Toxic goiter

 ‫به لٌين صالح كويى‬.‫د‬

 ‫جراح أخصائي‬
 )‫بورد(دكتوراه‬
 FICMS, FICS, MB Ch B
 GENERAL SURGEON
• Thyrotoxicosis = “any condition that results in thyroid hormone excess”
– Includes: Graves Disease, Toxic Goiter, Thyroiditis, and Excessive
Thyroxine Ingestion

• Hyperthyroidism = “Specifically hyperfunctioning of the thyroid gland”

– Most Commonly caused by Graves Disease in the young
– Toxic Nodular Goiter in the elderly
Clinical Types
 Toxic Diffuse goitre (Graves’ disease )

 This is characterized by a diffuse vascular goitre,

& usually occurs in younger women.
 The syndrome is that of primary thyrotoxicosis
 50% of patients have a family history of
autoimmune endocrine diseases.
 The whole of the functioning thyroid tissue is
involved, and the hypertrophy and hyperplasia
are due to an IGg abnormal thyroid-stimulating
antibodies (TSH-RAb ) that bind to TSH receptor
sites and produce a prolonged effect.
.Graves’ disease
 Toxic nodular goitre
A simple nodular goitre is present for a long
time before the hyperthyroidism, usually seen
in the middle-aged or elderly patients.
The syndrome is that of secondary
thyrotoxicosis.
 Toxic nodule

This is a solitary overactive nodule.

It is autonomous & its hypertrophy and
hyperplasia are not due to TSH-RAb.
 Histology
The normal thyroid gland consists of acini
lined with flattened cuboidal epithelium
and filled with homogeneous colloid
 In hyperthyroidism there is hyperplasia
of acini, which are lined by high columnar
epithelium. Many of them are empty and
others contain vacuolated colloid with a
characteristic ‘scalloped’ pattern adjacent
to the thyrocytes.
Thyrotoxicosis Normal histology
 Clinical features of thyrotoxicosis
Symptomatology : Female/Male 8/1.
The most significant symptoms are
• Tiredness;
• Emotional lability;
• Heat intolerance;
o Hair loss
• Weight loss;
• Excessive appetite;
• Palpitations.
 The clinical signs of thyrotoxicosis are :
General signs: like
Irritability, nervousness & agitation
Are they thin ? since patients with thyrotoxicosis
have a generalized loss of weight ,specially of
the face, but may also have localized wasting of
their hands,face &shoulder muscle.
Are they under-clothed ? since patients with
thyrotoxicosis they feel hot
Hair loss
 Local signs :are

i. Hand sign
ii. Eye sign
iii. Neck sign
 i. Hand signs
1. Tachycardia & atrial fibrillation
2. Palmar erythema
3. Moist hand
4. Wasting of the hand muscle
5. Tremor (fast ,fine tremor)
6. Clubbing
clubbing
Palmar erythema
ii. Eye signs: there are 4 clinical signs
1. Exophthalmos: (both lids moved
away from the center , with sclera
visible below or all round the iris).
exophthalmos
2. Lid retraction & lid lag:
 This sign is caused by over-activity of the
involuntary (smooth muscle) part of the levator
palpebrae superioris muscle,
 if the upper eyelid is higher than normal & the
lower lid is in its correct position , the patient
has lid retraction(Dalrymple’ s sign).
 when the upper eyelid does not keep pace with
the eyeball as it follows a finger moving from up
downward , the patient has lid lag.
Lid retraction( Dalrymple’s sign)
Lid Lag (Von Graefe’s) sign
3. Ophthlmoplegia
 The cause of the weakness is oedema & cellular
infiltration of the occular muscles & occulomotor
nerves.
 The muscles most commonly affected are
superior& lateral rectus & inferior oblique , so the
patient can not looks upwards & outwards.
 Weakness of the extraocular muscles may
results in diplopia (double vision) & failure of
convergence (Moebius` sign)
Medial deviation of the left eye
due to ophthalmoplegia
4. Chemosis:
chemosis is oedema of the conjuctiva.

