Property of Prof. Dr. Mohamed Ahmed Yehia, Department of General Surgery, Faculty of Medicine, University of Zagazig, Egypt

1. Thyroid GlandThyroid Gland
Prof. Dr. Mohamed Ahmed YehiaProf. Dr. Mohamed Ahmed Yehia
Professor of general surgeryProfessor of general surgery
Zagazig Faculty Of MedicineZagazig Faculty Of Medicine

2. Anatomy of thyroid glandAnatomy of thyroid gland
 Weight : 15 – 25 gmWeight : 15 – 25 gm
 Shape : Butterfly , consisting of two lobes connected by an isthmus. TheShape : Butterfly , consisting of two lobes connected by an isthmus. The
 pyramidal lobe is projection extends up wards from left border of thepyramidal lobe is projection extends up wards from left border of the
 isthmusisthmus
 Extension : - Upper pole which extends to the middle of thyroid cartilage .Extension : - Upper pole which extends to the middle of thyroid cartilage .
 - Lower pole which extends to the 5th tracheal ring.- Lower pole which extends to the 5th tracheal ring.
 Capsule : The thyroid gland has two capsules :Capsule : The thyroid gland has two capsules :
 True capsule from condensation of its connective tissueTrue capsule from condensation of its connective tissue
 False capsule from pretracheal fascia.False capsule from pretracheal fascia.
 Relations :Relations :
 Anteriorly :Anteriorly : Skin , SC. fat , platysma , deep cervical fascia,Skin , SC. fat , platysma , deep cervical fascia,
 pretracheal muscles :-pretracheal muscles :-
 Omo hyoid muscle .Omo hyoid muscle .
 Sterno hyoid muscle.Sterno hyoid muscle.
 Sterno thyroid muscle.Sterno thyroid muscle.
 Its lower poles is overlapped by sterno mastoid muscle.Its lower poles is overlapped by sterno mastoid muscle.
 Posteriorly :Posteriorly :
 Two tubes ( trachea , esophagus)Two tubes ( trachea , esophagus)
 Two cartilages ( thyroid , cricoid )Two cartilages ( thyroid , cricoid )
 Two muscles (Cricothyroid , inf. Constrictor of the pharynx)Two muscles (Cricothyroid , inf. Constrictor of the pharynx)
 Two nerves ( recurrent – external laryngeal )Two nerves ( recurrent – external laryngeal )

3.  Blood supply :Blood supply : It is high vascular organIt is high vascular organ
Arterial :Arterial : 55
 Superior thyroid artery from external carotid arterySuperior thyroid artery from external carotid artery
 Inferior thyroid artery from thyrocervical trunk ofInferior thyroid artery from thyrocervical trunk of
subclavian artery.subclavian artery.
 Thyrodima artery from innominateThyrodima artery from innominate
Venous :Venous : 66
 Sup. thyroid veinSup. thyroid vein
 Drain into internal jugular vein.Drain into internal jugular vein.
 Middle thyroid veinMiddle thyroid vein
 Inferior thyroid vein Drains into innominate vein.Inferior thyroid vein Drains into innominate vein.
→
→

4. NervesNerves relatedrelated to the glandto the gland ::
1- The Superior laryngeal nerves.1- The Superior laryngeal nerves.
2- The Recurrent laryngeal nerves.2- The Recurrent laryngeal nerves.
1- The Superior laryngeal nerves :1- The Superior laryngeal nerves :
(branch. of the vagus)(branch. of the vagus)
 Divides into two branches :Divides into two branches :
a) Internal laryngeal nerve, which pierces (with sup.a) Internal laryngeal nerve, which pierces (with sup.
laryngeal art.) the thyrohyoid membrane to thelaryngeal art.) the thyrohyoid membrane to the
larynx.larynx.
It is sensory to larynx above the level of vocal cordsIt is sensory to larynx above the level of vocal cords
b) The external laryngeal nerve, which descends withb) The external laryngeal nerve, which descends with
the sup. thyroid art.the sup. thyroid art.
 It is motor to the cricothyroid muscle.It is motor to the cricothyroid muscle.

5. 2-2- The Recurrent laryngeal nervesThe Recurrent laryngeal nerves :: ( branches of vagi )( branches of vagi )
 In the early fetus the neck is divided into 6 branchialIn the early fetus the neck is divided into 6 branchial
arches each contains anarches each contains an aortic arch.aortic arch.
 the recurrent laryngeal nerve is the nerve of the 6ththe recurrent laryngeal nerve is the nerve of the 6th
branchial arch which gives rise to the developingbranchial arch which gives rise to the developing
larynx.larynx.
 As the neck elongates and the heart descends, theAs the neck elongates and the heart descends, the
recurrent laryngeal nerves are dragged downward byrecurrent laryngeal nerves are dragged downward by
the descending aortic arches.the descending aortic arches.
 On the Rt. side the 5th & 6th arches disappearOn the Rt. side the 5th & 6th arches disappear
leaving the Rt. R.L.N. to hook around the 4th archleaving the Rt. R.L.N. to hook around the 4th arch
=Rt. subclavian artery.=Rt. subclavian artery.
 On the Lt. side R.L.N. remains hooking around theOn the Lt. side R.L.N. remains hooking around the
6th arch, which doesn`t disappear but forms the6th arch, which doesn`t disappear but forms the
ductus arterious which later gives ligamentum.ductus arterious which later gives ligamentum.
Arteriouses which is overlapped by the aortic arch.Arteriouses which is overlapped by the aortic arch.

6. SoSo
 The Lt. one hooks around the aortic thenThe Lt. one hooks around the aortic then
ascendsascends
 The Rt. one hooks around the Rt. subclavianThe Rt. one hooks around the Rt. subclavian
art. then ascends.art. then ascends.
 Both of them ascends in the trachea-esophagealBoth of them ascends in the trachea-esophageal
groove to enter larynx JUST behind thegroove to enter larynx JUST behind the
suspensory ligament of berry ( anatomicalsuspensory ligament of berry ( anatomical
landmark for recurrent laryngeal nerve )landmark for recurrent laryngeal nerve )
 The recurrent nerves are motor to all intrinsicThe recurrent nerves are motor to all intrinsic
muscles of larynx and sensory to the larynxmuscles of larynx and sensory to the larynx
below the level of vocal cords.below the level of vocal cords.
 Lymphatics :Lymphatics : Into the near by deep cervicalInto the near by deep cervical
lymph nodeslymph nodes

7. Surgical important pointsSurgical important points

Thyroid gland is one of sites ofThyroid gland is one of sites of occultoccult carcinoma in the bodycarcinoma in the body
 The thyroid gland moves up and down during deglutition because it isThe thyroid gland moves up and down during deglutition because it is
enclosed in the pretracheal fascia "enclosed in the pretracheal fascia "false capsulefalse capsule""""surgical capsulesurgical capsule"which is"which is
attached to the ligament of berry " suspensory ligament" which attached toattached to the ligament of berry " suspensory ligament" which attached to
the tracheal and thyroid cartilage.the tracheal and thyroid cartilage.
 The middle thyroid veinThe middle thyroid vein must be ligated first, as it`s easily rupturesmust be ligated first, as it`s easily ruptures
with massive hemorrhage which may be mask the surgical field.with massive hemorrhage which may be mask the surgical field.
 TheThe Superior Thyroid ArterySuperior Thyroid Artery must be ligated within the gland tomust be ligated within the gland to
avoid injury ofavoid injury of superior laryngeal nervesuperior laryngeal nerve which leads to :which leads to :
- Choking : due to loss of sensation above level of vocal cords. (I.L.N)- Choking : due to loss of sensation above level of vocal cords. (I.L.N)
- Loss of high pitched voice due to paralysis of erico-thyroid M. (E.L.N)- Loss of high pitched voice due to paralysis of erico-thyroid M. (E.L.N)
 The Inferior Thyroid ArteryThe Inferior Thyroid Artery must be ligated away and lateral to themust be ligated away and lateral to the
gland to avoid injury of recurrent nerve and parathyroid glandsgland to avoid injury of recurrent nerve and parathyroid glands
 The infrahyoid musclesThe infrahyoid muscles must be divided ( in thyrodectomy for big ormust be divided ( in thyrodectomy for big or
malignant gland) near their upper end to avoid injury of its nerves whichmalignant gland) near their upper end to avoid injury of its nerves which
comes from below ( from ansacervicalis)comes from below ( from ansacervicalis)
 InIn Near Total ThyroidectomyNear Total Thyroidectomy we must leave post medial part of thewe must leave post medial part of the
gland to avoid injury of parathyroid glands and recurrent nerves.gland to avoid injury of parathyroid glands and recurrent nerves.
 In thyroidectomyIn thyroidectomy we have to put a drain before closure of the skin towe have to put a drain before closure of the skin to
avoid post operative hematoma.avoid post operative hematoma.

8.  In unilateral recurrent nerve injury :In unilateral recurrent nerve injury :
vocal cord on that side becomes motionless sovocal cord on that side becomes motionless so
the voice is weak and hoarseness is usuallythe voice is weak and hoarseness is usually
improve within weeksimprove within weeks
 In bilateral recurrent injuryIn bilateral recurrent injury ::
IncompleteIncomplete :: Leads to adduction of cords and suffocationLeads to adduction of cords and suffocation
so, tracheostomy must be done immediately.so, tracheostomy must be done immediately.
CompleteComplete :: Leads to aphonia as the cord lie mid wayLeads to aphonia as the cord lie mid way
between adduction and abduction inbetween adduction and abduction in
cadaveric position.cadaveric position.
 Complete removal or devascularization of the fourComplete removal or devascularization of the four
parathyroidparathyroid glands leading toglands leading to TetanyTetany

9. Development of thyroid glandDevelopment of thyroid gland
 The thyroid gland develops as a medianThe thyroid gland develops as a median
downgrowth of a column of cells from thedowngrowth of a column of cells from the
pharyngeal floor between the 1st and the 2ndpharyngeal floor between the 1st and the 2nd
pharyngeal pouch (subsequently marked bypharyngeal pouch (subsequently marked by
thethe foramen caecumforamen caecum of the tongue). Theof the tongue). The
canalized column becomes the thyroglossalcanalized column becomes the thyroglossal
duct. The thyroglossal duct forms theduct. The thyroglossal duct forms the
pyramidal lobe, the isthmus and most ofpyramidal lobe, the isthmus and most of
lateral lobes of the thyroid. Its remnant maylateral lobes of the thyroid. Its remnant may
appear in adult as :appear in adult as :
 Thyroglossal cystThyroglossal cyst oror thyroglossal fistulathyroglossal fistula oror
ectopic thyroid.ectopic thyroid.

