Thyroid

Thyroid glands - 'H' or butterfly shaped, 2 lateral lobes and isthmus

- In visceral compartment of neck
- 1st EDC organ to develop

Visceral compartment of - Pharynx, trachea, esophagus, thyroid gland, …

Neck

Site - In front of the neck

- Below and lateral to thyroid cartilage

Extension of thyroid glands - From oblique line of thyroid cartilage to 5th/ 6th tracheal
cartilage
anterior surfaces of 2nd 3rd 4th
Isthmus location - On 2nd - 4th tracheal cartilages

Pyramidal lobe - Extend superiorly from isthmus and attached hyoid bone by
levator glandulae thyoridae
- Remnant of epithelium & cnnt tissue of distal part of
thyroglossal duct

Blood supply - Superior Thyroid A from ECA {with External Laryngeal N}

- Descends along lateral of thyrohyoid m/s
- Ante glandular Br - along superior border
- Post glandular Br - along posterior side --- Anas with
descending Br of ITA
- Inferior thyroid A from thyrocervical Trunk {with Recurrent
Laryngeal N}
- Ascend along medial of Anterior scalene m/s
- Ascending Br - supplied PT gland
- Descending Br - PGB of STA
- Thyroid ima A from brachiocephalic trunk - supply isthmus
- Superior and middle TV into IJV
- Inferior TV into Rt & Lt brachiocephalic V

Ligation Anatomy - Prox: STA closes to ELN

- Superior pole: STA superficial, ELN deep to apex (STA stay
away from ELN) - ligate STA near the thyroid to prevent nerve
injury
- Prox: ITA away from RLN
- Inferior pole: ITA close to RLN - ligate ITA away from lower pole
of thyroid glands to prevent nerve injury

Lymphatic - Prelaryngeal, pretracheal, paratracheal LN --- deep cervical LN

(inferior to omohyoid m/s along IJV)

Most frequent cause of - Hashimoto thyroiditis aka chronic lymphocytic thyroiditis (♀ > ♂)
HypoTH
 - Is associated with DM 1, celiac disease {autoimmune disorder
where gluten ingestion trigger immune mediated damaged to
small intestine leading to malabsorption}

Note on Thyroidectomy - Assessment of vocal fold before and after surgery (RLN or ELN
or PT gland may be damaged during surgery)
- If PT gland damaged, tetany results.

Histology of Thyroid Gld - External Capsule aka outer pretracheal fascia

- Inner true capsule: fibroelastic and separated from external
capsule

Stroma - Numerous thyroid follicles in vascularized cnnt tis stroma

- Parafollicular C cell

Follicles - Structural and functional units

- Follicular lumens filled with colloid: TG aka thyroglobulin
- TG aka thyroglobulin - storage form of T4 & T3
- Follicles are lined by simple cuboidal epithelium which contain
thyroid follicular cell {secrete TH}
- BM - indistinct
- Hyperactive stage: tall cuboidal to columnar with scanty colloid
- Inactive stage: simple squamous with filled colloid

C cell - As a cluster between follicular cells

- Secrete Calcitonin and decrease Cal level (C for C for C)
- derived from Ultimobronchial body

Development of Thyroid - First EDC organ to develop

gland

Time - About 24th day of IUL (~ 1 month)

From what - Endodermal thickening in the floor of pharynx between

Tuberculum impar and copula

Thyroglossal duct {TD} - Connecting the Thyroid Gld with tongue

Thyroid diverticulum - Descend in front of pharyngeal gut

1
7th week ( ~ 12 months) - Thyroid Gld reach its final site in front of neck

Prox opening of TD - Persist as Foramen caecum of tongue

End of 3rd month - Begin its Functions

Thyroglossal cyst - Cyst remnant of TD in the midline of neck or behind arch of

hyoid bone
Thyroglossal fistula - d/t TD cyst connect to outside of fistula (inferior to hyoid body)