Chemosis is caused by the obstruction of

the venous & lymphatic drainage of the
conjuctiva by the increased retro-orbital
pressure.
CHEMOSIS
In severe cases
papilloedema and
corneal ulceration Progressive (malignant)
occur. exophthalmos
When severe and
progressive it is
known as malignant
exophthalmos ,and
the eye may be
destroyed.
iii. neck signs :
The most significant signs are the
presence of a goitre,
The goitre in primary thyrotoxicosis is
diffuse and vascular; it may be large or
small, firm or soft, and a thrill and a bruit
may be present.
In secondary thyrotoxicosis the goitre is
nodular.
Thyroid dermopathy (pretibial
• In severe cases the skin
myxoedema
of the whole leg below
the knee is involved,
together with that of
the foot and the ankle,
and there may be
clubbing of the fingers
and toes (thyroid
acropathy).
 Cardiac rhythm
 A fast heart rate, which persists during sleep, is
characteristic.
 Cardiac arrhythmias are more common in elderly
patients because of the prevalence of coincidental heart
disease.
 Stages of development of thyrotoxic arrhythmias are:
1 multiple extrasystoles;
2 paroxysmal atrial tachycardia;
3 paroxysmal atrial fibrillation;
4 persistent atrial fibrillation, not responsive to digoxin.
 Myopathy

• Weakness of the proximal limb muscles is

commonly found if looked for.
• Severe muscular weakness (thyrotoxic
myopathy) resembling myasthenia gravis,
occasionally occurs.
 Diagnosis of thyrotoxicosis
Most cases are diagnosed clinically.
 Difficulty is most likely to arise in the
differentiation of mild hyperthyroidism from
an anxiety state when a goitre is present. In
these cases TFT is required.
 Thyrotoxicosis should always be
considered in:
• Children with a growth spurt,
behaviour problems or myopathy;
• Tachycardia or arrhythmia in the
elderly;
• unexplained diarrhoea;
• unexplained weight loss.
Principles of treatment of thyrotoxicosis

Non-specific measures are rest and

sedation, avoiding loud voice, crowded
place, even changing work place.

 specific measures, i.e. the use of anti-

thyroid drugs, surgery and radioiodine
 Anti-thyroid drugs
 carbimazole and propylthiouracil.
 β- blockers such as (indeal)propranolol and
nadolol are used to block the cardiovascular
effects of the elevated T4.
Iodides, which may reduce the vascularity of
the thyroid, should be used only as
immediate preoperative preparation in the 10
days before surgery
Anti-thyroid drugs are used to restore the
patient to an euthyroid state and to maintain
this for a prolonged period in the hope that a
permanent remission will occur i.e. the
production of TSH-RAbs will diminish or
cease.
Anti-thyroid drugs cannot cure a toxic nodule.
Advantages. No surgery and no use of radioactive
materials.
• Disadvantages. Treatment is prolonged and the
failure rate is at least 50%.
Duration of treatment : 6month-2 years
S.E: Very rarely there is a dangerous drug reaction,
particularly agranulocytosis or aplastic anaemia. If
a sore throat develops the patient should be
instructed to discontinue treatment until WBC has
been checked because of the risk of
agranulocytosis
Dose : carbimazole 10mg X3 OR
10mgX4 is given, with a latent interval
of 7–14 days before clinical
improvement is apparent.
When the patient becomes
biochemically euthyroid, a
maintenance dose of 5 mg X2 OR
5mgX3 is given for 6–24 months.
An alternative technique is to continue with
the high dose of carbimazole and inhibit all
T3 and T4 production by giving a maintenance
dose of 0.1–0.15 mg of thyroxine daily.
(‘block and replacement treatment’)
The levels of TSH-RAbs usually fall during
treatment and this accounts for the
permanent cure that occurs in 50% of
patients
 Surgery
 In all types of toxic goiter(diffuse,nodular
&autonomous toxic nodule) surgery cures by
removing all of the overactive thyroid tissue;
this allows the suppressed normal tissue to
function again.
• Advantages. The goitre is removed, the cure is
rapid and the cure rate is high if surgery has
been adequate.
Disadvantages.
 Radioiodine
 Radioiodine destroys thyroid cells and, as in
thyroidectomy, reduces the mass of functioning
thyroid tissue to below a critical level.
 Advantages. No surgery and no prolonged drug
therapy.
 Disadvantages. Isotope facilities must be available.
 The rate and timing of late thyroid failure are
influenced by the dose selected (200–600 MBq).
 The higher dose is likely to result in thyroid failure in
6 months, whereas the lower dose may result in late
thyroid insufficiency.
44 MEDICAL COLLEGE-HMU 07/03/2024 05:47 AM