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  1. THYROID GLAND REDA FAWZY ABBAS, MD H&N& Endocrine surgeon Lecturer Of General Surgery KFS UNIVERSITY
  3. Toxic goitre Diffuse Nodular STN Recurrent
  4. Graves’ disease Etiology: TSI, LATS Symptoms. Signs: Local: Diffuse gland – inc. vasc.
  5. Thyroid gland diffuse enlargement, butterfly shape uniform .smooth, rubbery, thrill can be felt
  6. Symptoms Metabolic -progressive wt loss - sweeting (hands , face) -intolerance to heat - warm hands - Easy fatigability
  7. CNS Symptoms - insomnia - Nervousness, irritability, - Nightmares - Anxiety Signs - Pts looks tense - Tremors (fingers tongue) - Exaggerated reflexes.
  8. CVS Symptoms palpitations, dyspnea, anginal pain Signs Tachycardia Arrhythmia
  9. Muscle weakness, atrophy, quadriceps, shoulder Skin Worm, moist pigmentations, pretibial myxedema
  10. GIT diarrhea Genital Females irregular menses, menorrhagia , amenorrhea Males gynecomastia , abnormal libido
  11. Signs: General 1. General appearance: Eye signs Hair falling Thyroid acropathy ( skin thickening) 2. Body metabolism: Excessive sweating Loss of weight in spite of good appetite Heat intolerance.
  12. Signs: General 3. GIT: Diarrhea Distention Increased glucose intolerance 4. Respiratory system: Dyspnea on effort
  13. Signs: General 5. CNS: Fine tremors. Irritability – nervousness – easy excitability Headache – insomnia. 6. CVS: Systolic HTN – wide pulse pressure. Tachycardia. Arrhythmias. Thyrocardia.
  14. Signs: General 7. Genitourinary: Polyuria. Menstrual disturbances. Infertility with impotence & frigidity. 8. Musculoskeletal: Pretibial myxedema. Proximal myopathy. Hypercalcemia & osteoporosis.
  15. Eye Symptoms – Blurred vision. – Diplopia – Excessive tearing – Pain and photophobia (corneal ulcers). – . Swollen black eyelids. – Bulging
  16. 9. Eye signs: opthalmopathy( exophthalmos) Infrequent blinking Lid retraction Lid lag Staring look No forehead wrinkling Lack of maintained convergence Backer’s sign Exophthalmos Vs Proptosis Malignant exophthalmos
  17. Investigations 1. Laboratory Tests: FT3, FT4, & TSH. Antibodies. Protein bound iodine. Serum cholesterol: It is decreased. Creatinine: < 0.6 mg/dl excludes D. 2. Plain X-Ray: neck & chest. 3. Ultrasound. 4. Indirect laryngoscopy.
  18. Differential Diagnosis 1. Anxiety neurosis. 2. Myasthenia gravis or other muscular disorders. 3. Menopausal syndrome. 4. Pheochromocytoma. 5. Other causes of exophthalmos. 6. Thyrotoxic Factitia.
  19. TREATMENT: MEDICAL 1. Physical and mental rest. 2. Diet. 3. Good sedation. 4. Anti-thyroid drugs: – Propyl-thiouracil – Neomercazole – Lugol’s iodine 5. Beta-blockers.
  20. TREATMENT: MEDICAL Indications: 1. Small goiters. 2. Mild thyrotoxicosis. 3. Contraindication to anesthesia or surgery. 4. High thyroid antibodies indicating thyroiditis. 5. Treatment of Exophthalomos (refer back). 6. Postoperative recurrence.
  21. TREATMENT: MEDICAL Indications: 7. Preoperative preparation in general & especially in: Pregnancy: followed by thyroidectomy in the 2nd trimester. Thyrocardiac patient.
  22. TREATMENT: MEDICAL Contraindications: 1. Retrosternal goiter. 2. As a definitive management for toxic nodular goiter. 3. Development of side effects.
  23. TREATMENT: MEDICAL Advantages: 1. It avoids the hazards & complications of surgery. 2. It avoids the hazards & side effects of radio-active iodine (RAI).
  24. TREATMENT: MEDICAL Disadvantages: 1. It is expensive, has many side effects, and requires observation for life 2. No guarantee for cure & relapses occur in 50-70% of cases. 3. Drug resistance may occur. 4. Goitrogenic.
  25. TREATMENT: RAI Dose: It differs according to the age, sex, body weight & degree of toxicity. It takes 3 months to give its effects. During this period, one may depend on ATD & inderal for control of symptoms
  26. TREATMENT: RAI Contraindications Indications 1. Pregnancy & lactation because it is teratogenic. 2. Large nodular goiter. 3. Tracheal narrowing. 4. Retrosternal extension. 5. Children 1. Toxic adenoma. 2. Contraindications to operation. 3. Persons who refuse surgery e.g. singers. 4. Postoperative recurrence. 5. If there is no evidence of local pressure by the thyroid swelling.
