Thyroid Thyroiitis

10 THYROIDITIS

      Inflammatory disease of the thyroid occurs in four different varieties:

10.1 Septic or suppurative thyroiditis is due to sterepto or staphylococcus infected and is extremely rare

10.2 de Quervain’s thyroiditis, also known as subacute or granulomatous thyroiditis is most likely due to a viral infection. The onset is usually acute following a throat infection. The ESR is raised but there is no rise of WBC

10.2.1 Treatment is with aspirin in some cases. Predinisolone 5-10mg a day will be required

10.3 Autoimmune or lymphocytic thyroiditis (Hashimoto’s). The thyroid is moderately enlarged non-tender and has a firm lobulated surface, it may progress to hypothyroidism. Thyroid antibodies (TRC, TMA) are demonstrable. Cytology can be of help in diagnosis.

10.3.1 Treatment is with replacement of thyroid hormones for hypothyroidism

10.4 Reidels thyroiditis is characterised by an overgrowth of fibrous tissue and presents with a hard (woody thyroid) gland. Its presentation is like a carcinoma and a biopsy is the only means of diagnosis

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Thyroid multinodular goitre

9.2 NODULAR GOITRE

      The large majority of these goitres produce a cosmetic defect or cause pressure symptoms (respiratory distress, dysphagia). Some, however, may present with symptoms of excess thyroid hormone (Toxic Goitre)

      The symptoms in toxic goitre are similar to those of Grave’s Disease, except for those due to disturbed immune system which are absent. A single nodule in the thyroid can also produce excess hormones and present with all the clinical features of toxicity.

      The diagnosis is established by measuring thyroid hormones in the serum and a scan helps to establish the autonomously functioning nodule (AFN)

      Treatment of surgery after control of the hyperfunction of the thyroid with Neomercazole.

9.3 Goitre and Carcinoma

      The risk of Carcinoma developing in a multinodular goitre is small.

      However, carcinoma can co-exist with a multinodular goitre (4-17%).

      In cases of solitary nodule Fig. 31.6 is viewed by surgeons with greater suspicion, since it represents a focal replication of thyroid cells. An I131 scan and a fine needle aspiration cytology may further help to come to a decision. In most cases, a hemithyroidectomy is recommended

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Thyroid Simple Goitre 1

9. SIMPLE GOITRE

Fig 31.5 a, b, c & d

9.1 Goitrogens

      Goitrogens are substances that have the ability to inhibit hormonegenesis, they can occur in foods or may be drugs. The two groups of goitrogens are cyanogenic glucosides (cassava, sorghum, maize and millet) and thioglucoside containing substances (cabbage, kale, brussel sprouts, cauliflower, turnips and horse raddish)

A list of chemicals with hormone blocking action include

*     Phenylbutazone

*     Sulfonylureas

*     Salicytates

*     Phenytion

*     Furosemide

*     Iodides

*     Lithium

*     Proplythiouroal and

*     Carbiomizole

      The last four are usd for treatment of hyperthyroidism

9.1.1 Pathology

      Simple goitre (non-toxic, Endemic or Sporadic) when examined under the microscope may show a variable picture depending upon the stage at which it is examined.

      In the early stage there is uniform hyperplasia and hypertrophy. Repeated hyperplasia and involution cycles with the passage of time introduce alteration of thyroidal architecture with adjoining areas of hyperinvolution and hyperplasia. Fibrosis produces further demarcration of the adjoining area with at first microscopic nodularity and later followed by palpable nodularity with the growth of these nodules. Later there may be haemorrhage and calcification in any one of these areas.

      Functional autonomy in a hyperplastic nodule may result in hyperthyroidism (Toxic Multinodular Goitre)

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Thyroid congenital disorders

CONGENITAL DISORDERS

8.1 Lingual Thyroid

      Lingual thyroid occurs when all or a part of the thyroid does not descend during development. In 70% of cases it represents the whole of the thyroid at the back of the tongue. The patient complains of dyspagia or airway obstruction. A I131  scan will identify the lingual thyroid at the back of the tongue. Small doses of thyroxin will reduce the size and symptoms.

8.2 Thyroglossal Cyst

      Thyroglossal cyst presents as a cystic swelling in the midline and is due to persistence of thyroid tissue in the thyroglossal duct. Its mobility is from side to side and is restricted on protrusion of the tongue.

8.2.1 TREATMENT

Treatment is by surgery of the cyst with the duct and the portion of the hyoid bone are excised. A similar procedure is required for a thyroglossal fistula.

8.3 Inborn Errors Of Iodine Metabolism

      These inherited disorders are due to the deficiency of enzymes required for trapping, organification or coupling in the process of hormone production. Absence of thyroid hormone production in utero results in cretinism and later in goitre in childhood.

8.4 Lateral Aberrant Thyroid

      It is now believed that this is most often a metastasis in a lymphnode from a primary in the thyroid which is not palpable

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