An Approach To A Thyroid Swelling
Dr Surendra Shah
Lecturer, Dept of Surgery
Patan Hospital, PAHS
Anatomy
TWENTY TO 25 g
TWO LOBES
ISTHMUS (10% ABSENT)
PYRAMID LOBE (50% ‘+’)
C5 TO T1
Venous Drainage
Arterial Supply
Recurrent Laryngeal N.
Superior Laryngeal N.
II
IA
IB
III
V VI
IV
Terminology
GOITRE
GENERALISED ENLARGEMENT
SOLITARY THYROID NODULE
DISCRETE SWELLING IN ONE
LOBE WITH NO PALPABLE
ABNORMALITY ELSEWHERE IN
THE GLAND
Terminology
DOMINANT THYROID NODULE
DISCRETE SWELLING IN ONE LOBE WITH PALPABLE
ABNORMALITY ELSEWHERE IN THE GLAND
INCIDENTALOMA
THE CLINICALLY NOT PALPABLE NODULES, FOUND
INCIDENTALLY DURING USG NECK FOR ANY OTHER
REGION
INCIDENCE OF MALIGNANCY: 3-6% SIMILAR TO PALPABLE
NODULES (>1.5cm)
Presentation
SWELLING IN THE NECK
ASSOCIATED WITH THYROID DYSFUNCTION
MASS EFFECT
Dealing with swelling
Etiology of swelling should be in the mind
What should be in mind……
Is there feature of thyroid dysfunction?
Is there pain over swelling?
Is there features of retrosternal goitre?
Is there sign of tracheal compression?
Is there h/o sudden increase in size?
Is there another swelling in the neck?
Is there recent change in voice or not?
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Features of Hypothyroidism
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Enthusiasm In Patient With Hyper Thyroidism
Leading Too Hot Environment After Thyrotoxicosis
Physical Examination
Inspection
Size and shape
Locations
One side
Midline
Both sides
Borders
SCM muscles
Suprasternal notch
Pizillo’s method
Physical Examination
Inspection
Surface
Smooth
Nodular
Bosselated
Overlying skin
Redness/edema
Scar
Dilated veins
Sinuses
Physical Examination
Swelling moves with deglutination
Thyroid
Thyroglossal cyst
Pretracheal lymph nodes
Subhyoid bursa
Extrinsic carcinoma of larynx
Physical Examination
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s m e t ho od
Lahey’
Physical Examination
n Kocher’s
Berry’s sig test
Physical Examination
Palpation
Location
Surface
Smooth/Bosselated
Consistency
Soft: Colloid goitre
Firm: Multinodular goitre
Hard: Carcinoma, Reidel’s thyroiditis
Retrosternal extension
Thrill and fixity
Physical Examination
Signs of retrosternal extension
Palpate tracheal ring at suprasternal notch
Dull on percussion over manubrium
Positive Pemberton’s sign
Dilated neck veins
Physical Examination
Signs of metastasis
Palpable LN in the neck
Hard nodules on skull
Long bone metastasis
Nodular liver & ascitis
Chest effusion/consolidation
Physical Examination
Eye signs
Dalrymple’s sign: lid
retraction
Stellwag’s sign:
infrequent and
incomplete blinking
Von graefe’s sign: lid lag
Physical Examination
Exophthalmos
Mobius sign
Naffziger’s method
Association of thyroid dysfunction
Goitre with hypothyroidism
Hashimoto’s thyroiditis
Most common cause of hypothyroidism
Thyroid microsomal antibodies are produced
Infiltration of lymphocytes and fibrosis result decrease in
number and efficiency of individual follicles
De Quervain’s thyroiditis
Riedel’s thyroiditis
Association of thyroid dysfunction
Goitre with hyperthyroidism
Grave’s disease (primary thyrotoxicosis)
Diffuse and vascular goitre
Appears at the same time as hyperthyroidism
Common in younger women (20-40Yrs)
