THYROID

Embryology

Developmental Abnormalities
Thyroglossal Duct Cyst and Sinus
 It results due to failure to complete obliteration of the thyroglossal
duct
 Thyroglossal duct cysts may occur anywhere along the migratory path of the thyroid,
although 80 percent are found in juxtaposition to the hyoid bone.
 Symptoms They are usually asymptomatic, but occasionally become infected by oral
bacteria. Sinuses result from infection of the cyst secondary to spontaneous or surgical
drainage and are accompanied by minor inflammation of the surrounding skin.
 The diagnosis is usually established by observing 1-2cm smooth, well-defined midline neck
mass that moves upward with tongue protrusion.
 Investigation Routine thyroid imaging is not necessary, although thyroid scintigraphy and
ultrasound have been performed to document the presence of normal thyroid tissue in the
neck.
 Treatment involves the “Sistrunk operation,” which consists of en bloc cystectomy and
excision of the central hyoid bone to minimize recurrence.
Lingual Thyroid
 This represents failure of the median thyroid anlage to descend normally and may be the
only thyroid tissue present.
 Symptoms Some patients are hypothyroid and intervention becomes necessary for
obstructive symptoms such as choking, dysphagia, airway obstruction, and hemorrhage.
 Treatment options include administration of exogenous thyroid hormone to treat
hypothyroidism or to suppress thyroid-stimulating hormone (TSH), radioactive iodine, or
surgical excision.
Ectopic thyroid
 Normal thyroid tissue may be found anywhere in the central neck compartment and also
has been observed adjacent to the aortic arch, in the aortopulmonary window, within the
upper pericardium, and in the interventricular septum.
  Thyroid tissue situated lateral to the carotid sheath and jugular vein, previously termed
“lateral aberrant thyroid,” almost always represents metastatic thyroid cancer in lymph
nodes.
Pyramidal lobe
 In approximately 50 percent of individuals, the distal end of the thyroglossal duct that
connects to the thyroid persists as a pyramidal
 lobe projecting up from the isthmus, lying just to the left or right of the midline.
 It is attached to the hyoid bone by a fibrous band or muscle fibres called levator glandulae
thyroideae.

Thyroid Anatomy
 The adult thyroid gland is brown in color, weighs
about 20 g,
 Location
o Isthmus – 2nd-4th tracheal ring
o Lobe-C5-T1
 Parts
o Right and left lobe
o Pyramidal lobe (50%)
o isthmus
 supportive structure
o Suspensory ligament of Berry: This pair of strong condensed
connective tissue binds the gland firmly to each side of cricoid cartilage
and upper tracheal rings.
o Pretracheal fascia, which is part of deep cervical fascia splits to invest the gland.
These structures (ligament of Berry and pretracheal fascia) are responsible for
thyroid gland moving with deglutition.
o Thyroid capsule
 Arterial supply
• Superior thyroid artery, a branch of the external carotid artery, enters the upper
pole of the gland, divides into anterior and posterior branches and anastomoses
with ascending branch of inferior thyroid artery. Since the upper pole is narrow,
ligation is easy.
• Inferior thyroid artery is a branch of thyrocervical trunk' and enters the posterior
aspect of the gland. It supplies the gland by dividing into 4 to 5 branches which
enter the gland at various levels (not truly lower pole).
Inferior thyroid artery used to be ligated well away from the gland to avoid damage
to RLN. However, ligation of these arteries on both sides will cause permanent
hypoparathyroidism.
Hence, the current practice is to identify and ligate the branches of inferior thyroid
artery (3-4) separately.
 Thyroidea ima artery is a branch of either brachiocephalic trunk or direct branch
of arch of aorta and enters the lower part of the isthmus in about 2 to 3% of the
cases.
  Venous drainage
o Superior thyroid vein drains the upper pole and enters the internal
jugular vein. The vein follows the artery.
o Middle thyroid vein is single short and wide and drain into internal
jugular vein.
o Inferior thyroid veins form a plexus which drain into innominate
vein. They do not accompany the artery.
 Nerves in relationship with thyroid gland
o Superior laryngeal nerve: The vagus nerve gives rise to superior
laryngeal nerve, which separates from it at skull base and divides into
two branches. The larger internal laryngeal nerve is sensory to the
supraglottic larynx. The smaller external laryngeal nerve runs close to the
superior thyroid vessels and supplies cricothyroid. This nerve is away from the
vessels near the upper pole. Hence, during thyroidectomy, the upper pedicle should
be ligated as close to the thyroid as possible.
o Recurrent laryngeal nerve (RLN) is a branch of vagus, hooks around ligamentum
arteriosum on the left and Subclavian artery on the right and runs in the
tracheoesophageal groove near the posteromedial surface. Close to the gland, the
nerve lies in between (anterior or posterior) branches of inferior thyroid artery in
the Riddle's triangle).
o Sympathetic: Superior and middle cervical sympathetic ganglia (vasomotor).
o Parasympathetic: From vagus nerves, via branches of laryngeal nerves.

 Lymphatic drainage of thyroid

o Subcapsular lymphatic plexus drains into
pretracheal nodes (delphic nodes means
uncertain) and prelaryngeal nodes which
ultimately drain into lower deep cervical nodes
and mediastinal nodes
o Supraclavicular nodes and nodes in the
posterior triangle can also be involved in
malignancies of the thyroid gland, especially
papillary carcinoma thyroid.
Histology
 Microscopically, it is divided into lobules. Each lobule has 20-40 follicles.
 Each follicle is lined by cuboidal epithelial cells. In the centre, colloid is present which is
secreted from epithelial cells.
 Parafollicular cells are present in the interfollicular stroma.

PHYSIOLOGY
 Tri-iodothyronine (T3) and thyroxine (T4) are the hormones secreted by the thyroid gland.
 Dietary requirement of iodine per day is 100-200 micrograms or 0.1 mg. Sources of iodine
are milk, dairy products and sea food including fish.
 Dietary iodine is rapidly converted to iodide and absorbed into the bloodstream. Iodide is
actively transported into the thyroid follicular cells by an ATP-dependent process.
Steps involved in the synthesis of these hormones

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In the euthyroid state, T4 is the predominant hormone produced by the thyroid. Most T3
(80 percent) is produced by extrathyroidal, peripheral deiodination (removal of 5_-iodine
from the outer ring) of T4 in the liver, muscles, kidney, and anterior pituitary, a reaction
that is catalyzed by 5_-monodeiodinase. T3 is 3 to 4 times more potent than T4
Some T4 is converted to rT3, the metabolically inactive compound, by deiodination of the
inner ring of T4.
Thyroid hormones are transported in serum bound to carrier proteins such as thyroxine-
binding globulin (TBG), thyroxine binding prealbumin (TBPA), and albumin.
Only a small fraction (0.02 percent) of thyroid hormone (T3 and T4) is free (unbound) and
is the physiologically active component. The secretion of thyroid hormone is controlled by
the hypothalamic–pituitary–thyroid axis.

