History

Fact Explanation
Swelling of the neck Enlargement of the thyroid gland is often present with swelling over anterior aspect of the neck[1]
Local compressive symptoms such as cough, dyspnoea,wheezing,stridor Especially in patients with retrosternal goitre presents with dyspnoea with or without obstructive sleep apnea due to compression of the airway.Usually due to the symptoms patients can be misdiagnosed to have asthma. [1],[2]
Local compressive symptoms: Dysphagia Compression of oesophagus causes dysphagia. This is a relatively late symptom.[1],[2]
Hoarseness of voice This is be either due to malignant infiltration of recurrent laryngeal nerve or the compression of recurrent laryngeal nerve[1],[2],[3]
Pain Pain is a common symptom usually due to hemorrhage, inflammation, necrosis, or malignant transformation. [1],[4]
Symptoms of hypothyroidism: weight gain, loss of appetite, constipation, cold intolerence Thyroxine regulates metabolic function and maintains the basal metabolic rate. Lack of thyroxine hormone there are variety of symptoms and signs.[5][6]
Symptoms of hyperthyroidism: increased appetite, weight loss, loose stools, heat intolerence In toxic nodular goitres there is an increased secretion of thyroxine hormone as well as thyroid enlargement. Also there can be transient thyrotoxicosis with multinodular goitres.[7] [8]
Symptoms of thyroid carcinoma metastasis: chest pain, heamtaemisis , back pain Thyroid carcinomas also presents with a goitre. There will be features of local as well as systemic metastasis commonly to lung , liver. bone and brain.
References
  1. KIERNAN HUGHES, CRESWELL EASTMAN, Goitre Causes, investigation and management,Australian family physician[online] Volume 41, No.8, August 2012 Pages 572-576,[viewed 04 June 2014] Available from: http://www.racgp.org.au/afp/2012/august/goitre/
  2. RODRIGUES J, FURTADO R, RAMANI A, MITTA N, KUDCHADKAR S, FALARI S. A rare instance of retrosternal goitre presenting with obstructive sleep apnoea in a middle-aged person Int J Surg Case Rep [online] , 4(12):1064-1066 [viewed 04 June 2014] Available from: doi:10.1016/j.ijscr.2013.07.040
  3. KHANDWALA HM, CHIBBAR R. An unusual cause of goitre and hypothyroidism CMAJ [online] 2004 Aug 17, 171(4):329 [viewed 04 June 2014] Available from: doi:10.1503/cmaj.1040448
  4. NICHOLAS WC. Goiter: An Approach to Management Can Fam Physician [online] 1978 Apr:371-375 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379312
  5. GUPTA V, LEE M. Central hypothyroidism Indian J Endocrinol Metab [online] 2011 Jul, 15(Suppl2):S99-S106 [viewed 04 June 2014] Available from: doi:10.4103/2230-8210.83337
  6. KALRA S, KHANDELWAL SK. Why are our hypothyroid patients unhappy? Is tissue hypothyroidism the answer? Indian J Endocrinol Metab [online] 2011 Jul, 15(Suppl2):S95-S98 [viewed 04 June 2014] Available from: doi:10.4103/2230-8210.83333
  7. AREM R. Recurrent transient thyrotoxicosis in multinodular goitre. Postgrad Med J [online] 1990 Jan, 66(771):54-56 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2429373
  8. EBERTS EM. Goitre with Hyperthyroidism Can Med Assoc J [online] 1923 Jul, 13(7):516-519 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1707067
  9. SEARLS HH, DAVIES O, LINDSAY S. METASTATIC CARCINOMA OF THE THYROID GLAND AS THE INITIAL MANIFESTATION OF THE DISEASE Calif Med [online] 1952 Feb, 76(2):62-65 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1521341
  10. SHAHA AR, FERLITO A, RINALDO A. Distant metastases from thyroid and parathyroid cancer. ORL J Otorhinolaryngol Relat Spec [online] 2001 Jul-Aug, 63(4):243-9 [viewed 04 June 2014] Available from: doi:55749

