anatomy of thyroid

Thyroid diseaseThyroid disease

Libo Li MDLibo Li MDDepartment of General SurgeryDepartment of General Surgery

Sir Run Run Shaw HospitalSir Run Run Shaw HospitalSchool of medicine, Zhejiang UniversitySchool of medicine, Zhejiang University

Anatomy of ThyroidAnatomy of Thyroid

Thyroid diseaseThyroid disease

Nontoxic goiterNontoxic goiter HyperthyroidismHyperthyroidism Thyroid CancerThyroid Cancer ThyroiditisThyroiditis

Nontoxic GoiterNontoxic Goiter

GoiterGoiter from the French from the French (goitre)(goitre) and Latin and Latin (guttur)(guttur), both meaning throat, both meaning throat

Defined as an enlargement of the thyroid gland Defined as an enlargement of the thyroid gland Endemic when it involves more than 10% of the Endemic when it involves more than 10% of the

populationpopulation The majority, secondary to iodine deficiencyThe majority, secondary to iodine deficiency Especially found in high mountain regions Especially found in high mountain regions


Clinical thinkingClinical thinking

Whether the patient has local symptoms Whether the patient has local symptoms Whether the goiter is toxic or nontoxicWhether the goiter is toxic or nontoxic Whether any of the nodules harbor a cancerWhether any of the nodules harbor a cancer The number and bilaterality of the nodules The number and bilaterality of the nodules TSH level, differential diagnosis of TSH level, differential diagnosis of

hypothyroidism or hyperthyroidismhypothyroidism or hyperthyroidism Appropriate treatment options for each particular Appropriate treatment options for each particular

patientpatient


Taking historyTaking history

Asymptomatic neck massAsymptomatic neck mass– A cough, shortness of breath, stridor, or hoarsenessA cough, shortness of breath, stridor, or hoarseness

– Choking or aspiration, dysphagia, or painChoking or aspiration, dysphagia, or pain

– Symptoms of hyperthyroidismSymptoms of hyperthyroidism

– Whether the patient has cosmetic concernsWhether the patient has cosmetic concerns From iodine deficiency regionFrom iodine deficiency region


Physical examinationPhysical examination

Whether the goiter is confined to the neck Whether the goiter is confined to the neck Whether it has a substernal componentWhether it has a substernal component Whether tracheal deviation is present Whether tracheal deviation is present The size and consistency of the goiter The size and consistency of the goiter The mobility of the vocal cords by either indirect The mobility of the vocal cords by either indirect

or direct laryngoscopyor direct laryngoscopy

Nontoxic Nontoxic

GoiterGoiter

Ultrasound Ultrasound – How many nodules?How many nodules?

– Bilateral?Bilateral?

– Ultrasound characteristicsUltrasound characteristics


CT scan CT scan – Neck and chest, especially substernal thyroidNeck and chest, especially substernal thyroid

– Rare intrathoracic or aberrant thyroidRare intrathoracic or aberrant thyroid


Fine needle aspiration (FNA) Fine needle aspiration (FNA) – Suspicious malignent goiterSuspicious malignent goiter


TreatmentTreatment

Iodine diet replacement (endemic goitor)Iodine diet replacement (endemic goitor) Surgical resectionSurgical resection

– SymptomsSymptoms Local compressionLocal compression Secondary hyperthyroidisimSecondary hyperthyroidisim

– Any suspicious or malignant lesionAny suspicious or malignant lesion– Cosmetic reasonsCosmetic reasons

Radioiodine therapy, high risk of ptsRadioiodine therapy, high risk of pts Thyroid hormone suppression (not for sporadic Thyroid hormone suppression (not for sporadic

goiter)goiter)

Sporadic Nontoxic GoiterSporadic Nontoxic Goiter

AsymptomaticAsymptomatic EuthyroidEuthyroid Most bilaterallyMost bilaterally No efficiency of thyroid hormone replacementNo efficiency of thyroid hormone replacement High recurrence postoperatively 30%~40%High recurrence postoperatively 30%~40%


