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Endocrine > Thyroid > Flashcards

Thyroid Flashcards

1
Q

What is the thyroid gland shaped like?

A

Butterfly

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2
Q

Where is the thyroid gland located?

A

Anterior neck:

From thyroid cartilage to 3rd tracheal ring.

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3
Q

What are the three main areas of the thyroid gland?

A

L+R lobes

Isthmus

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4
Q

What is an additional 4th area of the thyroid gland sometimes present?

A

Pyramidal lobe

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5
Q

How many people have a pyramidal lobe?

A

45%

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6
Q

Where is the isthmus located?

A

Between lobes anteriorly to 2nd and 3rd tracheal rings

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7
Q

What is found attached to the back of the thyroid gland?

A

Parathyroid glands

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8
Q

What are the four compartments of the neck?

A

Prevertebral fascia
Investing fascia
Pretracheal fascia
Carotid sheaths

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9
Q

What muscles are not contained in a fascia compartment?

A

Platysmal muscles

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10
Q

What do platysma muscles do and what innervates them?

A

Facial expression

CNVII

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11
Q

What is contained in the prevertebral fascia?

A

Vertebrae

Postural neck muscles

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12
Q

Where is the investing fascia found?

A

Surrounding the other compartments of the neck

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13
Q

What is contained within the investing fascia?

A

Trapezius

Sternocleidomastoid

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14
Q

What is contained in the carotid sheaths?

A

Vagus nerve
Deep cervical lymph nodes
Carotid artery
Internal jugular vein

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15
Q

What links the carotid sheaths?

A

Retropharyngeal space

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16
Q

What is important to know about the retropharyngeal space?

A

Back links with chest lining therefore infection can spread.

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17
Q

What is contained within the paratracheal fascia?

A 
Oesophagus
Trachea
Thyroid gland
Strap muscles
Recurrent laryngeal nerves
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18
Q

What are the four strap muscles?

A

Thyrohyoid
Sternothyroid
Sternohyoid
Omohyoid

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19
Q

What innervates the strap muscles?

A

Fibres from C1 travelling with hypoglossal- Thyrohyoid

Anas cervicalis from C1-3- Others

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20
Q

How many arteries supply the thyroid gland?

A

4 or 5

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21
Q

What are the arteries that supply the thyroid gland?

A

R+L superior thyroid
R+L inferior thyroid
Ima artery (not always present)

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22
Q

Where do the superior thyroid arteries originate from?

A

Common carotid arteries

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23
Q

Where do the inferior thyroid arteries originate from?

A

Subclavian arteries

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24
Q

Where does the ima artery originate from?

A

Brachiocephalic artery

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25
Q

How many veins drain the thyroid gland?

A

6

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26
Q

What six veins drain the thyroid gland?

A

R+L Superior thyroid vein
R+L Middle thyroid vein
R+L Inferior thyroid vein

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27
Q

Where do the superior and middle thyroid veins originate from?

A

Internal jugulars

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28
Q

Where do the inferior thyroid veins originate from?

A

Brachiocephalic vein

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29
Q

How many groups of lymph nodes drain the thyroid gland?

A

5

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30
Q

What five groups of lymph nodes drain the thyroid gland?

A

Superior deep cervical lymph nodes
R+L Inferior deep cervical lymph nodes
Paratracheal
Paratracheal

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31
Q

Which lymph nodes often metastasise?

A

Tracheal ones.

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32
Q

What two nerves are often impinged by the thyroid gland?

A

Recurrent laryngeal nerve

Vagus nerve

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33
Q

Where do the recurrent laryngeal nerves run?

A

In the carotid sheaths then loop under the arch of the aorta (L) and right subclavian artery (R)

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34
Q

Where do the vagus nerves run?

A

In the carotid sheaths beside the pretracheal fascia

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35
Q

What vertebra levels does the thyroid gland span?

A

C5-T1

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36
Q

What part of the thyroid gland needs to be moved to perform a tracheostomy?

A

Isthmus

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37
Q

What are the basic units of the thyroid gland?

A

Follicles

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38
Q

What are the two areas of a thyroid follicle?

A

Follicular cells

Colloid

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39
Q

Where are follicular cells found?