Ectopic Thyroid gland - Migration defect (commonly found in base of tongue, behind
FC)

Thyroid - T3 = triiodothyronine
hormones - T4 = tetraiodothyronine
- Calcitonin from C cell

Synthesis

Transport - prealbumin called transthyretin

protein - Thyroxine binding globulin - TBG (great affinity)
- Albumin (largest capacity)
- T3 not bind to transporter, thus action is faster th an T4

Metabolism - Some EHC

- Some excreted in bile

Action of TH - MSS: growth and maturation of skeleton {if too much thyrotoxic
myopathy}
- NNM: development of fetal brain (if defi: mental retardation}
- Stimulate basal metabolic rate, O2 consumption, heat production (xpt
Adult: A- [Link], Ad- adult brain, U - uterus, L - lymph node, T - testis)
- Increased EN consumption by increasing activity of Na K ATPase
- Calorigenic d/t metabolism of FA

HTH HTH

- Raise body temperature - Fall in body temperature

- Heat intolerance - Cold intolerance
- Warm, moist smooth skin - Cool, dry pallor skin
- Vd, BF increase - Vc, BF decrease
- If{EN demand > food - Decrease fuel breakdown
intake}, catabolism of fat, → Wt gain
protein → Wt loss - Decrease mobilization of
- ↑ excretion of N2, K, UA, protein polysaccharide
hexosamine complex (accumulation
- Vit Defi $ with water retention →
non-pitting edema aka
myxedema
 - Increase GI secretion, - ↓ hepatic conversion of
motility → Carotene to Vit A
hyperdefecation - ↓ GI secretion and motility -
constipation

- Direct stimulation of SA - Bradycardia

node (HR ↑),
- +Cat action on heart
(FOC ↑)
- ↑ no. of isoenz form of
myocardial myosin
ATPase (Tachycardia)
- PP widen (↑SBP d/t ↑CO
& ↓DBP d/t Vd)

- Rapid cerebration (+Cat - Slow cerebration

action on reticular (mentation)
activation system) - Prolonged reaction time of
- Shortened reaction time reflex
of reflex (rapid reflex)

- m/s weakness - m/s weakness

- Thyrotoxic myopathy d/t - Anemia d/t ↓ EPO rate
excess catabolism of m/s
protein
- Essential for normal mst cycle, fertility, lactation
- Increase rate of itst Glucose absorption, Glycogenolysis, lower plasma
cholesterol d/t ↑ LDL receptor in liver
- Maintain optimal EPO rate
- Increase dissociation of O2 to Hb by ↑ 2,3 DPG
- Surfactant syn stimulation

Regulation - TRH secretion - TSH secretion

- Stimulated by: Cold, Fall in - Stimulated by: TRH, fall in plasma

plasma T4, T4
- Inhibited by: stress, - Inhibited by: fall in plasma T4, SS,
warmth Dopamine, GC

-
 -
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Antithyroid

Steps of TH - Iodine trapping

synthesis - Oxidation of Iodide to Iodine
- Iodination of tyrosine residue
- Coupling
- Proteolysis and release
- Conversion of T4 to T3 at peripheral tissue

Thiourea - Inhibit 2, 3, 4
(carbimazole, - Propylthiouracil also inhibit 6 & use in pregnancy
methimazole,
propylthiouracil)

Use: - Hyperthyroidism, Grave's dz

- Adjunct to RI
- Thyroid storm

SE: - Agranulocytosis
- Hepatotoxicity

Iodides - inhibit 2, 3, 5
- Substantial excess Iodine inhibit hormone release

Use: - Limited use in hyper TH

- Prophylactic (iodine salt)

SE: - Iodism
- Goiter (long term use)
- Hypersensitivity

Radio Iodine I131 - cytotoxic activity, inhibit proliferation of follicular cell

 Use: - Adjunct to surgery of HTH
- CA thyroid in elder

CTR: - Pregnancy and children

Symptomatic control (propranolol, GC, - Symptomatic control

Propylthiouracil)