10. Thyroglossal CystThyroglossal Cyst
 It may occur at any site along the course of the thyroglossal duct.It may occur at any site along the course of the thyroglossal duct.
It is considered to be one type of tubulodermoids. It may occurIt is considered to be one type of tubulodermoids. It may occur
above the hyoid bone (suprahyoid) but it is more commonlyabove the hyoid bone (suprahyoid) but it is more commonly
found below it (infrahyoid).found below it (infrahyoid).
 It has the following characters :It has the following characters :
 Exactly in the middle line (in 25% of cases it may be shifted to oneExactly in the middle line (in 25% of cases it may be shifted to one
side , usually to the left) - Shapeside , usually to the left) - Shape globular .globular .
 - Surface- Surface smooth .smooth .
 - Consistency- Consistency firm .firm .
 Moves with deglutition and protrusion of the tongue.Moves with deglutition and protrusion of the tongue.
 A fibrous band can usually be felt extending from the cystA fibrous band can usually be felt extending from the cyst
upwards towards the tongue.upwards towards the tongue.
 Attached to deep structures but not to the skin unless infectionAttached to deep structures but not to the skin unless infection
has occurred.has occurred.
 TreatmentTreatment :: Excision and dissection of the tractExcision and dissection of the tract “Sistrunk’s“Sistrunk’s
operationoperation”. The thyroglossal cyst must be excised because”. The thyroglossal cyst must be excised because
infection is inevitable due to fact that the wall contains nodules ofinfection is inevitable due to fact that the wall contains nodules of
lymphatic tissue which communicate by lymphatics of lymphlymphatic tissue which communicate by lymphatics of lymph
nodes of the neck.nodes of the neck.
→
→
→

11.  It is never congenital , alwaysIt is never congenital , always acquiredacquired due to infection ordue to infection or
incision of pre-existing cyst. It appears as a tiny opening inincision of pre-existing cyst. It appears as a tiny opening in
the middle line of the neck discharging serous fluid orthe middle line of the neck discharging serous fluid or
purulent mucoid material. The opening moves up withpurulent mucoid material. The opening moves up with
deglutition and protrusion of the tongue and becomesdeglutition and protrusion of the tongue and becomes
inverted inwardinverted inward due to uneven rates of growth of the neckdue to uneven rates of growth of the neck
as a whole and that of the thyroglossal tract. The tract canas a whole and that of the thyroglossal tract. The tract can
be felt as a fibrous band extending upwards from the fistula.be felt as a fibrous band extending upwards from the fistula.
It is adherent to hyoid bone and may even pass through it.It is adherent to hyoid bone and may even pass through it.
 TreatmentTreatment :: excision of the whole tract up to the base of theexcision of the whole tract up to the base of the
tongue. In order to avoid the recurrence the middle portiontongue. In order to avoid the recurrence the middle portion
of hyoid bone must be excised.of hyoid bone must be excised.
 Multiple transverse incisions in the neck the first enclosingMultiple transverse incisions in the neck the first enclosing
the opening of the fistula and dissection proceeds upwardsthe opening of the fistula and dissection proceeds upwards
as for as possible. Another incision may done following theas for as possible. Another incision may done following the
tract upwards “tract upwards “Sistrunk’s operationSistrunk’s operation”. Unless the fistula is”. Unless the fistula is
completely removed recurrence is inevitable.completely removed recurrence is inevitable.
ThyroglossalThyroglossal Fistula " Sinus"Fistula " Sinus"

12.  Ectopic thyroid tissue may occur anywhere along the course of theEctopic thyroid tissue may occur anywhere along the course of the
thyroglossal tact. The comment site is the point of origin of thethyroglossal tact. The comment site is the point of origin of the
thyroid at the base of tongue or foramen cecum (lingual , cervicalthyroid at the base of tongue or foramen cecum (lingual , cervical
intro thoracic)intro thoracic)
 The lingual thyroid appears as a firm nodule dating from birthThe lingual thyroid appears as a firm nodule dating from birth
and may increase in size during menstruation If it is big it mayand may increase in size during menstruation If it is big it may
interfere with swallowing , speaking and breathing. Ulcerationinterfere with swallowing , speaking and breathing. Ulceration
and bleeding may be caused by traumaand bleeding may be caused by trauma
 TreatmentTreatment ::excision ,excision , butbut , before excision one must be sure of, before excision one must be sure of
the presence of the normal thyroid in the neck thyroid tissuethe presence of the normal thyroid in the neck thyroid tissue
present in the body this can be achieved by :present in the body this can be achieved by :
 Radio – active iodine uptake.Radio – active iodine uptake.
 Surgical exploration of the neck.Surgical exploration of the neck.
The lateral aberrant thyroidThe lateral aberrant thyroid
 Thyroid tissue to be ectopic in nature but it is nowThyroid tissue to be ectopic in nature but it is now
considered to be secondaries in the lymph gland from aconsidered to be secondaries in the lymph gland from a
small papillferous cacinoma of the thyroid.small papillferous cacinoma of the thyroid.
Ectopic Thyroid

13. RetrosternalRetrosternal GoitreGoitre A very few retrosternal goitres arise from ectopic thyroid T. but , most arise fromA very few retrosternal goitres arise from ectopic thyroid T. but , most arise from
the lower pole of nodular goitre. If the neck is short and pretracheal muscles arethe lower pole of nodular goitre. If the neck is short and pretracheal muscles are
strong as in men , intrathoracil pressure tends to draw these nodules into superiorstrong as in men , intrathoracil pressure tends to draw these nodules into superior
mediastinum.mediastinum.
The degree of descent :The degree of descent :
Substernal type :Substernal type : when nodule is palpable.when nodule is palpable.
plunging type :plunging type : when intrathoracic goitre is forced into the neck by increased intrawhen intrathoracic goitre is forced into the neck by increased intra
thoracic pressure.thoracic pressure.
Intra thoracic type :Intra thoracic type :
Clinical FeaturesClinical Features
It may be symptomless or produce severe obstructive symptoms :It may be symptomless or produce severe obstructive symptoms :
 Dyspnea particularly at night / cough "brassy cough" which is spasmodicDyspnea particularly at night / cough "brassy cough" which is spasmodic
with stridor.with stridor.
 Engorgement of neck veins : in severe cases sup. veins on chest wall.Engorgement of neck veins : in severe cases sup. veins on chest wall.
 Dysphagia rare (Recurrent N. paralysis)Dysphagia rare (Recurrent N. paralysis)
 It also may be malignant or toxic.It also may be malignant or toxic.
InvestigationInvestigation
 X.Ray (AP and lat. View) : soft T. shadow in the sup. mediastinum ,sometimes withX.Ray (AP and lat. View) : soft T. shadow in the sup. mediastinum ,sometimes with
calcification, Deviation or compression of trachea.calcification, Deviation or compression of trachea.
 I3 scan : may help to distinguish a retrosternal goitre from a mediastinal tumor.I3 scan : may help to distinguish a retrosternal goitre from a mediastinal tumor.
Treatment :Treatment : if obstructive symptoms are present, it is unwise to treat a retrosternalif obstructive symptoms are present, it is unwise to treat a retrosternal
goitre with anti-thyroid drugs or radio iodine as these may enlarge the goitre sogoitre with anti-thyroid drugs or radio iodine as these may enlarge the goitre so
resection must done and carried out from the neck.resection must done and carried out from the neck.

14. Struma ovariiStruma ovarii
 It is not ectopic , but port of an ovarian teratoma very rarelyIt is not ectopic , but port of an ovarian teratoma very rarely
carcinogenic change occurs or hyperthyroidism develops.carcinogenic change occurs or hyperthyroidism develops.
 It is a congenital deficiency of thyroid function which mayIt is a congenital deficiency of thyroid function which may
be associated with aplasia of the thyroid or with a goitrousbe associated with aplasia of the thyroid or with a goitrous
gland cretinoid goitre.gland cretinoid goitre.
 ClinicallyClinically
The child is sluggish , constipated, puffy face, thick lips ,The child is sluggish , constipated, puffy face, thick lips ,
flattened nose, protruding tongue , short neck and thickflattened nose, protruding tongue , short neck and thick
short hand (spade shaped hands). He rare cries , and learnshort hand (spade shaped hands). He rare cries , and learn
to suck , walk, talk and control of the sphincters much laterto suck , walk, talk and control of the sphincters much later
than normal.than normal.
In adolescence , the pat is dwarfed and mentally retardedIn adolescence , the pat is dwarfed and mentally retarded
with dry wrinkled skin , supraclavicular pads of fat delayedwith dry wrinkled skin , supraclavicular pads of fat delayed
epiphyseal ossification and very low B.M.R.epiphyseal ossification and very low B.M.R.
 Treatment :Treatment :
Thyroid extract should be given for life. In continued goitreThyroid extract should be given for life. In continued goitre
partial thyroidectomy is indicated to reduce the size of thepartial thyroidectomy is indicated to reduce the size of the
swelling.swelling.
CretinismCretinism

15. GoitersGoiters
"" gutturguttur == throatthroat""
 definitiondefinition :: Any enlargement of thyroid glandAny enlargement of thyroid gland
 clinical diagnosesclinical diagnoses :: mass in the anatomical site of thyroid glandmass in the anatomical site of thyroid gland
and moves up and down with deglutition.and moves up and down with deglutition.
PhysiologyPhysiology
 - The circulating inorganic iodine is picked up to the thyroid cells and- The circulating inorganic iodine is picked up to the thyroid cells and
oxidation occurs by peroxidase enzyme forming oxidized iodineoxidation occurs by peroxidase enzyme forming oxidized iodine
 - This oxidized iodine bind to tyrosine forming mono and- This oxidized iodine bind to tyrosine forming mono and
di-iodotyrosine by the iodonase enzyme.di-iodotyrosine by the iodonase enzyme.
 - Coupling of mono iodotyrosine and di-iodotyrosine occurs forming- Coupling of mono iodotyrosine and di-iodotyrosine occurs forming
tri-iodotyrosine T3 and two molecules of di-iodotyrosine formingtri-iodotyrosine T3 and two molecules of di-iodotyrosine forming
tetra-iodotyrosine T4 which stored in the thyroid follicles .tetra-iodotyrosine T4 which stored in the thyroid follicles .
 - When T3 and T4 are required ,the protease enzyme acted on- When T3 and T4 are required ,the protease enzyme acted on
thyroglobulin to release the free T3 and T4 into the circulation .thyroglobulin to release the free T3 and T4 into the circulation .
 - The thyroid hormones in the blood are bound to serum protein (thyroid- The thyroid hormones in the blood are bound to serum protein (thyroid
binding globulin) and only very small part of it are free in the serum .binding globulin) and only very small part of it are free in the serum .
This free fraction of the thyroid hormones is the biological active part .This free fraction of the thyroid hormones is the biological active part .
 - T3 is more rapid and more potent in its action than T4 .- T3 is more rapid and more potent in its action than T4 .

16. Hormones of thyroid glands:Hormones of thyroid glands:
 Hormones secreted by the thyroid :Hormones secreted by the thyroid :
 Tetraiodothyronine (T4) or thyroxine.Tetraiodothyronine (T4) or thyroxine.
 Tri-iodothyronine (T3)Tri-iodothyronine (T3)
 Thyrocalcitonine, which regulates calcium metabolism .Thyrocalcitonine, which regulates calcium metabolism .
its increase leads to hypocalcemia and vice-versa.its increase leads to hypocalcemia and vice-versa.
 Hormones acting on the thyroid :Hormones acting on the thyroid :
 Thyroid stimulating hormone (T.S.H). it is secreted by theThyroid stimulating hormone (T.S.H). it is secreted by the
anterior pituitary to regulate the thyroid function. Its level risesanterior pituitary to regulate the thyroid function. Its level rises
in cases of stress and according to a feed-back mechanismin cases of stress and according to a feed-back mechanism
whenever thyroid hormones (T3 and T4) are diminished T.S.H.whenever thyroid hormones (T3 and T4) are diminished T.S.H.
increase the vascularity of the gland.increase the vascularity of the gland.
 Long Acting Thyroid Stimulator (L.A.T.S). This is an Lg foundLong Acting Thyroid Stimulator (L.A.T.S). This is an Lg found
in 85% of cases of thyrotoxicosis and may be cause ofin 85% of cases of thyrotoxicosis and may be cause of
exophthalmos.exophthalmos.
 Exophthalmos Producing Substance (E.P.S). This is supposedExophthalmos Producing Substance (E.P.S). This is supposed
to to produce infiltrative changes in the orbit in cases ofto to produce infiltrative changes in the orbit in cases of
exophthalmos and its level drops after hypophysectomy.exophthalmos and its level drops after hypophysectomy.

