Thyroid Disease

Ian A Forde

The Thyroid Gland

An Endocrine gland located in the neck
located inferiorly to the thyroid cartilage
that in most individuals consists of two
lobes connected by an isthmus. It produces
thyroxine & calcitonin.

Thyroid Function
Makes thyroid hormone triiodothyronine (T3) and thyroxine (T4) from
iodine and tyrosine. T3 and T4 are stored in the gland where it is
bound to thyroglobulin .
The secretion of T3 and T4 is under the control of thyrotropinreleasing hormone (TRH) secreted by the hypothalamus, which
regulates thyroid stimulating hormone (TSH) from the anterior
pituitary.
Increased plasma levels of T3 and T4 result in negative feedback on
TRH and TSH.
Calcitonin is secreted by parafollicular or C-cells , which are involved
in medullary thyroid cancer.

Effects of Thyroid Hormone

CVS: Increases Heart rate and force of contractions leading to increased Cardiac
Output. Also promotes peripheral vasodilation
CNS: Aids in normal brain development, nerve myelination, cerebellar growth as well
as normal intellectual growth. Also aids with emotional stability in adults
GI: Increases appetite and gastric motility
:Hematological: Promotes Erythropoesis
Metabolic: Widespread increase of basal metabolic rate, increased oxygen
consumption, heat production and fat, carbs and protein metabolism
MSK: Aids in bone development and maturation and tooth development

Embryology

Both the thyroid and parathyroid are derivatives of endodermal pharyngeal

pouches.
Thyroid gland is the first endocrine gland to develop at approx. the 24 th day
of gestation
The thyroid gland develops from the thyroglossal duct, mainly from the 4th
pharyngeal pouch. The parafollicular cells of thyroid arise from the 5th
pharyngeal. (Ultimobranchial bodies)
The thyroglossal duct develops as a diverticulum in the floor of the pharynx
at foramen cecum at base of the tongue.
It then bifurcates and both leaflets of bifurcation proliferate and give rise to
two lobes of the thyroid gland.

Gross Anatomy
Two lobes, isthmus, pyramidal lobe (pyramidal lobe present in 50 80%)
Suspended from larynx, attached to trachea (criycoid cartilage and tracheal
rings).
Weighs 2025 g in adults.
Relationships:
Anterior: Strap muscles (sternohyoid, sternothyroid, thyrohyoid, omohyoid).
Posterior: Trachea.
Posterolateral: Common carotid arteries, internal jugular veins, vagus nerves.

It is contained in a fibrous capsule formed by the Deep Cervical Fascia.

Parathyoid glands on posterior surface of thyroid, and may be within capsule.

Gross Anatomy

Histology
The functioning unit is the lobule supplied by a single arteriole and
consists of 2440 follicles lined with cuboidal epithelium. The follicle
contains colloid in which thyroglobulin is stored.

Anatomy

There is an extensive lymphatic network within the

gland. Lymphatics ultimately drain to internal jugular
nodes.
Intraglandular lymphatics connect both lobes, explaining
the relatively high frequency of multifocal tumors in the
thyroid.

Vasculature
Arterial
Superior thyroid arteries (on each side). It arises from the first
branch of external carotid artery at the level of the carotid
bifurcation.
Inferior thyroid artery (on each side).Arises from the
thyrocervical trunk of subclavian artery.
Thyroid Ima artery (present in 10% of the world pop). It can
arises from the brachiocephalic trunk, aorta or carotid artery.
Runs anterior to the trachea and is unpaired.

Vasculature

Venous
Superior thyroid veins & Middle thyroid veins drain into the Internal Jugular Veins.
Inferior thyroid veins however drain into the brachiocephalic vein.

Lymphatic Supply

Innervation

Sympathetic: Superior and middle cervical sympathetic ganglia (vasomotor).

Parasympathetic: From vagus nerves, via branches of laryngeal nerves.

