Management of Thyroid

Diseases Part I
The Thyroid Anatomy and
Physiology
Thomas Ashley
Anatomy

• Thyroid is situated in the pretracheal fascia in the anterior part of the neck
• It is one of the largest endocrine glands – 20g (7-25g in Africans; 15-25 in Caucasians)
• Consists of 2 lobes lying on either side of the trachea connected by the Isthmus which
lies across the trachea at level of C6
• Lateral lobes extend from the sides of the thyroid cartilage down to the 6th Tracheal Ring
• The Pyramidal lobe if present extends from the isthmus usually on the left and represents
the embryologic reminant of the thyroid
Anatomy

• Anatomical relations are

• Anteriorly – strap muscles overlapped by SCM; anterior jugular vein runs anteriorly over the
isthmus
• Deep – lies the larynx and trachea. Further posteriorly ly the pharynx and oesophagus with the
carotid sheath on either side. Between the trachea and the oesophagus lies the recurrent
laryngeal nv. Deep to the upper lobe lies the external laryngeal nv which supplies the
cricothyroid muscle
Posteriior view Venous drainage
Arterial supply
Anatomy

• Blood supply is very rich

• 3 arteries
• Superior thyroid artery from external carotid – supply the upper pole
• Inferior thyroid from thyrocervical trunk – supply inferior and posterior part
• Thyroidae ima artery – absent in many people. Arises from the arch of the aorta or
brachiocephalic artery
• 3 veins
• Superior –drain into internal jugular vein
• Middle – drain into internal jugular vein
• Inferior – drain into the brachiocephalic veins
 Primary
• Tracheo-oesophageal nodes
• Prelaryngeal (delphian) nodes
Lymphatic supply • Mediastinal nodes

Secondary
• Deep cervical
• Supraclavicular
• Occipital
 • Autonomic nervous system
• Parasympathetic from vagus
Innervation
• Sympathetic from Superior, Middle and Inferior cervical
ganglia of the Sympathetic trunk
Thyroid gland - Development

The thyroid gland starts to develop in the 3rd week of gestation (day 24)

It is the 1st of the endocrine glands to develop

It develops from a median downward growth of a column of cells from the pharyngeal floor
between the 1st and 2nd pharyngeal pouches
It develops from neural crest cells and the primitive pharynx which is mesodermal
Thyroid gland Development

The thyroid ends in the neck

During its development a canalized column is formed called the

thyroglossal duct
The duct bifurcates to form the lobes with the central portion
forming the pyramidal lobe
Anatomy of thyroglossal duct
showing its pathway
Anatomy - histology

• Thyroid tissue is composed of Follicles

• The follicles consist of cuboidal cells in a sphere in which there is a protein-rich material
called colloid made up of thyroglobulin
• Thyroglobulin is a large glycoprotein synthesized in the RER of the the cells
• The glolgi apparatus add a carbohydrate moiety to form thyroglobulin
• Thyroid gland has two secretory cells:
1. Follicular cells—secretes thyroid hormones (Thyroxine
• (T4), Tri-iodothyronine (T3).
2. Parafollicular cells (‘C’ cells)—secretes calcitonin.
Synthesis of thyroid hormones – T3, T4

• T3 and T4 formed from iodination of Tyrosine

• Iodine obtained from the diet in the form of iodide and actively taken up in the thyroid
follicular cells where it diffuses to the apical cell where it is oxidized to iodine and
diffuses into the adjacent colloid where it is stored as thyroglobulin
• Cell service enzymes catalyses the iodination of tyrosine residue in thyroglobulin to form
Monoiodotyrosine and Diiodotyrosine
• Coupling of these molecules form T3 and T4
Synthesis of thyroid hormones – T3, T4

• When the thyroid cells are stimulated to form thyroid hormones villae extend from the
follicular cells and then engulf the colloid
• These thyroglobulin-containing droplets are combined in the cell with lysozymes which
contain proteolytic enzymes which breakdown the thyroglobulin to produce T3 and T4
• The hormones are then released into the circulation
• T4 is the principal secretion; T3 is more potent
• Tissues convert T4 to T3
Synthesis of thyroid hormones – T3, T4
factors
• Higher centres eg thermoregulatory centre → TRH(hypothalamus) → TSH (anterior
pituitary) → Synthesis and release of T3/T4
• T3 and T4 exert negative feedback to anterior pituitary and hypothallamus
Thyroid Hormone Transport