17. CLASSIFICATIONCLASSIFICATION
OFOF
GOITREGOITRE

18. Simple GoiterSimple Goiter
 It is due to stimulation of thyroid gland by the anterior pituitaryIt is due to stimulation of thyroid gland by the anterior pituitary
i.e. by increased levels of circulating T.S.H. secretion is increasedi.e. by increased levels of circulating T.S.H. secretion is increased
by low levels of circulating thyroid hormones. Any factor ,by low levels of circulating thyroid hormones. Any factor ,
therefore that maintains a persistently low level of circulatingtherefore that maintains a persistently low level of circulating
thyroid hormones can be responsible for a simple goitre. The mostthyroid hormones can be responsible for a simple goitre. The most
important factor is iodine deficiency but , defects in hormoneimportant factor is iodine deficiency but , defects in hormone
synthesis may be responsible.synthesis may be responsible.
1. Iodine deficiency :1. Iodine deficiency : one mg/kg/body wt/dailyone mg/kg/body wt/daily - Daily requirement- Daily requirement
of iodine is aboutof iodine is about 100 – 125 mg100 – 125 mg. In endemic areas there is very low. In endemic areas there is very low
iodide content in the water and food. The endemic areas are rockyiodide content in the water and food. The endemic areas are rocky
mountains , the alps and the Himalayas. In England it is found inmountains , the alps and the Himalayas. In England it is found in
Mendips , Chilterns and Cotswolds. Endemic goitres is also foundMendips , Chilterns and Cotswolds. Endemic goitres is also found
in low land areas where the water supply comes from far awayin low land areas where the water supply comes from far away
mountain areas e.g. great lakes of North America , the Nile Valleymountain areas e.g. great lakes of North America , the Nile Valley
and the Congo although iodides in food and water may beand the Congo although iodides in food and water may be
adequate , failure of intestinal absorption may produce iodineadequate , failure of intestinal absorption may produce iodine
deficiency .deficiency .

19. 2.2. Defects in synthesis of thyroid hormones.Defects in synthesis of thyroid hormones.
 Enzyme deficiency within the thyroid gland.Enzyme deficiency within the thyroid gland.
 Goitrogens :Goitrogens :
 Vegetables of the brassica family (cabbage , kale andVegetables of the brassica family (cabbage , kale and
cauliflower) contains thiocynate.cauliflower) contains thiocynate.
 P.A.S / Anti thyroid / cyanides / cyanates sulphurP.A.S / Anti thyroid / cyanides / cyanates sulphur
containing drugs.containing drugs.
 Iodides in large quantities are goitrogenic as theyIodides in large quantities are goitrogenic as they
inhibit the organic binding of iodine and give andinhibit the organic binding of iodine and give and
iodide goitre which is usually seen in asthmatics whoiodide goitre which is usually seen in asthmatics who
have taken proprietary preparations containing iodideshave taken proprietary preparations containing iodides
over a prolonged period.over a prolonged period.
 Genetic enzymatic deficiencies , the condition mayGenetic enzymatic deficiencies , the condition may
be associated with congenital hypothyroidism.be associated with congenital hypothyroidism.

20. Natural History of simple GoitreNatural History of simple Goitre::
"stages of goitre formation ""stages of goitre formation "
 Persistent T.S.H stimulation causes diffuse hyperplasia allPersistent T.S.H stimulation causes diffuse hyperplasia all
lobules are composed of active follicles and iodine uptakes islobules are composed of active follicles and iodine uptakes is
uniform. This is a diffuse hyperplastic goitre which mayuniform. This is a diffuse hyperplastic goitre which may
persist for along time but , is reversible if T.S.H stimulationpersist for along time but , is reversible if T.S.H stimulation
stop.stop.
 Later , as result of fluctuating T.S.H levels mixed patternLater , as result of fluctuating T.S.H levels mixed pattern
develops with in area of active lobules and areas of inactivedevelops with in area of active lobules and areas of inactive
lobules.lobules.
 Active lobules become more vascular and hyperplastic tillActive lobules become more vascular and hyperplastic till
hemorrhage occurs causing central necrosis and leaving onlyhemorrhage occurs causing central necrosis and leaving only
a surrounding rind of active follicles.a surrounding rind of active follicles.
 Necrotic nodules coalesce to form nodules filled either withNecrotic nodules coalesce to form nodules filled either with
iodine free colloid or a mass of new but inactive follicles.iodine free colloid or a mass of new but inactive follicles.
Continual repetition of this process result in a nodularContinual repetition of this process result in a nodular
goitre.goitre.

21. Clinical types of S.N.G :Clinical types of S.N.G :
1. Diffuse hyperplastic goitre.1. Diffuse hyperplastic goitre.
2. Nodular goitre.2. Nodular goitre.
3. Solitary nodule.3. Solitary nodule.
4. Retrosternal goitre.4. Retrosternal goitre.

22. 1. Diffuse1. Diffuse hyperplastichyperplastic goitregoitre
(physiological and colloid(physiological and colloid goitregoitre))
The diffuse hyperplastic goiter corresponds to the firstThe diffuse hyperplastic goiter corresponds to the first
stages of the natural history of simple goitre.stages of the natural history of simple goitre.
PhysiologicalPhysiological goitregoitre ::
It occurs usually in female during puberty, menstruationIt occurs usually in female during puberty, menstruation
and lactation where the metabolic demands are high. Ifand lactation where the metabolic demands are high. If
T.S.H stimulation stop , the goitre may regress but , tendsT.S.H stimulation stop , the goitre may regress but , tends
to recur later at times of stress such as pregnancy, theto recur later at times of stress such as pregnancy, the
gland isgland is symmetricallysymmetrically enlargedenlarged soft , smooth surface , notsoft , smooth surface , not
associated with general or local manifestation.associated with general or local manifestation.
Cut sectionCut section the gland is fleshy and pale , the cells liningthe gland is fleshy and pale , the cells lining
the acini arethe acini are columnarcolumnar with minimal colloid.with minimal colloid.
Treatment :Treatment :
 Prophylactic : Iodized table saltProphylactic : Iodized table salt
 Curative : - Reassurance of the patient and her parentsCurative : - Reassurance of the patient and her parents
- L. thyroxin- L. thyroxin

23. Frequently seen between 15 – 30 years , markedFrequently seen between 15 – 30 years , marked
enlargement of gland with smooth surface , softenlargement of gland with smooth surface , soft
consistency , rarely produces local pressure effectsconsistency , rarely produces local pressure effects
by its size.by its size.
Microscopically :Microscopically :the acini are distended withthe acini are distended with
abundantabundant colloidcolloid and lined withand lined with squamoussquamous cells.cells.
Colloid goitre is a late stage of diffuse hyper plasticColloid goitre is a late stage of diffuse hyper plastic
type of goitre when T.S.H stimulation has fallen offtype of goitre when T.S.H stimulation has fallen off
and when many follicles are inactive and full ofand when many follicles are inactive and full of
colloid.colloid.
TreatmentTreatment ::
- Early: L thyroxin- Early: L thyroxin
- Late : Subtotal thyroidectomy for huge goiter- Late : Subtotal thyroidectomy for huge goiter
ColloidColloid goitregoitre ::

24. 22..Nodular GoiterNodular Goiter
As regards to natural history of S.N.G , persistAs regards to natural history of S.N.G , persist
fluctuating T.S.H stimulation results inevitably influctuating T.S.H stimulation results inevitably in
progressive nodule formation nodules are usuallyprogressive nodule formation nodules are usually
multiple forming a multinodular goitre nodules maymultiple forming a multinodular goitre nodules may
be colloid or cellular and cystic degeneration andbe colloid or cellular and cystic degeneration and
hemorrhage are common , as is subsequenthemorrhage are common , as is subsequent
calcification when epithelial hyperplasia is marked ,calcification when epithelial hyperplasia is marked ,
it may be associated with hyperthyroidism andit may be associated with hyperthyroidism and
condition is then referred to as 2ry toxic goitre. Allcondition is then referred to as 2ry toxic goitre. All
types of S.G are more common in the female than intypes of S.G are more common in the female than in
male.male.
Clinically :Clinically : the gland is variable in its enlargement notthe gland is variable in its enlargement not
symmetrical , nodular surface , its consistency maysymmetrical , nodular surface , its consistency may
be firm , soft or cystic.be firm , soft or cystic.

25.  Diagnosis of S.N.G :Diagnosis of S.N.G : diagnosis of nodulardiagnosis of nodular
goiture is usually straightforward the pat isgoiture is usually straightforward the pat is
euthyroid , nodules are palpable and ofteneuthyroid , nodules are palpable and often
visible , they are usuallyvisible , they are usually smoothsmooth ,, firmfirm ,, notnot
hardhard painlesspainless moves with swallowingmoves with swallowing..
Investigation of S.N.G:Investigation of S.N.G:
 Thyroid function test to exclude mild hyperThyroid function test to exclude mild hyper
thyroidism.thyroidism.
 Estimation of titres of thyroid antibodies toEstimation of titres of thyroid antibodies to
differentiate from lymphadenoid goitre.differentiate from lymphadenoid goitre.
 Plain X-Ray : may show calcification,Plain X-Ray : may show calcification,
tracheal deviation or compression ,tracheal deviation or compression ,
pulmonary metastases, retrosternol goitre.pulmonary metastases, retrosternol goitre.

26. Complication of nodular goitre :Complication of nodular goitre :
1.1. Toxic changeToxic change : In long standing cases in about 30%.: In long standing cases in about 30%.
2.2. HageHage into cystinto cyst : This cause rapid distension of the cyst.: This cause rapid distension of the cyst.
3.3. Malig. ChangeMalig. Change : In about 4 – 8 % cases commoner with: In about 4 – 8 % cases commoner with
solitary type.solitary type.
4. Calcification4. Calcification : Hard nodule.: Hard nodule.
5.5. Pressure effectPressure effect : Dyspnea / dysphagia/ hoarseness of: Dyspnea / dysphagia/ hoarseness of
voice.voice.
6.6. DisfigurementDisfigurement : when it is big .: when it is big .
7.7. TracheomalaciaTracheomalacia : Rare due to long standing goitre: Rare due to long standing goitre
pressing on trachea for long time ending into softpressing on trachea for long time ending into soft
trachea so after operation , collapsing occurs leadingtrachea so after operation , collapsing occurs leading
to suffocation.to suffocation.

27. Indication for surgical removal of nodular goiter :Indication for surgical removal of nodular goiter :
1. Suspicion of malignancy1. Suspicion of malignancy
2. Symptoms of pressure2. Symptoms of pressure
3. Hyper thyrodism3. Hyper thyrodism
4. Substernal extension4. Substernal extension
5. Cosmetic deformity5. Cosmetic deformity
6. Solitary nodule that are cold on radio – iodine6. Solitary nodule that are cold on radio – iodine
scan and solid by ultrasound should be removed.scan and solid by ultrasound should be removed.
Non operative treatment is indicated inNon operative treatment is indicated in
Hashimoto’s diseaseHashimoto’s disease

28. Prevention and treatment of simple goitre :Prevention and treatment of simple goitre :
 All table salt should be iodised.All table salt should be iodised.
 In endemic areas , the incidence has been reduced byIn endemic areas , the incidence has been reduced by
this prophylaxis.this prophylaxis.
 In early stages a hyper plastic goitre is reversible if 1In early stages a hyper plastic goitre is reversible if 1
thyroxine is given in maximum doses 0.3 mg daily forthyroxine is given in maximum doses 0.3 mg daily for
several months and then very slowly reduction to 0.1several months and then very slowly reduction to 0.1
mg daily for many years. If regression does not occur .mg daily for many years. If regression does not occur .
 Thyroidectomy may be indicated for cosmetic reasonsThyroidectomy may be indicated for cosmetic reasons
or pressure symptoms.or pressure symptoms.
 Nodular stage of S.G is irreversible so subtotalNodular stage of S.G is irreversible so subtotal
thyroidectomy is indicated. The rule is to leave athyroidectomy is indicated. The rule is to leave a
portion equal to one normal thyroid lobe , on eachportion equal to one normal thyroid lobe , on each
side.side.