A

As a single cell layer round the outside of the follicle

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40
Q

Where is the colloid found?

A

In the centre of the follicle

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41
Q

What is stored in the colloid?

A

Thyroglobulin

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42
Q

What other cells are found in the follicle?

A

Parafollicular C cells (rare).

Little role in humans

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43
Q

What chemical does the thyroid gland predominantly use?

A

Iodine

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44
Q

What happens to iodine once it has been taken up into follicular cells?

A

It is excreted into the colloid along with thyroglobulin where they are conjugated to form T3 and T4.

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45
Q

What are the first products of iodine and thyroglobulin conjugation?

A

MIT

DIT

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46
Q

What happens to MIT and DIT?

A

Joined together to form T3 and T4

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47
Q

What are T3 and T4?

A

Thyroid hormones.

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48
Q

Which thyroid hormone is most abundant?

A

T4 (makes up 90%)

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49
Q

Which thyroid hormone is most active?

A

T3 (4x more active)

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50
Q

What happens to T4 in the tissues?

A

Converted to T3

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51
Q

How is the majority of thyroid hormone transported in the blood?

A

Bound to proteins

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52
Q

What proteins commonly bind thyroid hormone?

A

Thyroxine binding globulin/TBG (70%)
Thyroxine binding prealbumin/TBPA (20%)
Albumin (5%)
Free thyroid hormone

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53
Q

What kind of receptor is the thyroid hormone receptor?

A

Nuclear

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54
Q

What general effects does thyroid hormone have on the body?

A 
Increased met
Increased thermogenesis
Increased growth
Aids development
Modifies behaviour
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55
Q

What effect do thyroid hormones have on metabolism?

A

Increase it

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56
Q

How do thyroid hormones increase metabolism?

A

Increase mitochondria
Mobilize fats
Build protein
Increase blood glucose

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57
Q

What effect do thyroid hormones have on thermogenesis?

A

Increase it

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58
Q

How do thyroid hormones increase thermogenesis?

A

Increase electron uncoupling

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59
Q

What effect do thyroid hormones have on growth?

A

Increase it

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60
Q

How do thyroid hormones increase growth?

A

Increase release of GHSH

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61
Q

Is thyroid hormone important for foetal brain development?

A

Yes

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62
Q

What affect does thyroid hormone have on behaviour?

A

Can cause Permissive Sympathomimetic activity

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63
Q

What is Permissive Sympathomimetic activity?

A

Increased sensitivity to adrenalin and noradrenalin bu increasing receptors.

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64
Q

What effect does Permissive Sympathomimetic activity

have?

A

Increase HR and force

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65
Q

How is thyroid hormone release regulated?

A

Hypothalamus thyrotropin releasing hormone (TRH) stims pit thyroid stimulating hormone (TSH) which stims thyroid hormone release from thyroid.

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66
Q

How can thyroid hormones regulate their release?

A

T3/T4 inhibit TRH and TSH release therefore decreasing further thyroid hormone release.

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67
Q

What kind of feedback loop regulated thyroid hormone release?

A

Negative feedback

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68
Q

What external factors can stimulate thyroid hormone release?

A

Cold- Increases TRH
Stress- Increases TRH and TSH
Circadian rhythm- Levels highest at night

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69
Q

Where does thyroid hormone metabolism occur?

A

All tissues

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70
Q

What enzymes cause thyroid metabolism?

A

Deiodinase 1
Deiodinase 2
Deiodinase 3

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71
Q

Where are the individual deoidinases found and what do they do?

A

D1- Liver and kidneys. T4 -> T3
D2- All tissues. T4 -> T3
D3- T4 -> rT3 to inhibit function

72
Q

Why do we have D1?

A

Incase D2 fails

73
Q

What are the four broad pathological categories of thyroid disease?

A

Hypothyroidism
Thyrotoxicosis/Hyperthyroidism
Subclinical thyroid disease
Non-thyroid illness/sick euthyroid syndrome

74
Q

What external factors can decrease thyroid hormone release?

A

Steroids- inhibit TSH

75
Q

What is Non-thyroid illness/sick euthyroid syndrome?

A

Disruption of the HPT axis due to systemic illness decreases TSH levels.

