Thyroid Goitre Flashcards
How does a thyroid goitre present?
Thyroid lumps are often asymptomatic and are noticed by family members or seen in the mirror.
They may sometimes cause pain and rarely present with features of compression of the trachea.
Ask about previous radiation.
What are signs of a thyroid goitre?
Ask the patient to drink some water and note the thyroid move as she/he swallows.
Note enlargement or asymmetry.
Stand behind a seated patient and use the second and third fingers of both hands to examine the gland as she/he swallows again.
Note lumps, asymmetry, size and tenderness.
Check for regional lymphadenopathy
What are red flags with thyroid goitre?
Prompting same day referral
Stridor associated with a thyroid mass
Prompting urgent (two-week rule) referral
Child with a thyroid nodule.
Unexplained hoarseness or voice changes associated with goitre.
Painless thyroid mass enlarging rapidly over a period of a few weeks.
Palpable cervical lymphadenopathy.
Other potential red flags:
Family history of thyroid cancer or endocrine tumour.
History of previous irradiation or exposure to high environmental radiation.
Insidious or persistent pain lasting for several weeks.
What are some non-urgent referral causes?
Thyroid nodules with abnormal TFTs. Refer to an endocrinologist.
Sudden onset of pain within a thyroid lump. (Likely cause is a bleed into a thyroid cyst.)
What differentials are there?
Non-toxic (simple) goitre - non-functioning nodules. TFTs are normal.
Toxic multinodular goitre - functioning nodules. Abnormal TFTs.
Retrosternal goitre (usually multinodular).
Hyperplastic nodule (single nodule or part of multinodular goitre).
Colloid nodule.
Thyroid adenoma.
Thyroid cyst.
Thyroid carcinoma.
Graves’ disease - diffusely enlarged overactive thyroid gland.
Hashimoto’s thyroiditis - autoimmune destruction of the gland may cause diffuse enlargement.
Other types of thyroiditis:
De Quervain’s thyroiditis - neck pain, fever and lethargy soon after an upper respiratory infection or a viral illness.
Acute suppurative thyroiditis - results from bacterial or fungal infection causing abscess.
What investigations can be carried out?
Perform TFTs. British Thyroid Association guidelines recommend GPs perform the TFTs to determine the need for referral, and if so who to. Those with abnormal TFTs and no suspicious features should be referred to an endocrinologist. Those with thyroid swelling and normal TFT should be referred under the timeline in the “Red flag features” section, above. These guidelines advise that in those with a new thyroid swelling, GPs should NOT arrange an ultrasound as this delays specialist opinion in those who may have thyroid cancer. Referral should be to a surgeon, endocrinologist or other member of a specialist multidisciplinary team.
Ultrasound is highly sensitive for detection and characterisation of thyroid nodules. It is far more sensitive than clinical examination and only a small percentage of nodules detected by ultrasound are clinically palpable. Ultrasound helps to inform which nodules need aspiration for cytology.
Fine-needle aspiration (FNA) gives tissue for cytology. It is performed under ultrasound guidance for maximum accuracy. It is safe, inexpensive and provides direct information.
Basal plasma calcitonin and carcinoembryonic antigen (CEA) are not used routinely but are measured if medullary thyroid cancer is suspected.
CT scans and MRI scans may be needed to detect local and mediastinal spread and regional lymph nodes.