Use - HTH
- Prepare for surgery
- Adjunct to Iodide, thioureas
- Thyroid storm

EXAMINATION OF THYROID DISORDER

Age

1. Simple goiter - puberty

2. Multinodular, solitary nodular, colloid goiter - 20-30 years old

3. Papillary CA - young girl

4. Follicular CA - middle aged women

5. Anaplastic - old age

6. Primary toxic - young

7. Hashimoto - middle aged women

8. (man – old – goiter as large as MNG == CA)

Sex - female > male

Occupation - thyrotoxicosis (working under stress and strain conditions)

Address - Goiter due to iodine deficiency

Chief complaint - swelling in front of the neck for (_) duration and other symptoms

History of present illness

Swelling

1. Site

2. Duration

3. Mode of onset

4. Changes of size

a. Simple Goiter – same size or grow very slowly

b. MNG, Colloid goiter – increase in size by slowly for years

c. Papillary, Follicular – slow growth

d. Anaplastic – Fast growth

Pressure effect - dyspnea, dysphagia, dysphonia (hoarseness of voice)

Pain

a. Usually painless

b. Inflammatory conditions – painful

c. Malignant – painful in late stage

Any toxic symptoms

1. Loss of Wt in spite of good appetite

2. Preference of cold

3. Excessive sweating

4. Excitability, irritability, insomnia, tremor of hand, weakness of m/s

5. Protruding of eye, double vision, edema, conjunctival swelling

6. Change in menstruation usually amenorrhea

Symptoms of 2°thyrotoxicosis

1. Palpitation

2. Dyspnea on exertion, chest pain

(1° = eye symptoms, 2° = CVS symptoms)

Symptoms of Myxedema

1. Increase of Wt in spite of poor appetite

2. Preference of warm weather

3. Minimal swelling of thyroid

4. Loss of hair

5. Dry skin, puffiness of face with protruding lips, dull expression

6. Muscle fatigue and lethargy

7. Failing memory, hoarseness of voice

8. Constipation and oligomenorrhea

Past History – the course of treatment the patients have and its effect on the swelling

Personal History – dietary habit (vegetable, cabbage, kale, rape)

Family History – often occur in more than one of the family members, familial enzyme deficiency

Drug History – Goitrogenic drugs (PAS, sulphonyl-urea, antithyroid)

Physical Examination

1. Let the pts sit straight (not laying down)

Examine the built and state of nutrition

a. Thyrotoxicosis – thin and underweight

b. Hypothyroidism – obese and overweight

c. CA – anemia and cachexia

 2. Facies

a. Thyrotoxicosis – expression of excitement, tension, nervousness, agitation,

exophthalmos

b. Hypothyroidism – puffy face without expression

Local Examination

1. Swelling

a. Pizzillo’s method

b. Number, site, size, shape, surface, margin, overlying skin, pressure effect

i. Uniform swelling involving the whole thyroid gland – physiological goiter, colloid
goiter

ii. Isolated nodule of different size – nodular goiter (not dominant nodule)

c. Ask the patient to swallow,

i. Thyroid swelling (goiter) & thyroid cyst move upward with deglutition

d. Retrosternal goiter

i. Dilation of SC vein over the upper anterior part of thorax

ii. Determine lower border of swelling during deglutition

iii. Ask to raise both arms over his head until they touch the ears- congestion of face
and distress

(can see thoracic inlet clearly)

iv. (ပ ါးစပ်ဟ, လ ျှာထုတ် - cyst က တက်၊ gland ကမတက်)

v. Move upward with deglutition – Crile’s method (placing the thumb on the glad while the patient
swallows)

vi. Note whether Gland is enlarged, swelling is localized, mobility, to get below Gland – to exclude
retrosternal extension

2. Palpation

• First examine the trachea whether or not it is on the midline with sternal notch)

• Palpated from behind the neck

• Pts neck slightly flexed

• The thumbs of both hands are placed behind the neck and the other four fingers of each hand
are placed on each lobe and isthmus