29. The problem of clinically solitary nodule andThe problem of clinically solitary nodule and
its evaluation :its evaluation :
Clinically only one macroscopic nodule isClinically only one macroscopic nodule is
found , but microscopic changes will befound , but microscopic changes will be
present throughout the gland. This is one formpresent throughout the gland. This is one form
of clinically solitary nodule which is referredof clinically solitary nodule which is referred
to asto as cystadenoma of the thyroidcystadenoma of the thyroid and itsand its
commonest site is at junction of the isthmuscommonest site is at junction of the isthmus
with one lobe , and although it appearswith one lobe , and although it appears
solitary multiple small adenomata aresolitary multiple small adenomata are
scattered around it. When there is a solitaryscattered around it. When there is a solitary
nodule of thyroid it is must be differentiatednodule of thyroid it is must be differentiated
from true adenoma.from true adenoma.

30. Causes of solitary nodule in thyroid:Causes of solitary nodule in thyroid:
1. solitary nodular goiter.1. solitary nodular goiter.
2. Toxic nodular goiter.2. Toxic nodular goiter.
3. Malignant nodule (medullary adenoma)3. Malignant nodule (medullary adenoma)
4. True adenoma of thyroid.4. True adenoma of thyroid.

31. Adenoma of thyroid may be :Adenoma of thyroid may be :
 Embryonal adenomaEmbryonal adenoma
 Fetal or micro-follicular adenomaFetal or micro-follicular adenoma
 Colloid or macro-follicular adenomaColloid or macro-follicular adenoma
 Hurthle-cell adenoma with acidophilic cytoplasmHurthle-cell adenoma with acidophilic cytoplasm
 Papillary cystadenoma highly suspicious of being malignant.Papillary cystadenoma highly suspicious of being malignant.
Diagnoses of solitary nodule in thyroidDiagnoses of solitary nodule in thyroid
1. Clinically1. Clinically
 Many cases are asymptomaticMany cases are asymptomatic
 The solitary nodule in thyroid is more likely be malignant thanThe solitary nodule in thyroid is more likely be malignant than
multi nodular goitre.multi nodular goitre.
 A thyroid nodule is more likely to be cancer in man than inA thyroid nodule is more likely to be cancer in man than in
woman.woman.
 Patient with thyroid nodules who received X-Ray treatment to thePatient with thyroid nodules who received X-Ray treatment to the
head and neck in infancy and childhood have 35 – 50 % chance ofhead and neck in infancy and childhood have 35 – 50 % chance of
having thyroid cancer.having thyroid cancer.
 cystic lesions less than 10 Cm in diameter are almost never cancer.cystic lesions less than 10 Cm in diameter are almost never cancer.
 Toxic manifestation in toxic noduleToxic manifestation in toxic nodule
 Malignant features in malignant noduleMalignant features in malignant nodule

32. 2. Investigations2. Investigations
A.A. is helpful in determining whether the lesion is singleis helpful in determining whether the lesion is single
or multiple and whether it is functioning (hot) or non functioningor multiple and whether it is functioning (hot) or non functioning
(cold).(cold).
 Hot noduleHot nodule = overactive nodule= overactive nodule
Takes up isotope , while the surrounding tissue does not , here , theTakes up isotope , while the surrounding tissue does not , here , the
surrounding. T. is inactive because the nodule is producing such highsurrounding. T. is inactive because the nodule is producing such high
levels of thyroid hormones that T.S.H is suppressed.levels of thyroid hormones that T.S.H is suppressed.
 Worm noduleWorm nodule = active nodule= active nodule
Takes up isotope and so does normal surrounding tissue about it.Takes up isotope and so does normal surrounding tissue about it.
 Cold noduleCold nodule = inactive nodule Takes up no isotope= inactive nodule Takes up no isotope
D.D of cold nodule : degenerative cyst, calcification, haemorrhage,D.D of cold nodule : degenerative cyst, calcification, haemorrhage,
abscess or hydatid cyst.abscess or hydatid cyst.
N.B.N.B.
The fluorescent scanning using a collimated source of radiationThe fluorescent scanning using a collimated source of radiation
is now used to differentiate benign from malignant thyroidis now used to differentiate benign from malignant thyroid
nodules. This procedure has advantage that no radio – activenodules. This procedure has advantage that no radio – active
materials are introduced into the body.materials are introduced into the body.
Thyroid scanThyroid scan ::

33. B. Ultrasound (echography)B. Ultrasound (echography)
• It is helpful to differentiate solitary from multipleIt is helpful to differentiate solitary from multiple
nodulesnodules
• It is also used for differentiating solid from cysticIt is also used for differentiating solid from cystic
lesions .lesions .
C. BiopsyC. Biopsy
• FNAC or Trucut or Excisional biopsy.FNAC or Trucut or Excisional biopsy.
N.B.N.B.
Percutaneous needle biopsy is helpful if goodPercutaneous needle biopsy is helpful if good
endocrine cytologists are available , needle biopsyendocrine cytologists are available , needle biopsy
should not performed in patients with history ofshould not performed in patients with history of
irradiation to the neck, because radiation – inducedirradiation to the neck, because radiation – induced
tumors are often multi focal and –ve biopsy maytumors are often multi focal and –ve biopsy may
therefore be unreliable.therefore be unreliable.

34. 3. Treatment :3. Treatment :
A.A. Enucleation :Enucleation : Removal of the nodule from its capsule.Removal of the nodule from its capsule.
But it is not recommended because recurrenceBut it is not recommended because recurrence
is the rule as the nodule is never solitary.is the rule as the nodule is never solitary.
B. Resection Enucleation :B. Resection Enucleation : Excision of the nodule with theExcision of the nodule with the
surrounding thyroid tissue.surrounding thyroid tissue.
It is the recommended operation asIt is the recommended operation as
we remove the scattered small noduleswe remove the scattered small nodules
around the clinical solitary nodule.around the clinical solitary nodule.
C. Hemithyroidectomy :C. Hemithyroidectomy : Removal of the affected lobe togetherRemoval of the affected lobe together
with the isthmus and pyramidal lobe.with the isthmus and pyramidal lobe.
The specimen must be sent for biopsy.The specimen must be sent for biopsy.
It is the operation of choice.It is the operation of choice.

36. N.B.N.B.
 The term thyrotoxicosis is retained because hyperthyroidism i.e.The term thyrotoxicosis is retained because hyperthyroidism i.e.
symptoms due to a raised level of circulating thyroid hormonessymptoms due to a raised level of circulating thyroid hormones
are not responsible for all manifestations of the disease.are not responsible for all manifestations of the disease.

37. Toxic GoitreToxic Goitre
Clinical Types :Clinical Types :
1. primary toxic goitre (Grave’s disease)1. primary toxic goitre (Grave’s disease)
2. Toxic nodular goitre (2ry toxic)2. Toxic nodular goitre (2ry toxic)
3. Toxic nodule3. Toxic nodule
4. Hyper thyrodism due to rare cases.4. Hyper thyrodism due to rare cases.
1.1. Primary ToxicPrimary Toxic GoitreGoitre : (Greave’s disease): (Greave’s disease)
 It is a diffuse vascular goitre appearing at the same time as the hyperIt is a diffuse vascular goitre appearing at the same time as the hyper
thyroidism usually in the younger woman than man (8 times), andthyroidism usually in the younger woman than man (8 times), and
frequently associated with eye signs.frequently associated with eye signs.
 The onset is usually insidious with insomnia , irritability and wt loss.The onset is usually insidious with insomnia , irritability and wt loss.
Sometimes the onset is acute and the course may be progressive orSometimes the onset is acute and the course may be progressive or
intermittent.intermittent.
 The whole of the functioning thyroid tissue isThe whole of the functioning thyroid tissue is
involved and the hypertrophy and hyperplasia are due to abnormalinvolved and the hypertrophy and hyperplasia are due to abnormal
thyroid stimulators such as L.A.T.S which is an immunoglobulin ,thyroid stimulators such as L.A.T.S which is an immunoglobulin ,
found in 85% of cases of thyrotoxicosis.found in 85% of cases of thyrotoxicosis.
 Grave`s disease is considered now an auto immune disease in whichGrave`s disease is considered now an auto immune disease in which
antibodies binding to T.S.H receptors leading to release of thyroxine.antibodies binding to T.S.H receptors leading to release of thyroxine.

38. I. Pathology :I. Pathology :
A. Gross appearance :A. Gross appearance :
 The gland : is moderately enlarged , brick red inThe gland : is moderately enlarged , brick red in
colour and highly vascular, fleshy in consistencycolour and highly vascular, fleshy in consistency
with an opaque meaty appearance. In some cases nowith an opaque meaty appearance. In some cases no
enlargement is detected clinically and even atenlargement is detected clinically and even at
operation the gland may not enlarged at all. Theoperation the gland may not enlarged at all. The
enlargement is characteristically diffuse althoughenlargement is characteristically diffuse although
one lobe may be more affected than the other.one lobe may be more affected than the other.
B. Microscopically :B. Microscopically :
 Marked hyperplasia of the cells , which becomeMarked hyperplasia of the cells , which become
arranged in several layers.arranged in several layers.
 Marked diminution of the lumen of the acini.Marked diminution of the lumen of the acini.
 Disappearance of the colloid from the lumenDisappearance of the colloid from the lumen..
 Marked lymphocytic infiltrationMarked lymphocytic infiltration

39. II.II. Clinical FeaturesClinical Features ::
 Thyrotoxicosis affects all the systems of the body startingThyrotoxicosis affects all the systems of the body starting
with excitation and ending with failure or depressionwith excitation and ending with failure or depression
 Wayne’s clinical diagnostic index gives all the importantWayne’s clinical diagnostic index gives all the important
symptoms and signs of thyrotoxicosis and indicates by their scoresymptoms and signs of thyrotoxicosis and indicates by their score
the relative importance of each.the relative importance of each.
Cardinal signs of thyrotoxicasis are : E + 3TCardinal signs of thyrotoxicasis are : E + 3T
1. Eye manifestation.1. Eye manifestation.
2. Tremors2. Tremors
3. Tachycardia.3. Tachycardia.
4. Tumors4. Tumors
Cardinal symptoms of thyrotoxicasis are : HLPCardinal symptoms of thyrotoxicasis are : HLP
1. Heat intolerance.1. Heat intolerance.
2. Loss of weight in-spite of good appetite.2. Loss of weight in-spite of good appetite.
3. Palpitation.3. Palpitation.

40. A) General FeaturesA) General Features
1. C.V.S1. C.V.S
a)a) Dyspnea on exertion , palpitation , tachycardia are early featuresDyspnea on exertion , palpitation , tachycardia are early features
b)b) Slight elevation of systolic pressure. with decrease ofSlight elevation of systolic pressure. with decrease of
diastolic pressure so that , the pulse pressure is increased. Thediastolic pressure so that , the pulse pressure is increased. The
pulse is easily felt at the wrist (water hammer pulse).pulse is easily felt at the wrist (water hammer pulse).
c)c) Auricular fibrillation and heart failure may occur but , this isAuricular fibrillation and heart failure may occur but , this is
more usual in 2ry toxic goitre.more usual in 2ry toxic goitre.
2. C.N.S2. C.N.S
a)a) Insomnia, occurs early in the course of the disease.Insomnia, occurs early in the course of the disease.
b)b) Irritability , anxiety and tremors of out stetted hands andIrritability , anxiety and tremors of out stetted hands and
protruding tongue are common features.protruding tongue are common features.
c)c) In severe cases , mania may be present.In severe cases , mania may be present.
3. Metabolic disturbances :3. Metabolic disturbances :
a)a) Loss of weight in-spite of good appetite.Loss of weight in-spite of good appetite.
b)b) Sweating especially of the palms of hands , which feel worm.Sweating especially of the palms of hands , which feel worm.
c)c) Intolerance to heat the patient can tolerate cold weather well.Intolerance to heat the patient can tolerate cold weather well.
d)d) Flushing and feeling of hotness.Flushing and feeling of hotness.