EVALUATION OF PATIENTS WITH THYROID DISEASE

Thyroid Function Tests
1. Serum T3:
Normal levels-1.5-3.5 nmol/L
The half-life of T3 is approximately 24 hours, whereas half-life of T4 is about 7 days
2. Serum T4:
Normal levels-55 to 150 nmol/L
 They are measured by radioimmunoassay. In euthyroid state, T4 is the predominant
hormone produced by the thyroid. Total T4 levels reflect output from the thyroid gland
3. Free T4 and Free T3 –
These radioimmunoassay-based tests are a sensitive and accurate measurement of
biologically active thyroid hormone.
Free T4 (reference range: 12 to 28 pmol/L) measurement is confined to cases of early
hyperthyroidism in which total T4 levels may be normal but free T4 levels are raised..
Free T3 (reference range: 3 to 9 pmol/L) is most useful in confirming the diagnosis of early
hyperthyroidism, in which levels of free T4 and free T3 rise before total T4 and T3.
4. Serum TSH (thyroid stimulating hormone)
Normal level-0.5 to 5 μU/mL
Serum TSH levels reflect the ability of the anterior pituitary to detect free T4 levels.
There is an inverse relationship between the free T4 level and the logarithm of the TSH
concentration—small changes in free T4 lead to a large shift in TSH levels.
The ultrasensitive TSH assay has become the most sensitive and specific test for the
diagnosis of hyper- and hypothyroidism and for optimizing T4 therapy.
5. Serum thyroglobulin
It is produced by thyroid tissue only. Hence, the levels should be low after total
thyroidectomy.
The most important use of this test is to monitor patients after total thyroidectomy for
well-differentiated carcinoma. It is not normally released into circulation in large amount
but increases suddenly in thyroiditis, Graves' disease or toxic multinodular goitre (MNG)..
6. Thyroid autoantibody levels:
More than 90% of the patients with Hashimoto's thyroiditis and 80% of patients with
Graves' disease have antibodies which are called as 'LATS' (long acting thyroid stimulator).
The detection of these antibodies help in the diagnosis of such cases and also to suspect
these diseases before clinical manifestation.

Thyroid imaging
1. Radionuclide imaging.
 Both iodine-123 (123I)and iodine-131 (131I) are used to image the thyroid gland.
o iodine-123 (123I) low-dose radiation, has a half-life of 12–14 h, and is used to
image lingual thyroids or goiters.
o iodine 131 (131I) In contrast use leads to higher-dose radiation exposure and has a
half-life of 8–10 days. Therefore, this isotope is used to screen and treat patients
with differentiated thyroid cancers for metastatic disease.
 It can demonstrate 3 different patterns as follows:
o Hot nodule: The gland does not take up isotope but the nodule takes it up, which is a
feature of autonomous solitary toxic nodule. Here, the normal thyroid tissue is
suppressed. Localisation of over activity in a nodule with suppression of remainder
of the gland is characteristic of solitary toxic nodule. In toxic MNG, multiple areas
show overactivity.
o Warm nodule: The entire gland takes up isotope. This is typical of Graves' disease
(primary thyrotoxicosis) wherein each cell is active and equally stimulated.
o Cold nodule is a nodule which does not take up isotope. The risk of malignancy is
higher in “cold” lesions (15–20 percent) than in “hot” or “warm” lesions (< 5
percent).
  Technetium-99m (99mTc) pertechnetate is taken up by the thyroid gland, but is not
organified. It also has the advantage of having a shorter half-life and minimizes radiation
exposure. It is particularly sensitive for nodal metastases.
 More recently, 18F-fluorodeoxyglucose positron emission tomography (FDG PET) has been
used to screen for metastases in thyroglobulin positive patients with thyroid cancer, in
whom other imaging studies are negative.
2. Ultrasound
 This modality allows assessment of the gland and the regional lymphatics.
 It can show the characteristics of the gland substance and the presence and features of
thyroid nodules can be described.
 Number, size, shape, margins, vascularity and specific features such as the presence of
microcalcifications can be used to predict the risk of malignancy within a specific nodule.
 Regional lymphatics, particularly in the lateral neck can be assessed accurately for the
presence of metastatic deposits.
 during ultrasound, fine needle aspiration (FNA) can be performed more accurately than
free-hand techniques allow.
 Ultrasound has the advantages that it is not associated with ionising radiation and is non-
invasive and cheap
 Visualisation of the central neck nodes, in particular those behind the sternum, is however
limited. For this reason, when metastatic disease is detected cross-sectional imaging is
required to fully stage the disease.

3. CT/MRI scan
 These studies are primarily used in evaluating the extent of large, fixed, or substernal
goiters and their relationship to the airway and vascular structures.
 Retrosternal extension, which can often be predicted on plain chest x-ray, also requires
more advanced techniques to determine the extent adequately prior to considering
management. For most of these indications, the imaging modality of choice is computed
tomography (CT).
 In the setting of an invasive primary thyroid cancer, both CT and magnetic resonance
imaging (MRI) may have a role. Contrast enhanced CT is useful for determining the extent
of airway invasion and MRI is superior at determining the presence of prevertebral fascia
invasion.
4. Positron emission tomography (PET) scans
 have limited application in thyroid disease. They may be considered in the setting of
recurrent thyroid cancer. This is particularly useful when the disease does not concentrate
iodine, at which point fluorodeoxyglucose (FDG) uptake increases and lesions become
positive on PET scans.

Fine-needle aspiration cytology

Fine-needle aspiration cytology (FNAC) is the investigation of choice in discrete thyroid
swellings. FNAC has excellent patient compliance, is simple and quick to perform in the out-
patient department and is readily repeated.
THYROID ENLARGEMENT
The normal thyroid gland is impalpable.
 The term goitre (from the Latin guttur = the throat) is used
to describe generalized enlargement of the thyroid gland.
 A discrete swelling (nodule) in one lobe with no palpable
abnormality elsewhere is termed an isolated (or solitary)
swelling.
 Discrete swellings with evidence of abnormality elsewhere in
the gland are termed dominant.

SIMPLE GOITRE
Aetiology
Simple goitre may develop as a result of stimulation of the thyroid
gland by TSH,
 either as a result of inappropriate secretion from a
microadenoma in the anterior pituitary (which is rare), or
 in response to a chronically low level of circulating thyroid
hormones.
DIFFUSE HYPERPLASTIC GOITRE
 Diffuse hyperplasia corresponds to the first stages of the natural history.
 The goitre appears in childhood in
o endemic areas where there is iodine deficiency.
o sporadic cases, it occurs at puberty and pregnancy.
 If TSH stimulation ceases the goiter may regress.
 The goitre is soft, diffuse and may become large enough to cause discomfort.
 A colloid goitre is a late stage of diffuse hyperplasia, when TSH stimulation has fallen off and
when many follicles are inactive and full of colloid
1. PUBERTY GOITRE, PREGNANCY GOITRE
 It is seen in girls at puberty or during pregnancy when the metabolic demands are high and
the production of T3, T4 are comparatively normal.
 Due to feedback mechanism, TSH levels increase, which stimulate thyroid gland and causes
diffuse hypertrophy and hyperplasia.
 Treatment - This is also called physiological goitre and can be treated by giving tablet
thyroxine (T4) 0.2 mg/day to suppress TSH. Goitre may disappear if treatment is given in
the stage of diffuse hypertrophy

