Thyroid Gland

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 Thyroid Gland
• The thyroid gland is the largest endocrine gland like a
butterfly shaped organ located in the lower neck,
anterior to the trachea
• The thyroid is a gland responsible for production of
thyroid hormones (T3,T4, and calcitonin).
• These hormones help to regulate the body's
metabolism and affect important processes, such as
growth.

• The thyroid gland uses iodine (mostly from the diet in

seafood and salt) to produce thyroid hormones.
• Urinary iodine is >10 µg/dL in iodine-sufficient
populations. 2
The thyroid gland and surrounding structures

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 Thyroid Gland…
• The two most important thyroid hormones are
thyroxine (T4) and triiodothyronine (T3), representing
99.9% and 0.1% of thyroid hormones, respectively.

• The hormone with the most biological power is T3.

• Once released from the thyroid gland into the blood, a

large amount of T4 is converted to T3 - the active
hormone that affects the metabolism of all cells.
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 Thyroid gland …
The blood flow to the thyroid is very high (about 5
mL/min per gram of thyroid tissue), approximately five
times the blood flow to the liver.

This reflects the high metabolic activity of the thyroid

gland.

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 Thyroid hormones
• The hypothalamus releases TRH, which sends a signal to
the pituitary gland to release TSH.

• TSH controls the rate of thyroid hormone release. In

turn, the level of thyroid hormone in the blood
determines the release of TSH.

If the thyroid hormone concentration in the blood

decreases, the release of TSH increases, which causes
increased output of T3 and T4.
 Negative feed back mechanism.

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Negative feed back mechanism thyroid hormone

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 Thyroid hormones
 Thyroid gland produce another hormone called
calcitonin.
 Calcitonin regulates calcium by lowering calcium levels
in the blood.

 Unlike T3 and T4, calcitonin is not involved in the

regulation of metabolism.

 The term euthyroid refers to thyroid hormone

production that is within normal limits (T4= 5-13.5µg
and T3= 0.1-0.2µg).
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 Function of thyroid hormones
• The primary function of thyroid hormone is to control
cellular metabolic activity.

• The thyroid hormones influence cell replication and are

important in brain development.

• Thyroid hormone is also necessary for normal growth.

• T4 is a relatively weak hormone, maintains body
metabolism in a steady state.

• T3 is about five times as potent as T4 and has a more

rapid metabolic action. 9
 Function of thyroid hormones…
• If over activity of any of these three glands (Hypothalamus,
pituitary & thyroid) occurs, an excessive amount of thyroid
hormones can be produced, thereby resulting in
hyperthyroidism.
• Similarly, if under activity of any of these glands occurs, a
deficiency of thyroid hormones can result, causing
hypothyroidism.
• Goiter is a diffuse or focal enlargement of the thyroid gland
that may be metabolically hyperactive, hypoactive, or
normoactive (Euthyroid)
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 Hypothyroidism
• Hypothyroidism is a common endocrine disorder
resulting from deficiency of thyroid hormone

• is a state in which the thyroid gland does not

produce a sufficient amount of the thyroid
hormones T4 and T3.

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 Causes
Autoimmune disease (Hashimoto's thyroiditis, post–
Graves' disease)
Atrophy of thyroid gland with aging
Therapy for hyperthyroidism
Radioactive iodine (131I)
Thyroidectomy
Medications
Lithium, Iodine compounds
Antithyroid medications
Radiation for treatment of head and neck cancer.
Iodine Deficiency is the most common cause of
hypothyroidism
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 Classification
• Central hypothyroidism: If the cause of the thyroid
dysfunction is failure of both the pituitary gland, the
hypothalamus.
• Primary or thyroidal hypothyroidism: which refers to
dysfunction of the thyroid gland itself. More than 95%
of patients have primary hypothyroidism.
• Secondary hypothyroidism or pituitary: If the cause is
entirely a pituitary disorder.
• Tertiary hypothyroidism or hypothalamic: If the cause is
a disorder of the hypothalamus resulting in inadequate
secretion of TSH due to decreased stimulation by TRH.

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 Thyroid Screening
• Thyroid Screening No universal
recommendation
• The American Thyroid Association
• Screening at age 35 years and every 5 years
• More frequent if at high risk
 Pregnant women
 Women older than 60 years
 Patients with type 1 diabetes or other
autoimmune disease
 Patients with a history of neck irradiation
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 Hypothyroidism

• Thyroid deficiency can affect all body functions

and can range from mild, subclinical forms to
myxedema, an advanced form.

