Benign Diseases of the Thyroid

Dr. Ezekiel Therese Bautista

GS 1st Year
 Hyperthyroidism
• Important to distinguish
disorders that result from
those disorders that lead
to a release of stored
hormone from injury to
the thyroid gland or from
other nonthyroid gland-
related conditions
 Diffuse Toxic Goiter (Graves’ Disease)
• Most common cause of hyperthyroidism in
North America (60-80%)
• Manifestations:
– Thyrotoxicosis
– Diffuse goiter
– Extrathyroidal manifestations: Ophthalmopathy,
dermopathy (pretibial myxedema), thyroid
acropachy, gynecomastia
 Diffuse Toxic Goiter (Graves’ Disease)
• Antibodies directed against the thyroid
hormone receptors (TSH-R)  Thyroid-
stimulating immunoglobulin (TSI)
• Ophthalmopathy – due to presence of TSH-R
in orbital fibroblasts  increase in retro-
orbital fat and GAGs  proptosis and diplopia
 Diffuse Toxic Goiter (Graves’ Disease)

• PE:
– Diffusely and symmetrically enlarged thyroid gland
– Bruit or thrill over the thyroid gland
– Loud venous hum in the supraclavicular space
 Diffuse Toxic Goiter (Graves’ Disease)
• Diagnosis:
– Suppressed TSH with or without an elevated free
T4 or T3 levels
– (+) eye signs
– (-) eye signs  123I uptake and scan
• Elevated uptake and diffusely enlarged gland
– Elevated TSH-R or TSI are diagnostic of Graves’
 Diffuse Toxic Goiter (Graves’ Disease)
• Treatment
– Antithyroid drugs – in preparation for RAI ablation
or surgery
• Propulthiouracil
• Methimazole – associated with congenital aplasia
• Betablockers (propranolol) – for cathecolamine
response to thyrotoxicosis
– Curative for:
• Small, nontoxic goiters <40g
• Mildly elevated thyroid hormone levels
• Negative or low titers of TSI
• Rapid decrease in gland size
 Diffuse Toxic Goiter (Graves’ Disease)
• Treatment
– Radioactive Iodine Therapy (131I) – mainstay
– Surgery – for complete and permanent control of
the disease with minimal morbidity
• Recommended for:
– Confirmed cancer or suspicious thyroid nodules
– Young
– Desire to conceive soon (<6months) after treatment
– Severe reactions to antithyroid medications
– Large goiters (>80g) with compressive symptoms
– Reluctant to undergo RAI
• Total or near-total thyroidectomy
 Toxic Multinodular Goiter (Plummer
Disease)
• In older patients who often have a prior history of
a nontoxic multinodular goiter
• Manifestations:
– Signs and symptoms of hyperthyroidism without the
extrathyroidal manifestations
• Diagnosis:
– suppressed TSH, elevated FT4 or FT3
– Increased RAI uptake showing multiple nodules with
increased uptake and suppression of the remaining
gland
 Toxic Multinodular Goiter (Plummer
Disease)
• Treatment:
– RAI – elderly patients with poor operative risks
– Near-total or toatal thyroidectomy – avoid
recurrence and consequent increased
complications with repeat surgery
 Toxic Adenoma
• Hyperthyroidism from a single
hyperfunctioning nodule
• Found in younger patients
• Somatic mutations of the TSH-R gene
• PE: solitary thyroid nodule without palpable
thyroid tissue on the contralateral side
• Diagnosis: “hot” nodule with suppression of
the rest of the thyroid gland
 Toxic Adenoma
• Treatment:
– Smaller nodules: antithyroid medications and RAI
– Larger nodules and young patients: Lobectomy
and isthmusectomy
 Thyroid Storm
• Condition of hyperthyroidism accompanied by fever, CNS
changes, cardiovascular and GI dysfunction, hepatic
failure
• Triggered by precipitating factors
• Treatment:
– Betablockers
– O2 supplementation and hemodynamic support
– Nonaspirin compounds for hyperpyrexia
– Lugol’s iodine or sodium ipodate
– PTU
– Corticosteroids
Hypothyroidism
Hypothyroidism
• Low T4 and T3
• Primary: Inc TSH
• Secondary: Dec TSH that
do not increase with TRH
stimulation
• Treatment: T4
 Thyroiditis
• Acute (suppurative) thyroiditis - Streptococcus and anaerobes
account for 70% of the cases
– more common in children, preceded by URTI or otitis media
– Symptoms:
• Severe neck pain radiating to jaws or ear
• Fever
• Chills
• Odynophagia
• Dysphonia
– Treatment:
• Parenteral antibiotics
• Drainage of abscesses
• Thyroidectomy – persistent abscesses or failur to open drainage
 Thyroiditis
• Subacute thyroiditis
– Painful thyroiditis – from postviral inflammatory response
• Gradual onset of neck pain with radiation to the mandible and the ear, preded by
URTI
• Four stages:
– Hyperthyroid – due to release of thyroid hormones
– Euthyroid
– Hypothyroidism
– Euthyroid
• Treatment: primarily symptomatic
– Aspirin or NSAIDs fir oain
– Short-term thyroid replacement
– Thyroidectomy – not responsive to medical treatment or for recurrent disease
 Thyroiditis
• Subacute thyroiditis
– Painless thyroiditis – autoimmune in origin and
may occur sporadically or postpartum
• PE: Normal-sized or minimally enlarged, slightly firm, nontender
gland
• Treatment:
– With symptoms: betablockers and thyroid hormone replacement
– Reccurent, disabling thyroiditis: Thyroidectomy or RAI ablation
 Thyroiditis
• Chronic thyroiditis
– Lymphocytic (Hashimoto’s) Thyroiditis – transformation of thyroid
tissue to lymphoid tissue
• Most common inflammatory disease of the thyroid and the leading
cause of hypothyroidism
• Autoimmune  antibiodies directed against:
– Thyroglobulin (60%)
– TPO (95%)
– TSH-R (60%)
– Sodium/Iodine Symporter (25%)
• PE: mildly enlarged, firm, granular thyroid gland
• Histology: Diffusely infiltrated by small lymphocytes and plasma
cells with well-developed germinal centers
 Thyroiditis
• Chronic thyroiditis
– Lymphocytic (Hashimoto’s) Thyroiditis – transformation of thyroid
tissue to lymphoid tissue
• Diagnosis: elevated TSH with thyroid autoantibodies
– FNAB: used in patients with a solitary suspicious nodule or rapidly enlarging
goiter
• Treatment: Thyroid hormone replacement therapy
– Levothyroxine
» All patients with TSH >10 uIU/mL
» 5-10 uIU/mL in the presence of a goiter or anti-TPO antibodies
– Surgery – suspicion of malignancy or those with compressive symptoms or
cosmetic deformity
 Thyroiditis
• Chronic thyroiditis
– Riedel’s Thyroiditis – replacement of all or part of the thyroid
parenchyma by fibrous tissue, which also invades into adjacent tissues
• Painless, hard anterior neck mass which can produce compresive symptoms
• Symptoms of hypothyroidism and hypoparathyroidism
• PE: Hard, “woody” thyroid gland with fixation to the surrounding tissues
• Diagnosis: via open thyroid biopsy
• Treatment: Surgery via wedge excision of the isthmus
THANK YOU