2. IODINE DEFICIENCY
 The daily requirement of iodine is about 0.1–0.15mg.
  The most important factor in endemic goitre is dietary deficiency of iodine, but defective
hormone synthesis probably accounts for many sporadic goitres.
 ENDEMIC GOITRE
o In nearly all districts where simple goitre is endemic, there is a very low iodide
content in the water and food. Endemic areas are in the mountainous ranges.
Endemic goitre is also found in lowland areas where the soil lacks iodide or the
water supply comes from far away mountain ranges,
o Calcium is also goitrogenic and goitre is common in low-iodine areas on chalk or
limestone
o Although iodides in food and water may be adequate, failure of intestinal absorption
may produce iodine deficiency.
 SPORADIC GOITRES
DYSHORMONOGENESIS
o Enzyme deficiencies of varying severity may be responsible for many sporadic
goitres, i.e. in non-endemic areas.
o There is often a family history, suggesting a genetic defect.
o Environmental factors may compensate in areas of high iodine intake; for example,
goitre is almost unknown in Iceland where the fish diet is rich in iodine.
GOITROGENS
o Well-known goitrogens are the vegetables of the brassica family (cabbage, kale and
rape), which contain thiocyanate, drugs such as para-aminosalicylic acid (PAS) and
the antithyroid drugs.
o Thiocyanates and perchlorates interfere with iodide trapping;
o carbimazole and thiouracil compounds interfere with the oxidation of iodide and the
binding of iodine to tyrosine.
o Iodides in large quantities are goitrogenic because they inhibit the organic binding of
iodine and produce an iodide goitre.
o Excessive iodine intake may be associated with an increased incidence of
autoimmune thyroid disease.
Stages in goitre formation are:

MULTINODULAR GOITRE
 Nodules are usually multiple, forming a multinodular goiter.
 Occasionally, only one macroscopic nodule is found, but microscopic changes will be
present throughout the gland; this is one form of a clinically solitary nodule.
 Nodules appear early in endemic goitre and later (between 20 and 30 years) in sporadic
goitre, although the patient may be unaware of the goitre until his or her late 40s or 50s.
 All types of simple goitre are more common in the female than in the male owing to the
presence of oestrogen receptors in thyroid tissue.
 Diagnosis
o The patient is euthyroid, the nodules are palpable and often visible; they are
smooth, usually firm and not hard and the goitre is painless and moves freely on
swallowing.
o Hardness and irregularity, due to calcification, may simulate carcinoma.
o A painful nodule, sudden appearance or rapid enlargement of a nodule raises
suspicion of carcinoma but is usually due to haemorrhage into a simple nodule.
o Differential diagnosis from autoimmune thyroiditis may be difficult and the two
conditions frequently coexist.
 Investigations
o Thyroid function should be assessed to exclude mild hyperthyroidism,
o Thyroid antibodies test to differentiate from autoimmune thyroiditis.
o Ultrasound is the gold standard assessment when undertaken by a suitably trained
and experienced operator.
o FNAC is only required for a nodule within the goitre that demonstrates ultrasonic
features of concern. This may or may not be the largest ‘dominant’ nodule. The
biopsy should be performed under ultrasonic guidance to ensure the correct nodule
is sampled.
o If there are swallowing or breathing symptoms then a CT scan of the thoracic
inlet is the best modality to assess tracheal or oesophageal compression.
  Complications
o Tracheal obstruction may be due to gross lateral displacement or compression in a
lateral or anteroposterior plane by retrosternal extension of the goitre.
o Acute respiratory obstruction may follow haemorrhage into a nodule impacted in
the thoracic inlet.
o secondary thyrotoxicosis Transient episodes of mild hyperthyroidism are
common, occurring in up to 30% of patients.
o Carcinoma An increased incidence of cancer (usually follicular) has been reported
from endemic areas. Dominant or rapidly growing nodules in longstanding goitres
should always be subjected to aspiration cytology.

Clinically discrete swellings

 They are three to four times more frequent in women than men.
 Diagnosis
o A discrete swelling in an otherwise impalpable gland is termed isolated or
solitary, whereas the preferred term is dominant for a similar swelling in a gland
with clinical evidence of generalised abnormality in the form of a palpable
contralateral lobe or generalised mild nodularity.
o About 70% of discrete thyroid swellings are clinically isolated and about 30% are
dominant
o Demonstrating the presence of impalpable nodules does not change the
management of palpable discrete swellings and begs the question of the necessity of
investigating incidentally found nodules.
o The importance of discrete swellings lies in the risk of neoplasia compared with
other thyroid swellings. Some 15% of isolated swellings prove to be malignant and
an additional 30–40% are follicular adenomas. The remainder are non-neoplastic,
largely consisting of areas of colloid degeneration, thyroiditis or cysts. Although the
incidence of malignancy or follicular adenoma in clinically dominant swellings is
approximately half of that of truly isolated swellings, it is substantial and cannot be
ignored
 Investigation
 thyroid function If hyperthyroidism associated with a discrete swelling is confirmed
biochemically, it indicates either a ‘toxic adenoma’ or manifestation of toxic multinodular
goitre. The combination of toxicity and nodularity is important and is an indication for
isotope scanning to localise the area(s) of hyperfunction.
 isotope scan Isotope scanning used to be the mainstay of investigation of discrete thyroid
swellings but has been abandoned except when toxicity is associated with nodularity
 autoantibody titres The autoantibody status may determine whether a swelling is a
manifestation of chronic lymphocytic thyroiditis. The presence of circulating antibodies
increases the risk of thyroid failure after lobectomy.
 ultrasonography This is gold standard investigation to determine the physical
characteristics of thyroid swellings. There are a number of ultrasonic features in a thyroid
swelling associated with thyroid neoplasia, including microcalcification and increased
vascularity, but only macroscopic capsular breach and nodal involvement are diagnostic of
malignancy. Ultrasound should be used as the primary investigation of any thyroid nodule
as a reassuring appearance mitigates the need for an FNAC
 fine-needle aspiration cytology FNAC should be used, ideally under ultrasound guidance,
on all nodules that do not fulfil a fully benign (U2) classification on ultrasound. FNAC is
reliable in identifying,papillary thyroid cancer but cannot distinguish between a benign
 follicular adenoma and follicular carcinoma, as this distinction is dependent not on cytology
but on histological criteria, which include capsular and vascular invasion. FNAC is both
highly specific and sensitive. Using ultrasound improves this further, particularly in part
cystic, part solid nodules in which ultrasound allows targeting of the solid element for
biopsy.
 radiology Plain films have previously been used to assess tracheal compression and
deviation, but the modality of choice now is CT scanning. CT scanning is also useful if
ultrasound has identified metastatic disease in the neck as it can assist surgical planning
and also assess the superior mediastinum and lungs.
 laryngoscopy Flexible laryngoscopy has rendered indirect laryngoscopy obsolete and is
widely used preoperatively to determine the mobility of the vocal cords. The presence of a
unilateral cord palsy coexisting with an ipsilateral thyroid nodule of concern is usually
diagnostic of malignant disease.
 CORE BIOPSY Core biopsy is rarely indicated in thyroid masses due to the vascularity of the
thyroid gland and the risk of post procedure hemorrhage. It can be useful in the rapid
diagnosis of widely invasive malignant disease, for example anaplastic carcinoma, or in the
diagnosis of lymphadenopathy.
 The main indication for operation is the risk of neoplasia, which includes follicular adenoma
as well as malignant swellings. The reason for advocating the removal of all follicular
neoplasms is that it is seldom possible to distinguish between a follicular adenoma and
carcinoma cytologically.
 There are useful clinical criteria to assist in selection for operation according to the risk of
neoplasia and malignancy.
o Hard texture alone is not reliable as tense cystic swellings may be suspiciously hard
but a hard, irregular swelling with any apparent fixity, which is unusual, is highly
suspicious.
o Evidence of RLN paralysis, suggested by hoarseness and a non-occlusive cough and
confirmed by laryngoscopy, is almost pathognomonic.
o Deep cervical lymphadenopathy along the internal jugular
vein in association with a clinically suspicious swelling is
almost diagnostic of papillary carcinoma.
o In most patients, however, such features are absent but
there are risk factors associated with sex and age.
o The incidence of thyroid carcinoma in women is about
three times that in men, but a discrete swelling in a male is
much more likely to be malignant than in a female and it is seldom justifiable to
avoid removing such a swelling in a man.
o The risk of carcinoma is increased at either end of
the age range and a discrete swelling in a teenager of
either sex must be provisionally diagnosed as
carcinoma. The risk increases as age advances
beyond 50 years, more so in males.
Thyroid cysts
 Routine FNAC (or ultrasonography) shows that over 30% of
clinically isolated swellings contain fluid and are cystic or
partly cystic.
 Tense cysts may be hard and mimic carcinoma.
  Bleeding into a cyst often presents with a history of sudden painful swelling, which resolves
to a variable extent over a period of weeks if untreated. Aspiration yields altered blood but
reaccumulation is frequent.
 About 50% of cystic swellings are the result of colloid degeneration, or of uncertain
aetiology because of an absence of epithelial cells in the lining.
 Although most of the remainder are the result of involution in follicular adenomas,
 some 10–15% of cystic follicular swellings are histologically malignant (30% in men and
10% in women). Papillary carcinoma is often associated with cyst formation
 Ultrasound is the most useful tool for assessing cysts.
o If there is no discernable solid element then the cyst is almost certainly benign and
does not need to be further investigated.
o If there is an associated solid element then consideration should be given to
targeting that area with an ultrasound-guided FNAC.
Retrosternal goitre
 Very often, it is a multinodular goitre that develops in the neck and is slowly pulled down
behind the sternum due to following reasons.
1. Negative intrathoracic pressure
2. Pretracheal muscles are strong in men
3. Short neck, obesity
 Rarely, it arises from an ectopic thyroid tissue.
 Classification
o Primary: It arises from ectopic thyroid tissue in the mediastinum. It also derives
blood supply from mediastinum It is rare (1 %)
o Secondary: It is the common variety-It is MNG which gets pulled down into thorax.
 Clinical types
o Substernal: The most common type where the lower border of the gland is behind
the sternum.
o Intrathoracic: No thyroid is seen in the neck, diagnosed by radio-iodine scan.
o Plunging goitre: When patient is asked to cough, intrathoracic pressure increases.
As the thyroid plunges out, the lower border of gland is clearly seen in the neck.
 Clinical features of retrosternal goiter
o It can be suspected when the lower border of the swelling is not seen.
o Most of the patients have difficulty in breathing or even stridor.
o Dysphagia is more common.
o Engorgement of neck veins and superficial veins. These become more prominent
when the hands are raised above the head, and the arms touch the ears-
Pemberton's sign
 Investigations
 They are similar to MNG. However, isotope scan is very useful in the diagnosis of
intrathoracic goitres.
CT scan to localise and to know the size and extent