• T3/T4 are fairly insoluble

• It is transported bound to plasma proteins – mainly thyroid binding globulin, but also to
albumin
• T4 is more closely associated to plasma proteins,
• Hence more T3 is available but more rapidly removed from the body
Functions of thyroid hormone

• Primarily controls the basic metabolic rate and heat production

• It works slowly and has a prolonged period of action
• High levels cause most tissues, excluding the brain to increase their basal metabolism and
O2 consumption
• Hence high levels increase heart contractility and HR aid increase O2 delivery
• Ventillation increases
• Red cell concentration rises
Functions of thyroid hormone

• It enhances the glycogenic effect of insulin

• Increases the number and sensitivity of beta adrenergic receptors
• Enhances fat storage in normal quantities but in high concentrations cause an imbalance between
synthesis and breakdown of fat stores
• Increased lipolysis and proteolysis
• Increases growth hormone levels
• Vital in growth and development of the nervous system
• Influences mental alertness and speed of nerve conduction
Causes of hyperthyroidism

• Autoimmune disease cause 99% of cases – Usually Grave’s disease

• Carcinima
• Increase TSH secreation
• Administration of exogenous TH
Hyperthyroidism and Grave’s

• In graves disease antibodies bind to and activate TSH receptors causing increased, unregulated
thyroid hormone
• This can be triggered in
• Pregnancy
• Iodine excess
• Lithium therapy
• Viral or bacterial infections
• Withdrawal of glucocorticoids

• It is 7-10x more common in women

Features of Hyperthyroidism

• General features
• Weight loss
• Malaise
• Tremor
• Heat intolerance
• Proximal myopathy
• Gynaecomastia
• goitre
Thyroid Diseases
• Congenital anomalies
• Goitres
Congenital Anomalies of thyroid

Ectopic thuyroid Thyroglossal cyst Thyroglossal fistula

Lingual thyroid Dyshormongenesis Agenesis

Ectopic thyroid

• Ectopic thyroid tissue may lie anywhere along the line of descent.
• Whole of the thyroid gland or residual thyroid lies in an abnormal position either in the
posterior part of the tongue, or in the upper part of the neck in midline, or intrathoracic
region.
• Radioisotope scan, CT scan for intrathoracic thyroid will confirm the diagnosis.
Thyroiglossal Cyst

• Cystic remnant of embryologic thyroglossal duct

• The thyroid may be in the usual site or may not be present and the cyst is the only source of thyroid tissue
• It is a tubulodermoid type lined with pseudostratified ciliated columnar epithelium
• Usual site
1. Beneath the foramen caecum
2. In the floor of mouth
3. Suprahyoid
4. Subhyoid—commonest site
5. On the thyroid cartilage
Thyroglossal cyst

• Presents has an anterior neck swelling

• Moves with protrusion of the tongue as well as with
swallowing
• Smooth, soft, fluctuant
• May transilluminate light
Differentials of thyroglossal Cyst

• Subhyoid bursa
• Pre-tracheal lymph node
• Drermoid cyst
• Solitary thyroid of the isthmus
Thyroglossal Cyst - Treatment

• Treatment
• Sistrunk operation: Excision of cyst and also full tract upto the foramen caecum is done
along with removal of central part of the hyoid bone, as the tract passes through it.
• Complications
• Infection – abscess
• Fistula
• Malignancy (usually Papillary ca)
Thyroglossal Fistular

• Occur in different scenarios

• Infected thyroglossal cyst complicated with fistula
• Incomplete resection of thyroglossal cyst together with its tract

• Lined by columnar epithelium

• Discharges and it is a seat for recurrent infections
• Treatment is Sistrunk procedure
Lingual Thyroid