41. 4. Gastro – intestinal :4. Gastro – intestinal :
 Polyphagia i.e. increased appetite, later there may be loss of appetite.Polyphagia i.e. increased appetite, later there may be loss of appetite.
 Abdominal pains.Abdominal pains.
 Looseness of stools or even diarrhea.Looseness of stools or even diarrhea.
5. Sexual system.5. Sexual system.
a)a) Menorrhagia, dysmenorrhea or amenorrhea.Menorrhagia, dysmenorrhea or amenorrhea.
b)b) In male , at first there is increase sexual desire, later the patient mayIn male , at first there is increase sexual desire, later the patient may
become impotent.become impotent.
6. Muscle – skeletal system6. Muscle – skeletal system
a)a) Bone pains due to osteoporosisBone pains due to osteoporosis
b)b) Muscle weakness (thyrotoxic myopathy or myasthenia)Muscle weakness (thyrotoxic myopathy or myasthenia)
7. Urinary system7. Urinary system
a)a) PolyuriaPolyuria
b)b) GlycosuriaGlycosuria
8. Skin8. Skin
a)a) FlushingFlushing
b)b) Abdominal pigmentationAbdominal pigmentation

42. c)c) PretibialPretibial myxedemamyxedema
 It is thickening of skin by a mucin – like deposit. It isIt is thickening of skin by a mucin – like deposit. It is
rare sign of thyrotoxicosis but may occur at any stage ofrare sign of thyrotoxicosis but may occur at any stage of
the disease it is usually follows thyroidectomy , Iodinthe disease it is usually follows thyroidectomy , Iodin
therapy or prolonged antithyroid ttherapy or prolonged antithyroid treatment .reatment .
 It is usually associated with progressive exophthalmos.It is usually associated with progressive exophthalmos.
 It starts as bilateral symmetrical pitting edema with red andIt starts as bilateral symmetrical pitting edema with red and
then deep purple colour.then deep purple colour.
 In severe cases , whole leg below its knee is involvedIn severe cases , whole leg below its knee is involved
“thyroid acropachy”. Although it is resistant to treatment .“thyroid acropachy”. Although it is resistant to treatment .
it tends to subside spontaneously.it tends to subside spontaneously.

43. B) Thyroid manifestationB) Thyroid manifestation
 Moderately, symmetrical enlargement of thyroid glandModerately, symmetrical enlargement of thyroid gland
with smooth surface and firm or rubbery in consistencywith smooth surface and firm or rubbery in consistency
associated with increased vascularity.associated with increased vascularity.
Evidence of increased vascularity :Evidence of increased vascularity :
1.1. Dilated vein on the skinDilated vein on the skin
2.2. Hot sensationHot sensation
3.3. Bruit may be feltBruit may be felt
4.4. Murmur may be heard.Murmur may be heard.
 Sometimes the enlargement is very small or noSometimes the enlargement is very small or no
enlargement at all, this type occurs in old patientsenlargement at all, this type occurs in old patients
who present with weight loss and myasthenia overwho present with weight loss and myasthenia over
a long period, the eye manifestation in that cases isa long period, the eye manifestation in that cases is
absent and the heart is mainly affected so it may beabsent and the heart is mainly affected so it may be
pass into heart failure while the original causes arepass into heart failure while the original causes are
over locked .over locked .

44. C) Eye ManifestationC) Eye Manifestation
Exopthalmos is commonly classified into 4 grades :Exopthalmos is commonly classified into 4 grades :
1.1. Mild :Mild : consists of widening of the palpepral fissure due toconsists of widening of the palpepral fissure due to
retraction of the upper eyelids without any bulging ofretraction of the upper eyelids without any bulging of
the eyes.the eyes.
SteStellllwag’s sign and Von Graefe’s sign are positive.wag’s sign and Von Graefe’s sign are positive.
2.2. Moderate :Moderate : due to actual bulging of eyeballs from increaseddue to actual bulging of eyeballs from increased
compositions of retrobulbar fat.compositions of retrobulbar fat.
Darlymple and Joffroy’s signs are positive.Darlymple and Joffroy’s signs are positive.
3.3. Severe :Severe : due to intra – orbital oedema and congestion ,due to intra – orbital oedema and congestion ,
marked protrusion of the eye balls is associated with wateringmarked protrusion of the eye balls is associated with watering
of the eyes , dilatation of conjunctival vessels and muscleof the eyes , dilatation of conjunctival vessels and muscle
paresis.paresis.
 Limitation of movement in an upwards and outwardsLimitation of movement in an upwards and outwards
directions, also downwards and inwards directions must bedirections, also downwards and inwards directions must be
tested.tested.
Moebius signs is positiveMoebius signs is positive

45. 4.4. Malignant exophthalmos :Malignant exophthalmos :
It is a progressive form , which may increased afterIt is a progressive form , which may increased after
otherwise successful treatment of thyrotoxicosisotherwise successful treatment of thyrotoxicosis
particularly by thyrodectomy increasing exophthalmos isparticularly by thyrodectomy increasing exophthalmos is
associated with chemosis of conjunctiva impairment ofassociated with chemosis of conjunctiva impairment of
corneal sensibility and paralysis of the eye muscles withcorneal sensibility and paralysis of the eye muscles with
grave risks of corneal ulceration, panophthalmitis and lossgrave risks of corneal ulceration, panophthalmitis and loss
of vision.of vision.
Exophthalmos of graves disease is probably due toExophthalmos of graves disease is probably due to
infiltration of retrobulbar tissues with fluid and roundinfiltration of retrobulbar tissues with fluid and round
cells with varying degree of retraction or spasm of uppercells with varying degree of retraction or spasm of upper
eyelid the cause is unknown but it is not due to an increaseeyelid the cause is unknown but it is not due to an increase
of T.S.H as it is not found in mxyedema where TSH is atof T.S.H as it is not found in mxyedema where TSH is at
its highest level.its highest level.
L.A.T.S or E.P.S may be responsible.L.A.T.S or E.P.S may be responsible.
The condition is usually bilateral but unilateral mayThe condition is usually bilateral but unilateral may
occur in rare cases.occur in rare cases.

46.  Stellwag’s sign :Stellwag’s sign : infrequency of blinking with ainfrequency of blinking with a
staring look.staring look.
 Von graefe’s sign :Von graefe’s sign : upper lid lays behind the eyeupper lid lays behind the eye
ball as the patient looks down without movingball as the patient looks down without moving
the head.the head.
 Dalrymple‘s sign :Dalrymple‘s sign : a rim of white sclera betweena rim of white sclera between
the upper eye lid and upper edge of cornea due tothe upper eye lid and upper edge of cornea due to
retraction of upper lid and protrusion of the eyeretraction of upper lid and protrusion of the eye
ball.ball.
 Joffroy’s sign :Joffroy’s sign : lack of wrinkling of the foreheadlack of wrinkling of the forehead
on looking upwards without moving the head.on looking upwards without moving the head.
 Moebius sign :Moebius sign : imperfect convergence on lookingimperfect convergence on looking
at a near object due to muscular paresis (medialat a near object due to muscular paresis (medial
recti muscles)recti muscles)

47.  N.B.N.B.
Other causes of exophthalmos :Other causes of exophthalmos :
1. A space – occupying lesion in orbit.1. A space – occupying lesion in orbit.
2. Cavernous sinus thrombosis.2. Cavernous sinus thrombosis.
Treatment of exophthalmos :Treatment of exophthalmos :
I.I. Mild casesMild cases ( most common ) :( most common ) :
It is usually self limiting and may even regressIt is usually self limiting and may even regress
treatment of thyrotoxicosis will improve the eye signs.treatment of thyrotoxicosis will improve the eye signs.
lid retraction disappears in 2/3 of cases.lid retraction disappears in 2/3 of cases.
II. Severe casesII. Severe cases ( rare ):( rare ):
The proptosis can be measured with an exophthalmometer.The proptosis can be measured with an exophthalmometer.
1.1. Protection of eye (wind – dust – sun)Protection of eye (wind – dust – sun)
2.2. Sleep sitting to decrease venous pressure.Sleep sitting to decrease venous pressure.
3.3. Lateral tarsorrhaphy may be needed.Lateral tarsorrhaphy may be needed.
4.4. Prednisone with massive doses + metronidazole (flagyl)Prednisone with massive doses + metronidazole (flagyl)
5.5. Irradiation of retro orbital Tissue may be necessary.Irradiation of retro orbital Tissue may be necessary.
• Pituitary :Pituitary :
irradiationirradiation
stalk sectionstalk section
cryo surgerycryo surgery
• Orbital decompression (trans-frontal and trans-antral)Orbital decompression (trans-frontal and trans-antral)

48. 2. Secondary toxic goiter2. Secondary toxic goiter
 Here a simple nodular goitre is present for long time before the hyperthyroidism.Here a simple nodular goitre is present for long time before the hyperthyroidism.
 In many cases of toxic nodular goitre ,the nodules are inactive and it is theIn many cases of toxic nodular goitre ,the nodules are inactive and it is the
internodular thyroid tissue that is over active , here the hyperthyroidism is due tointernodular thyroid tissue that is over active , here the hyperthyroidism is due to
abnormal thyroid stimulators such as L.A.T.S.abnormal thyroid stimulators such as L.A.T.S.
 In some toxic nodular goitre one or more nodules are overactive and here theIn some toxic nodular goitre one or more nodules are overactive and here the
hyperthyroidism is due to autonomous thyroid tissue as in toxic nodule.hyperthyroidism is due to autonomous thyroid tissue as in toxic nodule.
The 2ry toxic goitre differs from Grave’s diseases in the following :The 2ry toxic goitre differs from Grave’s diseases in the following :
 The thyroid gland is nodular either prior to toxic manifestation or nodularity andThe thyroid gland is nodular either prior to toxic manifestation or nodularity and
toxicity started together.toxicity started together.
 C.V. manifestations are prominent and nervous manifestation are less marked thanC.V. manifestations are prominent and nervous manifestation are less marked than
in Grave’s disease.in Grave’s disease.
 Proptosis is usually absent.Proptosis is usually absent.
 Medical treatment is less effective and has to be given for long periods to obtain aMedical treatment is less effective and has to be given for long periods to obtain a
response.response.
 Recurrence of symptoms after thyroidectomy : for 2ry toxic goitre is rare (1% orRecurrence of symptoms after thyroidectomy : for 2ry toxic goitre is rare (1% or
less) where as in grave’s disease the incidence of recurrence is from 10 to 20less) where as in grave’s disease the incidence of recurrence is from 10 to 20
percent.percent.
 Post operative myxedema is extremely rare in 2ry toxic goitre but it is frequent inPost operative myxedema is extremely rare in 2ry toxic goitre but it is frequent in
graves’s disease.graves’s disease.
 2ry toxic goitre occurs in an older age group it is better treated surgically because2ry toxic goitre occurs in an older age group it is better treated surgically because
the other lines of treatment usually fail to control it.the other lines of treatment usually fail to control it.
 More ever the cardiac affection which is commonly associated with it responds toMore ever the cardiac affection which is commonly associated with it responds to
surgical removal of the goitre.surgical removal of the goitre.