• Each lobe palpation (Lahey’s method)

• For left lobe – thyroid gland is pushed to the left by the left hand of the examiner

• This makes the left lobe more prominent

• Palpate thorough with the right hand

3. Pressure effect

• Trachea, larynx – stridor, dyspnea

 • Kocher’s test – stridor (gentle press on the trachea)

4. Pulsation and thrill (superior pole of the gland – Blood flow increased due to Hyperthyroidism)

5. Palpation of Cervical LN

((Inspection

Visual Inspection: Look for any visible swelling, asymmetry, or skin changes in the neck area.

Palpation

Use Fingertips: Use the pads of your index and middle fingers for palpation.

a. Sequence:

a. Submental: Below the chin.

b. Submandibular: Under the jawline.

c. Tonsillar: At the angle of the mandible.

d. Anterior Cervical: Along the sternocleidomastoid muscle.

e. Posterior Cervical: Behind the sternocleidomastoid muscle.

f. Supraclavicular: Just above the clavicle.

ii. Technique:

a. Gentle Pressure: Apply gentle but firm pressure.

b. Circular Motion: Use a circular motion to feel for the nodes.

c. Characteristics to Assess

d. Size: Normal lymph nodes are usually less than 1 cm.

e. Consistency: Feel if the nodes are soft, firm, or hard.

f. Mobility: Check if the nodes are freely movable or fixed.

g. Tenderness: Ask the patient if there is any pain when you palpate.

h. Number: Note if the lymph node is solitary or part of a cluster.))

6. Percussion over the manubrium sterna

7. Auscultation – Bruit (superior pole – BF increasing – hearing the “shu shu”sound)

8. sign of myxedema

General examination

1. 1°toxic manifestations

• Eye signs

• Lid retraction (The upper eyelid is abnormally high, exposing more of the sclera

• Exophthalmos

• Stellwag’s sign – staring look

• Von Graefe’s sign – lid lag (Delay in the upper eyelid moving downward as the gaze
moves from up to down.
 • Joffroy’s sign – absence of wrinkle on forehead

• Moebius’s sign – failure to convergence (the eyes don’t follow the finger when it become
close to the pts’nose)

• Ophthalmoplegia (examiner – pts distance about 1-2 feet. Move the finger in an H
shaped. Let him follow the finger with his eyes only, don’t let him move his head, examine
whether there is eye muscle paralysis or not)

• Chemosis (conjunctival edema)

• Tachycardia

• Tremor (extend both hands to the front, put a sheet of paper on the hands)

• Moist skin

• Thyroid bruit

2. 2°thyrotoxicosis

• It is a Complication of MNG or adenoma

• Cardiovascular system is mainly affected

• A. fib

• Cardiomegaly

• Cardiac failure

• Absence of eyes sign and tremor

Search for metastasis

• Thyroid – stony hard, irregular and fixed

• Cervical LN

• Skull, spine end of long bone, pelvis

• Lung

Hyperthyroidism: hyperfunction of thyroid gland

Thyrotoxicosis: hypermetabolic state caused by elevated cir levels of free T3 and T4 c/b
hyperthyroidism

Common cause of HTH

1. Common
a. Diffuse toxic hyperplasia (DTH) aka Graves Dz
b. Toxic multinodular goiter
c. Toxic adenoma
2. Less common
a. Iodide induced hyperthyroidism
b. Neonatal thx assc with maternal Grave dz
c. TSH secreting Pit adenoma
d. Acute or sub@ thyroiditis
e. Struma ovarii
 f. Iatrogenic (exogenous hyperthyroidism
g. H. mole or choriocarcinoma

Clinical feature of HTH (d/t hypermetabolic state induced by excess TH + overactivity of SNS.