Eye sign is common while cardiac sign is rare
Severe form of hyperthyroidism
Association of thyroid dysfunction
Goitre with hyperthyroidism
Toxic nodular goitre-Toxic adenoma
Appears long time before hyperthyroidism
Common in middle aged or elderly
Cardiac sign is common, eye sign is very infrequent
Nodules within an otherwise goitrous thyroid gland
Nodules are inactive in many cases with overactive internodular
tissue
In toxic adenoma, nodules are overactive
Association of thyroid dysfunction
Primary thyrotoxicosis
Eye sign
Tremor
Secondary thyrotoxicosis
Cardiac sign
Tachycardia
Cardiomegaly
Atrial fibrillation
CCF
Association of thyroid dysfunction
Goitre without dysfunction
Physiological goitre
Diffuse hyperplasia
No pain
Smooth, bilateral, symmetrical
Below teens,
Often females who are menstruating, lactating or pregnant
Association of thyroid dysfunction
Goitre without dysfunction
Multinodular goitre
Patient from endemic area
Multiple nodules of long standing
Soft to firm (sometimes calcified)
No fixity or pressure effect
Physical Examination
Points in favor of benign disease
SN with feature of hypo/hyperthyroidism
F/H/O benign thyroid nodule
Diffuse enlargement of thyroid
Soft, smooth, mobile nodule
SOFT NODULE MAY BE PTC AND FIRM TO HARD NODULE WITH
IRREGULAR SURFACE MAY BE DUE TO CHRONIC THYROIDITIS
ABOUT 15-30% PATIENT WITH SN HAVE 2ND NODULE IN THE
SAME OR OPOSITE LOBE AT IMAGING INVESTIGATION LIKE
USG
Physical Examination
Feature S/O malignant disease
Hoarseness of voice
Persistent unexplained diarrhea
Enlarge LN at the level 3,4,5
H/O irradiation, F/H/O MEN Type 2
Nodules of short duration
Increase in size and pain
Firm, hard and nodular surface
Restriction of movement
Dimpling of skin during deglutination
Prognostic risk classification for patients with
thyroid carcinoma (AMES OR AGES)
Low risk High risk
Age < 40 Yrs > 40 Yrs
Sex Female Male
Extent No local extension Extrathyroidal
Intrathyroidal Capsular invasion
No capsular invasion
Metastasis None Regional/Distant
Size <2 cm >4 cm
Grade Well differentiated Poorly differentiated
Investigation
Serum thyroid hormone
Thyroid autoantibody
Ultrasound/CT scan
FNAC
Isotope-scanning
Thoracic inlet X-ray
Indirect laryngoscope
Investigation
Thyroid function test
TSH
Normal High Low
No Free T4 T3, T4, TRAb
further TPOAb
study
Diff. Grave’s disease from
Raise TPOAb: hashimoto’s toxic nodular goitre
thyroiditis
Investigation
Ultrasound Feature of malignancy
Irregular margin
Size of the nodule
Micro-calcification
Multicentricity
Hypo-echodencity
Solid or cystic Predominantly solid
component
Cervical nodes
Intranodular vascularity
For follow up Regional lymphadenopathy
Guide for FNA Invasive growth
Though benign appearance-FNAC is mandatory
Investigation
USG WITH COLOR DOPPLER
ECHOGRAPHY ADVANTAGES OF USG:
DELINEATES INTERNAL • EASY AVAILABILITY
MORPHOLOGY • LOW COST
COLOR DOPPLER: • LIMITED DISCOMFORT
OUTLINE THE VASCULAR • NON-IONISING NATURE
PATTERN
Investigation
ULTRASOUND WITH COLOR DOPPLER
FOUR PATTERNS:
1. TOTALLY SONOLUSCENT UNILOCULAR LESION:
CYST (~10%)
2. A SONOLUSCENT CYST WITH INTERNAL ECHOES,
SEPTASE, AND/OR ECHOGENIC (SOLID TISSUE)
PROJECTIONS FROM THE WALL (~15%)
3. A NODULE WITH HOMOGENOUS ECHOGENICITY
