Thyroid Disorder

Aishah
Idham
Aishah
Munirah
ANATOMY
• Largest endocrine gland in
the body
• Situated in front of the
larynx and trachea in the
neck, at the level of C5-T1
vertebrae
• Butter-fly shaped
• Consists of right and left
lateral lobes connected by
a narrow part, isthmus
• Thyroid gland has a fibrous
capsule; It is enclosed by
pretracheal fascia
Relations of Thyroid Gland
Blood Supply of Thyroid

Arterial Supply
• Superior thyroid artery
• Inferior thyroid artery
• Thyroid ima artery (in 3%)

Venous Drainage
• Superior thyroid vein
• Middle thyroid vein
• Inferior thyroid vein
 Synthesis of Thyroid hormone
• Synthesized by follicular cells of
thyroid gland
• Synthesis :
-Trapping of iodide from the blood
-Oxidation of iodide to iodine by thyroid
peroxidase
-Binding of iodine with tyrosine to form
iodotyrosines
-Coupling mono-iodotyrosine and di-
iodotyrosine to form T3 and T4.
Hypothalamic Pituitary Axis
• Thyroid gland produces
– 90% thyroxine (T4)
– 10 % triiodothyronine (T3)

Most of T3 is formed from peripheral

conversion of T4 (liver, muscle, heart,
kidney)

• Most T3 and T4 in plasma is

protein bound, mainly thyroxine-
binding globulin (TBG)
• The unbound or free hormones
are the biologically active part
which produce physiological
effects
 Physiological effects of Thyroid
Hormone
• Growth and tissue development
– Increase protein synthesis
– Stimulate endochondral ossification of bone and maturation of tooth,
epidermis and nails
– axonal and dendritic development and myelination of nervous system
• Stimulate metabolic activities
– Increase basal rate of oxygen consumption and heat production
– Promote metabolism of carbohydrate, fat, protein
• Cardiovascular effect
– Direct vasodilation, rapid oxygen utilization and heat production
– Increase excitability and contractility of the heart, cardiac output and blood
pressure
• Nervous system
– Enhanced wakefulness, alertness and responsiveness, peripheral reflex
• Other important roles in skeletal muscle, reproductive system and
respiratory system
HYPERTHYROIDISM
 CAUSES
1. Primary 2. Secondary
Grave’s disease TSH secreting pituitary tumor
Toxic multinodular goiter Drug induced (eg: amiodarone)
Metastatic thyroid carcinoma
Toxic adenoma
Subacute thyroiditis
Postpartum thyroiditis

3. Iodine induced hyperthyroidism

 SYMPTOMS & SIGNS
• Weight loss • Palmar erythema
• Tremor
• Irritability
• Thyroid acropachy
• Heat intolerance • Tachycardia
• Restlessness • Proximal myopathy
• Exophthalmos (GD)
• Diarrhea
• Lid lag
• Excessive sweating • Proptosis
• Tremor • Conjunctival and periorbital
oedema
• Goitre
• Goitre
• Oligomenorrhea • Pretibial myxedema (GD)
• Eye complaints (GD)
 INVESTIGATION
1. Thyroid function test 3. US of the neck
• Nodule (solitary, multiple)
• T3 , T4
• Consistency (solid, cystic)
• TSH • Vascularity (doppler)

2. Thyroid stimulating Ig (TSI)

4. Thyroid uptake scan
/ thyroid autoantibodies
• Differentiate cold & hot
• Diagnostic for GD nodules
• Hot – hyperthyroidism
• Cold – hypothyroidism,
hemorrhage, malignancy
 MANAGEMENT
1. MEDICAL
2. RADIOACTIVE IODINE THERAPY (RAI)
• Most commonly used in Grave’s disease.
• Orally administered radioactive iodine (200- Relative
contraindication:
550MBq).
 Moderate to severe
• This radiation (I-131) emit β-ray that destroy thyroid GD- worsen eye
parenchyma. sign
• Need to stop antithyroid medication at least 4 days
before that therapy.
• Need to avoid seafood (iodine).
Absolute
contraindication:
 Precaution  Toxic multinodular
• Patients need to avoid close contact with young goiter – cause
children and pregnant women (α-ray) for a inflammation and
worsen
duration of 10 days after radioiodine therapy.
compressive
• Women are advised not to become pregnant for at symptom.
least 4-6 months.
3. Surgery : subtotal thyroidectomy

 Indications :
 Failed medical treatment i.e. relapse after one or more courses of
 antithyroid drugs, non-compliance or development of side-effects.
 Those with large goitres, especially with pressure effects.
 Patients who prefer surgery.