History of Thyroid SurgeryHistory of Thyroid Surgery

First thyroidectomy, in Paris in 1791 by Pierre-First thyroidectomy, in Paris in 1791 by Pierre-Joseph DesaultJoseph Desault

Antisepsis, hemostasis, and general anesthesia in Antisepsis, hemostasis, and general anesthesia in the 1840s the 1840s – thyroid surgery became safethyroid surgery became safe

Theodore Kocher, a Nobel Prize in 1909Theodore Kocher, a Nobel Prize in 1909– From Bern, SwitzerlandFrom Bern, Switzerland

– His pioneering efforts in thyroid surgeryHis pioneering efforts in thyroid surgery

Primary HyperthyroidsimPrimary HyperthyroidsimGrave’s DiseaseGrave’s Disease

Clinical StatisticsClinical Statistics

Graves Disease is the most common cause of Graves Disease is the most common cause of hyperthyroidism (60-80%) of all caseshyperthyroidism (60-80%) of all cases

Females are affected more frequently than men Females are affected more frequently than men 10:1.510:1.5

Monozygotic twins show 50% concordance ratesMonozygotic twins show 50% concordance rates Incidence peaks from ages 20-40Incidence peaks from ages 20-40 Incidence is similar in whites and Asians, but is Incidence is similar in whites and Asians, but is

somewhat decreased for African Americanssomewhat decreased for African Americans

Graves' DiseaseGraves' Disease

Autoimmune systemic disorderAutoimmune systemic disorder Thyroid receptor antibody binding to and Thyroid receptor antibody binding to and

stimulating the TSH receptorstimulating the TSH receptor Excessive synthesis and secretion of thyroid Excessive synthesis and secretion of thyroid

hormonehormone Usually diffusely and symmetrically enlarged Usually diffusely and symmetrically enlarged

and firmand firm

Hyperthyroidism—uptakeHyperthyroidism—uptake

A. NormalA. Normal B. Graves’ DzB. Graves’ Dz C. Toxic Multinodular C. Toxic Multinodular

GoiterGoiter D. Toxic AdenomaD. Toxic Adenoma E. ThyroiditisE. Thyroiditis

HyperthyroidismHyperthyroidism

SymptomsSymptoms

Heat intolerance, sweating, palpitations, fatigueHeat intolerance, sweating, palpitations, fatigue Weight loss, diaphoresis, increased stool Weight loss, diaphoresis, increased stool

frequencyfrequency Muscle weakness, anxiety, insomnia Muscle weakness, anxiety, insomnia Nervousness or restlessness; irritability, Nervousness or restlessness; irritability,

emotional lability emotional lability In women, irregular mensesIn women, irregular menses

HyperthyroidismHyperthyroidism

Clinical findingsClinical findings

Tremor, tachycardia (A. fib), Tremor, tachycardia (A. fib), Goiter, lid lag, proptosis, periorbital edema, Goiter, lid lag, proptosis, periorbital edema,

exophthalmos; chemosis; hyperreflexiaexophthalmos; chemosis; hyperreflexia Warm, moist skin; dermopathy; and pretibial Warm, moist skin; dermopathy; and pretibial

edema,edema, osteoporosisosteoporosis

Exopthalamos in Graves Exopthalamos in Graves DiseaseDisease

Lid Lag in Graves Lid Lag in Graves DiseaseDisease

Hyperthyroidism—treatmentHyperthyroidism—treatment

Beta-blockers: control sxsBeta-blockers: control sxs– Propranolol decr peripheral T4 -> T3 conversionPropranolol decr peripheral T4 -> T3 conversion

Graves’ DzGraves’ Dz– PTU (safe in pregnancy) or methimazolePTU (safe in pregnancy) or methimazole