Examination

Fact Explanation
Examination of the goitre: anterior neck lump , that moves up with swallowing The thyroid is situated in the anterior triangle of the neck. Due to it's attachment to the cricoid cartilage it moves up with swallowing.[1]
Examination of the goitre: Consistency of the goitre - a firm, hard Firm rubbery consistency is suggestive of thyroiditis where as hard consistency suggestive of malignancy[1][2]
Examination of the goitre: Nodularity of the goitre- multiple single solitary hard nodule suggestive of malignancy. Solitory soft nodule suggestive of thyroid cyst. multiple nodules can be seen in multinodular goitre[1][2]
Neck examination:Inspection: Pemberton sign Pemberton's sign is achieved by having the patient elevate both arms until they touch the sides of the face. A positive Pemberton's sign is marked by the presence of facial congestion, visible neck veins and cyanosis,positive sign is due to pressure effect by retro-sternal goitre on SVC[1][2]
Neck examination:Inspection: visible neck veins Venous engorgement of the neck veins can be seen this is due to the pressure exert on SVC .[1][2]
Neck examination:palpation: palpable cervical lymph nodes To look for signs of a metastatic thyroid cancer[5]
Neck examination: tracheal deviation due to the local compressive effect by the goitre[2]
Neck examination: displacement of carotid pulsation due to the local compressive effect by the goitre[2]
Neck examination: Auscultation of thyroid : thyroid bruit A soft bruit auscultated over the inferior thyroidal artery indicate increased vascularity of the gland which seen in Graves disease and malignancy[1][6]
Examination of eyes: exophthalmos, ptosis, chemosis, Lid Lag Thyroid-associated orbitopathy is thought to be an antibody-mediated reaction which is carried out against the TSH (thyroid-stimulating hormone) receptor with orbital fibroblast modulation of T lymphocytes. The releasing cytokines due to lymphocytic infiltration of the orbital tissue causes a la fibroblast reaction resulting in tissue oedema. the increase in orbital volume with fat and extraocular muscles causes forward protrusion (exophthalmos or proptosis )[7]
Signs of hyperthyroidism: increased pulse rate, fine tremor , sweaty palms Higher level of thyroxine causes impairment of variety of metabolic function[1]
Signs of hypothyroidism: low pulse rate, loss of lateral third of eyebrow, bradycardia, nonpitting edema, facial puffiness, slow speech, and delayed relaxation phase of deep tendon reflexes. Loss of thyroxine causes impairment of variety of metabolic function[1][4]
References
  1. NICHOLAS WC. Goiter: An Approach to Management Can Fam Physician [online] 1978 Apr:371-375 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379312
  2. ANDERS HJ. Compression syndromes caused by substernal goitres. Postgrad Med J [online] 1998 Jun, 74(872):327-329 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2360941
  3. WEETMAN AP, MCGREGOR AM, HALL R. Ocular manifestations of Graves' disease: a review. J R Soc Med [online] 1984 Nov, 77(11):936-942 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1440185
  4. HEINRICH TW, GRAHM G. Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited Prim Care Companion J Clin Psychiatry [online] 2003, 5(6):260-266 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419396
  5. SHI L, SONG H, ZHU H, LI D, ZHANG N. Pattern, predictors, and recurrence of cervical lymph node metastases in papillary thyroid cancer Contemp Oncol (Pozn) [online] 2013, 17(6):504-509 [viewed 09 June 2014] Available from: doi:10.5114/wo.2013.38910
  6. NOHERIA A, KHANNA S, WEST CP. 37-Year-Old Woman With Palpitations and Fatigue Mayo Clin Proc [online] 2011 Jan, 86(1):75-78 [viewed 09 June 2014] Available from: doi:10.4065/mcp.2009.0696
  7. WEETMAN AP, MCGREGOR AM, HALL R. Ocular manifestations of Graves' disease: a review. J R Soc Med [online] 1984 Nov, 77(11):936-942 [viewed 09 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1440185