 Complications :
 Laryngeal nerve palsy (hoarseness)
 Transient hypocalcemia (10%), permanent hypoparathyroidism <1%
 Recurrent hyperthyroidism
 Hypothyroidism
 GRAVE’S DISEASE
• Most common cause of hyperthyroidism
• Serum IgG antibodies bind to the thyroid TSH receptor
stimulating thyroid hormone production
• (TSHR-Ab) are specific for Graves’ disease, can be measured in
serum, are present in 85–90% of cases and decline with
treatment.
 THYROID EYE DISEASE / GRAVE’S
OPHTHALMOPATHY
• due to a specific immune response that causes retro-orbital inflammation.
• Swelling and oedema of the extraocular muscles lead to limitation of
movement and to proptosis which is usually bilateral but can sometimes
be unilateral
• increased pressure on the optic nerve may cause optic atrophy

Symptoms : Signs :
• Eye discomfort • exophthalmos
• Lacrimation • Conjunctival edema
• Diplopia • Proptosis
• Lid retraction
• Corneal damage
HYPOTHYROIDISM

By Siti Aishah binti Samshuri

• A disorder when there is a reduced production of
thyroid hormones.
• Two causes which are:
– Primary hypothyroidism : failure of the thyroid
gland to produce or release thyroid hormones
– Secondary hypothyroidism : due to hypothalamic-
pituitary disease (↓ stimulation → Thyroid )
• Subclinical hypothyroidism (normal T4, elevated TSH)

• Women > Men

 CAUSES
PRIMARY SECONDARY
• Thyroid dysfunction • Hypopituitarism
• Autoimmune: Hashimoto’s • Mass lesion
Thyroiditis/ Atrophic Thyroiditis/ • Pituitary surgery
Postpartum Thyroiditis. • Hemorrhagic apoplexy
• Congenital: Agenesis/ectopic thyroid (Sheehan’s syndrome)
gland
• Iatrogenic: Post thyroidectomy • Hypothalamic disorders
• Post-irradiation: Radioactive iodine • Tumor
therapy/ External neck irradiation. • Infiltrative disorders
• Destruction of thyroid tissue caused (sarcoidosis.
by infiltrative disorders (amyloidosis, Hemochromatosis)
sarcoidosis)
• Infective: Post-Subacute Thyroiditis

• Impaired synthesis of thyroid hormone

• Iodine Deficiency
• Drug induced: Antithyroid drugs,
Amiodarone, Lithium
 CLINICAL FEATURES
Symptoms

Tiredness/ malaise
Weight gain
Cold intolerance
Poor memory
Depression

Hair – dry, brittle

Skin – dry, coarse

Arthralgia
Myalgia
Muscle weakness/stiffness
Poor libido
Puffy eyes
Constipation
Deafness
Menorrhagia
Signs

Mental slowness
Psychosis/dementia
Ataxia
Periorbital edema
Dry thin hair
Loss of eyebrows
Hypertension
Periorbital puffiness, coarse and brittle hair
Hypothermia
Heart failure
Bradycardia
Pericardial effusion
Dry skin
Mild obesity
Slow-relaxing reflexes
Cold peripheries
Myotonia
Carpal tunnel syndrome
Oedema
Deep voice (goitre)
 HASHIMOTO TYROIDITIS
 An autoimmune disease, in which the immune system
reacts against a variety of thyroid antigens.
 Common in woman and in late middle age.
 Associated with antithyroid antibodies → lymphoid
infiltration of the gland→ atrophy and fibrosis.
 TPO antibodies are present, usually in very high titres
(>1000IU/L).
 LABORATORY
DIAGNOSIS Differential Diagnosis
 Depression
 Cushing’s
syndrome
 PCOS
To confirm diagnosis:
• Thyroid Function Test (serum TSH and T4)
– Low T4
– high TSH (primary hypothyroidism)
– low TSH (secondary hypothyroidism)
– Subclinical hypothyroidism: Normal T4, High TSH
To support diagnosis:
1. Full blood count : anaemia (usually
normochromic,normocytic) but may be
macrocytic (due to pernicious anaemia)
2. BUSE : hyponatraemia (increase in ADH)
3. Lipid profile : hypercholesterolemia and
hypertriglyceridaemia
4. Cardiac enzymes : increase serum creatine kinase levels.

