Thyroid Gland Enlargement

Ns. Ahmad Hasyim W, M.Kep, MNg, Sp.Kep MB

Nursing program
Faculty of Medicine, Brawijaya University
2023
 Contents

• Anatomy of the thyroid

• Physiology of thyroid hormone secretion
• Physiological effect of thyroid hormone
• Thyroid disorders
• Goiter
 Thyroid Anatomy
1-The gland as seen from the front is
more nearly the shape of a butterfly.
2-composed of 2 encapsulated lobes,
one on either side of the trachea,
connected by a thin isthmus.
3-The pyramidal lobe is a narrow
projection of thyroid tissue extending
upward from the isthmus and lying on
the surface of the thyroid cartilage.
 Thyroid Anatomy

4-The thyroid is enveloped by a thin, fibrous,

nonstripping capsule.
5-The weight of the thyroid of the normal nongoitrous
adult is: 10-20 g depending on body size and iodine
supply.
6-The width and length of the isthmus average; 20 mm,
and its thickness is ;2-6 mm.
7-The lateral lobes from superior to inferior poles
usually measure 4 cm. and their thickness is 20-39
mm.
 The arterial supply to the thyroid gland
1-Superior thyroid artery
The superior thyroid artery is the first anterior branch of the external
carotid artery. In rare cases, it may arise from the common carotid
artery just before its bifurcation.

2-Inferior thyroid artery

The inferior thyroid artery arises from the thyrocervical trunk, a
branch of the subclavian artery.

3-The thyroidea ima, if present:

May arise from the brachiocephalic artery or the arch of the aorta to
supply the isthmus.
 Lymphatic drainage
The lymph from the thyroid gland drains mainly
laterally into the deep cervical lymph nodes.
A few lymph vessels descend to the
paratracheal nodes.
innervation of the thyroid gland :
Derives from the autonomic nervous system.
Parasympathetic fibers come from the vagus
nerves, and sympathetic fibers are distributed
from the superior, middle, and inferior ganglia
of the sympathetic trunk
 Physiology
• The thyroid follicles secretes tri-iodothyronine(T3)and
thyroxin(T4)synthesis involves combination of iodine with tyrosine group
to form mono and di-iodotyrosine which are coupled to form T3 andT4.
• The hormones are stored in follicles bound to thyroglobulin .
• When hormones released in the blood they are bound to plasma proteins and
small amount remain free in the plasma .
• The metabolic effect of thyroid hormones are due to free (unbound)T3 and
T4.
• 90% of secreted hormones is T4 but T3 is the active hormone so, T4 is
converted to T3 peripherally.
 Differences between T4 and T3

• The thyroid secretes about 80 microg of T4, but only 5

microg of T3 per day.
• However, T3 has a much greater biological activity (about
10 X) than T4.
• An additional 25 microg/day of T3 is produced by peripheral
monodeiodination of T4
• This conversion takes place mainly in the liver and kidneys.
The T3 formed is then released to the blood stream.
 Why is Iodine Important in Thyroid
Hormone Production?
• Thyroid hormones are unique biological molecules in that they
incorporate iodine in their structure.
• Thus, adequate iodine intake (diet, water) is required for normal thyroid
hormone production.
• Major sources of iodine:
- iodized salt
- iodated bread
- dairy products
- shellfish & salt water fish
• Minimum requirement: 75 micrograms/day
• US intake: 200 - 500 micrograms/day
 Physiological control of secretion
• Synthesis and libration of T3 and T4 is controlled by
thyroid stimulating hormone(TSH) secreted by
anterior pituitary gland.
• TSH release is in turn controlled by thyrotropin
releasing hormone (TRH)from hypothalamus .
• Circulating T3 and T4 exert negative feedback
mechanism on hypothalamus and anterior pituitary
gland .
• So, in hyperthyroidism where hormone level in
blood is high ,TSH production is suppressed and
vice versa.
 One Major Advantage of this System

• The thyroid gland is capable of storing

many weeks worth of thyroid hormone
(coupled to thyroglobulin).