Differential Diagnoses

Fact Explanation
Enlarged lymphnode Enlarged lymph node in anterior triangle will mimic thyroid nodule. but lymph nodes will not move with swallowing. usually they tend to be multiple and the site will be suggestive.[1]
Branchial cyst Branchial cysts classically lie anterior to the sternocleidomastoid muscle at the junction of its upper third and lower two-thirds , where as goitre may diffuse or present to right or left as in a solitary nodule; cystic nature is more suggestive of branchial cyst. confirmation can be done with FNAC. [2]
Chemodectoma(carotid body tumour) Is a vascular lump present in the anterior triangle. It will not move up with swallowing as the thyroid. The Mass is typically fixed vertically as of its attachment to the common carotid bifurcation (Fontaine sign). Presence of a bruit more suggestive of chemodectoma.Duplex US, CTA and MRA can all be used to assess the vascularity of a neck lesion.[3]
Thyroglossal cyst Smooth rounded lump present in the mid line in cystic nature, both thyroglossal cyst and goitre can be moved up with swallowing, but if the lump moves with tongue protrusion it is likely to be a thyroglossal cyst. [4],[5]
Cold abscess Presents as a chronic painless mass in the neck, no acute inflammatory changes . but overlying skin changes can be seen at times. It is usually accompanied by other symptoms of the disease, such as fever, chills, malaise and weight loss does not move with swallowing as in thyroid goitre. further differentiation can be done by FNAC.[7][8]
Lipoma lipomas are soft, easily movable, lumps which are not attached to skin or underlying structures. does not move with swallowing as thyroid goitre.[9]
Mid line dermoid Congenital inclusion dermoids are rare presentation. they present in mid line of the head and neck area. It is not attached to the skin. usually painless , transilluminable tense lump. When present in the mid line of the neck , it does not move up with swallowing and the shape does not compatible with the goitre. [10]
thyroid cartilage chondroma Thyroid cartilage chondroma is a benign cartilaginous tumour, presence as anterior neck lump. hard in consistency. Can differentiate further by radiological investigations as CT. [11]
References
  1. SILVERMAN PM. Lymph node imaging: multidetector CT (MDCT): Monday 3 October 2005, 14:00–16:00 Cancer Imaging [online] , 5(Spec No A):S57-S67 [viewed 06 June 2014] Available from: doi:10.1102/1470-7330.2005.0031
  2. SHINKWIN C, WHITFIELD BC, ROBSON AK. Branchial cysts: congenital or acquired? Ann R Coll Surg Engl [online] 1991 Nov, 73(6):379-380 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2499442
  3. COLLERAN GC, CRONIN KC, BROWNE AM, HYNES N, SULTAN S. Management of anterior triangle swellings in a tertiary vascular centre with emphasis on the roles of duplex ultrasound, computed tomography angiogram and magnetic resonance angiogram: a case series Cases J [online] :9112 [viewed 06 June 2014] Available from: doi:10.1186/1757-1626-2-9112
  4. HONG IS, CHUNG EB. Thyroglossal Cyst in Black Patients J Natl Med Assoc [online] 1977 Jan, 69(1):35-38 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2536844
  5. HOWARD DJ, LUND VJ. Thyroglossal ducts, cysts and sinuses: a recurrent problem. Ann R Coll Surg Engl [online] 1986 May, 68(3):137-138 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2498140
  6. JACKSON R, STEPHENS L, KELLY AP. Cold subcutaneous abscesses. J Natl Med Assoc [online] 1990 Oct, 82(10):733-736 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2571557
  7. JACKSON R, STEPHENS L, KELLY AP. Cold subcutaneous abscesses. J Natl Med Assoc [online] 1990 Oct, 82(10):733-736 [viewed 07 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2571557
  8. GARG RK, SOMVANSHI DS. Spinal tuberculosis: A review J Spinal Cord Med [online] 2011 Sep, 34(5):440-454 [viewed 07 June 2014] Available from: doi:10.1179/2045772311Y.0000000023
  9. MEDINA CR, SCHNEIDER S, MITRA A, SPEARS J, MITRA A. Giant submental lipoma: Case report and review of the literature Can J Plast Surg [online] 2007, 15(4):219-222 [viewed 09 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696007
  10. CHEDRAOUI A, ABBAS O, SALMAN S. Answer: Can you identify this condition? Can Fam Physician [online] 2010 Jan, 56(1):33 [viewed 09 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809174
  11. J. GALLINEA at el,Bila,teral Dystrophic Ossification of the Thyroid Cartilage Appearing as Symmetrical Laryngeal Masses, American journal of neuroradiology[online][viewed 09 June 2014] Available from:http://www.ajnr.org/content/26/6/1339.full