To rule out other causes/ ddx:

1. Test for thyroid autoantibodies.
2. Isotope uptake scan: Reduce in uptake (Hashimoto Thyroiditis)
 MANAGEMENT
• Aim : to make the patient clinically and biochemically
euthyroid. Treatment is life long and patient needs to be
informed of this to ensure good compliance.

REPLACEMENT THERAPY
• Replacement therapy with levothyroxine is given for life.
• Levothyroxine 50-100 ug/day increasing at 1-2 weeks interval
to a maintenance dose of 100-200 ug/day (titration).
• Elderly or IHD: Start with 25 ug/day. Increase dosage slowly
every 2-4 weeks according to the patient’s response.
• If angina occurs, reduce to previous dosage or withhold
treatment temporarily while management of IHD is optimized.

Practice Guidelines for Thyroid Disorder The Malaysian Consensus

 MONITORING
• Measurements of serum TSH and fT4 should
be done 2-3 months after initiation of
therapy to determine the maintenance
dose.
• Subsequently every 6 months to 1 year.
 THYROID
NEOPLASIA
 Thyroid neoplasia
• Primary thyroid malignancy is rare.

• Accounts for less than 1% of all carcinomas & has an incidence

of 25 per million per annum.

• Can be classified according to the cell type of origin.

• With the exception of medullary carcinoma, thyroid cancer is

more common in females.

Colledge, N. R., Walker, B. R., Ralston, S., & Davidson, S. (2014). Davidson's principles and practice of medicine
22nd edition. Edinburgh: Churchill Livingstone/Elsevier.
Colledge, N. R., Walker, B. R., Ralston, S., & Davidson, S. (2014). Davidson's principles and practice of medicine
22nd edition. Edinburgh: Churchill Livingstone/Elsevier.
PAPILLARY • Most common malignant thyroid tumour.
CARCINOMA • Spread is initially to regional lymph nodes.
• Some patients present with cervical lymphadenopathy with no
thyroid enlargement at all.

FOLLICULAR • Always a single encapsulated lesion.

CARCINOMA • Metastatic spread is mostly via bloodstream (often in bones,
lungs, and liver).
• Diagnosis requires a tissue biopsy. FNAC is not sufficient to
differentiate between benign or malignant.

Davidson's principles and practice of medicine 22nd edition (2014) & UpToDate.
MEDULLARY • Arises from the parafollicular C cells of the thyroid.
CARCINOMA • Serum calcitonin levels are raised  useful in monitoring
response to treatment.
• 10% familial; associated with MEN type 2.

ANAPLASTIC • Patients are usually > 60 years of age.

CARCINOMA & • Present with rapid thyroid enlargement over 2–3 months.
LYMPHOMA • May cause neck pain, tenderness, and compression (or
invasion) of the upper aerodigestive tract  dyspnoea,
dysphagia, hoarseness, cough

Davidson's principles and practice of medicine 22nd edition (2014) & UpToDate.
 Risk Factors

• Female : Male = 3:1

• Longstanding iodine deficiency (FTC)

• Familial: MEN type 2 (MTC), FAP (PTC)

• Exposure to radiation especially during childhood (head

neck radiation treatment)

Davidson's principles and practice of medicine 22nd edition (2014) & UpToDate.
 Clinical Features
• Thyroid nodule (neck swelling); rapidly growing

• Vagus nerve compression  Neck pain, radiated to ears

• Recurrent laryngeal nerve invasion  Hoarseness of voice

• Oesophageal compression  Dysphagia

• Trachea compression  Dyspnoea

Davidson's principles and practice of medicine 22nd edition (2014) & UpToDate.
 Management
Papillary & Follicular Thyroid Carcinoma
• Total thyroidectomy + RAI ablation (to destroy remaining tissue)
• Long term treatment with Levothyroxine  suppress TSH
• Monitor patient via serum thyroglobulin as tumor marker

Anaplastic Thyroid Carcinoma

• There is no effective treatment for anaplastic carcinoma (they
don’t respond to RAI)
• Surgery and radiotherapy may be considered in some
circumstances  but only produce temporary relief; do not
improve survival rate

Davidson's principles and practice of medicine 22nd edition (2014).