• Thyroid swelling at the foramen caecum

• Smooth or lobulated, blueh to red
Lingual thyroid – Clinical features

• Clinical symptoms may range from dysphagia, dysphonia, snoring with a plumy
voice, sore throat, occasional bleeding and upper airway obstruction.
• Usually asymptomatic until late adolescence.
• Rare cases of sleep apnoea syndrome due to lingual thyroid
• Acute symptoms - depends on size and other acute processes eg bleeding
• Sensation of a foreign body or lump in the throat, dysphonia, dysphagia, orthopnoea, or
dyspnoea.
Differential Diagnosis

• Differential diagnosis for lingual thyroid should include

• vascular tumours
• telangiectatic granuloma,
• teratomas, and
• benign or malignant processes in the posterior region of the tongue
Lingual thyroid – treatment

• Surgical eccision
Dyshormogenesis

• It is an autosomal recessive condition wherein there is either deficiency of thyroid

enzymes (either peroxidase or dehalogenase) or inability to concentrate or to bind or to
retain iodine.
• It may be familial and patient presents with large diffuse vascular goitre involving both
lobes.
• They respond very well to L-thyroxine and may not require surgery at any time.
• Condition may be associated with congenital deafness which is being called as Pendred’s
syndrome.
Goitres - Classification

• Goitre is enlargement of the thyroid gland

• Classication
• Simple (Nontoxic)
• Toxic
• Neoplastic
• Inflammatory
• others
Goitres – Simple Nontoxic

A. Diffuse hyperplastic—
i. Physiological
• Puberty.
• Pregnancy
ii. Primary iodine deficiency (Endemic; dietary iodine intake less than 100 μg/day)
iii. Secondary iodine deficiency
a. Goitrogens of Brassica family – cabbage
b. Drugs – Lithium, PAS
c. Excess flouride
Goitres – Simple Nontoxic

B. Colloid
C. Nodular
D. Solitary nontoxic
E. Recurrent nontoxic
Goitres – Toxic

A. Diffuse - Primary
B. Multinodular - Secondary
C. Toxic solitary nodule - Tertiary
D. Recurrent toxic
Goitres - Neoplastic

• Benign – Follicular, Hurtle cell

• Malignant
• Carcinomas
• Papillary cell
• Follicular cell
• Medullary cell
• Anaplastic
• Lymphomas
Goitres - Inflammatory

a. Hirshimoto’s autoimmune thyroiditis

b. de-Quervain’s autoimmune thyroiditis
c. Riedel’s
d. Bacterial (rare)
Goitres - Others

• Amyloidosis
Diffuse Goitre

• Due to increased TSH

• L-Thyroxine is helpful
Nodular Goitre

• Stages of multinodular goitre formation

• • Stage of hyperplasia and hypertrophy
• Stage of fluctuation in TSH
• Stage of formation of nodules (inactive); (inter- nodular tissues are active)
Colloid goiter is a goiter due to long standing iodine deficiency with localized accumulation
of significant colloid in the gland.
Multinodular goitre

• Clinical Features
• More common in middle aged females (10:1).
• It is a slowly progressive disease with many years of history.
• Multiple nodules of different sizes are formed in both lobes, also in isthmus, which is firm,
nodular, nontender, moves with deglutition.
• Recent increase in size signifies malignant transformation or haemorrhage
Multinodular Goitre

• Complications
• Secondary thyrotoxicosis (30%)
• Haemorrhage
• Obstruction – airway, oesophagus
• Malignant transformation (10%)
• Cosmetic problems
Multinodular goitre

• Investigations

• T3, T4, TSH, U/S neck, FNAC.

• X-ray neck shows ring or rim calcification; also reveals the position and compression of trachea.

• Indirect laryngoscopy to see vocal cords prior to surgery (This is mainly for documentation and
legal purpose as even in individual with normal voice, one of the vocal cords may have been
paralyzed by viral infection like mumps, probably during childhood and have compensated).
• Radioisotope iodine scan – in selected patients when indicated only.

• Routine blood investigations

Multinodular goitre - Treatment

• Usually surgery is preferred.

• Reason – it is an irreversible stage and chances of complications like development of
toxicity, haemorrhage and follicular carcinoma is high and also for cosmetic reason.

