MULTI
NODUL AR
GOITRE
L AYA K P I L L A I
CONTENTS
• ANATOMY AND PHYSIOLOGY OF THYROID
• GOITRE
• CLASSIFICATION OF GOITRE
• MULTI NODULAR GOITRE
• AETIOPATHOGENESIS
• CLINICAL FEATURES
• INVESTIGATIONS
• TREATMENT
• EXAMINATION OF THYROID SWELLING
GOITRE ??
Goitre from latin word ‘guttur’
meaning the throat
Goitre is generalised enlargement of
thyroid gland
ANATOMY
PHYSIOLOGY
CLASSIFICATION OF THYROID
SWELLING
SIMPLE GOITRE DIFFUSE HYPERPLASTIC PHYSIOLOGICAL
PUBERTAL
PREGNANCY
MULTINODULAR GOITRE
TOXIC DIFFUSE(GRAVES DISEASE)
MULTINODULAR
TOXIC ADENOMA
NEOPLASTIC BENIGN
MALIGNANT
INFLAMMATORY AUTOIMMUNE CHRONIC LYMPHOCYTIC
THYROIDITIS
HASHIMOTO’S
DISEASE
GRANULOMATOUS De QUERVAIN’S
THYROIDITIS
FIBROSING REIDEL’S
DIFFUSE HYPERPLASTIC GOITRE
MULTI NODULAR GOITRE
MNG
• There are multiple nodules in thyroid
• Progression from diffuse hyperplastic goiter
• Can weigh upto 2kg
• Mostly euthyroid
• More common in FEMALES
• They can be : NonToxic & Toxic
• Toxic MNG : a hyperfuntioning nodule may develop
within a long standing goiter resulting in
hyperthyroidism . The condition called PLUMMER
SYNDROME
AETIOPATHOGENESIS
• Puberty , pregnancy : demand feedback in TSH level hypertrophy of
gland
( physiological goiter)
• Endemic : iodine deficiency.
daily requirement : 0.1-0.15 mg
• Dyshormonogenesis: familial ; autosomal recessive condition with deficiency
of
peroxidase or dehalogenase resulting in sporadic goiters.
• Goitrogens : such as cabbage, drugs like sulfonamides , iodides
• Previous irradiation to neck
GOITROGENS
• Environmental
– Cassava root (contains thiocyanate)
– Vegetables cruciferae family (cabbage, cauliflower, brussel sprouts)
– Milk from regions where goitrogens are present in grass
– Others
• Drugs
– Iodides
– Amiodarone, aminoglutethemide, Lithium
– Cobalt
– Diiodoquinone
– Ethionamide
– PAS
ENDEMIC GOITRE AREAS
STAGES IN GOITER
FORMATION STIMULATION DIFFUSE HYPERPLASTIC GOITRE
(reversible if stimulation cea
MIXED PATTERN with areas of act
inactive lobule
Continual repetition of
this process results in (as a result of fluctuating stim
a nodular goitre
Necrotic lobules
coalesce to form Active lobules bcom more
nodules filled either vascular & hyperplastic until
wih iodine free colloid hemorrhage occurs, causing
or a mass of new but central necrosis .
PATHOLOGY
• GROSS : multilobulated ; cut section has irregular nodule containing
amts of gelatinous colloid.
Regressive changes occur frequently in older lesion which
include areas of hemorrhage, fibrosis, calcification, and cyst
changes
• MICROSCOPY : follicles of varying size.
area of hemorrhage, hemosiderin-laden macrophage
calcification
CLINICAL FEATURES
• Mass effects like dyspnea , dysphagia, hoarseness ,compression to
the great vessels (superior vene cava syndrome).
• Cosmetic effects
• Mostly euthyroid , may present with hyperthyroidism (toxic MNG)
• Hypothyroidic presentations in specific clinical settings.
INVESTIGATIONS
• Thyroid function tests
• Ultrasonography (USG)
• Fine needle aspiration cytology (FNAC)
• Complete blood picture (CBP)
• X-ray neck :AP & Lateral view
• CT scan : to look for retrosternal
extension
• Thyroid scan-contains radioactive I
•
COMPLICATIONS
• Dyspnoea / dysphagia
• Secondary thyrotoxicosis
• Calcification of nodules
• Degeneration of nodules
• Hemorrhage into nodules
• Malignant transformation (follicular/papillary)-
5%
• Cosmetic disfigurement
TREATMENT
• In the early stages a hyperplastic goiter may regress if thyroxine
is given in a dose of 0.15-0.2 mg daily for few months.
• Although the nodular stage is irreversible , more than half of
benign nodules will regress in size over years.
• Most of the MNG are asymptomatic and do not require operation.
• Operation may be indicated on cosmetic grounds, for pressure
symptoms, or in response to patient anxiety.
• Retrosternal extension is an indication for thyroidectomy.
• When entire gland Is involved – total thyroidectomy is better
• Subtotal thyroidectomy is done depending on the amt of gland involved,
location
8gms of thyroid tissue is retained in each lateral lobe
• often partial thyroidectomy or Harley dunhill operation (one lateral lobe
+ isthmus+ opp side subtotal or partial)
• Reoperation for recurrent nodular goiter is more difficult and hazardous and
for this reason, total thyroidectomy is favoured in younger patients.
• Total lobectomy and total thyroidectomy have additional advantage of being
therapeutic for incidental carcinomas.
• There is some evidence that radioactive iodine may reduce size of recurrent
nodular goiter after previous subtotal resection and in some circumstances it
• Incision : a gently curved skin crease incision made between the notch of
thyroid cartilage and suprasternal notch- KOCHERS
• Superior thyroid artery ligated
Inferior thyroid artery are not routinely ligated to
preserve Parathyroid blood supply.
POST OP COMPLICATIONS
• Bleeding
• infection
• Temporary\ permanent loss of voice
• Temp\permanent hypocalcemia
• Vocal cord paralysis
• Need for life long thyroid supplements like
L-thyroxine
PREVENTION
• Use of iodised salt
• At puberty : 0.1 mg or 0.2 mg thyroxine
• Reduce the use of goitrogens
EXAMINATION OF A THYROID
SWELLING
• INSPECTION : by Pizillo’s method
size, shape and location and borders, surface
look for redness, scar, dialated vein pulsation, sinuses.
• Palpation : Lahey’s method for palpation of deep surface
Crile’s method for small nodules
measure size, shape, consistency, mobility
kochers test for stridor
berry’s sign for carotid pulse
• Percussion : Dull note if retrosternal extension
• Auscultation: bruit
Pizillo’s method
Lahey’s
method
Crile’s method
Kocher’s test
PEMBERTON’S
SIGN
THANK YOU