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Nontoxic goitre

Nontoxic goitre. Dr Madhukar Mittal Medical Endocrinology. Goitre. Solitary Nodular Nontoxic Benign Malignant (20%) Multinodular Benign vs Malignant Diffuse Toxic Graves Nontoxic Simple autoimmune. Painful thyroid swelling. Subacute thyroiditis Acute thyroiditis

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Nontoxic goitre

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  1. Nontoxic goitre Dr Madhukar Mittal Medical Endocrinology

  2. Goitre • Solitary Nodular • Nontoxic • Benign • Malignant (20%) • Multinodular • Benign vs Malignant • Diffuse • Toxic • Graves • Nontoxic • Simple autoimmune

  3. Painful thyroid swelling Subacutethyroiditis Acute thyroiditis Invasive malignancy Amiodarone induced thyrotoxicosis, type 1

  4. Hard thyroid swelling • Reidel’sthyroiditis • Thyroid carcinoma • (firm : medullary CA, lymphoma)

  5. Thyroid examination From behind with neck flexed slightly forward Rt lobe is 25% larger than left lobe Palpable and smooth normally

  6. Midline neck swellings Goitre of thyroid isthmus & pyramidal lobe Thyroglossal cyst Suprasternal LN, lipoma Ludwig’s angina Submental LN Sublingual dermoid, lipoma

  7. Lateral neck swellings • Carotid triangle • Thyroid • Branchial cyst • Carotid body tumor • Carotid artery aneurysm • Submandibular triangle • LN • Enlarged submandibular salivary gland • Post triangle • LN • Cystic hygroma • Pharyngeal pouch • Subclavian aneurysm • Cervical rib

  8. Thyroid 12-20g Between cricoid cartilage & suprasternal notch Develops during 3rd week of GA from floor of primitive pharynx Hormone synthesis begins at 11 weeks GA Parathyroid glands located in posterior region of each pole of thyroid C cells : interspersed throughout thyrod gland

  9. Thyroid examination • Normally • Pizillo’s method • Hands clasped behind head and push • On swallowing • Thyroid moves up • Thyroglossal cysts • Subhyoid bursitis • Fixed prelaryngeal/pretracheal LN • For retrosternalgoitre • Raise both arms till they touch ears • Pemberton’s sign

  10. Thyroid examination • From behind with neck flexed • Lahey’s method • With both hands • Crile’s method • With thumb • Kocher’s test • Slight push on lat lobes produces stridor • To exclude retrosternal prolongation

  11. History • Age • Young – colloid goitre, STN • Middle age – hashimoto’s, follicular CA • Residence • Pain • Sleep • Compressive symp • Others • Respiratory • Myopathy • Cardiac • Neurologic • Family H/O

  12. Examination Anemia BP Pulse rate Skin of hands (moist, hot/cold) Tremors – hand, tongue LN Facies Eye signs Dermopathy Acropachy Vitiligo

  13. Malignancy • Hard swelling • Local signs • Dyspnea, dysphagia, hoarseness of voice • Carotid pulsations cannot be felt • LN – papillary, anaplastic • Metastases – follicular (bone, lungs) • Recent increase in size of swelling with pain • Diarrhea – medullary CA • Prior h/o irradiation • STN • Male • Solid nodule • Large nodule >4cm • Cold nodule (least imp sign)

  14. Treatment

  15. Hypothyroidism • Levothyroxine • Hyperthyroidism of Graves disease • Antithyroid drugs (Europe, Japan) • Radioiodine (USA)

  16. Acute thyroiditis Antibiotics Drainage of abscess

  17. Subacutethyroiditis Aspirin – large doses 600mg 4-6 hrly Prednisolone 40-60 mg/d Thyrotoxic phase – β-blockers Hypothyroid phase – low dose levothyroxine

  18. Silent thyroiditis Thyrotoxic phase – propranolol 20-40mg TDS/QID Hypothyroid phase – LT4 for 6-9 months Annual followup for permanent hypothyroidism