• Total, subtotal, partial thyroidectomy can be done

• L-Thyroxine is given post operatively to suppress TSH
Multinodular Goitre

• Prevention of multinodular goitre

• L-thyroxine (0.1-0.2 mg) when patient develops goitre in puberty.
• Formation of nodular goitre can be prevented by
• correcting iodine deficiency by using iodine rich diet like eggs/ seafood/milk or iodized salts
• avoiding goitrogenic drugs and diet.
Solitary Thyroid nodule

• A single palpable nodule in an otherwise normal thyroid gland

• Causes – Thyroid adenoma, papillary Ca, large palpable nodule in a MNG, thyroid cyst
• Can toxic or nontoxic
Solitary Thyroid Nodule

• Investigations
• Tripple assessment –
• Hx and Physical examination,
• USS
• FNAC
• TFT
• Radio-isotopes scan
• Neck X-ray
Solitary Thyroid Nodule

• Treatment
• Radio-iodine therapy
• Surgery

• Nontoxic – Hartley Dunhill operation

• Toxic
• Age>45yrs radio-iodine
• Age <45yr lobectomy

• Carcinima – Total/near total thyroidectomy + TSH suppression

• Medullary ca - total thyroidectomy + LN dissection
Solitary Thyroid Nodule

• Indications for surgery

• Malignacy
• Follicular neoplasm
• Toxic nodule in the young
• Recurrent
• Cosmesis
• Obstruction
Retrosternal Goitres

• >50% of thyroid below the suprasternal notch

• Primary (intrathoracic) vs Secondary (extension from neck)
Retrosternal Goitre - Clinical Features

• Dyspnoea on extention of neck or lying down

• Dysphagia
• Stridor
• Positive Pemberton’s sign
• Horse voice
• Dull percussion note
Thyroid Cyst

• It is thyroid swelling which is cystic in nature eliciting positive fluctuation

• But tensely cystic swelling can be hard (thyroid paradox—with cellular tumour of thyroid
can be soft also)
• Common cause is colloid degeneration–50%.There will be absence of epithelial lining
• 30% of solitary nodules are cystic
• 15% cystic swellings in thyroid are malignant
• Cyst formation is common in papillary carcinoma of thyroid
• A cyst if contains both solid and cystic areas is called as complex cyst which is
more likely to be malignant
• FNAC may cause regression of simple cyst. Even after three repeated aspirations
if recurrence occurs, surgery is needed
• Surgery is indicated in complex cyst and if cyst is more than 4 cm in size
Hyperthyroidism

• Symptom complex due to raised level of thyroid hormones

• Types
• Diffuse (Primary) – Grave’s
• Toxic multinodular (secondary)
• Toxic nodule
• Other causes –
• De-Quervain’s, thyrotoxicosis factitia, carcinoma thyroid, drugs eg amiodarone
• Jod Basedow thyrotoxicosis, stroma ovarii, neonatal thyrotoxicosis
Hyperthyroidism - Clinical features

1. Gastrointestinal system
• Weight loss in spite of increased appetite.
• Diarrhoea (due to increased activity at ganglionic
• level).

2. Cardiovascular system
• Palpitations.
• Shortness of breath at rest or on minimal exertion.
• Angina.
• Cardiac irregularity.
• Cardiac failure in the elderly (CCF).
1. Neuromuscular system • Integument
2. • Undue fatigue and muscle weakness. • Tremor. • • Hair loss.
• Pruritus.
3. Skeletal system
• Palmar erythema.
• • Increase in linear growth in children.