Investigations - for Diagnosis

Fact Explanation
Laboratory diagnosis: TSH levels, serum free T3, T4 level High TSH level suggest hypothyroidism and low TSH level suggestive of hyperthyroidism.The T4 level is required only if the TSH level is elevated.[1]
Laboratory investigation: thyroid antibodies (antithyroid peroxidase, antimicrosomal antibodies and antithyroglobulin) The presence of TPO antibodies in blood suggests that the cause of thyroid disease is an autoimmune disorder, such as Hashimoto's disease or Graves' disease. Reference range: thyroid peroxidase antibody (TPOAb): Less than 35 IU/mL. Anti microsomal antibody can be seen in thyroiditis (granulomatous or Hashimoto's) or a smaller percentage in Grave's disease. Thyroglobulin antibodies are found in 70% of Hashimoto's thyroiditis, 60% of idiopathic hypothyroidism, 30% of Graves' disease, a small proportion of thyroid carcinoma and 3% of normal individuals . Reference range: Thyroglobulin antibody (TgAb): Less than 20 IU/mL [.2][3][8][9]
Imaging Studies: USS of the neck USS will give a detail account on the size, consistency, nodularity and also the vascularity of the gland. Comet tail sign and coarse calcification suggests very low risk of malignancy. Micro calcifications are highly suggestive of malignancy. [4][5]
Imaging studies: Radionuclide uptake and radionuclide scanning This is more important in understanding of thyroid function. Since hyperfunctioning ('hot') nodules rarely harbour malignancy, if one is found that corresponds to the nodule in question no cytological evaluation is necessary. It s important in managing solitary nodules of the gland.[6]
Procedures: FNAC Fine needle aspiration cytology is important in diagnosis in thyroiditis as well as nature of the goitre whether it is benign or malignant.[7]
Pocedures: core biopsy or large needle biopsy Important in supplying samples for histology. but currently this is not recommended because of higher morbidity as opposed to having more complete sampling.[7]
References
  1. MUIRHEAD S. Diagnostic approach to goitre in children Paediatr Child Health [online] 2001 Apr, 6(4):195-199 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804541
  2. ARDY R, BLISS R, LENNARD T, BALASUBRAMANIAN S, HARRISON B, DEHN T. Management of Retrosternal Goitres Ann R Coll Surg Engl [online] 2009 Jan, 91(1):8-11 [viewed 05 June 2014] Available from: doi:10.1308/003588409X359196
  3. ANDERSON JR, BUCHANAN WW, GOUDIE RB, GRAY KG. Diagnostic tests for thyroid antibodies: A comparison of the precipitin and latex-fixation (Hyland TA ) tests J Clin Pathol [online] 1962 Sep, 15(5):462-471 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC480436
  4. ENG CY, QURAISHI MS, BRADLEY PJ. Management of Thyroid nodules in adult patients Head Neck Oncol [online] :11 [viewed 05 June 2014] Available from: doi:10.1186/1758-3284-2-11
  5. SOHN YM, YOON JH, MOON HJ, KIM EK, KWAK JY. Mixed Echoic Thyroid Nodules on Ultrasound: Approach to Management Yonsei Med J [online] 2012 Jul 1, 53(4):812-819 [viewed 05 June 2014] Available from: doi:10.3349/ymj.2012.53.4.812
  6. WONG KT, CHOI FP, LEE YY, AHUJA AT. Current role of radionuclide imaging in differentiated thyroid cancer Cancer Imaging [online] , 8(1):159-162 [viewed 05 June 2014] Available from: doi:10.1102/1470-7330.2008.0024
  7. GODINHO-MATOS L, KOCJAN G, KURTZ A. Contribution of fine needle aspiration cytology to diagnosis and management of thyroid disease. J Clin Pathol [online] 1992 May, 45(5):391-395 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC495298
  8. DE BRUIN TW, PATWARDHAN NA, BROWN RS, BRAVERMAN LE. Graves' disease: changes in TSH receptor and anti-microsomal antibodies after thyroidectomy. Clin Exp Immunol [online] 1988 Jun, 72(3):481-485 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1541569
  9. RAWSTRON JR, FARTHING CP. A comparison of tests for thyroglobulin antibody J Clin Pathol [online] 1962 Mar, 15(2):153-155 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC480365

