Benign thyroid disorders

1. Benign thyroid disorders Present by Chananya Karunasumetta

2. hyperthyroidism Result from excess of circulating hormone Grave’s disease Toxic nodular goiter

3. Grave’s disease It is an autoimmune disease of unknown cause F:M = 5:1 40 – 60 yr

4. Grave’s disease Etiology Autoimmune process , unknown causes Postpartum state Iodine excess Bacterial or viral infection Genetic factor

5. Grave’s disease The process causes sensitized T – helper lymphocyte to stimulate B lymphocyte which produce Ab. directed against the thyroid h. Receptor = TSH binding Ab

6. Grave’s disease Clinical features Hyperthyroidism symptoms 50 % develop clinically opthalmopathy Lid lag , lid retraction , chemosis , proptosis ,blindness 1- 2 % dermopathy pretibial myxedema Thyroid is usually diffusely and symmetrically enlarged

7. Grave’s disease Diagnosis test TFT = TSH ? , T3 ? ,T4? 123I uptake ? Anti Tg and anti TPO Ab ? 75 % TSH –R or TS Ab ? 90 %

8. Grave’s disease Treatment Antithyroid drugs PTU 100 – 300 mg three times daily Methimazole 10 – 30 mg three times daily SE = rarely , agranulocytosis Beta block 20 -40 mg four times daily Thyroxine 0.05 – 0.10 mg to prevent hypothyroidism , suppress TSH secretion

9. Grave’s disease Radioactive iodine therapy 131I Associate with hypothyroid 70 % at 11 yr Used in Older Pt. With small or moderate size goiters Relapse after medical or Sx treatment Contraindication Pregnant or breast feeding Young patients Pt. With ophthalmopathy

10. Grave’s disease Surgical treatment Confirmed cancer or suspicious thyroid nodule RAI is contraindicated Allergies to antithyroid drugs Compressive symptoms Rapid control of hyperthyroidism Poor compliance for medication

11. Grave’s disease Total or near total thyroidectomy Coexcistent thyroid cancer Severe opthalmopathy who refused RAI Life – threatening reaction to antithyroid medications

12. Grave’s disease Subtotal thyroidectomy Leaving 4 -7 g remnant Bilateral subtotal thyroidectomy , Hartley – Dunhill procedure 2 – 10 % recurrent rate >40 % hypothyroid

13. Toxic multinodular goiter Usually older than 50 yr Hx of nontoxic multinodular goiter Hyperthyroidism Autonomous precipitated

14. Toxic multinodular goiter Diagnostic studies Blood tests RAI = increase uptake

15. Toxic multinodular goiter Treatment Control hyperthyroidism Surgical resection is prefered = subtotal thyroidectomy RAI is reserved for elderly Pt. = poor operative risk

16. Plummer’s disease ( toxic adenoma) Hyperthyroid from a single hyper functioning nodule Young Pt. PE = solitary thyroid nodule RAI scanning show hot nodule Rarely malignancy Small nodule = med Rx or RAI Large nodule = surgery

17. Thyroiditis inflammatory disorders Classified Acute Subacute Chronic

18. Acute (suppurative)thyroiditis Infection can seed Hematogenous or lymphatic route Direct spread Penetrating trauma immunosuppression

19. Acute (suppurative)thyroiditis Organism Streptococcus , anaerobes More common in children URI Otitis media Characteristic Severe neck pain , fever , chill, odynophagia , and dysphonia

20. Acute (suppurative)thyroiditis Diagnosis CBC = leukocytosis FNA biopsy for Gram’s strain , C/S , cytology CT scan Ba swallowing

21. Acute (suppurative)thyroiditis Treatment Parenteral ATB Drainage of abscess Complete resection of the sinus tract

22. Subacute thyroiditis Can painful or painless form Etiology is unknown

23. Subacute thyroiditis Painful thyroiditis Commonly occur in 30 – 40 yr , woman Sudden or gradual of neck pain URI Gland is enlarge , tender ,firm Progress four stage Lab = TSH ?,T4?,T3? ,ESR> 100 Self limited ,symptomatic Rx = NSAID Steroids use in severe case

24. Subacute thyroiditis Painless thyroiditis Autoimmune in origin Common in woman 30 – 60 yr PE : normal size or slightly enlarged Lab : normal ESR Beta block , thyroid hormone replacement RAI or thyroidectomy indicated in Pt with recurrent

25. Chronic thyroiditis Lymphocytic (Hashimoto’s) thyroiditis Etiology Autoimmune process Activated of T-helper with specific for thyroid Ag ?Recruit of cytotoxic T cell apoptosis

26. Lymphocytic (Hashimoto’s) thyroiditis Clinical Common in woman 1 : 10 – 20 30 – 50 yr Minimal or moderate enlarge , firm gland 20 % hypothyroidism 5 % hyperthyroidism Lab : TSH ?, T4?, T3? Thyroid Ab positive FNA

27. Lymphocytic (Hashimoto’s) thyroiditis Treatment Thyroid hormone replacement in overtly hypothyroidism Sx = suspected of malignancy , compressive symptom

28. Reidel’ s thyroiditis Rare varient of thyroiditis Invasive thyroiditis Etiology is controversial Predominated in woman 30 -60 yr Painless , hard anterior neck mass DX =open biopsy Surgery is the mainstay treatment

29. Goiter Result from TSH stimulate May diffuse, uninodular , or multinodular Etiology Familial Endemic Dietary goitrogen

30. Goiter Clinical Most of nontoxic goiter is asymptomatic Compression symptom PE : soft ,diffuse enlarged gland

31. Goiter Test TSH : normal Low or normal free T4 RAI uptake : patchy , hot or cold nodule FNA in dominant nodule or painful

32. Goiter Treatment Exogenous thyroid hormone Surgical Size ? Obstructive symptom Substernal extension Suspected malignancy cosmetic