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 Hypothyroidism
Cretinism: If thyroid deficiency is present at birth.
It is characterized by mental and growth retardation.
 In such instances, the mother may also have thyroid
deficiency.
• Myxedema also refers to the swelling of the skin and
soft tissue that occurs in patients who are hypothyroid.
• The term myxedema refers to the accumulation of
mucopolysaccharides in subcutaneous and other
interstitial tissues. It implies presence of non-pitting
mucosal edema
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 Myxedema Coma
• Myxedema Coma A severe form
of hypothyroidism that results in
• An altered mental status
• Hypothermia, Bradycardia,
Hypercarbia, Hyponatremia,
Cardiomegaly.
• Myxedema coma most
commonly occurs in individuals
with undiagnosed or untreated
hypothyroidism who are
subjected to an external stress.

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 Clinical features
Early
• Appearance: thin, brittle fingernails; dry, itchy skin;
weight gain, water retention, myxedema, hair loss
• Neurological: depression, mood instability, irritability
rapid thoughts.
• Muscular: depressed reflexes, hypotonia, muscle cramps,
joint pain.
• Cardiovascular: bradycardia, elevated serum cholesterol.
• Endocrine: female infertility, menstrual irregularities,
hyperprolactinemia and galactorrhea.
• Other: fatigue, sleepiness, cold intolerance, decreased
sweating
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 Clinical features…
Late
• Appearance: thinning of the outer third of the eyebrow
dry 'puffy' facial skin
• Neurological: slow speech and hoarse voice, deepening
of the voice due to Reinke's Edema.
• Muscular: carpal tunnel syndrome and bilateral
paresthesia
• Cardiovascular: hypotension
• Endocrine: goiter, decreased libido in men due to
impairment of testicular testosterone synthesis
• Other: low basal body temperature

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 Diagnostic evaluation
• History: dry skin, intolerance to cold, constipation
,fatigue
• Physical examination: B/P, HR, Skin ,hair…
• Lab investigations:
Low serum T3
Too low of free T4 levels, the normal range for T4 is 5
to 13.5 µg/dl—it's a possible indicator of
hypothyroidism, even if previous TSH tests came back
normal.
Elevated TSH
0.4 mu/L: normal
2.5 mu/L: at risk
4.0 mu/L-10mu/L: mild – sever hypothyroidism
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 Treatment

Aim:- Restore normal metabolic state by replacing the

missing hormone, synthetic levothyroxin.

• Treat any underlying disorder

• In severe hypothyroidism and myxedema

management maintain vital function.

• Avoid application of external heat because it may

increase oxygen requirement.

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 Treatment
Levothyroxin sodium (Levoxyl)
• T4 replacement in adults is approximately 1.6µg/kg/day.

• Circulating serum T3 and T4 levels exert a feedback effect

on both TRH and TSH secretion.

• Ideally, synthetic T4 replacement should be taken in the

morning, 30 minutes before eating.

• Other medications containing iron or antacids should be

avoided, because they interfere with absorption.
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 Nursing responsibilities
The patient experiences decreased energy and moderate
to severe lethargy:
 avoid complication from immobility.
help the patient exercise with his/her energy level.
On going monitor vital signs.
Give extra blanket if feels cold.
Emotional support.
Instruct the patient not to interrupt medication even
symptoms disappear.
Follow dietary instruction.

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 Hyperthyroidism
• Hyperthyroidism is a condition in which the thyroid
gland produces and secretes excessive amounts of the
free thyroid hormones(T3 and T4).

• Hyperthyroidism is the second most prevalent

endocrine disorder, after diabetes mellitus.

• If there is too much thyroid hormone, every function of

the body tends to speed up.
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 Hyperthyroidism…
• Hyperthyroidism is a disorder that occurs when the
thyroid gland makes more thyroid hormone than the
body needs.

 Hyperthyroidism: is the hyperactivity of the thyroid

gland.

• Thyrotoxicosis: is the clinical syndrome that results

when tissues are exposed to high levels of circulating
thyroid hormone
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 Hyperthyroidism…
• The over stimulation of the thyroid gland leads to
hyperplasia of the gland and subsequently this leads to
an increase in the secretion of thyroid hormones.

• The growth in the cells and its multiplication manifest in

enlargement of the gland.

• There is elevation in metabolic rate manifesting in

elevation in metabolism of protein, fat and carbohydrate.
• The accelerated protein and fat metabolism lead to
weight loss and muscular weakness.

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 Hyperthyroidism…
• The body attempts to remedy the weight loss and so the
patient's appetite is increased in the process.
• Patient is unable to tolerate hot weather as a result of the
increase in the body metabolism.

• The superficial capillaries dilate leading to increased

peripheral blood flow and also an increase in cardiac
output as the body tries to eliminate excess heat from
the system.
• This accounts for warm and moist skin and also for the
perspiration.
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 Hyperthyroidism…
• The increase cardiac output in conjunction with hormonal
effects on the sympathetic nerves brings about palpitation
and tachycardia.

• Increased adrenergic activity results in the retraction of the

upper eyelids which presents with increased sclera exposure
or exophthalmoses.

