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Life Maintenance > Thyroid > Flashcards

Thyroid Flashcards

1
Q

Taking a history for a lump in neck

A 
Where?
When was it noticed?
How was it first noticed?
How does it bother you? pain etc
Age?
Persistent hoarseness?
Smoking/alcohol?
Weight loss?
FHx, SHx
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2
Q

Physical examination for neck lump

A 
Inspection
Palpation - is it soft, hard etc
Percussion
Auscultation
Trans-illumination
Flexible naso-laryngo-pharyngoscopy

any lump in neck could be lesion in oro/naso/larynx

Older patient, male, southeast asian with lump and nosebleed = most likely naso pharyngeal carcinoma

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3
Q

Diagnostic tests for neck lump

A

Panendoscopy and biopsy
Ultrasonography* main test, can use to target biopsy
CT
MRI
Radionuclide iodine scan - specialist test
Arteriography - carotid tumour

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4
Q

Sialography

A

Sialography (also termed radiosialography) is the radiographic examination of the salivary glands. It usually involves the injection of a small amount of contrast medium into the salivary duct of a single gland, followed by routine X-ray projection

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5
Q

Fine needle aspiration cytology

FNAC

A

The most useful investigation for lumps in neck

Minimally invasive

Provide cytological diagnosis and help in formulating amanagement plan

Pathologist dependent procedure

Complications: bleeding, infection, seeding of tumour

Results improved with ultrasound scan guidance

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6
Q

Core biopsy vs open biopsy

A 
CORE BIOPSY
More invasive
Seeding of tumour
Crushed tissue at the edge
Mostly superceded by FNAC
OPEN BIOPSY
Incisional, excisional biopsies
Require anaesthesia (local /
general)
Seeding of tumour
Essential in lymphoma
Disaster in other types of
tumour in head and neck
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7
Q

What culture and blood tests can be done if suspecting pathology in neck lump?

A
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8
Q

Differential diagnosis of neck lump

A
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9
Q

Lipoma

A 
Common
Soft
Mobile
Smooth edge
Subcutaneous
Lobulated
Rarely liposarcoma
Excision if symptomatic
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10
Q

Sebecous cyst

A 
Common
Attached to skin (cutaneous)
Smooth edge
Spherical
Punctum (not always)
Can become infected
Excision if symptomatic
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11
Q

Benign and malignant classification of thyroid tumours

A

BENIGN:
Follicular cell adenoma
Hurthle cell adenoma
Teratoma

MALIGNANT:
Primary
-Papillary carcinoma (80%)
-Follicular carcinoma (10%)
-Hurthle cell carcinoma
-Medullary carcinoma (5%)
-Anaplastic carcinoma
-Lymphoma
-Sarcoma
-Squamous cell carcinoma

Secondary
-Kidney, lung, colon and breast

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12
Q

Predisposing factors for thyroid malignancy

A

Prolonged stimulation by
elevated TSH

Solitary thyroid nodule

Ionizing radiation

Genetic factors

Chroic lymphocystic
thyroiditis

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13
Q

Presenting symptoms of thyroid tumours

A

Solitary thyroid nodule

Cervical lymphadenopathy

Rapidly enlarging goitre

Pain in neck

Stridor due to tracheal compression

Dysphagia due to oesophageal compression

Hoarseness due to vocal cord palsy

Distant metastasis (pulmonary, bony, liver brain)

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14
Q

Physical examination of thyroid tumour

A

mobile lower neck mass moves upwards on swallowing
Can have retrosternal extension
Consistence varies from soft, rubbery, hard
Palpate for any neck lymph nodes enlargement
Laryngoscopy for vocal cord paralysis (pre-operative check)

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15
Q

Investigations for thyroid tumour

A 
Thyroid function test (T3,
T4, TSH)
Serum calcium and calcitonin
if medullary carcinoma
Ultrasound scan
FNAC
MRI neck
Non-contrast CT scan neck
and chest
CXR
Thyroid lobectomy for
biopsy
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16
Q

Clinical practice: thyroglossal duct cyst

A

Mean age: 5 years (range 4 months to 70 years)

midline neck mass

painless, moves upwards on tongue protrusion

pain and rapid enlargement due to infection

1% thyroglossal duct carcinoma
(papillary thyroid carcinoma)

Investigations:

  1. FNAC
  2. ultrasound of thyroid

Excision of thyroglossal duct cyst and
removal of body of hyoid (Sistrunk’s
procedure)

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17
Q

CASE:

28 year old female

Painless midline neck lump for a few months

4x4cm mass at the level of thyrohyoid membrane

Moves upward on tongue protrusion

Investigation and diagnosis?

