APPROACH TO THYROID DISEASES

Basically how the approach would be depends on the way patients present. Common presentation is in the form of anterior neck swelling - GOITRE #What is the definition of goitre? It means any swelling of the thyroid and does not imply any particular pathological change.

#Now a patient presents with a goitre! Few questions need to be answered. Is it a diffuse giotre?

Is it a multinodular goitre?

*If multinodular check for any evidence of a dominant nodule which might suggest malignancy. OR Is it a solitary nodule?

Is there any retrosternal extension of the goitre? What about presence of enlarged neck nodes Any sudden rapid enlargement of the goitre? Any significant voice change recently? Any difficulty in breathing noted? Any problem in swallowing? Any associated pain reported?

Another question that need to be answered is; Whether patient is Euthyroid? Or Hyperthyroid? Or Hypothyroid?

How do we elicit h/o hyperthyroid symptom in a patient? Commonly we can ask them any changes in behavior at home / at work. .. Extra garang ke , anakanak or husband extra kerap kena tengking/marah. In case of a teacher selalu denda murid even for just a small mistake A surgeon Throw instruments in OT

A patient presented with a diffuse smooth goitre, no toxic symptoms or signs So the most likely aetiology would be either 1) 2) 3) 4) Simple goitre Physiological goitre Thyroiditis (autoimmune) Lymphoma

Sometimes those with smooth goitres also have toxic symptoms (Toxic diffuse goitre) 1) The most likely cause would be Graves disease Positive eye signs of thyrotoxicosis

Ix: 1) Any extension behind the sternum or any narrowing or deviation of trachea could be assessed by doing CXR / NXR. A PA view is informative rather than lat views Why? 2) A CT thorax needed in cases of huge goitre extending into the thorax , ? Malig. 3) Thyroid function tests should be done in all patients with goitres. Preop assessment of pathology: 1) Scan Isotope scan commonly performed using technetium or radio-iodine Scan provides a functional map of the thyroid gland. Differentiate active (hot) nodules from inactive (cold) nodules Patchy uptake denotes MNG 2) Ultrasound Ultrasound scanning help differentiate between solid and cystic swellings Specific features would be able to suggest whether a mass is benign or malignant USS could reveal presence of non palpable nodules in thyroid gland - a clinically sol thyroid nodule could well be prominent nod in a MNG

3) Biopsy Histological studies confirm the actual diagnosis of the disease FNAC quite helpful but not always correct Core biopsy not advisable due to complications Histopathological diagnosis ( paraffin section ) is the most reliable

Notes: Goitre is a clinical diagnosis All goitres need pathological diagnosis The most practical imaging investigation is USS The definitive investigation of a solitary thyroid nodule is FNAC

Thyroid Examination - IPPA Inspection; To ascertain that the swelling is a thyroid it should move upward when the patient swallows. It is also important to observe the patient in general , whether he/she look restless, could not stay still, anxious , talkative, wearing thick or thin see through clothings. Is the patient thin or fat? Observe while swallowing

Palpation: Palpate the lower border while swallowing Feel for the trachea Palpate the gland (from behind) Palpate the cervical lymph nodes Anterior and posterior triangle

Percussion: Percuss the sternal region to check for any clinical evidence of retrosternal extension

Auscultate: Palpate for the carotid pulses Listen to carotid bruit, thyroid bruit

Examine the hands for tremors , sweating Check the pulse rate is it tachycardic? Look for the eye signs of Thyrotoxicosis 1) Lid lag 2) Lid retraction 3) Exophthalmos

!!A Normal Thyroid Gland is non-palapable!!