• If no iodine is available for this period,

thyroid hormone secretion will be
maintained.
 Actions of Thyroid Hormones
• Thyroid hormones are essential for normal
growth of tissues, including the nervous
system.
• Lack of thyroid hormone during development
results in short stature and mental deficits
(cretinism).
• Thyroid hormone stimulates basal metabolic
rate.
• What are the specific actions of thyroid
hormone on body systems?
 Effects of Thyroid Hormone on Nutrient metabolism

• Effects on protein synthesis and degradation:

- Increased protein synthesis at low thyroid hormone levels (low
metabolic rate; growth)
- Increased protein degradation at high thyroid hormone levels
(high metabolic rate; energy)
• Effects on carbohydrates:
- Low level of thyroid hormone increase glycogen synthesis
(low metabolic rate; storage of energy)
- High level increase glycogen breakdown (high metabolic rate;
glucose production)
 Thyroid Hormone Actions which Increase
Oxygen Consumption

• Increase mitochondrial size, number and key enzymes

• Increase plasma membrane Na-K ATPase activity
• Increase thermogenic energy cycles
 Effects of Thyroid Hormones on the
Cardiovascular System
• Increase heart rate
• Increase force of cardiac contractions
• Increase stroke volume
• Increase Cardiac output
• Up-regulate catecholamine receptors
 Effects of Thyroid Hormones on the
Respiratory System

• Increase resting respiratory rate

• Increase minute ventilation
• Increase ventilatory response to hypercapnia and hypoxia
 Effects of Thyroid Hormones on the Renal
System

• Increase blood flow

• Increase glomerular filtration rate
 Effects Thyroid Hormones in Growth and
Tissue Development

• Increase growth and maturation of bone

• Increase tooth development and eruption
• Increase growth and maturation of epidermis, hair follicles
and nails
• Increase rate and force of skeletal muscle contraction
 Effects of Thyroid Hormones on the Nervous
System
• Critical for normal CNS neuronal development
• Enhances wakefulness and alertness
• Enhances memory and learning capacity
• Required for normal emotional tone
• Increase speed and amplitude of peripheral nerve reflexes
 Clinical presentation of specific condition
HYPOTHYRODISM;
Hypothyroidism is the disease state in humans caused by
insufficient production of thyroid hormone by the
thyroid gland.
Sign and symptoms:
Fatigue, Depression, Modest weight gain, Cold
intolerance, Excessive sleepiness, Dry + coarse hair
Constipation, Dry skin , Muscle cramps , Increased
cholesterol levels , Decreased concentration
Swelling of the legs
HYPOTHYROIDISM
 Thyroid Hormone Deficiency:
Hypothyroidism
• Early onset: delayed/incomplete physical and mental
development
• Later onset (youth): Impaired physical growth
• Adult onset (myxedema) : gradual changes occur.
Tiredness, lethargy, decreased metabolic rate,
slowing of mental function and motor activity, cold
intolerance, weight gain, goiter, hair loss, dry skin.
Eventually may result in coma.
• Many causes (insufficient iodine, lack of thyroid
gland, lack of hormone receptors, lack of TH binding
globulin)
 Clinical presentation of specific condition
Hyperthyroidism;
• Hyperthyroidism is a condition caused by the effects of
too much thyroid hormone on tissues of the body.
Although there are several different causes of
hyperthyroidism, most of the symptoms that patients
experience are the same regardless of the cause.
• Increase appetite ,weight loss
• Palpitations, Heat intolerance, Nervousness, Insomnia,
Increased bowel movements, Fatigue, Eye: lid
retraction, lid lag, exophthalmos ,ophthalmoplegia,
chemosis, tremors
• Increased BMR
Hyperthyroidism
 Goiter
A goiter is an abnormal enlargement of the thyroid gland and can
occur for a number of different reasons.
 Classification

Simple (non-toxic) goitre.

Toxic goitre.
Neoplastic goitre.
Inflammatory goitre.
 Simple (non-toxic) goitre
include:
simple hyperplastic goitre
Cause: -physiological in pregnancy, puberty
-iodine deficiency.
Appearance: Large, smooth firm, non-tendern goitre
Effect: euthyroid,
Multinodular goitre.
Cause: presence of areas of hyperplasia & areas of hypoplasia
in gland.
Appearance: Large, irregular, nodular goiter
Effect: euthyroid, hypothyroid
 How is Hypothyroidism Related to Goiter?

• During iodine deficiency, thyroid hormone

production decreases.
• This results in increased TSH release (less
negative feedback).
• TSH acts on thyroid: increasing blood flow, and
stimulating follicular cells
 Toxic goitre
Grave’s disease
Cause: Autoimmune disease characterized by presence of
antibodies stimulate TSH receptors in gland.
Appearance: Diffuse, nodular, hyperemic gland.
Effect: hyperthyroidism.