Rare side effect: agranulocytosisRare side effect: agranulocytosis– Radioactive iodineRadioactive iodine

75% of treated pts become hypothyroid75% of treated pts become hypothyroid– SurgerySurgery

Toxic Adenoma or TMNGToxic Adenoma or TMNG– RAI or surgeryRAI or surgery

HyperthroidismHyperthroidism

SurgerySurgery

Surgical approachSurgical approach– Bilateral near-total or total thyroidectomyBilateral near-total or total thyroidectomy

Indication of surgery (In China)Indication of surgery (In China)– Compressive symptomsCompressive symptoms

– Secondary or adenomaSecondary or adenoma

– Recurrence of medicine or iodine-131Recurrence of medicine or iodine-131

– No efficiency of medicineNo efficiency of medicine

– Second trimester of pregnancySecond trimester of pregnancy

Surgery for hyperthyroidismSurgery for hyperthyroidism

Preoperative preparationPreoperative preparation

Absolutely requiredAbsolutely required antithyroid drugs, for 3 to 6 weeks antithyroid drugs, for 3 to 6 weeks

– with a goal of nearly normalizing the T3 and T4 with a goal of nearly normalizing the T3 and T4 Propranolol or atenolol rapidly controls the Propranolol or atenolol rapidly controls the

adrenergic side effects of excess T4 and T3 adrenergic side effects of excess T4 and T3 – tachycardia, tremor, and diaphoresistachycardia, tremor, and diaphoresis

Lugol's solution rapidly but temporarily restores Lugol's solution rapidly but temporarily restores normal thyroid function and reduces thyroid normal thyroid function and reduces thyroid gland vascularitygland vascularity

Surgical complicationsSurgical complications

BleedingBleeding Recurrent Laryngeal Nerve DamageRecurrent Laryngeal Nerve Damage Hypoparathyroidism and HypocalcemiaHypoparathyroidism and Hypocalcemia Superior laryngeal nerve damageSuperior laryngeal nerve damage Thyroid stormThyroid storm

Thyroid cancerThyroid cancer


IntroductionIntroduction

The most common, 95% of all endocrine cancersThe most common, 95% of all endocrine cancers Increasing faster than any other cancer Increasing faster than any other cancer More than 90% , well differentiatedMore than 90% , well differentiated Good long-term prognosisGood long-term prognosis


Clinical PresentationClinical Presentation

Most, clinically with a palpable noduleMost, clinically with a palpable nodule Usually asymptomaticUsually asymptomatic Rare cases, with hoarseness, pain, dysphagia, Rare cases, with hoarseness, pain, dysphagia,

dyspnea, coughing, or choking spellsdyspnea, coughing, or choking spells PainPain ，， with the suspicion for with the suspicion for

– Medullary thyroid carcinoma Medullary thyroid carcinoma

– Anaplastic carcinomaAnaplastic carcinoma

– LymphomaLymphoma

Pertinent historical factors Pertinent historical factors predicting malignancypredicting malignancy

A history of head and neck irradiationA history of head and neck irradiation Total body irradiation for bone marrow transplantation Total body irradiation for bone marrow transplantation Exposure to fallout from the explosion of the Exposure to fallout from the explosion of the

Chernobyl nuclear power plant in 1986, especially in Chernobyl nuclear power plant in 1986, especially in children; children;

A family history of thyroid cancer; and rapid growth A family history of thyroid cancer; and rapid growth or hoarseness. or hoarseness.

