptoms)
Physical examination (Signs)

35. History (Symptoms)
Age
Sex
Main complaints
Anterior neck swelling
Duration
Mode of onset
Rate of growth
Associated pain

36. History (Symptoms)…
Pressure-related symptoms
Dysphagia, dyspnoea, hoarseness of
voice, neck vein engorgement etc
Review of systems to assess toxicity
CNS- tremors, irritability, mental
disturbance
CVS- palpitation, dyspnoea, orthopnoea
GI- change of appetite, constipation,
diarrhoea
MSS- bone pain, weight change, heat or
cold preference, excessive sweating

37. History (Symptoms)……..
Past medical history
Previous medication, previous h/o
irradiation
Family and social history
H/o goitre in the family or in the
community

38. Physical examination
General examination
Local examination
Systemic examination

39. General examination
Look for four cardinal features of
toxicity namely:-
Exophthalmosis
Tachycardia
Tremor
Moist skin

40. Local examination
Inspection
Palpation
Percussion
Auscultation

41. Systemic examination
Centro nervous system
Cardiovascular System
Respiratory system

42. WORK UP
Laboratory studies
Imaging studies
Endoscopic studies
Histopathology

43. Laboratory studies
Serum TSH(0.3-5IU/ml)
Serum T3(1.5-3.5nmol/l)
Serum T4(55 – 150nmol/l)
Disease T3 T4 TSH
ThyrotoxicosisIncreased Increased Supressed
T3 toxicosis 2X Normal Suppressed
HypothyroidismLow/normal Low Increased

44. Labs cont…
Serum thyroglobulin
Serum cholesterol
Thyroid autoantibody levels
Thyroid scintigraphy

45. Imaging studies
Plain x-ray of the neck
Thyroid ultrasound
Thyroid radioisotope scan
CT scan/MRI
Barium swallow

46. Plain x-ray of the neck
Plain radiography of the neck may
reveal the following:-
Tracheal deviation or compression
Calcification within the goitre

47. Thyroid ultrasound
Help to determine the
physical characteristics of the
goitre and used to:-
distinguish solid from cystic
nodules
assess whether more than
one nodule exists
to assess the exact size
and shape of the thyroid
gland
Aid in ultrasound guided
FNAC

48. Thyroid radioisotope scan
Used to determine the functional activiity by
distinguishing a nodule as hot, warm, or cold,
based on the relative amount of uptake of
radioactive isotope
Hot nodules take up excessive amounts of
isotope and indicate autonomously functioning
nodules
Cold nodules does not radioactive isotope and
therefore indicate hypofunctional or
nonfunctional thyroid tissue
Warm nodules appear gray and suggest normal
thyroid function
The radioactive isotopes that are most commonly
include 123-Iodine, 99m-Technetium and 131-
Iodine

49. CT scan/MRI
Give excellent anatomical detail of
thyroid swelling but have no role in
the first line of investigation
Help to assess recurrence and
intrathoracic or retrosternal goitres

50. Barium swallow
To assess compression of the
esophagus

51. Endoscopic studies
Indirect laryngoscopy
To assess the mobility of the vocal
cord

52. Histopathology
Fine needle aspiration cytology (FNAC)
Open biopsy

53. TREATMENT
Medical treatment
Radioiodine
Surgery

54. Medical treatment
Lugol’s iodine
¯ thyroid hormone synthesis
¯ vascularity
Antithyroid drugs eg Carbimazole
Used to restore the patient to a euthyroid
state
b-adrenergic blockers E.g. propranolol
¯ tachycardia & palpitation
 Used to restore the patient to a euthyroid
It also ¯ vascularity

55. Radioiodine
Thyroiodine destroys thyroid cells and
as in thyroidectomy reduces the
mass of functioning

56. Surgery
Indications
Preoperative care
Intraoperative care
Postoperative care

57. Indications
Cosmetic purpose
Suspected malignancy
Toxic goitre
Pressure symptoms

58. Preoperative care
Correct anemia, mobilize blood donor
Treatment of intercurent disease or
infections
The thyroid functional status should be
determined
The patient should be made euthyroid

59. Preoperative care……
Admit the patient a day before
operation
Anesthetic visit
An informed written consent for
operation and anaesthesia

60. Intraoperative care
Types of surgery (Thyroidectomy)
Subtotal thyroidectomy
Near-total thyroidectomy
Total thyroidectomy
Thyroid nodulectomy

61. Postoperative care
Iv fluid
Analgesics
Antibiotics
Monitor vital signs

62. COMPLICATIONS
Complications related to enlarged gland
Complications related to thyroidectomy

63. Complications related to
enlarged gland
Tracheal obstruction ® airway
obstruction
Secondary thyrotoxicosis
Malignant transformation

64. Complications related to
thyroidectomy
Haemorrhage
Respiratory obstruction
Recurrent laryngeal nerve palsy
Thyroid storm
Thyroid insufficiency
Parathyroid insufficiency
Wound infection
Hypertrophic scar
Keloids

65. PREVENTION
Primary
Secondary
Tertiary