Management
 Patient should be considered for surgery if
o there is significant airway compression,
o in young patients in whom symptoms are likely to develop. In elderly patients with
incidentally discovered retrosternal goitres, most surgeons would observe rather
than treat must be made.
  If a decision is made to proceed to surgery, assessment of the extent of disease is critical.
 The vast majority (>95%) of retrosternal goitres can be removed transcervically.
 Those at most risk of requiring conversion to an open sternotomy approach include
o malignant or revision cases,
o those which extend into the posterior mediastinum and
o those in which the diameter of the goitre exceeds that of the thoracic inlet. In such
cases a joint case with thoracic surgery should be planned.

TOXIC GOITRE-THYROTOXICOSIS
 It is a complex disorder which occurs due to increased levels of thyroid hormones
(hyperthyroidism) and manifests clinically with various signs and symptoms involving
many body systems.
 Following are the causes of thyrotoxicosis:
1. Primary thyrotoxicosis (Graves' disease, exophthalmic goitre, diffuse goitre)
2. Secondary thyrotoxicosis: Secondary to nodular goiter (multinodular)
3. Solitary toxic nodule: Autonomous nodule which is not under the influence ofTSH
but occurs due to hypertrophy and hyperplasia of gland (tertiary thyrotoxicosis).
4. Other causes of thyrotoxicosis
 Thyrotoxicosis factitia: False thyrotoxicosis occurs due to overdosage of
thyroxine, given for puberty goitre.
 Jod-Basedow's thyrotoxicosis: Jod means iodine in the German language, Basedow
means toxic goiter Iodine induced thyrotoxicosis (iodine given for hyperplastic
endemic goitres).
 Initial stage of thyroiditis: Hashimoto's thyroiditis,viral thyroiditis can produce
temporary thyrotoxicosis features.
 Very rarely, malignant goitres can be toxic ( differentiated carcinoma). Neonatal
thyrotoxicosis occurs in babies born to thyrotoxic mothers.
 TSH-secreting tumours of pituitary
 Struma ovarii

GRAVES' DISEASE
 Graves disease is, by far, the most common cause of hyperthyroidism in North America, accounting
for 60–80 percent of cases.
 It is an autoimmune disorder of unknown cause with a strong familial predisposition, female
preponderance (5:1), and peak incidence between the ages of 40 and 60 years.
 It is characterized by thyrotoxicosis, diffuse goiter, and extrathyroidal manifestations, including
ophthalmopathy, dermopathy (pretibial myxedema), thyroid acropachy, gynecomastia, and others.

Etiology, pathogenesis
 Autoimmune disorder is the first possible cause due to
o the demonstration of auto-antibodies in the circulation. Example: Thyroid stimulating
immunoglobulins (TSI) and longacting thyroid stimulator (LATS) are responsible for
pathological changes in the thyroid gland in Graves' disease. They stimulate thyrocytes
to grow and synthesise excess thyroid hormones.
o associated with other autoimmune disorders like vitiligo.
 Familial: The disease can run in families. Familial/genetic Graves' disease has been
documented in identical twins.
 The exact etiology of the initiation of the autoimmune process in Graves disease is unknown.
 However, conditions have been suggested as possible triggers such as
 o lithium therapy,
o iodine excess,
o infections
o postpartum state,
Pathology
As a result of continuous stimulation, acinar hypertrophy and hyperplasia take place. The acinar
cells which are normally flat, become tall columnar. The normal colloid disappears and the cells
are empty. However, rich vascularity is seen. Thus, small follicles with hyperplastic columnar
epithelium is characteristic.
Clinical features
 Symptoms of hyperthyroidism include heat intolerance, increased sweating and thirst, and weight loss despite
adequate caloric intake.
 Symptoms of increased adrenergic stimulation include palpitations, nervousness, fatigue, emotional lability,
hyperkinesis, and tremors.
 Female patients often develop amenorrhea, decreased fertility, and an increased incidence of miscarriages.
 Children experience rapid growth with early bone maturation, whereas older patients present with cardiovascular
complications.