A

FNAC
Ultrasound scan of thyroid

Thyroglossal duct cyst

→ Excision of thyroglossal duct cyst with body of hyoid
bone (Sistrunk’s procedure)

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18
Q

Benign cervical lymphadenopathy

A
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19
Q

Tuberculous cervical lymphadenitis: mycobacterial (tuberculosis) vs atypical mycobacterial

A
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20
Q

Malignant cervical lymphadenopathy

A
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21
Q

Cervical lymphadenopathy

A
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22
Q

Branchial cyst

A
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23
Q

Parotid gland neoplasm

A
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24
Q

Submandibular gland mass

A
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25
Q 
CASE:
49 years old female
Painless lump in left submandibular area for 3 months, not
related to eating
4cm hard mass
No facial weakness

Investigations? Diagnosis?

A

Submandibular mass

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26
Q

Lymphangioma

A
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27
Q

What’s the difference between a primary, secondary and tertiary dysfunction?

A

Primary- end organ
Secondary- pituitary
Tertiary- hypothalamus

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28
Q

Main target tissues of thyroid hormone

A

Heart
Liver
Bone
CNS

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29
Q

Any enlargement of thyroid is called a

A

GOITRE

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30
Q

Diffuse vs nodular goitre

A

A goiter can be smooth and uniformly enlarged, called diffuse goiter, or it can be caused by one or more nodules within the gland, called nodular goiter. Nodules may be solid, filled with fluid, or partly fluid and partly solid.

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31
Q

Hyperthyroidism

A

Excess thyroid hormone production

Symptoms:
Anxiety and irritability
Sweating and heat intolerance
Palpitations
Weakness
Fatigue
Increased appetite and weight loss
Signs:
Tachycardia
Tremor
Goiter
Warm moist skin
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32
Q

What is the most common cause of hyperthyroidism?

A

Grave’s disease

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33
Q

Eye signs in Grave’s

A
34
Q

Features of Grave’s minus eye signs

A

Onycholysis
Dermopathy
Acropathy
Vitiligo

35
Q

Hyperthyroidism in patients older than 70

A

Classical signs and symptoms may be lacking
Goitre may be absent
Anorexia with wasting
AF or congestive heart failure may be predominant manifestations

36
Q

What is the hallmark of hyperthyrodism?

A

Suppressed TSH is the hallmark of hyperthyroidism

Measurement of FT3 will be necessary in patient with C/F of hyperthyroidism
Suppressed TSH
Normal FT4
Called T3 toxicosis usually seen in MNG

37
Q

In a patient with overt opthalmopathy what other testing is required?

A

No additional testing

in selected cases can do isotope uptake studies, thyroid USS, thyroid antibody assays

38
Q

In a patient without opthalmopathy, what scan is done and why?

A

131I uptake scan can help to establish the cause of thyrotoxicosis

Increased uptake in hyperthyroidism

Lack of uptake in thyroiditis and iodine ingestion

In MNG it serves to define the functional characteristics of the gland

39
Q

Initial investigations for hyperthyroidism

A

Assays of fT4, TSH

Autoantibody assays - TPO, TSH receptor

Imaging

  • Ultrasound
  • Nuclear medicine
40
Q

Identify these thyroid gland images- what do they show?

A
41
Q

At diagnosis all patients with hyperthyroidism should be what?

A

Referred to specialist

42
Q

Hyperthyroidism treatments and factors to consider

A

Treatment

  • Antithyroid drugs (ATD)
  • Radioiodine (131I)
  • Subtotal Thyroidectomy

Factors to consider are

  • Age of the patient
  • Size of the goitre
  • Presence of co-existing condition
43
Q

Carbimazole and pregnancy

A

Drugs are safe in pregnancy
Possible association of carbimazole with fetal aplasia cutis
Some physicians may substitute PTU for CMZ in pregnancy
No contraindication to breast feeding
PTU is excreted less in breast milk
Patients receiving CMZ in the dose of 20mg or less need not be changed to PTU

44
Q

Treatment regimens and outcomes for hyperthyroidism

A

CMZ typical starting dose 15-40mg once a day

PTU the starting dose 100-600mg twice a day

Titrate treatment against serum T4 concentrations at 4-6 weeks to a maintenance dose

Follow up at 3-4 months interval

For the aim of remission treatment has to be used 12-24 months

Long term remission can be achieved in 50-60% of cases

45
Q

Long term treatment with carbimazole

A

Long term treatment with 5-10mg CMZ is safe and is an option for patients with relapsed Graves’ disease, Toxic nodular goitre

No specific markers for long term remission.