• Genitourinary system
• Psychiatry
• Oligo- or amenorrhoea.
• • Irritability.
• Occasional urinary frequency.
• Nervousness. • Insomnia.
• Tremor is due to diffuse overactivity at the grey matter
• Sympathetic overactivity causes
• Dyspnoea
• Palpitation
• Increased swearing
• Heat intolerance
• Nervousness

• Increased catabolism causes – increased appetite, weight loss

• Bruit is usually heard in the upper pole because the superior vthyroid artery enters the gland superficially
Grave’s Disease

• Autoimmune
• Increased thyroid stimulating antibodies
• Goitre is not a usual feature
• Gland is diffusely hyperplastic
• 8x commoner in females
• Hyperthyroidism is usually more severe
Eye Signs

• Order of appearance
• Abnormal blinking (Stellwag’s sign)
• Lid lag (von Graefe’s sign)
• Absence of wrinking of forehead on upward gaze (Joffroy’s sign)
• Lack of convergence of eye ball (Moebius’ sign)

• Exolphthalmus
Eye Signs - Eponyms

• Stellwag’s sign • Jellinek’s sign – increased pigmentation of

• von Graefe’s sign eyelid margins

• Joffroy’s sign • Rosenbach’s sign – tremor of closed

eyelids
• Moebius’ sign
• Enroth’s sign – oedema of eyelids and
• Naffziger’s sign – eye seen protruding conjunctiva
when observed from behind with neck
• Dalrymple’s sign – upper eyelid retraction
extended
Exophthalmos

• Protrusion of eyeball due to retrobulbar oedema and round cell infiltrate with associated
upper eyelid spasm and visible sclera below the limbus
• Visible sclera first below the lower edge of the iris then upper part
• Severe exophthalmos is characterized by - Eyelid oedema, chemosis, conjunctival
injection, Diplopia, ophthalmoplegia (complete weakness of all extraocular muscles and so
no movements possible),Corneal ulceration, Papilloedema soon develops.
• Finally it may also cause loss of vision.
Exophthalmos – treatment

• Dark spectacles
• Steroids
• Antibiotics
• Lateral tarsorrhaphy
• Eye lid surgery
• Irradiation therapy
• Eye decompression
• Diuretics
Eye signs only
• Resistance to retro displacement of eye
• Oedema of conjunctiva and caruncle
• Lacrimal gland enlargement
• Injection of conjunctiva
• Oedema and fullness of lids
Grading of exophthalmos

1. Mild: Widening of palpebral fissure due to lid retraction

2. Moderate: Orbital deposition of fat causing bulging with positive Joffroy’s sign.

3. Severe: Congestion with intra-orbital oedema, raised intra-ocular pressure, diplopia and ophthalmoplegia

4. Progressive: In spite of proper treatment progression of eye signs is seen with chemosis, corneal ulceration and

ophthalmoplegia.
Cardiac Manifestations

• ECG findings • Crile’s classification

• Tachycardia • Grade I <90 bpm
• AF – paroxysmal or persistent • Grade II 90-110 bpm
• Ectopics • Grade III >110 bpm
• Extrasystoles

• Pulsus paradoxus
• Wide pulse pressure
Myopathy

• Weakness of proximal muscles – arm and front thigh

• Weakness is more during isometric contractions
• Walking downstairs
• Lifting a full bucket
• Severe cases may mimic myasthenia gravis
Pretibial Myxedema

• Myxomatous(hyaluronic acid) tissue deposit in the skin and subcutaneous tissue

• Thickened, shinny, red , dry skin, bilateral
• Commonly occur in the shin, but also in the ankle, dorsum of the foot, knees, shoulders,
elbows, upper back, pinnae, nose, and neck
• Usually associated with exophthalmos and autoimmune disease
• Treatment - topical steroids + compression stockings
Thyroid Acropachy

• Thyroid acropachy is a rare complication of autoimmune thyroid disease with

characteristic imaging findings.
• Clinically, it presents as nail clubbing, swelling of digits and toes,
• Almost always in association with thyroid ophthalmopathy and dermopathy
Primary Vs Secondary thyrotoxicosis

Primary Secondary
Age Younger age group Older age group
Timing of symptoms Symptoms first Swelling first
Severity of symptoms More severe Less severe and progressive
Commoner symptoms Eye symptoms Cardiac symptoms
Swelling Diffuse, bilateral, soft or firm Large and nodular
Toxic Nodule

• A single overactive nodule

• The normal gland is suppressed due to the high level of thyroid hormone exerting a
negative feedback on TSH
• Investigations - TFT, Radioiodine studies, TRH, ECG, FBC, thyroid antibody level
• Treatment – Antithyroid, radioiodine, surgery