76
Q

Why should you not check thyroid hormone levels in a sick patient?

A

Non-thyroid illness/sick euthyroid syndrome

77
Q

What is subclinical thyroid disease?

A

Altered TSH levels with no clinical symptoms

78
Q

How do you diagnose subclinical hypothyroidism?

A

Raised TSH and normal thyroid hormone

79
Q

When do you treat subclinical hypothyroidism?

A

TSH > 10 and always in pregnancy

80
Q

How do you diagnose subclinical hyperthyroidism?

A

Low TSH and normal thyroid hormone

81
Q

When do you treat subacute hyperthyroidism?

82
Q

What two conditions is subacute hyperthyroidism associated with?

A

Osteoporosis

AF

83
Q

What is hypothyroidism?

A

Lack of thyroid hormone

84
Q

What are the three categories of hypothyroidism?

A

Primary
Secondary
Myxoedema

85
Q

Where is the issue in primary hypothyroidism?

A

Thyroid gland

86
Q

Where is the issue in secondary hypothyroidism?

87
Q

What are the three kinds of primary hypothyroidism?

A

Goitrous
Non-goitrous
Self-limiting

88
Q

Give some examples of self-limiting primary hypothyroidism

A

Withdrawal of antithyroid drugs
Subacute thyroiditis with hypothyroidism
Post-partum thyroiditis

89
Q

Give some examples of non-goitrous primary hypothyroidism

A

Atrophic thyroiditis
Post radiotherapy or surgery
Congenital developmental defects

90
Q

Give some examples of goitrous primary hypothyroidism

A 
Chronic thyroiditis/Hashimoto's disease
Dietary lack of iodine
Drug induced
Maternally transmitted
Inherited biosynthetic defects
91
Q

What is Chronic thyroiditis/Hashimoto’s disease?

A

Autoimmune destruction of thyroid gland

92
Q

WHat groups is Chronic thyroiditis/Hashimoto’s disease most common in?

A

Women

Most common hypo in the west

93
Q

How do you test for Chronic thyroiditis/Hashimoto’s disease?

A

Antibody against thyroid peroxidase (TPO)

T cell infiltration

94
Q

What things can cause secondary hypothyroidism?

A 
Infection
Injury
Infiltration
Malignancy
Congenital
Radiotherapy
Drug induced
95
Q

What is myxoedema?

A

Severe hypothyroidism and a medical emergency.

96
Q

What group is mainly affected by myxoedema?

A

Elderly women

97
Q

How does myxoedema present?

A

Bradycardia
Heart block
T wave inversion
Prolonged QT intervals

98
Q

How do you treat myxoedema?

A

ABCDE
Rewarm
Thyroxine- give slowly

99
Q

How do you treat hypothyroidism generally?

A

Gradually restore levels with levothyroxine.

100
Q

What doses of levothyroxine should you start on?

A

Young: 50-100 micrograms
Old: 25-50 micrograms

101
Q

How often should you adjust levothyroxine dose at the start?

A

Every 4 weeks

102
Q

Once thyroid hormone levels are stable how often should they be checked?

A

12-18 months

103
Q

What is the drug of choice for treating hypothyroidism?

A

Levothyroxine- Take on an empty stomach and avoid meds containing Ca and Fe

104
Q

What should you use as your guide for restoring thyroid hormone levels?

A

Primary- TSH levels

Secondary- fT4 levels

105
Q

What is thyrotoxicosis?

A

Condition occurring when tissues are exposed to too much thyroid hormone

106
Q

What are some cardiac symptoms of thyrotoxicosis?

A

Palpitations
Af
Cardiac failure (rare)

107
Q

What are some systemic symptoms of thyrotoxicosis?

A 
Tremor
Sweating
Weight loss
Brittle thin hair
Rapid fingernail growth
Muscle weakness
Heat intolerance
108
Q

What are some GI symptoms of thyrotoxicosis?

109
Q

What are some psychiatric symptoms of thyrotoxicosis?

A

Anxiety

Irritability

110
Q

What are some eye symptoms of thyrotoxicosis?

A

Eyelid retraction
Double vision
Proptosis- bulging eyes seen in Grave’s due to fluid retention round orbits.