Investigations - Fitness for Management

Fact Explanation
Serum ionized calcium level Preoperative ionized calcium levels are checked. This is done in order to predict postoperative hypocalcaemia in both thyroid and parathyroid surgery. [1][2]
Indirect laryngoscopy Indirect laryngoscopy is performed prior to surgery in order to visualize the vocal cords. As vocal cord palsy due to recurrent laryngeal nerve damage is a common complication following thyroidectomy. [4][5]
References
  1. TREDICI P, GROSSO E, GIBELLI B, MASSARO MA, ARRIGONI C, TRADATI N. Identification of patients at high risk for hypocalcemia after total thyroidectomy Acta Otorhinolaryngol Ital [online] 2011 Jun, 31(3):144-148 [viewed 07 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3185817
  2. STEEN S, RABELER B, FISHER T, ARNOLD D. Predictive factors for early postoperative hypocalcemia after surgery for primary hyperparathyroidism Proc (Bayl Univ Med Cent) [online] 2009 Apr, 22(2):124-127 [viewed 07 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2666856
  3. ZAKARIA HM, AL AWAD NA, AL KREEDES AS, AL-MULHIM AM, AL-SHARWAY MA, HADI MA, AL SAYYAH AA. Recurrent Laryngeal Nerve Injury in Thyroid Surgery Oman Med J [online] 2011 Jan, 26(1):34-38 [viewed 07 June 2014] Available from: doi:10.5001/omj.2011.09
  4. RANDOLPH GW, KAMANI D. [Laryngoscopy in patients undergoing thyroidectomy]. Vestn Khir Im I I Grek [online] 2007, 166(3):29-34 [viewed 07 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18050638
  5. ZAKARIA HM, AL AWAD NA, AL KREEDES AS, AL-MULHIM AM, AL-SHARWAY MA, HADI MA, AL SAYYAH AA. Recurrent Laryngeal Nerve Injury in Thyroid Surgery Oman Med J [online] 2011 Jan, 26(1):34-38 [viewed 07 June 2014] Available from: doi:10.5001/omj.2011.09

Investigations - Screening/Staging

Fact Explanation
Imaging Studies: Chest xray To asses secondary deposits from thyroid carcinoma. Bone deposits and also pleural effusions. [1]
Imaging Studies: CT /MRI CT or MRI is recommended when malignancy is diagnosed to asses the attachment to it s surrounding structures. CT or MRI can demonstrate involvement of the larynx, pharynx, trachea, oesophagus or major blood vessels. CT can also help in detecting pulmonary metastasis.[2]
References
  1. JONES MK. Management of papillary and follicular thyroid cancer J R Soc Med [online] 2002 Jul, 95(7):325-326 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279933
  2. ENG CY, QURAISHI MS, BRADLEY PJ. Management of Thyroid nodules in adult patients Head Neck Oncol [online] :11 [viewed 05 June 2014] Available from: doi:10.1186/1758-3284-2-11

Management - General Measures

Fact Explanation
Patient education Patient education is an important aspect of management. Cause for the goitre. symptoms and nature of the disease, treatment options should be discussed with the patient.[1]
Dietary modification Iodine supplementation is recommended in endemic goitre secondary to iodine deficiency. Also there is increased daily requirements of the majority of pregnant and breastfeeding women.Iodine supplementation will usually reduce thyroid volume in children and adolescents living in iodine deficient environments. [1]
References
  1. KIERNAN HUGHES, CRESWELL EASTMAN, Goitre Causes, investigation and management, Australian family physician[online] Volume 41, No.8, August 2012 Pages 572-576, [viewed 05 June 2014] Available from: http://www.racgp.org.au/afp/2012/august/goitre/