49. 3. Toxic Nodule3. Toxic Nodule
It is solitary over active nodule (hot nodule)It is solitary over active nodule (hot nodule)
4. Thyrotoxicosis due to other causes4. Thyrotoxicosis due to other causes
1.1. Thyrotoxicosis fastitiaThyrotoxicosis fastitia
Patients whose given thyroxine as tonic.Patients whose given thyroxine as tonic.
2. Jod-basedow thyrotoxicosis2. Jod-basedow thyrotoxicosis
when large doses of iodide were given for an endemic goitre.when large doses of iodide were given for an endemic goitre.
3.3. Neonatal thyrotoxicosisNeonatal thyrotoxicosis
It occurs in babies who were born from hyperthyroid mothers.It occurs in babies who were born from hyperthyroid mothers.
L.A.T.S titres in both mother and child will be high.L.A.T.S titres in both mother and child will be high.
Hyperthyroidism manifestation will be gradually subsides inHyperthyroidism manifestation will be gradually subsides in
3 or 4 weeks3 or 4 weeks

50. Investigations for thyrotoxicosisInvestigations for thyrotoxicosis
1. Clinical diagnosis by Wayne Diagnostic Index.1. Clinical diagnosis by Wayne Diagnostic Index.
2. Sleeping pulse.2. Sleeping pulse.
3. Thyroid function tests3. Thyroid function tests
Sleeping pulseSleeping pulse
It is very important in grading the severity ofIt is very important in grading the severity of
thyrotoxicosisthyrotoxicosis
80 – 90 Mild case80 – 90 Mild case
90 – 110 Moderate case90 – 110 Moderate case
Above 110 Severe caseAbove 110 Severe case

51. Thyroid function testsThyroid function tests
1. Measurements of thyroid hormone in serum1. Measurements of thyroid hormone in serum
A. Serum protein bound iodine ( P.B.I. )A. Serum protein bound iodine ( P.B.I. )
B. Total serum thyroxine ( T4 )B. Total serum thyroxine ( T4 )
C. Total serum T3C. Total serum T3
D. Free serum T4D. Free serum T4
E. Thyroid indexE. Thyroid index
2. Measurements of free binding sites for thyroid hormones2. Measurements of free binding sites for thyroid hormones
3. Uptake and discharge of radio active iodine3. Uptake and discharge of radio active iodine
A. Radio active iodine uptake.A. Radio active iodine uptake.
B. T3 resin uptake test .B. T3 resin uptake test .
C. T3 suppression test “ werner “.C. T3 suppression test “ werner “.
D. Thyroid scanning.D. Thyroid scanning.
E. Iodine clearance test.E. Iodine clearance test.

52. 4. Miscellaneous tests4. Miscellaneous tests
A.A. B.M.R N. -10% to +15% of the standardB.M.R N. -10% to +15% of the standard
( 40 cal. / square meter / surface area / hour )( 40 cal. / square meter / surface area / hour )
False results in : neurosis / pregnancy / fever.False results in : neurosis / pregnancy / fever.
B. Serum cholesterol : normal 150 – 250 mg%B. Serum cholesterol : normal 150 – 250 mg%
It is decreased in thyrotoxicosis & Increased inIt is decreased in thyrotoxicosis & Increased in
myxedema.myxedema.
False result in : hypercholesteremia.False result in : hypercholesteremia.
C. Serum creatinine : normal 0.6 mg/100 mlC. Serum creatinine : normal 0.6 mg/100 ml
It increased in thyrotoxicosisIt increased in thyrotoxicosis
False increase in renal failure.False increase in renal failure.
D. E.C.G.D. E.C.G.

53. Protein bound iodine P.B.IProtein bound iodine P.B.I
 iodine containing hormones T3 and T4 are transported in theiodine containing hormones T3 and T4 are transported in the
plasma mainly by specific binding proteins (thyroxineplasma mainly by specific binding proteins (thyroxine
binding globulin) (T.B.G). As only a very small amount of T3binding globulin) (T.B.G). As only a very small amount of T3
and T4 are free in the blood, The P.B.I effectively representsand T4 are free in the blood, The P.B.I effectively represents
total circulation Thyroid hormones.total circulation Thyroid hormones.
 The euthyroid rangThe euthyroid rang 4 – 8 Mg/100ml4 – 8 Mg/100ml
False low results in :False low results in :
 hereditary decrease of T.B.Ghereditary decrease of T.B.G
 Nephrotic syndrome.Nephrotic syndrome.
False high results in:False high results in:
 X-ray contrast media containing Iodine biligrafinX-ray contrast media containing Iodine biligrafin
 Expectorants containing Iodine, Lugol’s IodineExpectorants containing Iodine, Lugol’s Iodine
 PregnancyPregnancy
 Oral contraceptivesOral contraceptives
 Estrogen administrationEstrogen administration
 Early hepatitisEarly hepatitis

54. Total serum T3 - free Serum T4Total serum T3 - free Serum T4
 Both measured by Radio - Immuno assay, andBoth measured by Radio - Immuno assay, and
are available in special laboratories, but, they willare available in special laboratories, but, they will
eventually become routine tests, for theeventually become routine tests, for the twotwo
reasonsreasons
1- Some cases of hyper thyroidism are due to1- Some cases of hyper thyroidism are due to
excessive production of T3 without anyexcessive production of T3 without any
accompanying rise in level of serum P.B.I or totalaccompanying rise in level of serum P.B.I or total
serum T4serum T4
2- Free serum T4 ( which not protein bound) is far2- Free serum T4 ( which not protein bound) is far
more representative of the level of hormonemore representative of the level of hormone
available to the individual thyroid cell than is theavailable to the individual thyroid cell than is the
total serum T4.total serum T4.

55. 2- Measurement of free binding sites for thyroid hormones2- Measurement of free binding sites for thyroid hormones
in the blood :in the blood :
 Radio active T3 is incubated with patient’s serum so that itRadio active T3 is incubated with patient’s serum so that it
becomes fixed to any thyroid binding protein not alreadybecomes fixed to any thyroid binding protein not already
carrying T3 or T4.carrying T3 or T4.
 The amount so fixed can be measured and from this can beThe amount so fixed can be measured and from this can be
estimated the number of binding sites in the serum which areestimated the number of binding sites in the serum which are
un occupied.un occupied.
 In the hyperthyroidism, the number of free binding sites isIn the hyperthyroidism, the number of free binding sites is
low because a few are not already carrying hormonelow because a few are not already carrying hormone
 In hypothyroidism and myxedema, the number of free sitesIn hypothyroidism and myxedema, the number of free sites
are high.are high.
 This is not accurate test in itself , but in conjunction with theThis is not accurate test in itself , but in conjunction with the
total serum T4 or serum P.B.Itotal serum T4 or serum P.B.I
 the free thyroxinthe free thyroxin indexindex can be calculated from the formula:can be calculated from the formula:
 FTIFTI = serum T4 or (B.P.I) × T3 uptake percent= serum T4 or (B.P.I) × T3 uptake percent
 euthyroid range of FTI 2.5 – 7.0euthyroid range of FTI 2.5 – 7.0

56. 3. Uptake and discharge of radio active iodine :3. Uptake and discharge of radio active iodine :
A. Radio active iodine uptake.A. Radio active iodine uptake.
normal thyroid uptake isnormal thyroid uptake is 15 – 55 %15 – 55 % of the given dose inof the given dose in
thyrotoxicosis the uptake increase above 55% inthyrotoxicosis the uptake increase above 55% in
hypothyrodism it decrease belowhypothyrodism it decrease below 10%10% technique.technique.
1- No drugs or materials containing iodine are allowed for1- No drugs or materials containing iodine are allowed for
the previous 3 weeks.the previous 3 weeks.
2-2- 5 Micro curies5 Micro curies of radio active iodine are given by mouthof radio active iodine are given by mouth
in a small amount of water or milk it is rapidlyin a small amount of water or milk it is rapidly
absorbed from the small bowel into blood and theabsorbed from the small bowel into blood and the
thyroid and kidneys compete for it in hyper thyroidismthyroid and kidneys compete for it in hyper thyroidism
the thyroid uptake is rapid and little is excreted in thethe thyroid uptake is rapid and little is excreted in the
urine.urine.
3-3- After 24h the uptake is measured over the thyroid byAfter 24h the uptake is measured over the thyroid by
Geiger Muller Counter.Geiger Muller Counter.

57. B- T3 Resin uptake test :B- T3 Resin uptake test :
 By incubating iodine T3 (Radioactive T3) withBy incubating iodine T3 (Radioactive T3) with
patient’s serum. Part of T3 is fixed by plasmapatient’s serum. Part of T3 is fixed by plasma
protein and the part which is not fixed isprotein and the part which is not fixed is
precipitated by resinprecipitated by resin and estimated.and estimated.
In the hyperthyroidism , the proteins are alreadyIn the hyperthyroidism , the proteins are already
saturated with thyroxine and the resin uptake issaturated with thyroxine and the resin uptake is
highhigh
in the hypothyroidism the resin uptake is low.in the hypothyroidism the resin uptake is low.
This is another vitro test through which hazardsThis is another vitro test through which hazards
of irradiation are thus avoided.of irradiation are thus avoided.

58. C- T3 suppression test “Werner”.C- T3 suppression test “Werner”.
 Goitre due to iodine deficiency in endemic areasGoitre due to iodine deficiency in endemic areas
has a rapid radio active iodine uptake , buthas a rapid radio active iodine uptake , but
simple goitre is under T.S.H control so thatsimple goitre is under T.S.H control so that
uptake can be diminished by suppressing T.S.Huptake can be diminished by suppressing T.S.H
that is done by giving 40 Mg every 8 hourly forthat is done by giving 40 Mg every 8 hourly for
7 days.7 days.
 In a toxic goitreIn a toxic goitre 10 – 20 %10 – 20 % reduction in uptakereduction in uptake
by suppression whole in simple goitreby suppression whole in simple goitre 50 – 80%50 – 80%
reduction.reduction.

59. D- Thyroid scanningD- Thyroid scanning
scanning of thyroid after a tracer dose of radioscanning of thyroid after a tracer dose of radio
active iodine shows which parts of the gland areactive iodine shows which parts of the gland are
functioning or functionless (Hot or Cold) : whilstfunctioning or functionless (Hot or Cold) : whilst
scanning is sometimes helpful in cases of thyroidscanning is sometimes helpful in cases of thyroid
carcinoma its principle value is in the diagnosis ofcarcinoma its principle value is in the diagnosis of
toxic nodule either as solitary or as a part of toxictoxic nodule either as solitary or as a part of toxic
multinodular goitre.multinodular goitre.
E- Iondine clearance test :E- Iondine clearance test :
in thyrotoxicosis most of isotope is taken byin thyrotoxicosis most of isotope is taken by
thyroid and there fore there is less excretion ofthyroid and there fore there is less excretion of
radio active iodine by the kidney. The normalradio active iodine by the kidney. The normal
range of excretion in 48h isrange of excretion in 48h is 30 – 70%30 – 70% of given doseof given dose
lower valueslower values are suggestive of thyrotoxicosis.are suggestive of thyrotoxicosis.

60.  D.D of thyrotoxicosisD.D of thyrotoxicosis
 Anxiety.Anxiety.
 Neurosis.Neurosis.
 HT disease.HT disease.
 Myasthenia.Myasthenia.
 T.B.T.B.
 Pheochromocytoma.Pheochromocytoma.
 Menopausal syndromeMenopausal syndrome
 Other causes of exophthalmos.Other causes of exophthalmos.

61.  How do you differentiate between psychoneurosis andHow do you differentiate between psychoneurosis and
thyrotoxicosis ?thyrotoxicosis ?
 Anorexia is an invariable presentation inAnorexia is an invariable presentation in
psychoneurosis while polyphagia is always presentpsychoneurosis while polyphagia is always present
in thyrotoxicosis taking notice ,in thyrotoxicosis taking notice ,
in both , there is loss of weight.in both , there is loss of weight.
 Sleeping pulse normal in psychoneurosis.Sleeping pulse normal in psychoneurosis.
 Although the hands show tremors and sweating inAlthough the hands show tremors and sweating in
both conditions , but the hand is hot inboth conditions , but the hand is hot in
thyrotoxicosis and cold in psychoneurosis.thyrotoxicosis and cold in psychoneurosis.
 Thyroid function tests are normal inThyroid function tests are normal in
psychoneurosis.psychoneurosis.

