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Met3B > Hyperthyroidism > Flashcards

Hyperthyroidism Flashcards

1
Q

Level of the thyroid?

A

Anterior neck

Between C5 and T1

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2
Q

How many lobes? What connects them?

A

Two

Isthmus

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3
Q

Anatomical location of the thyroid
Behind…?
Wrapping around…?
Inferior to…?

A

Behind the sternohyoid and sternothyroid muscles
Wrapping around the cricoid cartilage and superior tracheal rings
Inferior to the thyroid cartilage of the larynx

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4
Q

Blood supply to the thyroid

A

Superior thyroid artery (branch of external carotid artery)

Inferior thyroid artery (branch of thyrocervical trunk)

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5
Q

Venous drainage to the thyroid

A

Superior, middle and inferior thyroid veins

- drains into internal jugular veins and brachiocephalic veins

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6
Q

When operating on the thyroid, care must be taken to not damage which nerve?

A

Recurrent laryngeal nerves

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7
Q

Define goitre

A

Swelling of the neck due to enlargement of thyroid gland

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8
Q

Causes of diffuse goitre (5)

A 
Physiological (pregnancy/puberty)
Graves’ disease
Hashimoto’s thyroiditis
Subacute (de Quervain’s) thyroiditis
Iodine deficiency
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9
Q

Causes of nodular goitre (3)

A

Toxic multinodular goitre
Adenoma
Carcinoma

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10
Q

Most common cause of thyrotoxicosis

A

Graves’

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11
Q

Graves’ typical presentation

A

Women aged 30-50, signs of thyrotoxicosis, exopthalmos, ophthalmoplegia, pretibial myxoedema, thyroid acropachy

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12
Q

Pathology of Graves

A

Circulating IgG auto-antibodies binding to and activating G-protein-coupled thyrotropin receptors, which causes smooth thyroid enlargement and increased hormone production.

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13
Q

What are the blood results for Graves?

A

TSH receptor stimulating antibodies
Anti-thyroid peroxidase antibodies
Low TSH
High T4

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14
Q

Features of a thyroid storm

A

tachycardia, fever, atrial fibrillation, heart failure, fever, diarrhoea, vomiting, dehydration, jaundice, agitation, delirium, and coma

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15
Q

Define hyperthyroidism

A

Excess of circulating thyroid hormones (thyrotoxicosis) is produced by an overactive thyroid gland

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16
Q

How are thyroid hormone levels normally controlled?

A

Negative feedback on the hypothalamus and pituitary gland

Hypothalamus secretes thyrotropin-releasing hormone (TRH) which stimulates the anterior pituitary to secrete thyroid-stimulating hormone (TSH). This then acts on the thyroid to increase production of thyroxine and triiodothyronine.

17
Q

Overt vs subclinical hyperthyroidism

A

Overt = TSH is suppressed and free thyroxine or free triiodothyronine concentrations are above the normal reference range

Subclinical = TSH supressed but normal FT4 and FT3

18
Q

Causes of hyperthyroidism

A 
Graves
Toxic multinodular goitre
Adenoma
Drugs - iodine, lithium, interferon alpha, thyroxine, corticosteroids
High levels of HCG - e.g. multiple pregnancy, women with hyperemesis, tumour
Pituitary adenoma
Thyroid hormone resistance syndrome
Subacute (de Quervain's) thyroiditis
Acute thyroiditis
Post-partum thyroiditis
19
Q

Symptoms of hyperthyroidism (general)

A

Hyperactivity, emotional lability, insomnia, irritability, anxiety, palpitations.
Exercise intolerance, fatigue, muscle weakness.
Heat intolerance, increased sweating.
Increased appetite with weight loss (or occasionally weight gain), diarrhoea.
Infertility, oligomenorrhoea, amenorrhoea.
Polyuria, thirst, generalized itch.
Reduced libido, gynaecomastia in men.
Deterioration in blood glucose control and hyperglycaemia in people with diabetes mellitus.