46
Q

What hyperthyroid patients are unlikely to undergo remission?

A

Large goitre

Positive TSH receptor antibodies

F/H of thyroid disease

Opthalmopathy

Smoking

47
Q

Radio-iodine indications

A

Safe and appropriate treatment in nearly all types of hyperthyroidism, especially in elderly

Contraindicated in children, pregnancy and women who are breast feeding

Women of childbearing age should wait for 4 months after 131I before becoming pregnant

Should be used with caution in patients with opthalmopathy

Use prophylactic steroids and avoid hypothyroidism

48
Q

Things to check with patient when prescribing radio-iodine

A

Patient information sheet should be supplied
Patient should sign a consent form
The amount of 131I given should be sufficient to achieve euthyroidism
In 2-3 months
Moderate rate of hypothyroidism 15-20% at 1st yr
1-3% yearly subsequently
An ablative dose of 131I with higher rate of hypothyroidism is also acceptable

49
Q

In patients with hyperthyroidism and low 131I uptake what is the problem?

A

Thyroiditis

50
Q

How is thyroiditis resolved?

A

Spontaneous if mild

or:

B blockers
NSAIDs
Steroids

51
Q

What is subclinical hyperthyroidism?

A

Persistently suppressed TSH with normal FT4 and FT3 in a patient with no symptoms

52
Q

What could be the reason behind high FT4, FT3 and raised TSH?

A
  1. Interference with antibody or assay

2. Resistance to thyroid hormone

53
Q

Anti-thyroid antibody interference

A

Suspect if FT4 and FT3 assays are widely discordant with each other •

Usually evidence of thyroid autoimmunity •

Anti-T4 and anti-T3 antibodies more common in free than total thyroid hormone assays.

Determine free thyroid hormone levels by equilibrium analysis where confounding antibody is excluded by dialysis membrane •

Thyroid function can be monitored by TSH once interference confirmed

54
Q

Thyroid hormone resistance

A
55
Q

What drugs affect the thyroid?

A
56
Q

Why does amiodrone lead to hyper and hypothyroidism?

A

Binds to iodine

Regular testing in patients on amiodarone which may be difficult to detect clinically
- It can result in hypothyroidism or hyperthyroidism

Testing is recommended in patients with evidence of deteriorating cardiac function or weight loss

Early specialist referral is advised in view of difficulties in interpreting biochemical abnormalities

57
Q

Amiodrone related hypothyroidism

A
58
Q

Test results for hyperthyroidism type 1 and type 2

A
59
Q

Treatment for type 1 hyperthyroidism

A 
Carbimazole high dose
Perchlorate
Lithium
Radioiodine
Thyroidectomy
60
Q

Treatment for type 2 hyperthyroidism

A

Prednisolone

Carbimazole

61
Q

Signs and symptoms of hypothyroidism

A 
SIGNS:
Dry scaly skin
Course brittle thinning hair
Bradycardia
Hair loss
Anemia
Puffy eyes 
SYMPTOMS:
Fatigue
Cold intolerance
Depression
Poor concentration
Musculoskeletal aches and pains
Carpal tunnel
62
Q

Hypothyroidism effect on body systems

A
63
Q

Hypothyroidism mechanism

A

In primary hypothyroidism, decreased production of thyroid hormones by the thyroid gland causes a compensatory increase of TSH.

Secondary hypothyroidism is caused by pituitary disorders causing decreased TSH release and decreased T3/T4 levels.