Recurrent Laryngeal Nerves

A branch of the vagus nerve that descends along the internal carotid
artery, the RLN is located in close proximity to the inferior thyroid
artery branches.
The right RLN loops around the subclavian artery.
The left RLN loops around the aortic arch.
The RLN innervates all intrinsic muscles of the larynx except the
cricothyroideus.
The tubercle of Zuckerkandl (pyramidal extension of superior thyroid
tissue) and the notch of the cricothyroid membrane are landmarks
for RLN insertion

Thyroid Fuction Tests

ENLARGEMENT OF THE THYROID

GLAND (GOITRE)

A Goitre is a visible and/or palpable enlargement of the thyroid gland

It moves upward on swallowing
Enlargement may be physiological (This can occur during pregnancy and
puberty) or it can be pathological.
It can also be nodular or diffuse
Additionally the gland may be euthyroid, hyperthyroid or hypothyroid

Goitre
Diffuse Goitre

Physiological goitre
Non toxic/endemic
goitre
Graves disease
Hashimotos
thyroiditis
Subcute thyroiditis
Secondary to
goitrogens

Nodular Goitre

Multinodular goitre
(With or without
dominant nodule)
Fibrotic
goitre(Reidels
thyroiditis)

Goitres
Physiological
Non-toxic goitre
Thyrotoxic goitre
Thyroiditis
Neoplastic

SINGLE THROID NODULE:

o Cyst
o Adenoma
o Malignancy
o Nodule in a multinodular goitre

How to differentiate
History and examination
Laboratory investigations: Thyroid function tests, thyroid antibodies, CBC
Ultrasound (cystic vs solid vs multinodular)
Radionuclide scans/scintigraphy: hot lesion is hyperfunctioning, cold lesion
hypofunctioning and is suspicious for malignancy
Fine needle aspiration for cytology ( cannot differentiate follicular neoplasm
vs benign lesion)
Chest Xray with thoracic inlet view

Thyroglossal Duct Cyst

Results from the failure of the thyroglossal duct to involute and usually contains
thyroid tissue.
It usually presents as a painless midline neck mass that moves with tongue protrusion.
It can cause dysphagia or difficulty breathing. It can also become infected which would
result in pain.
The cyst can rupture leading to a draining sinus known as a thyroglossal fistula.
Sonography will confirm the cystic nature of the mass. Additional investigations such
as MRI, CT &Thyroid function test should be done. Also a Thyroid scan to make sure
that it is not the only thyroid tissue in the body.

Thyroglossal Cyst

Thyroglossal Duct Cyst

It usually presents in the Subhyoid region but can also be present in the
suprahyoid, in the region of floor of mouth, thyroid cartilage, cricoid cartilage
or at foramen cecum.
Clinical features
Midline, soft cystic, fluctuant swelling in the neck that moves up with
deglutition as well as with protrusion of tongue.
The surface of the swelling is smooth and it is mobile sideways and not fixed to
surrounding structures as well as overlying skin.
If it gets ruptured, the opening of the thyroglossal fistula also presents at the
site of the thyroglossal cyst with a hood of skin above the opening.
Other complication is carcinomatous changepapillary cancer. Medullary
cancer never arises in the thyroglossal cyst.

Thyroglossal Cyst

Treatment: Sistrunk Procedure

Complete excision of the cyst or fistula.
Complete excision of the remnants of the thyroglossal tract
Excision of the central portion of the hyoid bone.
Cosmetic skin incision and closure.

Non- Toxic nodular goitre

Aetiology: iodine deficiency ( now uncommon), high levels of background radiation

Gland undergoes nodular hyperplasia. It develops nodules, some of which are colloid
filled and others which are degenerative. There may also be cysts, calcification and
haemorrhagic areas.

 Clinical features:
May be asymptomatic

Dyspnoea, stridor ( due to tracheal compression, especially

when there is retrosternal extension)

Dysphagia ( due to oesophageal compression)

Pain ( due to haemorrhage- less common)

On examination multiple nodules are palpable

Tracheal deviation is possible especially with retrosternal
extension.
INVESTIAGATIONS: TSH, T3, T4 (normal)

Managment

Large goitres and those causing compression require total or

subtotal thyroidectomy
Some patients may also choose to have a thyroidectomy for
cosmesis.
Patients will need life long replacement therapy (levothyroxine
sodium)
The initial dosage can be 1.6 micrograms/kg of ideal weight.
Monitor TFTs

Hyperthyroidism

Hyperthyroidism
SIGNS
SYMPTOMS:
Weight loss

Eyes: exophthalmos, lid

Increased appetite

retraction, lid lag, chemosis

Heat intolerance

Palmar erythema

Fatigue
Irritability

Thyroid bruit

Decreased concentration

Fine tremor

Palpitations
Diarrhoea

Pretibial myxoedema(non-

Oligomennorhea

pitting)

Hair thinning

Tachycardia

Hyperthyroidism

Some Clinical Causes:

Graves disease.
Toxic nodular goiter. (Plummer`s Disease)
Toxic thyroid adenoma.

