Management of goiter

in short management of goiter

1. Welcome to CME program topic Management of goiter Dr. Md. Shahadad Hossain Department of surgery

2. Goiter Any enlargement of thyroid gland is called goiter Daily iodine requirement= 0.1- 0.15mg Endemic goiter occur in geographical areas with iodine-depleted soil, usually regions away from the sea coast. Common in central Asia and central Africa ,certain areas of Australia, including Tasmania and areas along the Great Dividing Range

3. Pathogenesis Dietary iodine deficiency or intake of goitrogens Decreased formation of T 3 & T 4 Reduced level of T 3 & T 4 in the circulation Increased secretion of TSH by anterior pituitary Persistent TSH stimulation of thyroid gland Hyperplasia of thyroid follicles & generation of new follicle Increased uneven accumulation of colloid or thyroglobulin within the follicles Rupture of follicles & vessels Hemorrhage & calcification Scarring & development of goiter.

4. Causes of goiter Type Varieties Causes Simple goiter ( euthyroid ) Diffuse hyperplasia Physiological , Puberty , pregnancy Multinodular goiter toxic Diffuse(Graves Disease) Multinodular Toxic adenoma Neoplastic Benign Malignant inflammatory autoimmune Chronic lymphatic thyroiditis Hashimoto’s thyroiditis Granulomatous DE Quervain’s thyroiditis Fibrosing Riedel’s thyroiditis Infective Acute (bacterial , viral, “subacute thyroiditis”) Chronic (TB , syphilis) Others Amyloid

5. Cont … Thyroid neoplasm Type Benign Follicular adenoma Malignant primary Papillary Ca Follicular Ca Medullary Ca Anaplastic Ca lymphoma secondary metastatic/ local infiltration

6. Presentation Asymptomatic Only swelling in front of the neck Some patient may come with feature of hypothyroidism or hyperthyroidism. Few patient may metastatic feature of thyroid malignancy.

7. Hypothyroidism Weight gain Cold intolerance Fatigue, somnolence Dry skin Dry hair Menorrhagia

8. Hyperthyroidism Weight loss despite normal or increased appetite Heat intolerance, sweating Palpitations, tremor Dyspnoea , fatigue Irritability, emotional lability

9. Assessment Brief history from the patient Clinical examination I nvestigation Laboratory Imaging Histopathology

10. Cont … History Age , sex, H/o weight loss ,H/o hoarseness of voice, H/o dysphagia, Duration of lump , slowly growing or rapidly growing , Painful or not, food habit & home town, h/o bone pain & cough

11. Cont … Clinical examination Inspection: enlarged/ not Look for JVP Any scar of surgery Skin color , any prominent vein Cervical lymphnode (visible enlarged/not) Moves with swallow & deglutination

12. Cont.. Palpation : tender/non tender solitary/multinodular, shape & surface , consistency, cervical lymphadenopathy, hepatomegaly Percussion : for retrosternal extension Auscultation: thyroid bruit

13. Investigation Thyroid profile(TSH,FT3,FT4) Thyroid autoantibodies Serum calcium Thyroid USG FNAC Thyroid scan X-ray neck with thoracic inlet A/P &lateral view CT-scan Indirect laryngoscopy

14. Cont … USG of thyroid X-ray of neck with thoracic inlet

15. Cont.. Different view of CT scan showing goiter

16. Cont.. Thyroid scan Indirect laryngoscope view

17. Malignancy

18. Treatment of endemic goiter Iodine supplementation If pressure effect occur then we have go for surgery Surgery : total thyroidectomy with life long thyroxine supplementation

19. Treatment of Graves disease Antithyroid drugs ( carbimazole , methimazole , propylthiouracil ) Radio-iodine therapy Surgery : T otal thyroidectomy with life long thyroxine supplementation

20. Treatment of inflammatory goiter Autoimmune : Steroid Antithyroid drug Thyroxine supplementation Bacterial : Nonspecific: antibiotic Specific : anti TB therapy Viral: U sually self limiting only supportive treatment

21. Treatment of nodular goiter Solitary nodular goiter : Hemi thyroidectomy Multinodular goiter Simple : subtotal thyroidectomy Toxic : total thyroidectomy with life long thyroxine supplementation

22. Treatment of neoplastic goiter follicular/ papillary/ medullary carcinoma: T otal thyroidectomy with life long thyroxine supplementation Anaplastic carcinoma : I sthmasectomy + external brim radiotherapy

23. Types of thyroid surgery Total thyroidectomy Subtotal thyroidectomy Near-total thyroidectomy( Dunhill procedure) lobectomy

24. Complication of thyroidectomy During operation Hemorrhage Recurrent/ superior laryngeal nerve injury Accidental removal of parathyroid gland Trachea & esophagus injury Early post-operative complication Reactionary hemorrhage Hypoparathyroidism Tetany Infection of wound Late Hypothyroidism Recurrent thyrotoxicosis Hypertrophic scar

25. Thyroid emergency Thyrotoxic crisis: It is a life threatening complication of thyrotoxicosis Clinical feature : raised temperature Tachycardia Convulsion Excessive sweating Cardiac arrhythmia on ECG Treatment : Ice cold sponging Injectable β - blocker Anticonvulsant ( diazepam,phenobarbiton ) Anti thyroid drugs