62. Treatment of Toxic GoitreTreatment of Toxic Goitre

63. 1. Medical treatment1. Medical treatment
Indications :Indications :
 Mild cases.Mild cases.
 Thyrotoxicosis occuring during periods ofThyrotoxicosis occuring during periods of
stress. As puberty , pregnancy and lactation.stress. As puberty , pregnancy and lactation.
Anti thyroid drugs are given in accurate doesAnti thyroid drugs are given in accurate does
and it is better to be on under dose side. Theyand it is better to be on under dose side. They
are stopped one month before delivery andare stopped one month before delivery and
lugol’s iodine given instead.lugol’s iodine given instead.
 Recurrent cases after operation specially 2ndRecurrent cases after operation specially 2nd
recurrence for fear of injuring the recurrentrecurrence for fear of injuring the recurrent
laryngeal nerves. (Patient under 45y).laryngeal nerves. (Patient under 45y).
 Bad general conditions as HT failure.Bad general conditions as HT failure.
 Progressive exophthalmos.Progressive exophthalmos.

64. Aim of treatment :Aim of treatment :
Inhibit the function of the gland without destroyingInhibit the function of the gland without destroying
it.it.
Advantages :Advantages :
 No surgery.No surgery.
 No use of radio active materials.No use of radio active materials.
Disadvantages :Disadvantages :
 The treatment isThe treatment is prolongedprolonged and the failure rateand the failure rate
after course of 1.5 or 2 years is at least 50 %after course of 1.5 or 2 years is at least 50 %
 It isIt is impossible to predictimpossible to predict which patient iswhich patient is
likely to go into a remission.likely to go into a remission.
 Some goitres enlarge and becomeSome goitres enlarge and become very vascularvery vascular
during treatment leading toduring treatment leading to pressure symptomspressure symptoms
and making the surgery is difficult .and making the surgery is difficult .

65.  Very rarely , there is a dangerous drug reactionVery rarely , there is a dangerous drug reaction
e.g.e.g. a granulocytosisa granulocytosis (0.1 – 0,4%). The drug is(0.1 – 0,4%). The drug is
stopped if sore throat develops or white countstopped if sore throat develops or white count
drops and the patient is given penicillin anddrops and the patient is given penicillin and
streptomycin as a guard against infection.streptomycin as a guard against infection.
 AllergicAllergic manifestation as itching – vomitingmanifestation as itching – vomiting
and rashes.and rashes.
 Persistent tachycardiaPersistent tachycardia due to markeddue to marked
vascularity this may mislead the physician tovascularity this may mislead the physician to
increase the dose of anti thyroids to degree ofincrease the dose of anti thyroids to degree of
producing myxoedema. Thickening of vocalproducing myxoedema. Thickening of vocal
cords and aedema of the glottis may occur andcords and aedema of the glottis may occur and
may necessitate tracheostomy.may necessitate tracheostomy.
 Myxoedema.Myxoedema.

66. Drugs used :Drugs used :
Thiouracil.Thiouracil.
Methyl thiouracil 300 – 600 mg /day.Methyl thiouracil 300 – 600 mg /day.
Propyl thiouracil 200 – 300 mg/dayPropyl thiouracil 200 – 300 mg/day
Neomercazol 5 – 15 mg/T.D.SNeomercazol 5 – 15 mg/T.D.S
Potassium Perchlorate 200 – 800Potassium Perchlorate 200 – 800
mg/daymg/day

67.  Scheme of treatment :Scheme of treatment :
 The patient is given forThe patient is given for one monthone month if there isif there is
improvement it is continued for upimprovement it is continued for up 3 months3 months then thethen the
dose isdose is halved for another 3 monthshalved for another 3 months.. After 6 months oneAfter 6 months one
fourth of the original dosefourth of the original dose is given for anotheris given for another one yearone year
on the whole the course takes abouton the whole the course takes about 1.5 year1.5 year..
 It is most important to maintain high concentration ofIt is most important to maintain high concentration of
the drug through out 24 h by spacing the doses at threethe drug through out 24 h by spacing the doses at three
times daily.times daily.
 IfIf there is no improvement after thethere is no improvement after the first monthfirst month , it is, it is
better to shift to surgical treatment because furtherbetter to shift to surgical treatment because further
medical treatment will be ineffective and will increase themedical treatment will be ineffective and will increase the
vascularity of the gland markedly so that the operationvascularity of the gland markedly so that the operation
will be very difficult.will be very difficult.

68. The results of medical treatment :The results of medical treatment :
50%50% of cases are cured completely.of cases are cured completely.
50%50% of cases will go into relapse , these areof cases will go into relapse , these are
treated either by surgery or radio active iodine.treated either by surgery or radio active iodine.
With anti-thyroid drugs, the following isWith anti-thyroid drugs, the following is
essential :essential :
1. Rest physically and mentally1. Rest physically and mentally
2. Sedation by luminal2. Sedation by luminal
3. Diet and fluids 3000 cal/daily3. Diet and fluids 3000 cal/daily
4. Inderal.4. Inderal.
This measures make your mild cases withoutThis measures make your mild cases without
any anti-thyroid drugsany anti-thyroid drugs

69. 22..Radio active iodineRadio active iodine
Indications :Indications : recurrent cases after surgery (overrecurrent cases after surgery (over
45y) bad risky cases due to age or disease.45y) bad risky cases due to age or disease.
 Aim of treatment its modification :Aim of treatment its modification : radio iodineradio iodine
destroys thyroid cell and as in thyroidectomy ,destroys thyroid cell and as in thyroidectomy ,
reduces the mass of functioning thyroid tissue toreduces the mass of functioning thyroid tissue to
below a critical level.below a critical level.
Advantages :Advantages :
 Safe , simpleSafe , simple
 Less expensive than operationLess expensive than operation
 No prolonged drug therapy.No prolonged drug therapy.

70. Disadvantages :Disadvantages :
1. No reliable method of estimating the exact dose1. No reliable method of estimating the exact dose
2. Complication of irradiation to the working physicians.2. Complication of irradiation to the working physicians.
3. Delayed action :3. Delayed action :
As its effect appears after 2 – 3 months , therefore if theAs its effect appears after 2 – 3 months , therefore if the
symptoms are severe anti thyroid drugs are given duringsymptoms are severe anti thyroid drugs are given during
this periodthis period
4. Incidence of thyroid insufficiency may reach 75% after 104. Incidence of thyroid insufficiency may reach 75% after 10
years.years.
Contraindication :Contraindication :
 Patient below 40y because of its potential carcinogenicPatient below 40y because of its potential carcinogenic
effect (20y or more later).effect (20y or more later).
 Pregnancy as it may lead to cretinismPregnancy as it may lead to cretinism
 Lactation as it is excreted in milk.Lactation as it is excreted in milk.

71. Dose of radio iodine for treatment :Dose of radio iodine for treatment :
 4 – 84 – 8 millicuries according to the size of themillicuries according to the size of the
gland given in a small amount of water orgland given in a small amount of water or
milk. The dose can be repeated once aftermilk. The dose can be repeated once after
3 months.3 months.
N.B.N.B.
Microcurie = 1/1000,000 of curieMicrocurie = 1/1000,000 of curie
MillicurieMillicurie = 1/1000 of curie= 1/1000 of curie

72. 3. Surgical treatment3. Surgical treatment
Indications :Indications :
 moderate and severe casesmoderate and severe cases
 pressure symptomspressure symptoms
 2ry toxic goitre2ry toxic goitre
 suspicion of malignancysuspicion of malignancy
 failure of medical treatment or relapse after itfailure of medical treatment or relapse after it
 retrosternal as medical treatment will increase theretrosternal as medical treatment will increase the
size of gland and cause more pressure symptoms.size of gland and cause more pressure symptoms.
Advantage :Advantage : rapid cure , low incidence of recurrencerapid cure , low incidence of recurrence
Disadvantage :Disadvantage :
 Recurrence of thyrotoxicosis in about 5% of cases.Recurrence of thyrotoxicosis in about 5% of cases.
 Complication of the operation.Complication of the operation.

73. Preoperative investigation :Preoperative investigation :
1. Indirect laryngoscope1. Indirect laryngoscope
2. Thyroid anti body titres2. Thyroid anti body titres
3. x-ray chest ( retrosternal extension –3. x-ray chest ( retrosternal extension –
calcification deviation of trachea ).calcification deviation of trachea ).
4. Scanning4. Scanning
5. Complete rest physically and mentally5. Complete rest physically and mentally
6. Sedation by luminal6. Sedation by luminal

74. 7. Anti thyroid drug till B.M.R falls to normal7. Anti thyroid drug till B.M.R falls to normal
8.8. 15 days15 days before operation anti thyroidbefore operation anti thyroid
are stopped instead we give lugol’s iodineare stopped instead we give lugol’s iodine
10 drops T.D.S to vascularity and make the10 drops T.D.S to vascularity and make the
gland tough.gland tough.
Lugol`s Iodine =Lugol`s Iodine = 5%5% iodine iniodine in 10%10% KIsolutionKIsolution
9. Inderal may be used as B. adrenergic9. Inderal may be used as B. adrenergic
blockers for severe tachycardia .blockers for severe tachycardia .

75. Subtotal ThyroidectomySubtotal Thyroidectomy
 Anaesthesia :Anaesthesia : general endo – trachealgeneral endo – tracheal
 Position :Position : supine with sand bag behind the shoulderssupine with sand bag behind the shoulders
to extent the neckto extent the neck
 Incision :Incision : kocher’skocher’s ((collarcollar) incision in one of the) incision in one of the
lower creases of the neck it extends from thelower creases of the neck it extends from the
posterior border of one sternomastoid to the post.posterior border of one sternomastoid to the post.
Border of the other.Border of the other.
 Incision divides the skin and superficial fasciaIncision divides the skin and superficial fascia
containing the platysma some prefer to divide thecontaining the platysma some prefer to divide the
platysma at a slightly higher level than the skin toplatysma at a slightly higher level than the skin to
obtain a good scarobtain a good scar
 mobilization of the skin flaps:mobilization of the skin flaps: The upper to the levelThe upper to the level
of upper border of thyroid cartilage and the lower toof upper border of thyroid cartilage and the lower to
level of manubrium.level of manubrium.

76.  Anterior jugular veins are divided betweenAnterior jugular veins are divided between
ligaturesligatures
 Opening the investing layer of deep fascia inOpening the investing layer of deep fascia in
midline vertically.midline vertically.
 Incising the sheath of pretracheal fascia in theIncising the sheath of pretracheal fascia in the
midlinemidline
 As a rule the larger lobe is dealt with first.As a rule the larger lobe is dealt with first.
 Separation or division of infrahyoid Ms.Separation or division of infrahyoid Ms.
In order to expose the thyroid the muscles areIn order to expose the thyroid the muscles are
divided in cases of :divided in cases of :
A. Big nodular goitre.A. Big nodular goitre.
B. Toxic goitre to minimize manipulation.B. Toxic goitre to minimize manipulation.
C. Malignant goitre.C. Malignant goitre.

77.  They are divided near their upper end as theirThey are divided near their upper end as their
nerve supply comes from below (fromnerve supply comes from below (from
ansacervicalis)ansacervicalis)
Devascularization :Devascularization :
 Ligation ofLigation of middle thyroid veinmiddle thyroid vein (easily rupture(easily rupture
with more bleeding) its division makeswith more bleeding) its division makes
mobilization of the gland easier.mobilization of the gland easier.
 Ligation ofLigation of sup. Thyroid artery and veinsup. Thyroid artery and vein as near toas near to
the gland as possible to avoid sup. Laryngeal n.the gland as possible to avoid sup. Laryngeal n.

78.  Ligation ofLigation of inf. Thyroid arteryinf. Thyroid artery as far from theas far from the
gland as possible (away and laterally) to avoid thegland as possible (away and laterally) to avoid the
recurrent laryngeal n.recurrent laryngeal n.
 Legation ofLegation of inf. Thyroid veininf. Thyroid vein in front of trachea.in front of trachea.
 Removal of required portion of gland leaving postRemoval of required portion of gland leaving post
medial part to protect parathyroid and recurrentmedial part to protect parathyroid and recurrent
nerves.nerves.
 In case ofIn case of simple goitresimple goitre , it is advisable to leave, it is advisable to leave
about equal to normal lobe on each side but , inabout equal to normal lobe on each side but , in
toxic goitretoxic goitre there are general tendency to leavethere are general tendency to leave
very little thyroid tissue since the risk of recurrentvery little thyroid tissue since the risk of recurrent
thyrotoxicosis is greater than that of myxaedemathyrotoxicosis is greater than that of myxaedema
the amount suggested is that which equals onethe amount suggested is that which equals one
third of normal lobe.third of normal lobe.

