1. GOITRE
Dr Echebiri, Promise
State House Medical Centre, Aso Rock, Abuja.
5th December,2011.

2. CONTENTS
• Definition
• Overview
• Background
• Pathophysiology
• Classification
• Presentation
• Investigations
• Differential Diagnoses
• Treatment
• Prognosis

3. DEFINITION
An enlarged thyroid gland.
-Clinically palpable gland.
-Gland enlargement more than twice of the
normal size.

4. OVERVIEW
• Geography: Worldwide, the most common
cause of goiter is iodine deficiency.
Approximately 800million people subsist on
iodine-deficient diet.
In industrialized countries,goiter is more often
due to Hashimoto’s thyroiditis.

5. OVERVIEW
• Sex: The female-to-male ratio is 4:1.
Thyroid nodules are more likely to be
malignant in men
The frequency of goiters decreases with
advancing age. although the incidence of
thyroid nodules increases with advancing age.
• Race: No racial predilection exists.

6. BACKGROUND
Thyroid gland surface marking

7. BACKGROUND
Hypothalamo-Pituitary-Thyroid Axis

8. BACKGROUND
Thyroid anatomy

9. BACKGROUND
Thyroid physiology

10. BACKGROUND
• TRH:Produced by Hypothalamus. Release is
pulsatile,circadian. Downregulated only by T3.
Travels through portal venous system to
adenohypophysis. Stimulates TSH formation.
• TSH: Produced by Adenohypophysis Thyrotrophs.Up
regulated by TRH .Down regulated by T4, T3.

11. BACKGROUND
Travels through portal venous system to
cavernous sinus, then thyroid gland.
Stimulates several processes
Iodine uptake
Colloid endocytosis
Growth of thyroid gland.
• Thyroid Hormone: Majority of circulating
hormone is T4
 98.5% T4
 1.5% T3

12. BACKGROUND
Total Hormone load is influenced by serum
binding proteins
 Albumin 15%
 Thyroid Binding Globulin 70%
 Transthyretin 10%
Regulation is based on the free component of
thyroid hormone

13. BACKGROUND
Hormonal interplay
TRH
TSH
T4,T3

14. PATHOPHYSIOLOGY

15. CLASSSIFICATIONS
Based on growth pattern
Goitre
Nodular Diffuse
Hypothalamic disease
Multinodular: Pituitary disease
Uninodular:
Iodine Iodine
Cysts deficiency deficiency(endemic, sporadi
Benign thyroid Thyroiditis c)
neoplasms
Sarcoidosis Grave’s disease
Thyroid cancers
Thyroid hormone
insensitivity

16. CLASSIFICATIONS
Based on size of gland
Grade III • Invisible
• Palpable
GradeII • Visible
• Palpable
• Visible
Grade I • Palpable
• Retrosternal extension

17. CLASSIFICATIONS
Based on activity of gland
Hyperthyroid
(toxic)
Hypothyroid

18. PRESENTATION

19. PRESENTATION
• History:
Anterior neck swelling
Pain: Haemorrhage, inflammation, necrosis, or
Malignant transformation
Compressive symptoms:
Dysphagia, dyspnea, stridor, plethora or
hoarseness
Symptoms of hyperthyroidism or
hypothyroidism

20. PRESENTATION
• Physical Examination
Characterisation of thyroid swelling
Check for signs of
hyperthyroidism/hypothyroidism
Check for signs of compression(Pemberton
manoeuvre).
Check for signs of malignancy

21. PRESENTATION
Hyperthyroidism versus Hypothyroidism

22. INVESTIGATIONS
• Laboratory Studies:
 TRH
 TSH
 Total T3, T4
 Free T3, T4
 RAIU
 Thyroglobulin
 Antibodies: Anti-TPO, Anti-TSHr

23. INVESTIGATIONS
• Imaging Studies:
Ultrasonography:Evaluate goiter
size, consistency, and nodularity. Localize
nodules for ultrasonographically guided
biopsy.
X Rays:Usually AP and Lateral with thoracic
inlet.Retrosternal goitre extension.Presence of
calcification.

24. INVESTIGATIONS
Computed tomography (CT) scanning:
Delineate the relationship of the thyroid gland
to nearby structures.CT-guided biopsies.
Radionuclide isotope scanning are used to
assess thyroid function and anatomy in
hyperthyroidism, as shown below.

25. INVESTIGATIONS

26. INVESTIGATIONS
Spirometry: The flow-volume loop is useful in
determining the functional significance of
compressive goiters.
Histology:fine needle aspiration or core biopsy.

27. DIFFERENTIAL DIAGNOSES
• Pseudogoitre
• Thyroglossal cyst
• Sublingual dermoid
• Lymphadenopathy(bull’s neck).
• Thyroid lipomas
• Thyroid lymphomas

28. TREATMENT
• Observation
 Small goiter
 Euthyroid
 Asymptomatic
• Medications:
 Hypothyroidism: Thyroid hormone replacement with
levothyroxine.
 Hyperthyroidism:May require medications to normalize
hormone levels for example
propylthiouacil,Methimazole
 Inflamed thyroid gland, aspirin or a corticosteroid

29. TREATMENT
• Surgery: Removing all or part of the thyroid
gland-Thyroidectomy.
Large goiters with compression
Malignancy
When other forms of therapy are not practical
or ineffective
• Radioactive iodine: Treatment results in
diminished size of goiter, but eventually may
also cause a hypothyroid state.

30. TREATMENT
• Minimally-invasive modalities
Endoscopic subtotal thyroidectomy
Embolization of thyroid arteries
Plasmaphoresis
Percutaneous ethanol injection into toxic
nodule
L-Carnitine supplementation may improve
symptoms and may prevent bone loss

31. PROGNOSIS
• Complications of thyroidectomy:
• Thyrotoxic storm
• Bleeding
• Infection
• Hypoparathyroidism
• Injury to recurrent laryngeal nerve
• Injury to superior laryngeal nerve
• Hypothyroidism

32. PROGNOSIS
• A small percentage of multinodular goiters do
lead to hyperthyroidism.
• Benign goiters have a good
prognosis,furthermore,the risk of malignant
transformation is low.

33. THANK YOU