64
Q

Classic features of myxoedema

A 
Nonpitting odema
Periorbital odema
Hoarseness
Sinus bradycardia
Decrease in body temperature
Delayed relaxation of ankle jerks
65
Q

Hypothyroidism types

A

Primary hypothyroidism:
- From thyroid destruction

Central or secondary hypothyroidism:

  • From deficient TSH secretion,
  • Generally due to sellar lesions such as pituitary tumor or craniopharyngioma
  • Infrequently is congenital

Central or tertiary hypothyroidism

  • From deficient TSH stimulation above level of pituitary
  • Lesions of pituitary stalk or hypothalamus
  • Is much less common than secondary hypothyroidism
66
Q

Investigations for hypothyroidism

A

Serum assays - fT4, TSH
Autoantibody assays - TPO, Thyroglobulin

Imaging

  • Ultrasound
  • Nuclear medicine
67
Q

Laboratory investigations to confirm hypothyroidism diagnosis

A

Hallmark is increased TSH

It antedates a decline in FT4

Presence of antibodies will confirm autoimmune thyroiditis as the cause

Can occur in association with other autoimmune disorders, pernicious anemia or Addisons’

Mild anemia

Increased CK

Abnormal lipids with high total and LDL cholesterol

68
Q

Treatment of hypothyroidism

A

THYROXINE- aim to normalise serum TSH concentration

always check for angina and perform ECG

69
Q

Thyroxine dosage

A

Initial dose should normally be 50-100ug
Measurement of TSH after 6 weeks
Adjust the dose by 25-50ug
Older patients especially those with IHD, initial dose should be 25ug increased every 4 weeks by 25ug
Dose of thyroxine in patients treated for thyroid carcinomas should suppress TSH below normal<0.05

70
Q

TSH values of ‘normal’ population

A

Lab reference range defined from values in “normal” population:
0.4 – 5.5 mU/L

71
Q

Variation in thyroxine dosage- when will it need to be changed?

A

Once the appropriate dose is established it remains constant in most patients

In pregnancy there is need to increase the dose by at least 50ug daily to maintain normal TSH concentration

TSH should be measured in each trimester

72
Q

Circumstances associated with altered T4 requirements

A
73
Q

How does mild hypothyroidism affect pregnancy?

A

TSH testing recommended in 1st trimester

To maintain euthyroid state, LT4 dose may need to be increased during pregnancy

Maternal hypothyroidism during gestation may result in a variety of fetal complications

Children of women with untreated hypothyroidism during pregnancy:

  • Averaged 7 points lower on IQ testing*
  • Had a significant percentage (19%) of IQ 85
74
Q

How to distinguish between thyroid nodules?

A

Serum TSH guides further management

Serum calcitonin:

  • sensitive marker of C-cell hyperplasia/MTC (Medullary thyroid cancer)
  • Useful in follow up of MTC

Serum thyroglobulin:

  • not sensitive/specific for diagnosis or thyroid malignancy
  • BUT useful in follow up of differentiated thyroid cancer
75
Q

Which thyroid nodules require FNAB?

A

Ultrasound used for thyroid nodules

76
Q

What is thyroid FNA?

A

A thyroid fine needle aspiration biopsy is a procedure that removes a small sample of tissue from your thyroid gland. Cells are removed through a small, hollow needle. The sample is sent to the lab for analysis.

77
Q

Limitations of thyroid FNA

A

False negatives: (< 5% of FNA) more likely in large (>4cm) or small (<1cm) nodules

Suspicious FNA (Follicular and Hurhtle cell neoplasm): cannot distinguish benign vs malignant of hypercellular nodules by FNA alone, ALWAYS require surgical pathology for dx (up to 10 – 30% of these will be CA)

Non-diagnostic results: NEVER consider equivalent to benign, up to 10% of ND FNA will contain CA on resection

78
Q

Thy classification

A
79
Q

What 3 problems can the size of a goitre cause?

A

Dysphagia
Dysphonia
Dyspnoea

80
Q

Types of thyroid tumours

A

Papillary Thyroid carcinoma

Follicular carcinoma

Anaplastic carcinoma

Medullary thyroid carcinoma

Lymphoma

81
Q

27 year old female with a 8 weeks history of :
Increasing anxiety, tremor, and heat intolerance.
She has lost about 4kg weight during this time.
She has no family history of thyroid problems or autoimmune diseases.

B/L proptosis
Large diffuse Goitre with bruit
Tremor
Pulse 120/min
BP 140/60mmHg

FREE T4 58.3 pmol/L (12.0 to 22.0)

FREE T3 4.7 pmol/L (3.1 to 6.8)

TSH <0.02 mU/L ( 0.27 to 4.20)

What is the most likely diagnosis ?

A

Grave’s disease

has hyperthyroid symptoms, but also proptosis

82
Q

What is ‘armout’?

A

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