  27. TREATMENT: RAI Disadvantages & Complications Advantages 1.Slow in producing its effects & often a long treatment period is required. 2.Associated with a higher degree of worsened eye manifestations than after surgery. 1.It is a simple method, given orally. 2.Cheap & effective. 3.It avoids the hazards & complications of surgery. 4.It avoids the hazards & side effects of ATDs.
  28. TREATMENT: Surgery Preoperative preparation. TTx then replacement therapy for life. Indications: 1. Large goiter with pressure manifestations. 2. Retro-sternal goiter. 3. Failure or contraindications to medical treatment 4. Patients who wish to become pregnant within one year of treatment.
  29. TREATMENT: Surgery Contraindications: 1. High risk patients with a contraindication to anesthesia or surgery. 2. Hyperthyroidism with high titre of thyroid antibodies indicating thyroiditis
  30. TREATMENT: Surgery Advantages: 1. Rapid effect with low incidence of hypothyroidism. 2. Low recurrence rate.
  31. Toxic nodular goiter 2ry Thyrotoxicosis 1ry Thyrotoxicosis Point of Difference > 35 years (older). Start after gland enlargement Asymmetrical, may be unilateral, firm & nodular surface More marked Less marked Less marked Less marked Less marked Surgery only (after preparation). Rare Progressive < 35 years Start with gland enlargement Symmetrical, bilateral, fleshy & smooth surface Not marked More marked More marked More marked More marked ATD, RAI or surgery Not uncommon Remission & relapses Age: Onset of S/S: The gland: CVS : CNS : GIT : Eye : BMR , T3, T4: Treatment: Recurrence: Course:
  32. Special situations In pregnancy. Thyrotoxic crisis.
  33. Special situations Hyperthyroidism due to rare causes: 1. Thyrotoxicosis factitia: due to over intake of T4. 2. Jod-Basedow’s disease. 3. Thyroiditis. 4. Neonatal thyrotoxicosis. 5. Massive metastasis from a normofunctioning follicular carcinoma. 6. T3 toxicosis with normal T4 levels.
  34. Thyroiditis Acute thyroiditis. Subacute thyroiditis (De Quervain’s). Chronic thyroiditis: Specific – non specific Hashimoto’s Vs Riedle’s
  35. 2. Riedle’s Disease 1. Hashimoto’s Disease Criteria Woody thyroiditis. Lymphadenoid goiter Synonyms Most probably, a collagen disease. Autoimmune Etiology The gland becomes a mass of dense F.T. 1.The gland is enlarged with a slightly lobulated surface. 2.Thickened non-adherent capsule. NEA: 1.The epithelial elements are replaced by a dense fibrous tissue in which a few distorted atrophic acini are widely scattered. 2.Evidence of hyperplasia of epithelial elements in the less affected portions of the gland. 1.Interfollicular lymphocytic & plasma cell infiltration. 2.Epithelial changes (from destruction to hyperplasia). 3.Tendency to eventual fibrosis. 4.Askanazy cells. MP:
  36. 1.Sex: Both males and females. 2.Age: young adults. 3.Complaints: •Neck swelling •Profound hypothyroidism. •Profound pressure symptoms. 1.Sex: More in females (20:1). 2.Age: older (menopausal). 3.Complaints: •Neck swelling. •Patient is initially euthyroid, with superimposed hashitoxicosis, then eventually she is hypothyroid. •Little or no pressure symptoms. History- Taking:
  37. 1.Goiter: Not uniformly enlarged, woody hard, fixed, irregular surface, and ill-defined edges. 2.Signs of hypothyroidism. 1.Goiter: Uniform enlargement, usually bilateral, firm, mobile with deglutition, smooth surface, butterfly shaped and well-defined edges. 2.Signs of hypothyroidism. 3.No palpable lymph nodes. Examina tion: Thyroid cancer Thyroid cancer DD:
  38. 1.Thyroid function tests show hypothyroidism. 2.Antibodies are not diagnostic. 3.US & plain X-ray chest & neck may help 4.Needle biopsy. 1.Thyroid function tests show hypothyroidism. 2.Highly raised titers of thyroid antibodies. 3.US: may help. 4.Needle biopsy. Investigati ons
  39. El-troxin for replacement. For diagnosis & to relief pressure effects by isthmectomy (thyroidectomy may be impossible). It is ineffective. El-troxin for replacement & cortisone (autoimmune). To rule out malignancy & to relief pressure effects. Contraindicated because it causes severe myxedema. Treatment a) Medical: b) Surgical: c) RAI: