Thyroid

Question 1

Classification of Goitre

Answer 1

1. SIMPLE 
•Diffuse: Physiological, primary and secondary iodine deficiency 
• Colloid Goitre
• MNG
• Solitary Nontoxic nodule
• Recurrent Nontoxic nodule
• Wolff-Chaikoff effect/ Hokkaido Goitre

2. TOXIC 
•
•Diffuse (Primary) - GRAVES’ Disease 
• Multinodular (Secondary) - Plummer’s disease
•Toxic Nodule - solitary (Tertiary)
•Recurrent toxicosis

3. NEOPLASTIC
   •Benign -
   ADENOMAS: follicular, hurthle cell

•Malignant -
CARCINOMAS: Papillary, Follicular, Medullary, Anaplastic
LYMPHOMAS: NHL

4. THYROIDITIS
   •Hashimoto’s Auto immune
   •de Queverian Auto immune
   •Reidel’s Thyroiditis
5. RARE
   Bacterial (Suppurative)
   Amyloid
   Thyroid cyst, abscess

Question 2

Classification of thyroid neoplasms

Answer 2

BENIGN : Follicular adenoma

MALIGNANT
🔹Primary:
Well diff. = Follicular and Papillary Ca.
Poorly Diff. = Anaplastic Ca.
Arising from Parafollicular cells = Medullary Ca.
Arising from Lymphatics = Non- Hodgkin’s Lymphoma

🔹Secondary (Metastasis)
Through blood from Ca. Breast, MM, RCC

Question 3

Congenital Anomalies of Thyroid

Answer 3

** Athyreosis

1. Ectopic Thyroid
2. Lingual Thyroid
3. Thyroglossal Cyst
4. Thyroglossal fistula
5. Lateral aberrant Thyroid
6. Agenesis
7. Dyshormonogenesis

Question 4

WHO Grading of GOITRE

Answer 4

Grade 1 :
no visible, no palpable Goitre

Grade 2:
Palpable Goitre, not visible in normal position of neck

Grade 3:
Visible in normal position neck

Question 5

Stages of Multinodular Goitre (MNG)

Answer 5

🔹Stage of Hyperplasia and Hypertrophy

🔹Stage of fluctuation in TSH

🔹Stage of formation of nodules (inactive)
Inter nodular tissue are ACTIVE🌟

Question 6

Solitary Thyroid Nodule

Answer 6

A discrete lesion/ nodule within the thyroid gland that is palpably or radiologically distinct from surrounding thyroid parenchyma

CAUSES: 
🔸Thyroid adenomas - Follicular
*Colloid
*Fetal
*Embryonal
*Hurthle cell/ Oxyphil or oncocytic
*Hyalinising Trabecular adenoma

🔸Carcinomas
🔸Thyroid cyst
🔸Thyroiditis as solitary nodule

Types—>

TOXIC SOLITARY

NONTOXIC SOLITARY
•Hot
•Warm
•Cold

Question 7

Types of Thyroidectomy

Answer 7

Hemithyroidectomy

Subtotal Thyroidectomy

Partial Thyroidectomy

Near total “ “

Total “ “

Hartley Dunhill Operation

🌹Rose position:
Supine position with neck hyperextended by placing a sandbag under shoulder

With table tilt of 15^ head up to reduce venous congestion

Question 8

Complications of Thyroidectomy

Answer 8

🔹Metabolic

Hyperparathyroidism (PTH)
(temporary, permanent, Hungry bone syndrome)

Thyroid Crisis/Storm

Hypothyroisim/ Thyroid Failure/ Myxedma

🔹Nerve injuries:
External Laryngeal N. - pitch of voice lost
Recurrent Laryngeal N.

🔹Vascular complications
•Haemorrhage: Primary and reactionary
•Haematoma formation
• Compromised Tracheo-esophageal Bloodsupply

🔹Immediate Post-op
•Haematoma
•Laryngeal Edema
•Respiratory Obstruction - Stridor

🔹Others:
Wound Infection
Scar hypertrophy or keloid
Granuloma formation

🔹Recurrent thyrotoxicosis

Question 9

Thyroid crisis/ Thyroid storm ⛈

(Rare and severe life- threatening complication of hyperthyroidism with acute hyper metabolic state induced by release of excessive thyroid hormones)

(Can be due to Sx or Mx causes)

Answer 9

Other causes- infection, trauma, pre-eclampsia, DKA,

C/F:
Present 12-24hours after surgery

Hyperpyrexia (>41^), Severe dehydration,

Circulatory collapse, Hypotension, palpitations, tachy-cardia/pnoea, Hyperventilation, Cardiac arrhythmias, Cardiac Failure ❣

GI - vomiting, diarrhoea, Jaundice 🤮

CNS - Restlessness, irritability, delirium, tremor, convulsions and coma 🧠

Investigations: 
Raised T3, T4, Calcium, total counts 🔝
Suppressed TSH⬇️
ECG and Echo changes
Altered LFT, ABG, electrolytes

Treatment:
💊Supportive-
Rehydration, tepid sponging, anti pyretics, IV DEXTROSE, correction of electrolytes, cardiac monitoring, ICU care with ventilators support

CVP, NG tube, urinary catheter

💊Anti adrenergics-
Propranolol 80mg oral or NG
IV Propranolol 1mg in 10min— 2mg in 10min

💊Thionamides- PTU 200mg 4th hourly

💊Iodide compounds- Lugol’s iodide / KI

💊Glucocorticoids (Hydrocortisone, Dexamethasone)

💊Bile acid suppressants - Cholestyramine 4g 6thhourly

💊Treat the specific cause

💊Other measures: hemodialysis, plasmapheresis, exchange transfusion

Question 10

BAILEY’s symptom Complex of thyroid storm

Answer 10

📌FA’’’ST AEI MOD

Fever
Anorexia, vomiting, diarrhoea
Sweating
Tachycardia

Aggravated toxic features
Emotional instability
Insomnia

Multi organ dysfunction (MOD)

🌟🌟🌟Burch-Wartofsky score:
To identify or predict the thyroid storm using different parameters

<25 Excludes storm
25-45 Impending Storm
>45 Thyroid Storm

Question 11

Differential diagnosis for Thyroid Storm ☔️

Answer 11

Malignant hyperpyrexia
Septic shock
Anxious status
Cardiac disorders ❣