Signs of primary thyrotoxicosis

 Signs of thyroid gland in Graves' disease
o Uniformly enlarged (mild degree)
o Smooth surface-no nodules (treated cases may have nodularity)
o Gland is soft or firm in consistency
o It is warm-highly vascular
o Auscultation-a bruit is usually heard.
o an overlying bruit or thrill and loud venous hum in the supraclavicular space.
o
 Central nervous system (CNS) signs
o Tremors of the tongue when the tongue is within the oral cavity and tremors of the
outstretched hands are characteristics.
o A piece of paper may be placed on the fingers in doubtful cases for demonstrating the
tremors of the hand. Extensor surface of the hand is used because extensors are weak
when compared to flexors.
o Hyperkinetic movements.
o Always a moist, warm hand (shake hands).
o hyperactive tendon reflexes often are present.
o
 Cardiovascular system (CVS) signs
o Pulse rate is always raised and rapid indicating tachycardia.
o Depending upon the pulse rate, thyrotoxicosis can be classified as follows: mild-90-
100/minute, moderate !00-110/minute, severe-more than 110/minute.
o Palpitation and extrasystoles can also be found in primary thyrotoxicosis even though
other cardiac features such as fibrillation and cardiac failure are rare.
 Eye signs Approximately 50 percent
o Prominent eyeballs and retraction of the eyelid result in thyrotoxic exophthalmos. This
is due to retrobulbar deposition of inflammatory cells and round cells with venous
congestion resulting in oedema (Figs 19.21 to 19.23).
o Levator palpebrae superioris muscle is innervated by oculomotor nerve which also
carries sympathetic fibres derived from cavernous plexus for the smooth muscle part of
the levator. Contraction of this muscle produces lid spasm.This is aided by spasm of
 Miiller's muscle, a sympathetic muscle which lies adjoining the levator palpebrae

superior .. . . . . . .. . . . . . ... .
o Malignant exophthalmos This occurs in untreated cases of Graves' disease. If the
disease continues, infrequent blinking secondary to exophthalmos results in constant
exposure of the cornea to the atmosphere. This results in keratitis, corneal ulcer,
conjunctivitis, chemosis and may even lead to bli Malignant exophthalmos is probably
due to autoimmum disease. In late stages, optic nerve damage and blindness can

occur. This is called malignant exophthalmos. .

Treatment of thyrotoxic ophthalmopathy
1. Massive doses of steroids-methylprednisolone and
metronidazole
2. Lateral tarsorrhaphy
3. Orbital decompression may be necessary in late cases
4. Guanethidine eyedrops are useful to decrease lid spasm
and lid retraction.
5. Head end elevation and disease control.
6. Dark spectacles, 7% methylcellulose eye drops.
 Thyrotoxic myopathy
o Mild weakness of proximal limb muscles, ocular and frontal is muscles is not
uncommon. On careful questioning, patient may admit difficulty in climbing steps.
Weakness of extraocular muscles results in double vision ( diplopia). Features
suggestive of myaesthenia gravis, periodic paralysis can be found.
o Myopathy improves with treatment.
 Thyrotoxic dermopathy
o Popularly called as pretibial myxoedema-is seen in thyrotoxicosis patients treated with
surgery or antithyroid drugs. It is always associated with exophthalmos. It is seen in 1-
2% of patients.
o Bilateral symmetrical deposition of myxomatous tissue (glycosaminoglycans) mainly in
the pretibial region, may also affect the foot and ankle, sometimes the entire leg below
knee. Skin is dry and coarse (thickening of skin by mucin-like deposits).
o Swelling is due to the obliteration of initial lymphatics by mucin ).Pretibial
myxoedema (misnomer) is nonpitting in nature and may be associated with clubbing of
fingers and toes called thyroid acropachy
o Responds to topical steroids and thyroid disorder treatment
Diagnostic tests
 The diagnosis of hyperthyroidism is made by a suppressed TSH with or without an elevated free T4
or T3 level.
 In the absence of eye findings, an 123I uptake and scan should be performed. An elevated uptake,
with a diffusely enlarged gland confirms the diagnosis of Graves disease and helps to differentiate it
from other causes of hyperthyroidism
 Anti-Tg andanti-TPO antibodies are elevated in up to 75 percent of patients, but are not specific.
Elevated thyroid-stimulating hormone receptor (TSH-R) or TSAb are diagnostic of Graves disease
and are increased in approximately 90 percent of patients.
 MRI scans of the orbits are useful in evaluating ophthalmopathy
Toxic Multinodular Goiter
 Toxic multinodular goiters usually occur in individuals older than 50 years of age who often have a
prior history of a nontoxic multinodular goiter.
 Over several years, enough thyroid nodules become autonomous to cause hyperthyroidism.
  Symptoms and signs of hyperthyroidism are similar to Graves disease, but are less severe and
extrathyroidal manifestations are absent.
 Diagnostic studies and treatment.
 TSH is suppressed with elevated free T4 or T3 levels.
 RAI uptake also is increased, showing multiple nodules with increased uptake and suppression of the
remaining gland.
 Surgical resection is the preferred treatment method, with subtotal thyroidectomy being the
standard procedure. RAI therapy is reserved for older adult patients who represent very poor
operative risks, provided there is no airway compression from the goiter and thyroid cancer is not a
concern.
Plummer Disease (Toxic Adenoma)
 Hyperthyroidism from a single hyperfunctioning nodule typically occurs in younger patients who
note recent growth of a long-standing nodule along with the symptoms of hyperthyroidism.
 Most hyperfunctioning nodules have attained a size of at least 3 cm before hyperthyroidism occurs.
 RAI scanning shows a “hot” nodule with suppression of the rest of the thyroid gland. These nodules
are rarely malignant.
 Smaller nodules may be managed with antithyroid medications and RAI, surgery (lobectomy and
isthmusectomy) is recommended to treat young patients and those with larger nodules.
Thyroid neoplasm
Benign tumours
 Follicular adenomas present as clinically solitary nodules and the distinction between a
follicular carcinoma and an adenoma can only be made by histological examination;
 in the adenoma there is no invasion of the capsule or of pericapsular blood vessels. For this
reason, FNA, which provides cytologic detail but not tissue architecture, cannot differentiate
between benign and malignant follicular lesions.
 Diagnosis and treatment is therefore, by wide excision, i.e. total lobectomy. The remaining
thyroid tissue is normal so that prolonged follow-up is unnecessary.
Malignant tumours
 The vast majority of primary malignancies are carcinomas derived from the follicular cells
(Table 50.6). Such tumors were thought of as differentiated (papillary, follicular and Hü rthle
cell) and undifferentiated (anaplastic).
 However, now an intermediate class of ‘poorly differentiated carcinoma’ is recognised, which is
likely to represent a state of dedifferentiated, between classic differentiated and
undifferentiated diseases
 . The parafollicular C cells can undergo malignant transformation into medullary carcinoma, and
thyroid lymphoma is another primary thyroid malignancy.
 In addition, the thyroid can be involved by direct spread from surrounding structures (larynx
and oesophagus) or metastases (most commonly from renal cell carcinoma). Lymph node and
blood-borne metastases of thyroid cancer occur primarily to bone and lung and may be the
mode of presentation
PAPILLARY CARCINOMA THYROID (PCT)
 Papillary carcinoma is the most common thyroid malignancy The disease is known for its
propensity for lymph node metastases.
 Papillary carcinoma accounts for 80 percent of all thyroid malignancies in iodine-sufficient areas
and is the predominant thyroid cancer in children and individuals exposed to external radiation
 Papillary carcinoma occurs more often in women, with a 2:1 female-to-male ratio; the mean age
at presentation is 30–40 years.
  Most patients are euthyroid and present with a slow-growing painless mass in the neck.
Dysphagia, dyspnea, and dysphonia are usually associated with locally advanced invasive
disease.
 Lymph node metastases are common, especially in children and young adults, and may be the
presenting complaint. The so-called “lateral aberrant thyroid” almost always denotes a cervical
lymph node metastases. Distant metastases are uncommon at initial presentation, but may
ultimately develop in up to 20 percent of patients. The most common sites are the lungs,
followed by bone, liver, and brain.