Management - Specific Treatments

Fact Explanation
Pharmacotherapy: Thyroid hormone replacement Thyroid hormone replacement is recommended in patient with hypothyroidism usually with levothyroxine. and regular monitoring with TSH levels are recommended. Patients are advised to take tabs before breakfast (30 min to 1hr) on empty stomach with a full glass of water and also advised not to use foods that decrease absorption such as soybean products. This therapy is proven to be beneficial in both diffuse goitres and thyroid nodules.[1][2]
Pharmacotherapy: Antithyroid drugs Carbimazole and propylthiouracil are commonly used in patients with thyrotoxicosis and a goitre due to Graves disease. Patients with multinodular goitre will also respond to thionamide medication, antithyroid drugs are recommended to the patients who refuses surgical management and prior to surgical management, definitive treatment with surgery is generally preferred.Their antithyroid action is mediated by their ability to act as a preferential substrate for TPO. [3][4]
Radio active iodine Radioactive iodine is effective in treatment of goitre and hyperthyroidism . But due to the higher doses , it is needed to ensure radiation safety. Also contraindicated in pregnancy and breast feeding. Useful in patients with toxic adenoma ,in graves disease and in thyroid carcinoma , Occasionally, hyperthyroidism can also occur with radioactive iodine treatment.[5][6]
Surgical management: surgical management is well accepted treatment modality.Indications: Specially recommended for patients with compressive symptoms , those who do not respond to medical treatment , malignancy, in chronic tyroiditis. Total, sub total or partial thyroidectomy are options
Surgical management: Total thyroidectomy Indications: thyroid carcinoma,Multi nodular goitre , thyrotoxicosis,medically refractory Graves disease or hyperthyroidism . Total thyroidectomy is increasingly the operation of choice. Complication: immediate complications are primary haemorrhage, and damage to surrounding structures including recurrent laryngeal nerve .Early complications are reactionary haemorrhage, laryngeal oedema, tracheomalacia and thyrotoxic crisis.Intermediate complications are hyoparathyroidism leading to hypocalcaemia , hoarseness of voice due to unilateral recurrent laryngeal nerve palsy .late complications are recurrence and hypothyroidism. Post operatively patient should be advised on possible complications following surgery ,importance of monitoring with TSH levels and compliance to thyroxine therapy. Levothyroxine is prescribed as a single dose (50-100micrograms) in morning 20-30 min before the breakfast. dose may be increased in increments of 25-50 depend on the response. TSH levels should be regularly monitored.[7][8][9][10][11]
Surgical management: Lobectomy Indications: Solitary benign nodule,a diagnostic thyroid lobectomy may be warranted, instead of repeated attempts at biopsy. if the primary tumor is less than 1 cm and intrathyroidal in the absence of known metastatic disease or prior radiation history. Method: 2 subtotal lobectomy + Isthmectomy . Complication: immediate complications are primary haemorrhage, and damage to surrounding structures including recurrent laryngeal nerve .Early complications are reactionary haemorrhage, laryngeal oedema, .Intermediate complications are hoarseness of voice due to unilateral recurrent laryngeal nerve palsy .late complications are recurrence and hypothyroidism.[12][13]