  19. Reidel’sthyroidits Surgery +tamoxifen

  20. Amiodarone induced • Hypothyroidism • LT4 • Thyrotoxicosis type 1 • Stop amiodarone if possible • High doses of ATD • Thyrotoxicosis type 2 • Oral contrast agents (Na ipodoate, Na tyropanoate) • K perchlorate • Glucocorticoids • Lithium • Near total thyroidectomy

  21. Simple goitre I2 or suppressive thyroxine therapy (young patients with soft goitre for 3-6 months) Radioiodine (decreases goitre size by 50%) Sx – for tracheal compression

  22. MNG - toxic Sx Radioiodine in elderly Antithyroid drugs – often stimulate growth of goitre

  23. MNG nontoxic Radioiodine Sx T4 suppressive therapy (rarely effective for decreasing goitre size)

  24. Thyroid Cancer Neck dissection only if LN involved • Lymphoma • External radiation • MTC • Total thyroidecctomy • Follicular • Near total thyroidectomy f/b radioiodine & LT4 suppression • Papillary • Near total thyroidectomy f/b radioiodine & LT4 suppression • Stage 1 – Sx f/b LT4 suppression

  25. STN Hyperfunctioning • Radioiodine ablation – esp >45yr • Sx resection – esp <45yr • Enucleation • Lobectomy • Ethanol injection

  26. STN Examination / USG → MNG / STN TSH if low → thyroid scan → hot nodule – RAIA /Sx FNAC ← cold or indeterminate (if <1cm/difficult, then USG guided FNAC) FNAC report

  27. FNAC report • Benign • Suppressive therapy with LT4 for 6-12 months (30% decrease in size) • Monitor by USG (Sx if increase in size or suspicious cytology) • Cyst • Reaspirate and follow by USG • Suspicious or malignant (10%) • Sx • NonDx (20%) • Repeat FNA

  28. MNG

  29. Nontoxic MNG Occurs in up to 12% of adults More common in females Increased prevalence with age More common in iodine deficient regions Most nodules are polyclonal in origin

  30. Risk Factors Iodine deficiency Radiation exposure Exposure to iodine from contrast dyes or other sources may precipitate or exacerbate thyrotoxicosis in MNG

  31. Etiology • Pathogenesis of MNG is multifactorial. • Genetic • Autoimmune • Environmental • Major difference between toxic and nontoxic MNG • Toxic MNG evolves from nontoxic MNG as part of the natural history of the disease • Stages of nodular transformation of the thyroid • Goitrogenic stimuli (iodine deficiency, autoimmunity, or nutritional goitrogens) cause diffuse thyroid hyperplasia • In the proliferating thyroid, growth factor expression is increased, stimulating cellular division and formation of independent clones • Most nodules in MNG are polyclonal in origin, but monoclonal nodules also occur

  32. Diagnosis • Detection of MNG by physical examination depends on goiter and nodule size, location, and anatomy of the patient’s neck • Laboratory evaluation • Determination of serum TSH will distinguish nontoxic MNG from toxic MNG • Diagnostic imaging is indicated in following situations: • To verify hyperfunctioning nodules in a patient with a MNG and concomitant clinical and/or laboratory evidence of hyperthyroidism • To evaluate the degree of obstruction in large MNG • Fine-needle aspiration (FNA) biopsy • A dominant or enlarging nodule within MNG • Nonfunctioning (cold) nodules ≥1–1.5 cm in diameter • Nodules found to have microcalcifications, hypoechogenicity, complex architecture, or increased vascularity on ultrasonography • FNA should not be used to evaluate autonomous (warm/hot) nodules

  33. Imaging • X-ray, CT, or MRI of the neck/chest indicated only when necessary for: • Goiter anatomy • Substernal extension • Extent of tracheal compression • Iodinated contrast agents should be administered cautiously to persons with a low TSH level • May precipitate or exacerbate underlying hyperthyroidism • Consider pretreatment with antithyroid drug therapy before imaging with contrast agents