Aetiology
1. Irradiation to the neck during childhood: In olden days radiotherapy was given for benign
conditions such as acne in teenagers or enlarged tonsils or thymus gland.
Those children had increased risk of papillary carcinoma thyroid. These indications are
obsolete now. However, accidental radiation to the neck or radiation given to Hodgkin's
lymphoma can precipitate the development of papillary carcinoma thyroid.
2. It can be a complication of Hashimoto's thyroiditis.
3. Papillary cancer of thyroid occurs more often in patients with Cowden's syndrome, Gardner's
syndrome or Camey's syndrome.
4. Associated mutations: Chromosomal translocation involving RET proto-oncogene (tyrosine
kinase) chromosome l Oq 11.
Pathology
 It is made up of colloid-filled follicles with papillary projections. Calcification, necrosis, or cystic
change may be apparent grossly.
 In some cases, calcific lesions are found which are called psammoma bodies. These are
diagnostic of papillary carcinoma of thyroid.
 Characteristic pale, empty, nuclei are present in a few cases which are described as Orphan
Annie eye nuclei.
 Multifocality is common in papillary carcinoma and may be present in up to 85 percent of cases
on microscopic examination. Multifocality is associated with an increased risk of cervical nodal
metastases and these tumors may rarely invade adjacent structures such as the trachea,
esophagus, and recurrent laryngeal nerves
 Papillary microcarcinoma: They measure 1 cm or less in diameter. Distant metastasis is
extremely rare. Hence a simple hemithyroidectomy is the treatment of choice.
 Follicular variant of papillary cancer: This is a mixed lesion with a predominance of follicles
over papillae. These are treated by total thyroidectomy. It is called Lindsay tumour.
 Tall cell papillary cancer: This is an aggressive and rapidly growing tumour. It occurs in
elderly patients and should be treated by total thyroidectomy.

Clinical presentation
 It can present as a solitary nodule. Very often, the lymph nodes in the lower deep cervical region
are involved and thyroid may or may not be palpable. When thyroid gland is not palpable, it is
called occult (hidden). However, papillary carcinoma less than 1.5 cm in diameter is also called
'occult'
 A few patients present late to the hospital with
fixed nodes in the neck, and fixed thyroid to the
trachea with or without recurrent laryngeal nerve
paralysis

Prognostic criteria
FOLLICULAR CARCINOMA
• Incidence:
 Follicular carcinomas account for 10 percent of thyroid cancers and occur more commonly in
iodine-deficient areas.
 Women have a higher incidence of follicular cancer, with a female:male ratio of 3:1, and a mean
age at presentation of 50 years
Aetiology
 Follicular carcinoma usually arises in a multinodular goitre, especially in cases of endemic
goitre.
 It should be suspected when MNG starts growing rapidly.
 It can present as solitary nodule
Pathology
 Follicular carcinomas are usually solitary lesions, the majority of which are surrounded by a
capsule . Histologically, follicles are present, but the lumen may be devoid of colloid.
 Malignancy is defined by the presence of capsular and vascular invasion.
 Minimally invasive tumors appear grossly encapsulated but have evidence of microscopic
invasion through the tumor capsule and/or invasion into small- to medium-size vessels (venous
caliber) in or immediately outside the capsule, but not within the tumor. On the other hand,
widely invasive tumors demonstrate evidence of large-vessel invasion and/or broad areas of
tumor invasion through the capsule. They may, in fact, be unencapsulated.
 Large follicular tumors (>4 cm) in older men are more likely to be malignant.

Clinical presentation
 It can present as a solitary nodule. The diagnosis is considered only after an ultrasound scan
reveals some features of malignancy such as microcalcification.
 In case of long-standing multinodular goitres, if the goiter is rapidly growing, hard or has
restricted mobility, follicular carcinoma can be considered.
 Metastasis in the flat bones: The only clinical situation wherein a follicular carcinoma can be
considered as the diagnosis is when a patient with a thyroid swelling presents with metastasis
in the bone in the fom1 of bony swelling or pathological fractures. Commonly, secondaries
develop in the flat bones such as skull, ribs, sternum, vertebral column because the flat bones
retain red marrow for a longer time.
 The clinical features of secondary in the skull are:
• They are rapidly growing
• They are warm
• Vascular and pulsatile
• Underlying bony erosion may be present .
Investigations
• Ultrasound scan
• FNAC of the nodule. It should be remembered that FNAC cannot differentiate a
follicular adenoma from follicular carcinoma. Hence, if FNAC reports as follicular cells,
overtreat the patient by total thyroidectomy. Some follow with frozen section and
proceed. This is not favoured by many. If it is reported as follicular carcinoma, no
further surgery is required. If it is reported as benign, patient requires to be treated for
hypothyroidism.
• CT scan
• Alkaline phosphatase-if increased, bone scan should be done.
• Plain X-ray of the involved bone can reveal osteolytic lesions When primary is not
found, bone biopsy is required to find out the site of the primary.
H¨urthle Cell Carcinoma
• H¨urthle cell carcinomas account for approximately 3 percent of all thyroid malignancies.
• Under the World Health Organization classification, H¨urthle cell carcinomas are considered to
be a subtype of follicular thyroid cancer.
• Like follicular cancers, H¨urthle cell cancers are characterized by vascular or capsular invasion,
and therefore cannot be diagnosed by FNA biopsy.
• Tumors contain sheets of eosinophilic cells packed with mitochondria, which are derived from
the oxyphilic cells of the thyroid gland.
• H¨urthle cell tumors also differ from follicular carcinomas in that they are more often multifocal
and bilateral (approximately 30 percent), usually do not take up RAI (approximately 5
percent), are more likely to metastasize to local nodes (25 percent) and distant sites, and are
associated with a higher mortality rate (approximately 20 percent at 10 years).
ANAPLASTIC CARCINOMA
• Anaplastic carcinoma accounts for approximately 1 percent of all thyroid malignancies in the
United States and is the most aggressive of thyroid tumors.
• The majority of tumors present in the seventh and eighth decades of life.
• The typical patient has a long-standing neck mass, which rapidly enlarges and may be painful.
Associated symptoms, such as dysphonia, dysphagia, and dyspnea are common.
• Lymph nodes usually are palpable at presentation. Evidence of metastatic spread also may be
present.
• Diagnosis is confirmed by FNA biopsy revealing characteristic giant and multinucleated cells.
Foci of more differentiated hyroid tumors may be seen, suggesting that anaplastic tumors arise
from more well-differentiated tumors. Incisional biopsy is occasionally needed to confirm the
diagnosis and isthmusectomy is performed to alleviate tracheal compression.
• ..

MEDULLARY CARCINOMA OF THE THYROID (MCT)

• These tumors account for about 5 percent of thyroid malignancies and arise from the
parafollicular or C cells of the thyroid, which are concentrated superolaterally in the thyroid
lobes.
• These tumours present in two different ways.
o Sporadic is most common
o Familial variety present as a part of multiple endocrine neoplasia (MEN).(25%)
• MEN Type I
o Pituitary adenoma
o Parathyroid adenoma
o Pancreatic adenoma
• MEN Type Ila
o Parathyroid adenoma
o Phaeochromocytoma
o Medullary carcinoma of thyroid
• MEN type lIb
o When it is associated with mucocutaneous neuromas involving lips, tongue, eyelids, it
is called Sipple syndrome,
• Pathology
• The tumors are typically unilateral, but are multicentric in familial cases. Familial cases also are
associated with C-cell hyperplasia, which is considered a premalignant lesion
• It has got a characteristic amyloid stroma
• These tumours are not TSH-dependent and do not take up radioactive iodine.
• Hormones produced by MCT
 o Calcitonin
o Prostaglandins
o Serotonin (5-HT), ACTH
• Spread
o Both by lymphatics and blood, thus, worsening the prognosis.
• Patients with medullary carcinoma often present with a neck mass that may be associated with
palpable cervical lymphadenopathy (15–20 percent).
• Local invasion produces symptoms of dysphagia, dyspnea, or dysphonia.
• Distant blood-borne metastases to the liver, bone (frequently osteoblastic), and lung occur later
in the disease.
• Diagnosis.
• The diagnosis of medullary carcinoma is established by history, physical examination, raised
serum calcitonin or CEA levels, and FNA cytology of the thyroid mass.
• Attention to family history is important because approximately 25 percent of patients with MTC
have familial disease. All new patients with MTC should be screened for RET point mutations,
pheochromocytoma, and hyperparathyroidism. It is important to rule out a coexisting
pheochromocytoma to avoid precipitating a hypertensive crisis and death.
LYMPHOMA
• Lymphomas account for less than 1 percent of thyroid malignancies, are mostly of the non–
Hodgkin B-cell type and tend to develop in patients with chronic lymphocytic thyroiditis.
• Patients usually present with symptoms similar to anaplastic carcinoma, although the rapidly
enlarging neck mass often is painless. Patients may present with acute respiratory distress.
• The diagnosis usually is suggested by FNA biopsy, although needle-core or open biopsy may be
necessary for definitive diagnosis. Staging studies should be obtained to assess the extent of
extrathyroidal spread.