 Management
Thyroid Lymphoma
• Combination chemotherapy + External beam radiotherapy

Medullary Thyroid Carcinoma

• Total thyroidectomy + Removal of regional cervical lymph nodes
• External beam radiotherapy may be considered in some patients at
high risk of local recurrence
• Vandetanib, a tyrosine kinase inhibitor, is licensed for patients with
advanced medullary cancer

Davidson's principles and practice of medicine 22nd edition (2014).

THYROID EMERGENCIES
• Thyroid Storm
• Myxoedema Coma
 THYROTOXIC CRISIS (‘Thyroid Storm’)

• = a life threatening exacerbation of the hyperthyroid state with

evidence of decompensation in one or more organ systems.

• Mortality is 10-20% despite early recognition and treatment.

• It may be precipitated by stress including concurrent infections,

surgery or pregnancy.

CPG for Thyroid Disorders (2000).

 Clinical Features

• It is a clinical diagnosis with features of severe thyrotoxicosis,

hyperpyrexia & neuropsychiatric manifestations e.g. delirium.

• Most prominent signs are fever, agitation, confusion,

tachycardia or atrial fibrillation and, in the older patient,
cardiac failure.

Davidson's principles and practice of medicine 22nd edition (2014) & CPG for Thyroid Disorders (2000).
 Management

• Rehydration.

• Treat hyperpyrexia (use fans, tepid sponging and oral paracetamol).

• Do NOT use aspirin or NSAIDs.

Beta sympathetic blocking agents.

• Oral propanolol 40 mg QID, or IV 1-2 mg 4-6 hourly.

CPG for Thyroid Disorders (2000).

 Management
Iodide
• Oral saturated solution of potassium iodide (SSKI) 5 drops 6-hourly
or
• IV Sodium Iodide 500 mg 8 hourly or
• Oral Lugol's iodine 5-10 drops, 6-hourly

Antithyroid Drugs
• Carbimazole 15-20 mg 6-hourly or
• Propylthiouracil 150-200 mg 6-hourly

CPG for Thyroid Disorders (2000).

 Management
Corticosteroids
• IV dexamethasone 2 mg 6-hourly or
• IV hydrocortisone 200 mg 6-hourly

 The above regime should be instituted simultaneously.

 Once the clinical situation stabilises (after 3 - 4 days):
• Iodide & corticosteroids may be stopped &
• the dose of anti-thyroid drugs and beta-blockers may be reduced

 The precipitating cause should be treated.

 Subsequently, appropriate treatment for thyrotoxicosis should be
continued.
CPG for Thyroid Disorders (2000).
 MYXOEDEMA COMA
• Severe hypothyroidism.

• Rare; high level of mortality when it occurs.

• Can be precipitated by stress, infection, or drugs (e.g. CNS

suppressants).

• Clinical features

1. Positive S&S of hypothyroidism: Hypothermia, hypotension,

hypoventilation, hyporeflexia.

2. Change in mental status: Confusion, delirium, psychosis, fit, coma.

Davidson's principles and practice of medicine 22nd edition (2014) & CPG for Thyroid Disorders (2000).
 Management

• Gradual rewarming with blankets.

• Accurate core temperatures should be recorded with a low
reading Rectal thermometer.

• Thyroid hormone replacement with L-thyroxine 300-400 ug given

orally via NG tube or parenterally if available.
• Alternatively, doses of triiodothyronine 10 ug 8-hourly (IV or
orally) may be used.

CPG for Thyroid Disorders (2000).

 Management

• IV hydrocortisone should be given, 200 mg stat & 100 mg 6-

hourly until patient regains consciousness.

• Ensure adequate hydration & nutrition.

• Use 5-10% dextrose solution to maintain normal blood glucose
levels.
• Correct electrolyte imbalance (patients tend to be
hyponatraemic).

CPG for Thyroid Disorders (2000).

 Management

• Ensure adequate ventilation.

• Patients tend to hypoventilate, resulting in hypercapnoea.

• Treat precipitating cause.

• Infection may be masked by the hypothyroid state.

CPG for Thyroid Disorders (2000).

Thank you.