Differential Diagnosis of
Hyperthyroidism

Primary Hyperthyroidism (usually a low TSH & elevated T3 & T4)

Graves` disease
Plummer`s disease
Subacute thyroiditits
Hashitoxiosis
Struma Ovarii
Exogenous Intake
Secondary Hyperthyroidism ( usually an elevated TSH, T3 & T4)
Pituitary Adenoma
Amiodarone-induced hyper thyroidism

Graves` Disease
The most common cause of hyperthyroidism, with an increased incidence in women.
Autoimmune disorder that causes an excess of TH to be produced due to the presence
of thyroid-stimulating immunoglobulins that stimulates production of TSH.
The patient can present with symptoms of hyperthyroidism, as well as a diffused
goitre, thyroid bruit and exophthalmos. Can also have fertility issues.
May also have a family Hx of autoimmune conditions.

Graves` Disease Investigations

Thyroid function tests (TFTs)increased T3 and/or T4 and decreased TSH (negative
feedback of hormone levels). TSH is the best initial test.
Serology for thyroid simulating immunoglobulin is the most accurate
CBC - Graves disease may be associated with normocytic anemia, low-normal to
slightly depressed total WBC count and/or a low-normal to slightly depressed platelet
count.
Radioactive iodide uptake test (RAIU): Scan shows diffusely increased uptake.
ECG (thyrotoxic cardiomyopathy can cause heart failure)
CT & MRI may be necessary to evaluate proptosis.

Treatment

The therapeutic approach to Graves' hyperthyroidism consists of both rapid

amelioration of symptoms with a beta blocker and measures aimed at
decreasing thyroid hormone synthesis: the administration of a thionamide,
radioiodine ablation, or surgery.

Treatment

Medical Management:
Initially Beta Blockers can be used to counteract hyperthyroid symptoms.
Antithyroid drugs include carbimazole and propylthiouracil.
Beta blockers and antithyroid drugs are usually used in combination

Treatment

Radioabalation: Radioiodide ablation with I 131

Treatment

Indications for thyroid surgery

Goitres larger than 80g
Goitres causing difficulty breathing or severe dysphagia
Patients with moderate-to-severe Graves' ophthalmopathy in whom surgery is
preferred over radioiodine since radioiodine may exacerbate Graves' ophthalmopathy.
Young or Pregnant patients
Patients with suspicious mass in the thyroid gland

Treatment

Presurgical Care:
Patients must be euthyroid before operating as operating in a state of hyperthyroidism
puts the patient at increased risk for thyroid storm.
This most often includes beta-blockers to prevent thyroid storm and control symptoms.

Treatment

Near total to total thyroidectomy

Thyroid Eye Disease

Referral to ophthalmology
Artificial tears, sunglasses, elevate bed when sleeping to decrease periorbital oedema,
frensel prism for diplopia ,metylprednisolone

Complications

Complications of thyroid surgery include wound infection, keloid formation at the site
of the incision, transient and permanent hypoparathyroidism, and recurrent or superior
laryngeal nerve palsy.

Plummer`s Disease & Toxic

Adenoma
Plummer`s disease = Toxic Multinodular goiter
Toxic Adenoma= Just one nodule
Causes hyperthyroidism, but without the extrathyroidal symptoms, with
weight loss being a common complaint.
On examination nodules may or may not be present
In addition to other tests, the initial best test is the TSH levels. RAIU scan
should also be performed which will show an increased uptake in the nodules
/hotnodules. Also locates the nodules.
Medical and Radioactive are attempted initially but have a high failure rate
in these conditions.
Solitary nodule: Lobectomy.
Multinodular goiter: Subtotal thyroidectomy.

THYROIDITIS

Subacute thyroiditis (De Quervains Disease)

influenza like symptoms, painful diffuse swelling of the thyroid gland
resolves spontaneously
Riedels thyroiditis
Unknown aetiology
Causes fibrosis of the thyroid gland and compression symptoms
Surgical management to relieve compression otherwise medical management

Autoimmune thyroiditis/
hashimotos disease

Antibodies against thyroglobulin. There is destruction of

the thyroid follicles by lymphocytes
Post menopausal women commonly affected.
Patient may present initially with thyrotoxicosis in early
disease but in the long term become hypothyroid as the
gland is progressively destroyed
The thyroid gland is diffusely enlarged and firm

Autoimmune thyroiditis/
hashimotos disease
Investigations: Thyroid function tests, test for
antithyroglobulin antibodies, ultrasound, ECG
Management
Thyroid hormone replacement therapy- levothyroxine sodium

Hypothyroidism

Hypothyroidism is a prevelant condition with many causes, however the treatment is

rarely surgical.