(HYPER/HYPO) (~15%)
Investigation
WHOLLY SONOLUSCENT (CYSTIC):
USG WITH COLOR UNLIKELY TO BE MALIGNANT
DOPPLER
ECHOGENIC PROJECTION FROM
FOUR PATTERNS:
WALL, SOLID NUBBINS
4. NODULES WITH
ESPECIALLY IF VASCULAR:
MIXED POSSIBILITY OF PCT
SONOLUSCENCY AND
ECHOGENICITY (~60%) AS THE ECHOGENIC COMPONENT IN
NODULE OR VASCULARITY
INCREASES: CHANCES OF TUMOR OR
MALIGNANCY INCREASES
Investigation
FNAC
Indications
All palpable symptomatic nodules
Nodule >1cm
Nodule <1cm but having suspicious clinical and
USG features
Solitary nodule + Hyperthyroidism + Hot
nodules
Retrosternal goitre may not be easy to pick
Investigation
FNAC
SENSITYVITY: 65-98%
SPECIFICITY: 72-100%
FALSE NEGATIVE RATE: 1-11%
FALSE POSITIVE RATE: 0-7%
Investigation
FNAC
DIFFERENT TYPES OF ASPIRATES
1. CLASS 0:
INDETERMINATE GROUP
2. CLASS 1:
POUCI-CELLULAR ASPIRATE WITHIN COLLOID (IMPLIES
BENIGN SN): 50-70%
3. CLASS 2:
POUCI-COLLOID ASPIRATE RICH IN FOLLICULAR CELLS
(11-30%)
Investigation
4. CLASS 3:
FRANKLY MALIGNANT GROUP, MADE UP OF PAPILLARY AND
MEDULLARY CARCINOMA (4-10%)
CAN NOT DIFFERENTIATE FOLLICULAR ADENOMA
FROM FOLLICULAR CARCINOMA
FNA-FOLLICULAR CELL= 6% - 20% MALIGNANT
Investigation
Isotope scan
Recommendation under the following circumstances:
If FNAC shows follicular pattern
Hot nodule-exclude FTC, most are autonomously
functioning adenoma
Hyperthyroid patient with palpable SN
If thyroxin suppression therapy is planned
Patient with hot nodule can not tolerate drug therapy
DIAGNOSTIC ROLE ERODED BY USE OF USG AND FNAC
Investigation
ISOTOPE SCAN
¹²³I HAS LOW DOSE (30 mrad) RADIATION AND
SHORT HALF LIFE (12-14 HOURS) COMPARE TO ¹³¹I
(500 mrad, 8-10 DAYS)
99mTc HAS LOW RADIATION AND SHORT HALF LIFE.
SHOW UPTAKE IN SALIVARY GLAND AND MAJOR
VASCULAR STRUCTURE THUS, REQUIRE HIGHER
SOPHISTICATION INTERPRETATION
Investigation
Isotope scan
Preferred with 123I or Tc
99m
If S/O Lymphoma: Gallium-67 citrate scan
Nodule of ≤ 1 cm: may be missed on scan
Three patterns are recognized
1. Cold or partially cold (malignant: 16%)
2.Neutral, warm or functional nodule
3.Hot nodule (malignant: <5%)
Investigation
ISOTOPE SCAN
1. COLD OR PARTIALLY COLD NODULE
TAKES UP LESS ISOTOPE THAN THE REST OF THE
GLAND
2. NEUTRAL, WARM OR FUNCTIONAL NODULE
SAME UPTAKE OF RADIONUCLIDE AS THE REST OF
THE GLAND
Investigation
ISOTOPE SCAN
3. HOT NODULE
TRAPS MOST OF THE ISOTOPE, TO THE EXCLUSION OF
TRAPPING BY THE REST OF THE GLAND
POSIBILITY OF MALIGNANCY IN HOT NODULE: <5%
LESSER THE UPTAKE OF THE ISOTOPE BY THE NODULE,
GREATER THE RISK OF MALIGNANCY; EVEN THEN,
MAJORITY OF NODULES ARE BENIGN
Investigation
Contrast CT scan
Not routinely done
Delineate
Recommended if Morphology and
Malignancy is vascularity of nodules
suspected Capsular
Suspicious thickness/vascularity,
intrathoracic Breach and pericapsular
extension Perinodular planes
INTEGRITY OF PLANE BETWEEN NODULE AND
CAROTID SHEATH, TRACHEA, OESOPHAGUS
Investigation
OTHER CAUSES OF RAISED
CALCITONIN
Tumor Marker • IMPAIRED RENAL FUNCTION
• PSEUDOHYPOPARATHYROIDISM
Serum calcitonin • TREATMENT WITH PPI
High level: diagnostic of MCT
Normal <10pg/ml
Serum thyroglobulin
Used in FU for well differentiated thyroid
carcinoma (After total thyroidectomy)
WILL BE CONTINUED…
THANK YOU