111
Q

What is a reproductive symptom of thyrotoxicosis?

A

Lighter less frequent periods

112
Q

What are the five categories of pathology that can cause thyrotoxicosis?

A 
Hyperthyroidism
Thyroiditis
Exogenous thyroid hormones
Ectopic thyroid tissue
Thyroid storm/crisis
113
Q

What are some causes of ectopic thyroid tissue?

A

Metastatic thyroid carcinoma

Struma ovarii

114
Q

What are some causes of exogenous thyroid hormone?

A

Overtreatment with levothyroxine

Thyrotoxicosis factitia- intentional levothyroxine OD

115
Q

What is a thyroid storm/crisis?

A

Medical emergency due to severe hyperthyroidism

116
Q

How does a thyroid storm/crisis present?

A

Reap and cardiac collapse
Hyperthermia
Exaggerated reflexes

117
Q

How do you treat a thyroid storm/crisis?

A 
ABCDE
Ventilation 
PTU
Lugol's iodine
Steroids
B-blockers
Fluids
Monitoring
118
Q

What are the three broad categories of hyperthyroidism?

A

Primary
Secondary
Choriocarcinoma

119
Q

What is the most common cause of primary hypothyroidism?

A

Autoimmune

120
Q

How do you diagnose primary hypothyroidism?

A

Low fT3/4
High TSH
95% positive for anti-TPO Ab

121
Q

How do you diagnose primary hyperthyroidism?

A

High fT3/4

Low TSH

122
Q

What are the four causes of primary hyperthyroidism?

A

Grave’s disease
Hashitoxicosis
Thyroid cancer
Thyroid nodules

123
Q

What is hashitoxicosis?

A

Hyperthyroidism as a precursor to Hashimoto’s disease

124
Q

How common is thyroid cancer?

125
Q

What is Grave’s disease?

A

Autoimmune disease where Thyroid stimulating immunoglobulin (TSI) acts like TSH but unchecked by T3/T4

126
Q

What antibody is responsible for Grave’s disease?

A

Thyroid stimulating immunoglobulin (TSI)

127
Q

How does Thyroid stimulating immunoglobulin (TSI) cause Grave’s disease?

A

Acts like TSH but unregulated by T3/T4

128
Q

What are the special signs and symptoms only seen in Grave’s disease?

A

Pretibial myxoedema- very rare
Thyroid acropachy- Severe finger clubbing
Thyroid bruits- Auscultate over thyroid in patients with large goiter
Thyroid eye disease (TED)/Grave’s ophthalmopathy (GO)

129
Q

Describe Thyroid eye disease (TED)/Grave’s ophthalmopathy (GO)

A

Occurs in 20% Grave’s patients but can predate it
Uni or bi lateral
Worse with smoking
TRAb driven

130
Q

How do you treat Thyroid eye disease (TED)/Grave’s ophthalmopathy (GO)?

A

Mild- Lubricants

Severe- Steroids, surgery, radiotherapy

131
Q

How do you diagnose Thyroid eye disease (TED)/Grave’s ophthalmopathy (GO)?

A

Low TSH- often 0
High fT3/4
TRAb (TSH receptor Ab)- if raised no need to image

132
Q

What can Thyroid eye disease (TED)/Grave’s ophthalmopathy (GO) be associated with?

A

Cardiac abnormalities
Increased calcium and ALP- gives osteoporosis
Leucopenia (low WCC)

133
Q

What are thyroid nodules?

A

Lumps of glandular tissue that can secrete excessive thyroid hormones or invade other structures.

134
Q

Describe thyroid nodules

A

Tend to be symmetrical and may feel nodular. Move with thyroid

135
Q

What are the two forms of thyroid nodule possible?

A

Solitary

Multinodular goiter

136
Q

How do you diagnose thyroid nodules?

A

Low TSH and high fT3/4
TRAb negative
High iodine uptake on imaging
US

137
Q

Give a cause of secondary hyperthyroidism

A

Thyrotropinoma

138
Q

What causes Thyrotropinoma?

A

Pit adenoma causing increased TSH release.

139
Q

What is a Choriocarcinoma?

A

Tumour is uterus which secretes hCG. hCG is structurally similar to TSH therefore get unregulated thyroid stim.