1. Hypermetabolic state
- Soft warm flushed skin (↑BF, Peripheral Vd)
- Heat intolerance
- Swf (d/t calorigenesis)
- Wt loss (d/t heightened catabolic metabolism despite increased appetite)
2. CVS manifestation
- ↑CO, FOC (d/t ↑peripheral O2 requirement)
- Tachy, palpitation, Cardiomegaly, A fib, Angina, CCF
- Myocardial change: focal lymphocytic, eosinophilic infiltrates, mild fibrosis, fatty change
- Reversible Lt Ven dysF: and Low output heart failure → HTH cardiomyopathy
3. Overactivity of SNS
- Tremor, hyperactive, emotion lability, anxiety, inability to concentrate, insomnia
- Prox m/s weakness, decrease m/s mass (thyroid myopathy)
- GI: hyperdefecation d/t hypermotility
- Ocular: wide staring gaze, lid lag (levator palpebral superioris m/s overstimulation), true thyroid
opthalmopathy assc with proptosis only in Grave dz
- Skm: atrophy & fatty infiltration, lymphocytic infiltration
- Bone: OPO → prone to fracture
- Liver: minimal fatty change, mild periportal fibrosis, mild lymphocytic infiltrate
- Repro: oligomenorrhea (no longer regular), amenorrhea
- LN: Generalized LAP in Grave

Dx:

1. Serum free T4 -- ↑
2. TSH - ↓ in Primary HTH, ↑ in secondary HTH
3. TRH stimulation test – normal rise in TSH exclude secondary
4. ↑T3 and ↓TSH in T3 Thx (normal T4)
5. Thyroid scan (radioactive I2 uptake measurement)
a. Diffusely increased uptake in whole gland → Grave
b. Increased uptake to a solitary nodule → toxic adenoma
c. Decreased uptake → thyroiditis

Hypothyroidism

Deficient thyroid Hormone syn interference Supra-thyroidal causes

parenchyma
- Developmental – - Idp Primary HTH - Pit lesion reducing
thyroid gld hypoplasia - Heritable biosynthesis TSH secretion
- Radiation injury defect - Hypothalamic lesion
- Surgical ablation - I2 defi (reducing TRH
- Hashimoto thyroiditis - Drug: lithium, iodide, P. secretion)
amino salicylic acid
- Hashimoto
Clinical features

Cretinism Myxoedema
- Onset: In infancy and childhood - Onset: Older child/ adult
- Mental retard, short stature, coarse - Slowing of mental and physical activity,
facial feature, macroglossia, protruded slow speech, and intellectual function
 tongue (mucopolysaccharide - General fatigue, apathy, mental
accumulation d/t decreased glucose sluggishness
catabolism) - Skin – cold and pale
- Umbilical hernia (abd m/s weakness) - Cold intolerance, ↓ Swf, overweight
- SoB, ↓ exercise capacity
- Cstp
- Non pitting edema, coarsening facial
feature
- Enlarged tongue, deep voice
- ↑ total clst, LDL – Proatherogenic
Goiter – enlargement of thyroid gland

- Nontoxic goiter
o Diffuse nontoxic / simple
o Nontoxic MNG
- Toxic
o Diffuse toxic Hyperplasia (Grave Dz)
o Toxic MNG
o Toxic adenoma (follicular adenoma)
- Ifm cause (thyroiditis)
o Hashimoto – AI, 30-50 yrs, F>M, HLA DR5, DR3 assc with SLE, RA, …; Auto Ab against
TG, thyroid peroxidase, TSH receptor, Iodide transporter
o De Quervain – fever, painful, HTH (20-50 y)
o Subacute lymphocytic – Post partum period, painless, HTH
o Riedel’s – hypothyroidism (40-70 y)
o Acute and chronic bacterial thyroiditis
- Neoplasia
o Benign: follicular adenoma (capsule, clear border, compression of parenchyma around
adenoma, lack of multinodularity) – painless, slowly increased in size, DDD,
o Malignancy: papillary, follicular, medullary, poorly differentiated, anaplastic/
undifferentiated