Surgical Management: Hemithyroidectomy Hemithyroidectomy is unilateral lobectomy. It can be associated with isthmectomy.Indications: Solitary benign nodule,a diagnostic thyroid lobectomy may be warranted, instead of repeated attempts at biopsy. if the primary tumor is less than 1 cm and intrathyroidal in the absence of known metastatic disease or prior radiation history. Method: 2 subtotal lobectomy + Isthmectomy . Complication: immediate complications are primary haemorrhage, and damage to surrounding structures including recurrent laryngeal nerve .Early complications are reactionary haemorrhage, laryngeal oedema, .Intermediate complications are hoarseness of voice due to unilateral recurrent laryngeal nerve palsy .late complications are recurrence and hypothyroidism.[12][13]
Surgical management: subtotal thyroidectomy Bilateral sub total lobectomy and isthmectomy is known as subtotal thyroidectomy. Indications: thyrotoxicosis or large goitres Complications:immediate complications are primary haemorrhage, and damage to surrounding structures including recurrent laryngeal nerve .Early complications are reactionary haemorrhage, laryngeal oedema, tracheomalacia and thyrotoxic crisis.Intermediate complications are hyoparathyroidism leading to hypocalcaemia , hoarseness of voice due to unilateral recurrent laryngeal nerve palsy .late complications are recurrence and hypothyroidism.Although risk of post operative hypothyroidism is lower but recurrence is higher in comparison to total thyroidectomy. Recurrent thyrotoxicosis is a recognized complication.[15][16]
References
  1. ACOSTA BM, BIANCO AC. New insights into thyroid hormone replacement therapy F1000 Med Rep [online] :34 [viewed 05 June 2014] Available from: doi:10.3410/M2-34
  2. KIERNAN HUGHES, CRESWELL EASTMAN, Goitre Causes, investigation and management Australian family physician[online] Volume 41, No.8, August 2012 Pages 572-576[viewed 05 June 2014] Available from: http://www.racgp.org.au/afp/2012/august/goitre/
  3. MCDONALD DO, PEARCE SH. Thyroid peroxidase forms thionamide-sensitive homodimers: relevance for immunomodulation of thyroid autoimmunity J Mol Med [online] 2009 Oct, 87(10):971-980 [viewed 05 June 2014] Available from: doi:10.1007/s00109-009-0511-y
  4. CARROLL R, MATFIN G. Endocrine and metabolic emergencies: thyroid storm Ther Adv Endocrinol Metab [online] 2010 Jun, 1(3):139-145 [viewed 05 June 2014] Available from: doi:10.1177/2042018810382481
  5. HERTZ S, ROBERTS A. RADIOACTIVE IODINE AS AN INDICATOR IN THYROID PHYSIOLOGY. V. THE USE OF RADIOACTIVE IODINE IN THE DIFFERENTIAL DIAGNOSIS OF TWO TYPES OF GRAVES' DISEASE J Clin Invest [online] 1942 Jan, 21(1):31-32 [viewed 05 June 2014] Available from: doi:10.1172/JCI101276
  6. POCHIN EE, HILTON G, MYANT NB, HONOUR AJ, CORBETT BD. Indications for Radio-iodine Treatment of Thyroid Carcinoma Br Med J [online] 1952 Nov 22, 2(4794):1115-1121 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2021902
  7. RENE G HOLZHEIMER,: Benign nodular thyroid disease,Surgical Treatment: Evidence-Based and Problem, [online] 1976 Jul, 6(1):8 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6893
  8. THOMAS CG JR, RUTLEDGE RG. Surgical intervention in chronic (Hashimoto's) thyroiditis. Ann Surg [online] 1981 Jun, 193(6):769-776 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1345172
  9. LUCCHINI R, MONACELLI M, SANTOPRETE S, TRIOLA R, CONTI C, PECORIELLO R, FAVORITI P, DI PATRIZI MS, BARILLARO I, BOCCOLINI A, AVENIA S, D’AJELLO M, SANGUINETTI A, AVENIA N. Differentiated thyroid tumors: surgical indications G Chir [online] , 34(5-6):153-157 [viewed 05 June 2014] Available from: doi:10.11138/gchir/2013.34.5.153
  10. ZAMBUDIO AR, RODRíGUEZ J, RIQUELME J, SORIA T, CANTERAS M, PARRILLA P. Prospective Study of Postoperative Complications After Total Thyroidectomy for Multinodular Goiters by Surgeons With Experience in Endocrine Surgery Ann Surg [online] 2004 Jul, 240(1):18-25 [viewed 07 June 2014] Available from: doi:10.1097/01.sla.0000129357.58265.3c
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