Hypothyroidism
Round puffy face
Cold intolerance
Slowed movement and loss of energy
Decreased sweating
Peripheral neuropathy
Depression, dementia, and other psychiatric disturbances, memory loss
Joint pains and muscle cramps
Hair loss from an autoimmune process directed against the hair follicles
Menstrual irregularities (typically menorrhagia, infertility, and loss of libido)
Reflexes relax slowly

Hypothyroidism

SOLITARY THYROID NODULES

May be the dominant nodule in a multinodular goitre

Of true solitary nodules 50% are benign adenomas and the next 50% are either cysts
or neoplasms
These nodules are typically slow growing and painless
Investigations: ultrasonography, thyroid function tests, scintigraphy, Fine needle
aspiration and cytology

NEOPLASMS OF THE THYROID

Follicular Adenoma

Present clinically as a solitary nodule

Follicular Adenoma and follicular carcinoma can only be distinguished by histological
examination.
In the adenoma there is no invasion of the capsule or pericapsular blood vessel.
Treatment is by wide local excision, i.e lobectomy

Increased suspicion for carcinoma

with:
History:
Rapid enlargement, voice change( vocal cord paralysis), dysphagia
young age, males, family history of thyroid cancer or a menII syndrome
Signs:
single nodule, hard immobile nodule, cold nodule, lymphadenopathy,

Papillary Carcinoma

Most prevalent before the age of 40 and presents as a slow growing, solitary
thyroid swelling
Enlarged lymph nodes may be the only finding in some patients but is
palpable in approximately 1/3.
Distant metastases is rare and the 10year survival rate is 90-95%
There is positive 131-I uptake
On histology Psammoma bodies (nuclear inclusions are seen), Orphan Annie
nuclei

Management
If unifocal microscopic disease of <1cm : hemithyroidectomy alone
<2cm and favorable histology: hemithyroidectomy
If multifocal : Total thyroidectomy
Follow up radioactive iodine scan for metastases
Involved lymph nodes are removed also
Life long Thyroid hormone replacement started postoperatively

Follicular carcinoma

Middle age individuals

Well differentiated
Cannot differentiated between adenoma and follicular carcinoma with FNAC. Histology
needed to see characteristic vascular and capsular invasion (open biopsy)
Haematogenous spread to bone and lungs or liver common
Boney secondaries may be pulsatile
Management: Total thyroidectomy

Of importance wrt thyroid cancer

Thryroxine given after surgery to suppress TSH which would stimulate growth of
residual cancer cells
Thyroglobulin useful for follow up monitoring for recurrence
Laryngoscopy may be useful pre operatively especially if patient elderly or if preexistent vocal cord pathology suspected pre-op

THYROIDECTOMY
Lobectomy
Hemi-thyroidectomy
Subtotal thyroidectomy
Near total thyroidectomy
Total thyroidectomy
INDICATIONS:
Pressure symptoms, relapse hyperthyroidism after >1 failed medical treatment,
carcinoma, cosmesis, symptomatic patients planning pregnancy

COMPLICATIONS
HAEMORRHAGE
INFECTION
SCAR COMPLICATIONS eg. Keloid formation
HYPOTHYROIDISM replacement therapy should commence
the following day with Levothyroxine sodium
HYPOPARATHYROIDISM leading to
hypocalcaemia(paraesthesia, numbness, hypercontractility
which can be demonstrated by Chvosteks and Trousseau
signs, prolonged QT interval on ECG and tetany in extreme
cases)

CHOVSTEK SIGN

TROUSSEAU SIGN
(carpal spasm on cuff
inflation)

NERVE DAMAGE

Recurrent laryngeal nerve:

Bruising or traction of the nerve causes temporary vocal cord paralysis and thus
hoarseness. This usually resolves in 3 months
Unilateral division of the nerve causes the voice to become weak hoarse and breathy.
There may also be some degree of stridor
Bilateral division causes airway obstruction (causes flaccid paralysis which progresses to
fibrosis which draws the cords together)

 Superior laryngeal nerve damage causes inability to tense

the vocal cords. Patients will have a deeper and quieter
voice. They are unable to achieve higher pitches.