79.  Closure leaving a drain on each sideClosure leaving a drain on each side
reaching the depth of wound behind thereaching the depth of wound behind the
infrahyoid muscles.infrahyoid muscles.
 The platysma is closed with plain cat gut asThe platysma is closed with plain cat gut as
a separate layer in order to allow removal ofa separate layer in order to allow removal of
the stitches of skin early. Skin is closed withthe stitches of skin early. Skin is closed with
interrupted silk suture or with metal clips.interrupted silk suture or with metal clips.
 The stitches or clips are removed after 3 – 4The stitches or clips are removed after 3 – 4
days.days.

80. What are indications of tracheastomy afterWhat are indications of tracheastomy after
thyroidectomy ?thyroidectomy ?
1. Post operative oedema of glottis.1. Post operative oedema of glottis.
2. Post operative deep haemorrhage beneath2. Post operative deep haemorrhage beneath
pre-tracheal M and not relieved by re-pre-tracheal M and not relieved by re-
opening of the wound.opening of the wound.
3. Bilateral injury of recurrent.3. Bilateral injury of recurrent.
4. Tracheomalacia .4. Tracheomalacia .

81. Complications of thyroidectomyComplications of thyroidectomy
Local complications :Local complications :
1. Hemorrhage1. Hemorrhage
2. Liquefying hematoma2. Liquefying hematoma
3. Wound infection (uncommon)3. Wound infection (uncommon)
4. Tracheitis4. Tracheitis
5. Phemothorax and mediastinal emphysema5. Phemothorax and mediastinal emphysema
6. Air embolism6. Air embolism
7. Unsightly scar7. Unsightly scar
8. Glottic oedema8. Glottic oedema
9. Tracheal collapse9. Tracheal collapse
10. N. injuries :10. N. injuries :
 R. laryngeal n.R. laryngeal n.
 Sup. Laryngeal n.Sup. Laryngeal n.
 Cervical sympathetics ( Horner’s syndrome).Cervical sympathetics ( Horner’s syndrome).

82. Endocrine :Endocrine :
1. Tetany1. Tetany
2. Thyrotoxic crisis2. Thyrotoxic crisis
3. Recurrent thyrotoxicosis3. Recurrent thyrotoxicosis
4. Progressive exophthalmos4. Progressive exophthalmos
5. Myxaedema5. Myxaedema

83. 1. Tetany1. Tetany
-- It is due to removal of all parathyroidsIt is due to removal of all parathyroids
- It is rare but permanent.- It is rare but permanent.
- It is frequently due to scheme resulting from- It is frequently due to scheme resulting from
ligation of all vessels of the thyroid and isligation of all vessels of the thyroid and is
temporary because the parathyroids regain newtemporary because the parathyroids regain new
blood supply from the neighboring vesselsblood supply from the neighboring vessels
Treatment :Treatment :
-- Calcium gluconate 10 cc 10% daily untilCalcium gluconate 10 cc 10% daily until
improvement occurs.improvement occurs.
- In permanent cases oral long therapy is given .- In permanent cases oral long therapy is given .

84. 2. Thyroxic crisis2. Thyroxic crisis
-- It is due to flooding of the circulation withIt is due to flooding of the circulation with
thyroxin after operation.thyroxin after operation.
- Usually in adequate preoperative preparation and- Usually in adequate preoperative preparation and
excessive manipulation during the operation areexcessive manipulation during the operation are
the cause of this crisisthe cause of this crisis
It is characterized by :It is characterized by :
1. Marked irritability1. Marked irritability
2. Marked sweating.2. Marked sweating.
3. Severe tachycardia.3. Severe tachycardia.
4. Hyperthermia4. Hyperthermia
5. Heart failure in neglected cases5. Heart failure in neglected cases

85. Treatment :Treatment :
1. Sedation : morphia1. Sedation : morphia
2. anti-pyretic : cold compresses and largactil2. anti-pyretic : cold compresses and largactil
3. Glucose 5% I.V for increased metabolic rate3. Glucose 5% I.V for increased metabolic rate
4. 5 c.c. Lugol`s iodine in one bottle of glucose I.V4. 5 c.c. Lugol`s iodine in one bottle of glucose I.V
5. A.C.T.H and cortisone may needed in severe5. A.C.T.H and cortisone may needed in severe
cases.cases.
6. Anti thyroid drugs should be given in big doses6. Anti thyroid drugs should be given in big doses
7. Inderal is given to control tachycardia7. Inderal is given to control tachycardia

86. Cancer thyroidCancer thyroid
1. Precancerous conditions1. Precancerous conditions
2. Pathological types2. Pathological types
3. Clinical features.3. Clinical features.
4. Investigations4. Investigations
5. Treatment5. Treatment
1. Precancerous conditions1. Precancerous conditions
1.1. AdenomaAdenoma of the thyroidof the thyroid
2.2. NodularNodular goitre specially in endemic areas (solitary nodular isgoitre specially in endemic areas (solitary nodular is
more liable to undergo malig.) usually givesmore liable to undergo malig.) usually gives follicularfollicular type.type.
3. Previous3. Previous irradiationirradiation of the neck in children (never in adult) ofof the neck in children (never in adult) of
enlarged thymus or T.B lymphadenitis usually givesenlarged thymus or T.B lymphadenitis usually gives papillarypapillary
type.type.
4.4. Genetic factorsGenetic factors : sometimes: sometimes medullarymedullary carcinoma run incarcinoma run in
families.families.
5. Carcinoma of thyroid is extremely rare with5. Carcinoma of thyroid is extremely rare with toxictoxic goitregoitre..

87. 2. Pathological Types2. Pathological Types
PapillaryPapillary adenocarcinoma 85%adenocarcinoma 85%
- Occult.Occult.
- Intra-thyroidal.Intra-thyroidal.
- Extra-thyroidal.Extra-thyroidal.
 It is commonest type , met with any age , commonIt is commonest type , met with any age , common
in children specially with previous irradiation of thein children specially with previous irradiation of the
neck. It is usually has good prognosis. It is formedneck. It is usually has good prognosis. It is formed
of delicate branching C.T covered by one or severalof delicate branching C.T covered by one or several
layers of cuboidal cells small calcified areas , calledlayers of cuboidal cells small calcified areas , called
“Psammoma bodies” are seen and may help in“Psammoma bodies” are seen and may help in
differentiation from benign.differentiation from benign.

88. It is characterized by :It is characterized by :
1. Low grade malignancy.1. Low grade malignancy.
2. Slow growth it may remain stationary with or2. Slow growth it may remain stationary with or
without metastases for many years.without metastases for many years.
3. Early lymphatic spread to deep cervical L.N.3. Early lymphatic spread to deep cervical L.N.
4. The affected L.N reach a big size while the4. The affected L.N reach a big size while the
primary is small “lat aberrant thyroid T.”primary is small “lat aberrant thyroid T.”
5. The papillary T. has a small or no radio-iodine5. The papillary T. has a small or no radio-iodine
uptake.uptake.

89. Treatment :Treatment :
 Total thyroidectomy with unilateral orTotal thyroidectomy with unilateral or
bilateral block dissection of Lymph Nodes.bilateral block dissection of Lymph Nodes.
 Thyroid extract is given post operatively inThyroid extract is given post operatively in
big doses as replacement therapy tobig doses as replacement therapy to
suppress the T.S.H in trial to inhibit furthersuppress the T.S.H in trial to inhibit further
of the glandof the gland..

90. 2. Follicular adenocarcinoma 10 %2. Follicular adenocarcinoma 10 %
 It is usually common in endemic nodular goitres met with anyIt is usually common in endemic nodular goitres met with any
age usually between 40 – 60 years. It forms grey , nonage usually between 40 – 60 years. It forms grey , non
encapsulated mass with varying degree of differentiation. Theencapsulated mass with varying degree of differentiation. The
well differentiated type is usually referred as “malignantwell differentiated type is usually referred as “malignant
adenoma” , and may remain without metastases for many years.adenoma” , and may remain without metastases for many years.
While , the undifferentiated tumors grow more rapidly in size ,While , the undifferentiated tumors grow more rapidly in size ,
spread mainly by BI. But lymphatic is also common.spread mainly by BI. But lymphatic is also common.
 The follicular tumors in which invasion is minimal are termedThe follicular tumors in which invasion is minimal are termed
“non-invasive“non-invasive” and those in which invasion is moderate or” and those in which invasion is moderate or
marked are termed “marked are termed “invasiveinvasive”.”.
 The follicular T. has a large radio-iodine uptake.The follicular T. has a large radio-iodine uptake.
Treatment :Treatment :
 Total thyroidectomy with block dissection.Total thyroidectomy with block dissection.
In case of 2ryies scanning for it with radio active iodine.In case of 2ryies scanning for it with radio active iodine.
 If active : radio active iodine ablationIf active : radio active iodine ablation
 If inactive deep x-ray therapy.If inactive deep x-ray therapy.

91. 3. Anaplastic Carcinoma 3%3. Anaplastic Carcinoma 3%
 It usually occurs in old age group.It usually occurs in old age group.
 It grows very rapidly to infiltrate the thyroid and theIt grows very rapidly to infiltrate the thyroid and the
surrounding T.surrounding T.
 two types are recognised : the small cell and giant celltwo types are recognised : the small cell and giant cell
types.types.
 TheThe small cellsmall cell type may be mistaken for atype may be mistaken for a
lymphosarcemalymphosarcema , while the, while the giant cellgiant cell type simulate ontype simulate on
anaplasticanaplastic fibrosarcomafibrosarcoma..
 The tumor spreads rapidly by the blood and lymph andThe tumor spreads rapidly by the blood and lymph and
kills the patient in a short time.kills the patient in a short time.
 It is of bad prognosesIt is of bad prognoses
90% of patient are dead within 1 year.90% of patient are dead within 1 year.
10 % of patient are dead within 3 years10 % of patient are dead within 3 years
TreatmentTreatment
 Surgery has little or no place , but deep x-ray therapySurgery has little or no place , but deep x-ray therapy
chemotherapy, tracheostomy may be needed.chemotherapy, tracheostomy may be needed.

92. 4. Medullary Carcinoma 2 - 4%4. Medullary Carcinoma 2 - 4%
 It is rare tumors , a rise fromIt is rare tumors , a rise from para-follicularpara-follicular cells “cells “CC””
cells which secretecells which secrete calcitonincalcitonin..
 The malignant cells contains amyloid.The malignant cells contains amyloid.
 The tumors are solid , hard , not hormone dependentThe tumors are solid , hard , not hormone dependent
and do not take up radio-iodineand do not take up radio-iodine
 High level of serum calcitonin are produced by manyHigh level of serum calcitonin are produced by many
medullary carcinoma.medullary carcinoma.
 DiarrheaDiarrhea is a feature of 30% of cases , this is may due tois a feature of 30% of cases , this is may due to
5 HT produced by malignant cells.5 HT produced by malignant cells.
 The tumors present usually in 50 – 70 age group butThe tumors present usually in 50 – 70 age group but
there is younger group which presents in childhood orthere is younger group which presents in childhood or
before 30 years with family history and is associatedbefore 30 years with family history and is associated
withwith hyperparathyroidismhyperparathyroidism andand pheochromocytomapheochromocytoma , a, a
combination known ascombination known as Sipple’s SyndromeSipple’s Syndrome..
 The prognosis depends upon the absence or presenceThe prognosis depends upon the absence or presence
of L.N. metastases.of L.N. metastases.