THYROIDITIS
Thyroiditis usually is classified into acute, subacute, and chronic forms, each associated with a distinct
clinical presentation and histology.
ACUTE (SUPPURATIVE) THYROIDITIS
 The thyroid gland is inherently resistant to infection due to
 its extensive blood and lymphatic supply,
 high iodide content,
 and fibrous capsule.
 However, infectious agents can seed it
 (a) via the hematogenous or lymphatic route,
 (b) via direct spread from persistent pyriform sinus fistulae or thyroglossal duct cysts,
 (c) as a result of penetrating trauma to the thyroid gland, or
 (d) due to immunosuppression.
 Streptococcus and anaerobes account for about 70% of cases; however, other species also have
been cultured.10
 Acute suppurative thyroiditis is more common in children and often is preceded by an upper
respiratory tract infection or otitis media.
 It is characterized by severe neck pain radiating to the jaws or ear, fever, chills, odynophagia,
and dysphonia.
 Complications such as systemic sepsis, tracheal or esophageal rupture, jugular vein thrombosis,
laryngeal chondritis, and perichondritis or sympathetic trunk paralysis may also occur.
 The diagnosis is established by leukocytosis on blood tests and FNAB for Gram’s stain, culture,
and cytology. CT scans may help to delineate the extent of infection and identify abscesses. A
 persistent pyriform sinus fistula should always be suspected in children with recurrent acute
thyroiditis. The sensitivity of identification of fistulae in the acute setting is lowest for barium
esophagography (50%) and best for direct endoscopy (100%), with CT scans being intermediate
(80%). Both barium esophagogram and CT scans have improved sensitivity once the acute
inflammation has resolved (100% and 83%, respectively), with CT being better at defining the
accurate anatomic pathway and its relationship to the thyroid gland.11
 Treatment consists of parenteral antibiotics and drainage of abscesses.
 Thyroidectomy may be needed for persistent abscesses or failure of open drainage. Patients
with pyriform sinus fistulae require complete resection of the sinus tract, including the area of
the thyroid where the tract terminates, to prevent recurrence.
 Transnasal flexible fiberoptic laryngoscopy is being increasingly used to identify the internal
opening of the pyriform sinus tract and may also allow electrocauterization of the tract, and
success rates similar to open surgery have been reported.
SUBACUTE THYROIDITIS( Granulomatous thyroiditis
, de Quervain’s thyroiditis)

 Subacute thyroiditis can occur in the painful or painless forms. Although the exact etiology is not
known, painful thyroiditis is thought to be viral in origin or result from a postviral inflammatory
response. Genetic predisposition may also play a role,
 Painful thyroiditis most commonly occurs in 30- to 40-year-old women and is characterized by
the sudden or gradual onset of neck pain, which may radiate toward the mandible or ear.
History of a preceding upper respiratory tract infection often can be elicited.
 The gland is enlarged, exquisitely tender, and firm. The disorder classically progresses through
four stages.
 An initial hyperthyroid phase, due to release of thyroid hormone,
 second, euthyroid phase.
 The third phase, hypothyroidism, occurs in about 20% to 30% of patients
 and is followed by resolution and return to the euthyroid state in >90% of patients.
 A few patients develop recurrent disease.
 In the early stages of the disease, TSH is decreased, and Tg, T4, and T3 levels are elevated due to
the release of preformed thyroid hormone from destroyed follicles. The erythrocyte
sedimentation rate is typically >100 mm/h. RAIU also is decreased (<2% at 24 hours), even in
euthyroid patients, due to the release of thyroid hormones from destruction of the thyroid
parenchyma.
 Painful thyroiditis is self-limited, and therefore, treatment is primarily symptomatic. Aspirin
and other nonsteroidal anti-inflammatory drugs are used for pain relief, but steroids may be
indicated in more severe cases. Short-term thyroid replacement may be needed and may
shorten the duration of symptoms. Thyroidectomy is reserved for the rare patient who has a
prolonged course not responsive to medical measures or for recurrent disease.
 Painless thyroiditis
 is considered to be autoimmune in origin and may occur sporadically or in the postpartum
period; the latter typically occurs at about 6 weeks after delivery in women with high TPO
antibody titers in early pregnancy. This timing is thought to coincide with a decrease in the
normal immune tolerance of pregnancy and consequent rebound elevation of antibody titers.
 Painless thyroiditis also is more common in women and usually occurs between 30 and 60 years
of age.
 Physical examination demonstrates a normal sized or minimally enlarged, slightly firm,
nontender gland.
 Laboratory tests and RAIU are similar to those in painful thyroiditis, except for a normal
erythrocyte sedimentation rate. The clinical course also parallels painful thyroiditis. Patients
with symptoms may require β-blockers and thyroid hormone replacement. Thyroidectomy or
 RAI ablation is only indicated for the rare patient with recurrent, disabling episodes of
thyroiditis.
CHRONIC THYROIDITIS
 Lymphocytic (Hashimoto’s) Thyroiditis. Lymphocytic thyroiditis
 It is the most common inflammatory disorder of the thyroid and the leading cause of
hypothyroidism.
 Etiology, Pathogenesis, and Pathology.
 Hashimoto’s thyroiditis is an autoimmune process that is thought to be initiated by the
activation of CD4+ T (helper) lymphocytes with specificity for thyroid antigens. Once activated,
T cells can recruit cytotoxic CD8+ T cells to the thyroid.
 Hypothyroidism results not only from the destruction of thyrocytes by cytotoxic T cells but also
by autoantibodies, which lead to complement fixation and killing by natural killer cells or block
the TSH-R.
 Antibodies are directed against three main antigens—Tg (60%), TPO (95%), and TSH-R (60%)
—and, less commonly, the sodium/iodine symporter (25%). Apoptosis (programmed cell death)
also has been implicated in the pathogenesis of Hashimoto’s thyroiditis.
 Chronic thyroiditis also has been associated with increased intake of iodine and administration
of medications such as interferon-α, lithium, and amiodarone.
 Support for an inherited predisposition includes an increased incidence of thyroid
autoantibodies in first-degree relatives of patients with Hashimoto’s
 On gross examination, the thyroid gland is usually mildly enlarged throughout and has a pale,
gray-tan cut surface that is granular, nodular, and firm.
 On microscopic examination, the gland is diffusely infiltrated by small lymphocytes and plasma
cells and occasionally shows well-developed germinal centers.
 Thyroid follicles are smaller than normal with reduced amounts of colloid and increased
interstitial connective tissue. The follicle are lined by Hurthle or Askanazy cells, which are
characterized by abundant eosinophilic, granular cytoplasm.
Clinical Presentation.
 Hashimoto’s thyroiditis is also more common in women (male:female ratio 1:10 to 20) between
the ages of 30 and 50 years old.
 The most common presentation is that of a minimally or moderately enlarged firm granular
gland discovere on routine physical examination or the awareness of a painless anterior neck
mass, although 20% of patients present with hypothyroidism, and 5% present with
hyperthyroidism (Hashitoxicosis).
 In classic goitrous Hashimoto’s thyroiditis, physical examination reveals a diffusely enlarged,
firm gland, which also is lobulated. An enlarged pyramidal lobe often is palpable.
 It commonly presents as a goitre, which may be diffuse or nodular with a characteristic ‘bosselated’
feel or with established or subclinical thyroid failure
Diagnostic Studies
 When Hashimoto’s thyroiditis is suspected clinically, an elevated TSH and the presence of
thyroid autoantibodies usually confirm the diagnosis.
 FNAB with ultrasound guidance is indicated in patients who present with a solitary suspicious
nodule or a rapidly enlarging goiter.
 Thyroid lymphoma is a rare but well-recognized, ominous complication of chroni autoimmune
thyroiditis and has a prevalence 80 times higher than expected frequency in this population
than in a control population. without thyroiditis.
Treatment.
 Thyroid hormone replacement therapy is indicated in overtly hypothyroid patients, with a goal
of maintaining normal TSH levels. The management of patients with subclinical
 hypothyroidism (normal T4 and elevated TSH) is controversial.
  Given the above, levothyroxine is recommended for all patients with TSH levels >10 μIU/mL and
patients with levels of 5 to 10 μIU/mL in the presence of a goiter or anti-TPO antibodies.
 Treatment is also advised especially for middle-age patients with cardiovascular risk factors
such as hyperlipidemia or hypertension and in pregnant patients.
 Surgery may occasionally be indicated for suspicion of malignancy or for goiterscausing
compressive symptoms or cosmetic deformity.
Complications of Hashimoto's thyroiditis
 Permanent hypothyroidism
 Papillary carcinoma of the thyroid
 Lymphoma