• Increased adrenergic activity also causes fine muscle tremors

which are noticeable when patient's hands are outstretched.
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 Causes
• It is usually associated with hyperplasia of the thyroid
gland and multinodular goiter.

– Graves' disease

– Adenoma of thyroid

– Thyrioditis

– Excessive ingestion of thyroid hormone

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 Graves’ disease
• Graves' disease-An autoimmune disease (the most
common etiology of hyperthyroidism) with 50%-80%
worldwide.
• Graves' disease, results from an excessive output of
thyroid hormones caused by abnormal stimulation of
the thyroid gland by circulating Immunoglobulin.
• It is common in women.
• The onset of symptoms of GD is usually gradual
• This symptoms may lead to symptoms of
hyperthyroidism.
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 Adenoma of thyroid
• Thyroid adenomas are benign lesions of the thyroid
gland.
• These lesions may be inactive or active, producing
thyroid hormones.
• Thyroid to produce too many hormones. This can
lead to symptoms of hyperthyroidism, or overactive
thyroid
• Patients with thyroid adenomas are usually
asymptomatic.

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 Thyroiditis…
Thyroiditis: inflammation of the thyroid gland, can be
acute, sub acute, or chronic.

• Each type of thyroiditis is characterized by inflammation,

fibrosis, or lymphocytic infiltration of the thyroid gland.
Acute thyroiditis
• Acute thyroiditis is a rare disorder caused by infection of
the thyroid gland by bacteria, fungi, mycobacterium, or
parasites.

• Staphylococcus aureus and other staphylococci are the

most common causes. 32
 Thyroiditis…
Acute thyroiditis….
• Infection typically causes anterior neck pain and
swelling, fever, dysphagia, and dysphonia.
• Pharyngitis or pharyngeal pain is often present.
• Examination may reveal warmth, erythema (redness), and
tenderness of the thyroid gland.
Treatment:
• Antimicrobial agents and fluid replacement.
• Surgical incision and drainage may be needed if an
abscess is present.
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 Clinical features
• Nervousness, Goiter or Hand tremor
• Emotionally hyperexitability, irritable, they can not sit
quietly.
• Tachycardia and palpitation,
• excessive sweating

• Wt loss despite large appetite

• Patient exhibits exophthalmoses (bulging of eyes)
• diarrhea
• Heat intolerance ,
• Irregular menstrual periods in women
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 Assessment and Diagnostic Findings…
Physical Examination

• High systolic blood pressure, increased heart rate

• Shaking of the hands

• Swelling or inflammation around the eyes

• soft and pulsate enlarged glands

• A thrill often can be palpated

• a bruit is heard over the thyroid arteries. These are signs of

greatly increased blood flow through the thyroid gland.
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 Assessment and Diagnostic Findings…

Blood tests:

• Thyroid hormones TSH, T3, and T4.

• Cholesterol levels

• Glucose

• Radioactive iodine uptake

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 Management
• Rx of hyperthyroidism is directed toward reducing thyroid
hyperactivity to relieve symptoms and preventing
complications.

• Appropriate treatment of hyperthyroidism depends on the

underlying cause and often consists of a combination of
therapies,.

 Antithyroid agents

 Radioactive iodine

 surgery
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 Management
Anti-thyroid agent

 Antithyroid medications that interfere with the synthesis of

thyroid hormones.

 Propthyluarcil (methimasole): prevent the thyroid gland from

converting iodine to its organic (hormonal) form in the
thyroid and block conversation of T4 to T3 in the tissue.

 Beta blocking adregenic drug propanolol is often given to

control nervousness, tachycardia, tremor by blocking
hyperthyroid state or SNS function. 38
 Management
 Radioactive iodine (131I) to destroy over active thyroid cells
and stops the excess production of hormones.
 The goal of radioactive iodine therapy (131I) is to eliminate
the hyperthyroid state with the administration of sufficient
radiation in a single dose.
 Radioactive iodine has been used to treat toxic adenomas,
toxic multinodular goiter, and most varieties of
thyrotoxicosis.
 Radioactive iodine is contraindicated during pregnancy
because it crosses the placenta.
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 Management
Surgical removal: Part or all the thyroid gland.

• Surgery is reserved for special circumstances in

 Pregnant women who are allergic to antithyroid medications

 Patients with large goiters

 Patients who are unable to take antithyroid agents.

• If thyroid is removed with surgery or destroyed with

radiation, it is must take thyroid hormone replacement
pills for the rest of the life.
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 Possible Complications…
• Surgery-related complications:

– Scarring of the neck

– Hoarseness due to nerve damage to the voice box

– Low calcium level due to damage to the parathyroid

glands (located near the thyroid gland)

– Hypothyroidism (underactive thyroid)

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 Possible Complications
• Thyroid crisis (storm), also called thyrotoxicosis, is a
sudden worsening of hyperthyroidism symptoms that
may occur with infection or stress.
• Fever, decreased alertness, and abdominal pain may
occur. Patients need to be treated in the hospital.