  34. Imaging • Thyroid scintigraphy (123iodine or 99mtechnetium)  • Limited to patients with a low TSH level to verify the clinical diagnosis of toxic MNG • Unnecessary in the setting of a normal TSH level. • Toxic MNG shows heterogeneous iodine uptake with multiple regions of increased and decreased uptake • Ultrasonography • Recommended for all patients with known or suspected thyroid nodules • Useful for accurate monitoring of nodule size or for guiding FNA biopsy of suspicious nodules

  35. Endemic goitre More common in mountainous regions Diffuse goitre caused by I2 deficiency affecting >5% of population comprising children

  36. Thank You

  37. Iodine Deficiency

  38. Iodine Deficiency • Iodine is an essential micronutrient • T4 synthesis • Brain growth and development • Daily requirement (adult) 150 ug/day • 1 teaspoonful of iodine is sufficient for lifetime • Iodine deficiency causes a wide spectrum of illness collectively termed iodine deficiency disorders (IDD)

  39. IDD: clinical spectrum Goiter and Cretinism • Goiter (all ages) • Primary hypothyroidism • Cretinism • Neurological • Myxoedematous • Mixed • Learning disability

  40. IDD Tiwari BD, Godbole MM, et al. Learning disabilities and poor motivation to achieve due to prolonged iodine deficiency. Am J Clin Nutr 1996;63:782– 6. Kochupillai N., The impact of iodine deficiency on human resource development. Prog Food Nutr Sci. 1989;13(1):1-15. Review. • Mild iodine deficiency causes, in children, poor school performance, reduced intellectual ability and impaired work capacity1,2 • Results • Compromised human potential • Poor socio-economic development • On a worldwide basis, iodine deficiency is the single most important preventable cause of brain damage

  41. IDD: Causes • Low dietary iodine contents • Soil with low iodine content due to past glaciations or the repeated leaching effects of snow, water (floods) and heavy rainfall • Crops grown in this soil, therefore, do not provide adequate amounts of iodine when consumed

  42. Global magnitude of IDD • WHO data: IDD is a public health problem in • 130 of 191 countries, • Data insufficient to categorize 41 • Only 20 countries free from IDD • Globally, • 740 million people with goiter, • 13% of world’s population • Over 2 billion people are exposed to the risk of IDD • 35.2% of populations with urinary iodine excretion (UIE)< 100 µg/L

  43. Global picture of IDD WHO Global Database on IDD

  44. Magnitude of iodine deficiency - India National Iodine Deficiency Disorders Control Program: National Health Program Series 5. Published by Department of Communication, National Institute of Health and Family Welfare, New Delhi, 2003; 99.  • Total districts in india: 587 • 321 districts surveyed • 260 (81%) districts endemic for IDD • 200 million people are at risk • 71 million with goiter • >8 million have neurological deficit

  45. IDD: National Health Problem IDD is still a significant public health problem in India As per recommendation of Central Council of Health (1984), the GOI took policy decision for “Universal Iodization of Salt” to be achieved by year 1992. UP: USI started 2 Oct, 1987 Realizing the importance of iodine deficiency in relation to human resource development, National IDD Control Program has been included in 20-point program of prime minister

  46. Shift in policies in salt iodination • 1992: sale of non-iodized salt declared as punishable offence • 2000: Punitive clause removed through Central notification • 2005, Nov: Punitive clause restored

  47. Non-uniform Iodized salt distribution in India • The use of iodized salt varies dramatically from one state to another • Why: number of factors • scale of salt production, • transportation requirements, • enforcement efforts, • differences in state regulations, • the pricing structure, and • storage patterns

  48. Presence of iodized salt in household Numbers expressed as % *Adequate iodine contents in salt >15ppm National Family Health Survey 3 (NFHS-3), 2005-06

  49. IDD: Epidemiological criteria

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