 RIEDEL’S THYROIDITIS
 Riedel’s thyroiditis is a rare variant of thyroiditis also known as Riedel’s struma or invasive
fibrous thyroiditis that is characterized by the replacement of all or part of the thyroid
parenchyma by fibrous tissue, which also invades into adjacent tissues.
 The etiology of this disorder is controversial, and it has been reported to occur in patients with
other autoimmune diseases.
 This association, coupled with the presence of lymphoid infiltration and response to steroid
therapy, suggests a primary autoimmune etiology.
 Riedel’s thyroiditis also is associated with other focal sclerosing syndromes including
mediastinal, retroperitoneal, periorbital, and retro-orbital fibrosis and sclerosing cholangitis,
suggesting that it may, in fact, be a primary fibrotic disorder.
 The disease occurs predominantly in women between the ages of 30 and 60 years old.
 It typically presents as a painless, hard anterior neck mass, which progresses over weeks to
years to produce symptoms of compression, including dysphagia, dyspnea, choking, and
hoarseness. Patients may present with symptoms of hypothyroidism and hypoparathyroidism
as the gland is replaced by fibrous tissue.
 Physical examination reveals a hard, “woody” thyroid gland with fixation to surrounding tissues.
 The diagnosis needs to be confirmed by open thyroid biopsy, because the firm and fibrous
nature of the gland renders FNAB inadequate.
 Surgery is the mainstay of the treatment. The chief goal of operation is to decompress the
trachea by wedge excision of the thyroid isthmus and to make a tissue diagnosis. More extensive
resections are not advised due to the infiltrative nature of the fibrotic process that obscures
usual landmarks and structures. Hypothyroid patients are treated with thyroid hormone
replacement. Some patients who remain symptomatic have been reported to experience
dramatic improvement after treatment with corticosteroids and tamoxifen. More recently
mycophenolate mofetil has been used to attenuate the inflammatory process and led to dramatic
symptom improvements in some patients.14

Chronic lymphocytic (autoimmune) thyroiditis

 Hashimoto's thyroiditis is the main component of thyroiditis.
 Autoimmune aetiology is characterised by extensive lymphocytic infiltration resulting in
destruction of thyroid follicles with variable degree of fibrosis
 Females in perimenopausal group (40-50 years) are commonl y affected.
 Initially, symptoms of mild hyperthyroidism (hashitoxicosis) may be present. Later, extensive
intrathyroidal fibrosis results in permanent hypothyroidism.
 The thyroid follicles are destroyed by significant fibrosis.
 The deep eosinophilic-staining thyroid follicular cell, Askanazy cell, is characteristic
ofHashimoto's thyroiditis

  The gland can be firm to hard and sometimes rubbery in consistency, smooth or irregular and
can involve a lobe or the entire gland.
 In many cases, thyroid antibodies are raised, suggesting an autoimmune disorder.
 Treatment
 Thyroxine 0.2 mg/day is given as a supplementary dose.
 If there is compression on the trachea, isthmusectomy is done to relieve compression
 If the goitre is big and causing discomfort, subtotal thyroidectomy can also be done.

Riedel’s thyroiditis
This is very rare, accounting for 0.5% of goitres. Thyroid
tissue is replaced by cellular fibrous tissue, which infiltrates
through the capsule into muscles and adjacent structures,
including parathyroids, recurrent nerves and carotid sheath.
It may occur in association with retroperitoneal and mediastinal
fibrosis and is most probably a collagen disease. The
goitre may be unilateral or bilateral and is very hard and fixed.
The differential diagnosis from anaplastic carcinoma can be
made with certainty only by biopsy, when a wedge of the isthmus
should also be removed to free the trachea. If unilateral,
the other lobe is usually involved later and subsequent hypothyroidism
is common. Treatment is with high-dose steroid,
tamoxifen and thyroxine replacement. Reduction in the size
of the goitre and long-term improvement in symptoms are to
be expected if treatment is commenced early.

THYROIDITIS
Bacterial infection of thyroid is very rare because of its
rich blood supply.
• Thyroiditis is broadly classified into granulomatous
autoimmune and Riedel's thyroiditis (Table 19.9).
GRANULOMATOUS THYROIDITIS
It is also called subacute thyroiditis or de Quervain's disease
This occurs due to viral infection. It usually follows son
throat (mumps virus has been incriminated in a few cases)
Patients present with fever, body ache and painfui
enlargement of thyroid gland. The gland is enlarged, tende1
to touch, soft to firm and a few symptoms of hyperthyroidism
occur initially.
• ESR is increased.
Treatment
Majority of the patients respond to conservative treatment in
the form of analgesics and a short course of prednisolone.
There are no permanent sequelae of this condition.
RIEDEL'S THYROIDITIS
This is a very, very rare cause of a goitre which is supposed
to be a collagen disorder.
It can be associated with m ediastinal fibrosis,
retroperitoneal fibrosis and sclerosing cholangitis.
• In this condition, there is intrathyroidal fibrosis but
extrathyroidal fibrosis is more.
• Involvement of trachea, oesophagus, internal jugular vein,
carotid artery, etc. result in dysphagia and dyspnoea.
As a result of fibrosis, all the thyroid follicles are replaced
by fibrous tissue.
• By the time patients present to the hospital, it is an
advanced stage and excision is very difficult.

Thyroiditis.