• Other complications of hyperthyroidism include:

– fast heart rate,
– abnormal heart rhythm,
– heart failure
– Osteoporosis
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 Goiter
• Goiter refers to a generalized enlargement of the
thyroid gland which is normally impalpable.

• Goiter is an increase in size of the thyroid gland it can

occur in hypothyroid, euthyroid, hyperthyroid state.

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 Risk factors for goiter
 Hereditary (inherited from family)

 Female gender

 Age over 40

 Exposure to radiation

 person who has had medical radiation treatments to the

head and neck has a greater risk of developing goiter.

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 World Health Organization (WHO) Goiter Classification
• Grade 0: No goiter: hardly palpable and visible (or un palpable or un
visible)
• Grade IA: clearly palpable, but un visible with neck extension
• Grade IB: clearly palpable and visible with complete neck extension
(head thrown). This grade involves nodular goiter, even if the thyroid
itself isn’t enlarged
• Grade II: clearly visible when the head is in normal position (palpation
isn’t necessary for diagnosis)
• Grade III: thyroid seen from the distance (palpation isn’t necessary for
diagnosis)
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 Revised goiter division
• Grade 0:-Thyroid not enlarged by inspection or palpation

• Grade 1:- Goiter palpable, but not seen when head and
neck are in normal position (thyroid isn’t enlarged
visually).

• This category includes nodules in normal sized thyroid

• Grade 2:- Thyroid visible when head is in normal

position, and palpatory enlarged
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 Type of goiter
Simple goiters
 develop when the thyroid gland does not make enough hormones
to meet the body's needs.
 The thyroid gland tries to make up for this shortage by growing
larger.
Endemic goiters
 occur in people who do not get enough iodine in their diet (iodine
is necessary to make thyroid hormone).
 because iodine is added to table salt in the United States and other
countries, this type of goiter usually does not occur in these
countries.
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 Types of goiter
Sporadic goiters
 most cases, have no known cause.

 In some cases, certain drugs can cause this type of goiter.

 For example, the drug lithium, which is used to treat certain

mental health conditions, as well as other medical conditions, can

cause this type of goiter.

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 Endemic(iodine deficient) goiter
• Endemic goiter is a type of goiter that is associated with
dietary iodine deficiency.

• Some High land areas where soil and water lacks in

iodine compounds and consumption of marine foods is
low are known for higher incidence of goiter. In such
areas goiter is said to be "endemic".

• Simple goiter represents a compensatory hypertrophy of

thyroid gland presumable caused by stimulation of the
pituitary gland.

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 Endemic Goiter….
• The pituitary Gland produce TSH hormone that controls
the level of thyroid hormone.

• Its production increases, if there is subnormal thyroid

activity as when insufficient iodine is available for
production of the thyroid hormone.

• Such goiters usually cause no symptoms, except for the

swelling in the neck, which may result in tracheal
compression when excessive.
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 What are the symptoms of goiter?
 A swelling in the front of the neck, just below the
Adam's apple

 A feeling of tightness in the throat area

 Hoarseness

 Neck vein swelling

 Dizziness when the arms are raised above the head

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 Other, less common symptoms :
 Difficulty breathing (shortness of breath)

 Coughing

 Wheezing (due to squeezing of the windpipe)

 Difficulty swallowing (due to squeezing of the esophagus, or

“food tube”)

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 Diagnosis
• Family history and examination of the patient.

• Physical Examination: palpation or Inspection.

• Blood test: to pinpoint the exact cause of thyroid

enlargement (levels T3 ,T4and TSH as well ESR).

• CT scans,

• MRIs, and

• Biopsy of the thyroid gland is for a suspected thyroid

cancer.
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 Management and treatment
No treatment/"watchful waiting."
 If the goiter is small.
 However, the goiter will be closely watched for any changes.
Medications.
 Levothyroxine is a thyroid hormone replacement therapy.
 It is prescribed if the cause of the goiter is an underactive thyroid
(hypothyroidism).
 if the cause of the goiter is an overactive thyroid
(hyperthyroidism) drugs like methimazole and propylthiouracil
used

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 Management and treatment
Radioactive iodine treatment.
 used in cases of an overactive thyroid gland (orally).
 the patient usually has to take thyroid hormone replacement
therapy for the rest of his or her life after radioactive iodine
treatment
Biopsy :
 a biopsy is the removal of a sample of tissue or cells from
living organisms to be studied in a laboratory.
 A biopsy is taken to rule out cancer.
Surgery:
 is performed to remove all or part of the thyroid gland.
 if the goiter is large and causes problems with breathing and
swallowing.
 the patient may need to take thyroid hormone replacement
therapy for the rest of his or her life. 55