20
Q

Signs and symptoms of de Quervain’s

A

Rapid-onset malaise, fever, and thyroid pain which may extend to the jaw, ears, or throat
Tender, enlarged, firm, irregular thyroid (usually diffuse)

21
Q

Signs and symptoms of toxic multinodular goitre

A

Breathlessness, dysphagia, neck pressure

Non-tender thyroid nodules

22
Q

Signs of hyperthyroidism

A

Agitation, fine tremor, warm moist skin, palmar erythema.
Sinus tachycardia, atrial fibrillation, heart failure, dependent oedema.
Eye signs (lid lag or retraction).
Goitre or nodule(s)
Bruit
Onycholysis and thyroid acropachy
Pruritus, urticaria, vitiligo, diffuse alopecia, thyroid dermopathy, pretibial myxoedema
Muscle wasting, proximal myopathy, hyper-reflexia.
Splenomegaly, lymphadenopathy.
Gynaecomastia in men.

23
Q

Investigations for hyperthyroidism

A

TFTs - TSH, FT4, FT3

ESR and CRP if suspect subacute thyroiditis

24
Q

How to manage overt hyperthyroidism in primary care

A

Admit as a medical emergency a person with symptoms of thyroid storm.

Refer using a suspected cancer pathway (for an appointment within 2 weeks) if a person has a thyroid nodule or goitre and malignancy is suspected.

Refer all other people with overt hyperthyroidism to an endocrinologist for further investigations and management.

Consider prescribing a beta-blocker while waiting and titrating the dose depending on clinical response), to provide relief of adrenergic symptoms (for example tremor or tachycardia).

25
Q

Radionuclide thyroid uptake scan in Graves’

A

Diffuse pattern of uptake in Graves’ disease

26
Q

Radionuclide thyroid uptake scan in toxic nodular goitre

A

One or more ‘hot’ nodules, patchy uptake

27
Q

Radionuclide thyroid uptake scan in de Quervain’s thyroiditis

A

Reduced or absent uptake of radioisotope into the thyroid

28
Q

Specialist drug treatments for hyperthyroidism

A

Carbimazole and propylthiouracil - Used short term before surgery, or medium-term to induce remission in Graves’ (4-8 weeks), or long-term if other options contraindicated.

When euthyroid, can use titration-block regime (thionamide used and dose adjusted every 4-6 weeks) or block and replace regime (a thionamide is used to block the synthesis of thyroid hormone and levothyroxine is added when the FT4 is in range).

29
Q

How does radioiodine treatment work?

A

Induces damage of DNA leading to death of thyroid cells

30
Q

Surgical treatment for hyperthyroidism

A

Total or near-total thyroidectomy

31
Q

Thyroidectomy post-op complications

A

Hypothyroidism, hypocalcaemia due to hypoparathyroidism (often transient), and vocal cord paresis due to damage to the recurrent laryngeal nerve.

32
Q

When to treat subclinical hyperthyroidism?

A

If TSH level persistently equal to or less than 0.1 mU/L, if they are aged 65 years or older, are postmenopausal, are at risk of osteoporosis, have cardiac risk factors, or have possible symptoms of hyperthyroidism.

33
Q

Complications of hyperthyroidism

A 
Graves' orbitopathy
Thyroid storm 
Atrial fibrillation 
Heart failure
Reduced bone mineral density
Increased mortality rate
Anxiety and depression 
Thyrotoxic periodic paralysis 
Increased risk of complications in pregnancy
34
Q

De Quervain’s pathology/stages

A

Thought to occur after a viral infection
Phases:
1. Hyperthyroidism, painful goitre, raised ESR (lasts 3-6 weeks)
2. Euthyroid (1-3 weeks)
3. Hypothyroidism (weeks-months)
4. Thyroid structure and function goes back to normal

35
Q

Management of De Quervain’s

A

Usually self-limiting - refer to specialists

36
Q

Toxic multinodular goitre pathology

A

Autonomously functioning thyroid nodules that secrete excess thyroid hormones

37
Q

Causes of thyroid enlargement in euthyroid patient

A

Solitary thyroid nodule – cyst, adenoma, discrete nodule in MNG or malignant
Sarcoid
TB

38
Q

How does carbimazole work?

A

Used to decrease thyroid hormone synthesis, by acting as a preferred substrate for iodination by thyroid peroxidase (key enzyme in thyroid hormone synthesis)

39
Q

Important adverse effect of carbimazole

A

Agranulocytosis

Met3B (9 decks)

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