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Diseases of the thyroid and mammary glands . L. Yu. Ivashchuk. Palpation of the thyroid gland ( isthmus ). Palpation of the thyroid gland ( right lobe ). Palpation of the thyroid gland ( left lobe ). Palpation of the thyroid gland. Palpation of the thyroid gland.
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CLASSIFICATION OF THE GOITER ACCORDING TO THE FORM OF ENLARGMENT • Diffuse goiter; • Nodular goiter; • Mixed goiter.
The degree of enlargement • 0– the thyroid gland is not palpated; • І – the isthmus of the gland is noticeable during swallowing and could be palpated; • ІІ – entire gland is noticeable during swallowing and could be palpated; • ІІІ – the enlargement of gland results in evident thickening of neck (“a thick neck”); • ІV – the gland considerably enlarged and sharply deforms neck; • V – the enlargement reaches excessive size (goiter of major sizes).
CLASSIFICATION OF THE GOITER ACCORDING TO THE FUNCTIONAL STATE • Euthyroid goiter (normal function); • Hyperthyroid (excessivefunction); • Hypothyroid (reducedfunction).
CLASSIFICATION OF THE GOITER ACCORDING TO THE LOCALIZATION • Typical localization (anterior surface of the neck); • Retrosternal goiter; • Ectopic goiter (goiter of the base of tongue, intrathoracic goiter); • Goiter of the additional glands; • Presternal goiter.
Clinical manifestations of hyperthyroidism Symptoms of hyperthyroidism include weight loss during normal or increased appetite, heat intolerance, excessive perspiration, muscle weakness, oligomenorrhea. Signs of hyperthyroidism include goiter, sinus tachycardia or atrial fibrillation, tremor, hyperreflexia, fine or thinning hair, muscle wasting.
Clinical features of hypothyroidism include cold intolerance, weight gain, constipation, edema (especially of the eyelids, hands, and feet), dry skin, weakness, somnolence, and menorrhagia.
Biochemical thyroid function testing Currently, measurement of serum TSH level and free T4 (FT4) is the best and most efficient combination of blood tests for diagnosis of most patients with thyroid disorders.
Biochemical thyroid function testing Measurement of TSH (0.3-5.0 mIU/L) by a second-generation sensitive TSH (sTSH) test is the single most useful biochemical test in the diagnosis of thyroid illness. In most ambulatory and hospitalized patients without pituitary disease, increased sTSH signifies hypothyroidism, suppressed sTSH suggests hyperthyroidism, and normal sTSH reflects a euthyroid state.
Biochemical thyroid function testing Measurement of T3 (80-200 ng/dL) is test in hypothyroidism. This test is useful in the occasional patient with suspected hyperthyroidism, suppressed sTSH.
Biochemical thyroid function testing Antithyroid microsomal antibodies are found in the serum of patients with autoimmune thyroiditis (Hashimoto's thyroiditis), and measurement of these antibodies is helpful to diagnose this common cause of hypothyroidism. Anti-TSH receptor antibodies, which stimulate the TSH receptor, are detectable in more than 90% of patients with autoimmune hyperthyroidism (Graves' disease); however, their measurement is not often needed in the diagnosis of this disease.
Thyroid Function Test Algorithm A useful thyroid function test algorithm (Clin Lab Med 13:673, 1993) includes sTSH assay as the initial test. If this is normal, no further tests are needed. If sTSH is elevated, FT4I and microsomal antibodies are measured to confirm hypothyroidism, which is often autoimmune. If sTSH is suppressed, FT4I is measured to confirm primary hyperthyroidism. If TSH is low and FT4I is normal, T3 is measured to diagnose T3 thyrotoxicosis.
Scaning of the thyroid gland Thyroid imaging is most often accomplished with radionuclide scanning or ultrasound; other imaging modes, including computed tomographic (CT) scanning and MR scan, are useful in special circumstances.
Technetium thyroid scanning Technetium thyroid scanning 20 minutes after the intravenous injection of technetium-99m (99mTc) is useful in determining the size of the thyroid and in differentiating solitary functioning nodules from multinodular goiter or Graves' disease. Hypofunctioning areas (cyst, neoplasm, or suppressed tissue adjacent to autonomous nodules) are "cold," areas of increased synthesis are "hot." "Cold" nodules have a 15-20% risk of malignancy; most should be removed. "Hot" nodules are almost never malignant. 99mTc thyroid scans are most useful as adjunctive tests to assess risk of malignancy in patients with indeterminate thyroid nodule cytology or in hyperthyroid patients suspected of having a hyperfunctioning thyroid adenoma. Thyroid scanning 4-24 hours after oral iodine-131 (131I) is useful to identify metastatic differentiated thyroid tumors and to both confirm a diagnosis of Graves' disease.
Radionuclide thyroid scans of thyroid gland (diffuse goiter)
Radionuclide thyroid scans of thyroid gland (diffuse goiter)
Radionuclide thyroid scans of thyroid gland (nodular goiter)
Thyroid ultrasonography with high-frequency (7.5-10.0 MHz) Thyroid ultrasonography with high-frequency (7.5-10.0 MHz) determines gland volume as well as the number and character of thyroid nodules. Although not completely reliable, features suggestive of malignancy on ultrasound include hypoechoic pattern, irregular margins, and microcalcifications. Ultrasound is useful to guide fine-needle aspiration (FNA) biopsy and cyst aspiration. Cysts seen on ultrasound, especially those larger than 3 cm, are malignant in up to 14% of cases.
X-Ray examination, CT scanning and MR scan X-Ray examination, CT scanning and MR scan of the thyroid are costly and generally are reserved for assessing substernal or retrosternal masses suspected to be goiters.
Autoimmune diffuse toxic goiter (Graves' disease) Autoimmune diffuse toxic goiter (Graves' disease) is the most common cause of hyperthyroidism and may be caused by stimulating immunoglobulins directed against the TSH receptor. Graves' disease may be treated with antithyroid drugs, ablation with radioactive iodine (RAI), or surgery, depending on the clinical situation.