140
Q

How do you treat hyperthyroidism?

A

Antithyroid drugs
Beta-blockers
Radioiodine
Thyroidectomy

141
Q

What two antithyroid drugs are used?

A

Carbimazole

Propythiouracil (PTU)

142
Q

When is Carbimazole used?

A

1st line- only don’t use in 1st trimester

143
Q

When is Propythiouracil (PTU) used?

A

In the first trimester

144
Q

Why is Carbimazole prefered to PTU?

A

More potente (once daily dose)

145
Q

Which beta blocker is routinely used in hyperthyroidism and why?

A

Propranolol- to reduce sympathetic NS stim and inhibits DIO1

146
Q

How do antithyroid drugs work?

A

Block TPO preventing thyroid uptake (?)

147
Q

What is a rare but dangerous side effect of antithyroid drugs?

A

Agranulocytosis- 0.5% of patients. Neutrophils stop being produced. Highest risk in first 6 weeks therefore warn patients verbally and in writing to stop and have FBC if have fever, oral ulcer or throat infection.

148
Q

What are the two methods for treating Grave’s disease?

A

Dose titration

Block and replace

149
Q

What is dose titration?

A

12-18 months normal hyperthyroidism treatment

150
Q

What is block and replace?

A

6 months intensive hyperthyroid treatment then replace with levothyroxine

151
Q

What should you do if primary treatment of Grave’s disease fails?

A

Surgery or radioiodine

152
Q

When is radioiodine used?

A

Relapsed Grave’s or nodular disease

153
Q

When should you not use radioiodine?

A

Pregnancy or thyroid eye disease

154
Q

What is a drawback of radioiodine?

A

Can cause hypothyroidism

155
Q

When should you do a thyroidectomy?

A

When radioiodine is contraindicated.

156
Q

What are potential complications of thyroidectomy?

A

Damage to the recurrent laryngeal nerve and parathyroid glands

157
Q

How do you treat thyroiditis?

A

Self limiting therefore will resolve with time

158
Q

What are some causes of thyroiditis?

A

Subacute/de Quervain’s thyroiditis
Post-partum thyroiditis
Drug induced- amiodarone
Subacute thyroiditis

159
Q

How does amiodarone cause thyroiditis?

A

Inhibits DOI1 therefore get increase in T4 and decrease in T3 but normal TSH.

160
Q

How can subacute thyroiditis present?

A

May be triggered by viral infection

Neck tenderness, fever etc

161
Q

How do you distinguish a thyroglossal cyst?

A

Stick tongue out and it moves

162
Q

Describe the goiter seen in Grave’s disease?

A

Smooth and regular

163
Q

How does a Graves goiter present on scanning?

A

Completely black

164
Q

Describe a toxic multinodular goiter?

165
Q

What effect can a hyperthyroid nodule have on the rest of the thyroid gland?

A

Cause hypothyroidism

166
Q

What is a side effect of radioiodine?

A

Can get brief surge of hyperthyroidism
Neck pain
2kg weight gain

167
Q

How do you treat Grave’s disease?

A

Radioiodine
Antithyroid drugs
Avoid surgery

168
Q

WHat is the Wolff-Chaikoff effect?

A

The ability of high dose iodine (KI) to block T4 production in the short term. Only lasts 10-14 days

169
Q

What is the only thyroid disease you tend to get eye involvement with?

170
Q

What does a low TSH by itself suggest?

A

Thyrotoxicosis

171
Q

Can a lymphoma affect the thyroid?

A

Yes but rarely

172
Q

What physical sign is important to ask about when examining a thyroid lump?

A

Voice changes

173
Q

What are some potential side effects of Carbimazole?

A

Minor rash

Agranulocytosis

174
Q

What are some side effects of PTU?

A

Liver failure

Agranulocytosis

175
Q

What should a patient be warned about when taking antithyroid drugs?

A

Agranulocytosis- if ill stop immediately and get FBC

176
Q

What is a potential problem with thyroxine?

A

Can have cardio effects therefore if have HD give low dose and work up

177
Q

What is a differential for thyroid swelling?

A

Enlarged lymph nodes- tend to be more laterally though

Endocrine (23 decks)

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