Toxic Multinodular goiter (plummer’s

disease)
Cause: Toxic effect of MNG
Appearance: Large, irregular, nodular goiter.
Effect: hyperthyroidism
 Neoplastic goitre
Include:
-benign: adenoma
-malignant: papillary, follicular, anaplastic, medullary and lymphoma
Cause: -complication of MNG, radiation
Appearance: Enlarged goiter associated with lymphadenopathy
Effect:
-pressure effect.
-euthyroid.
-invasive effect
 Inflammatory goitre

Rediel’s thyroditis De quervain’s thyroiditis

Cause: Fibrosis of thyroid Cause: Viral infection
Appearance: Enlarged stony hard thyroid Appearance: Diffuse, firm, tender swelling
Effect: Pressure effect Effect: Mild hyperthyroidism

Hashimoto’s thyroiditis
Cause: Autoantibody against thyroid gland.
Appearance: Diffuse, enlarged, non-tender goitre
Effect: Hypothyroidism
 -
Goiter Causes
• Worldwide, the most common cause for goiter is iodine deficiency
• Excess iodine or lithium ingestion
• Goitrogens(cassava, maize, bamboo shoots, and sweet potatoes)
 Goiter Causes
Side-effects of pharmacological therapy such as:
Amiodarone :
inhibits conversion of thyroxine to triiodothyronine
Phenobarbitone, phenytoin, carbamazepine, Rifampicin:
induce metabolic degradation of T3 and T4.
 Goiter Risk factor:
• A lack of dietary iodine.
• Women are more prone to thyroid disorders than men
• Age. Being age 50 or older
• Medical history. A personal or family history of autoimmune disease
• Pregnancy and menopause.
• Certain medications.
• Immunosuppressants,
• The heart drug amiodarone
• And the psychiatric drug lithium
• Radiation exposure.
 Examination

• Examination of the goiter is best performed with the

patient upright, sitting or standing. Inspection from
the side may better outline the thyroid profile. Asking
the patient to take a sip of water facilitates inspection.
The thyroid should move upon swallowing.
• Palpation of the goiter is performed either facing the
patient or from behind the patient, with the neck
relaxed and not hyperextended.
 Examination
• Each lobe is palpated for size, consistency, nodules, and tenderness.
Cervical lymph nodes should be palpated.
• Multiple nodules may suggest a multinodular goiter or Hashimoto
thyroiditis.
• A solitary hard nodule suggests malignancy, whereas a solitary firm
nodule may be a thyroid cyst.
• Diffuse thyroid tenderness suggests subacute thyroiditis, and local
thyroid tenderness suggests intranodal hemorrhage or necrosis
• Cervical lymph nodes are palpated for signs of metastatic thyroid cancer
 Tests and diagnosis

Hormone test: TSH, T3 and T4

If the thyroid is overactive,the level of thyroid hormone
in the blood will be high and the level of thyroid
stimulating hormone (TSH) will be low
If the thyroid is underactive the level of thyroid
hormone will be low while the level of TSH will be
high.
 Tests and diagnosis

Antibody test:
auto-immune antibodies.
Ultrasonography:
To show the size of the thyroid gland and the presence of any nodules.
BMR calculation
Fine needle aspiration biopsy
 Treatment:
Small benign euthyroid goiters do not require treatment. just observe.
Iodine supplementation by mouth
If hypothyroidism

thyroid hormone replacement with

levothyroxine(Levothroid,Synthroid)
aspirin or a corticosteroid
medication to treat the
inflammation.
Hyperthyroidism:
anti-thyroid drugs such as methimazole (Tapazole) or
propylthiouracil (PTU).
For advanced hyperthyroidism, radioactive iodine treatment
(RAI) .
Surgery indication

Large goiters with compression

Malignancy (certain stadium only)

When conventional drug therapy for overactive thyroid is not successful

Lifestyle:

Get enough iodine(Sea vegetables,

Yogurt, cow's milk, eggs, and
strawberries )
Avoid excessive consumption of
goitrogens
 Beta-adernergic blockers:
e.g: propranolol
it is control sympathetic over activity to control cardiovascular feature.
Radioactive iodine:
Taken orally in solution
Given for 8-12 wks.
Use for recurrent hyperthyroidism
Contraindication:
Pregnant women
Nursing mothers.
 Nursing diagnosis labels

• Risk-prone health behavior

• Imbalanced nutrition: less than body requirements
• Dysfunctional gastrointestinal motility
• Insomnia
• Fatigue
• Risk for decreased cardiac output
• Labile emotional control
• Hyperthermia
 Nursing interventions label

• Energy management
• Nutrition management
• Sleep enhancement
• Neurologic monitoring
• Hyperthermia treatment
• etc
THANK YOU 