Children, men, and adults older than 60 years have an Children, men, and adults older than 60 years have an increased risk of malignancyincreased risk of malignancy

Increase the risk of thyroid cancerIncrease the risk of thyroid cancer

Personal and family history of other endocrine Personal and family history of other endocrine disorders, disorders, – specifically hyperparathyroidism, pituitary adenomas, specifically hyperparathyroidism, pituitary adenomas,

pancreatic islet cell tumors, adrenal tumors, and pancreatic islet cell tumors, adrenal tumors, and

breast cancerbreast cancer. . A family history of papillary or medullary A family history of papillary or medullary

carcinoma (MEN syndromes), familial carcinoma (MEN syndromes), familial polyposis, Gardner's syndrome, and Cowden's polyposis, Gardner's syndrome, and Cowden's syndromesyndrome

Pertinent physical findings Pertinent physical findings Suggesting possible malignancy Suggesting possible malignancy

Gritty texture”(Gritty texture”( 颗粒样）颗粒样） of the thyroid noduleof the thyroid nodule Cervical lymphadenopathyCervical lymphadenopathy Vocal cord paralysisVocal cord paralysis Fixation of the nodule to surrounding tissueFixation of the nodule to surrounding tissue


DiagnosisDiagnosis

Ultrasound Ultrasound – Feature of malignancyFeature of malignancy

Irregular marginsIrregular margins Intranodular vascular patternIntranodular vascular pattern MicrocalcificationsMicrocalcifications

Fine needle aspiration (FNA)Fine needle aspiration (FNA)– The most reliable and cost-efficient methodThe most reliable and cost-efficient method

Thyroid cancer Thyroid cancer

DiagnosisDiagnosis

Thyroid function tests Thyroid function tests Serum markersSerum markers

– Thyroglobulin (TG) for well-differentiated thyroid Thyroglobulin (TG) for well-differentiated thyroid cancercancer

– Calcitonin and CEA for medullary thyroid cancerCalcitonin and CEA for medullary thyroid cancer All pts with medullary thyroid cancerAll pts with medullary thyroid cancer

– RET proto-oncogeneRET proto-oncogene

– pheochromocytoma and hyperparathyroidismpheochromocytoma and hyperparathyroidism

Management of thyroid cancer Management of thyroid cancer

The goals of therapy The goals of therapy

Removal of primary tumor, disease that extends beyond Removal of primary tumor, disease that extends beyond the thyroid capsule, and involved cervical lymph nodesthe thyroid capsule, and involved cervical lymph nodes

Minimization of treatment- and disease-related Minimization of treatment- and disease-related morbiditymorbidity

Accurate disease stagingAccurate disease staging Facilitation of postoperative treatment with radioiodine Facilitation of postoperative treatment with radioiodine

when appropriatewhen appropriate Accurate long-term surveillanceAccurate long-term surveillance Minimization of the risk of recurrent local and metastatic Minimization of the risk of recurrent local and metastatic

tumortumor

Well-Differentiated Thyroid CarcinomaWell-Differentiated Thyroid Carcinoma

Papillary Thyroid CarcinomaPapillary Thyroid Carcinoma

The most common endocrine The most common endocrine malignancymalignancy ，， approximately 80% of new cases approximately 80% of new cases

Associated with the best prognosisAssociated with the best prognosis At least twice as common in women as men At least twice as common in women as men A peak age of presentation of 38 to 45 yearsA peak age of presentation of 38 to 45 years 90% of radiation-induced90% of radiation-induced ，， familial in 5%familial in 5%

Well-Differentiated Thyroid CarcinomaWell-Differentiated Thyroid Carcinoma

PrognosesPrognoses

The risk of death The risk of death – approximately 5% in the low-risk group approximately 5% in the low-risk group

– 40% in the high-risk group 40% in the high-risk group Fortunately, most pts (70%) in the low-risk Fortunately, most pts (70%) in the low-risk

groupgroup

Other histological factors Other histological factors

To predict the behavior of thyroid cancer To predict the behavior of thyroid cancer – Ploidy of the tumorPloidy of the tumor

– Adenylate cyclase response to thyroid stimulating Adenylate cyclase response to thyroid stimulating hormone (TSH)hormone (TSH)

– Radioiodine uptakeRadioiodine uptake

– A positive positron emission tomography scanA positive positron emission tomography scan

– Epidermal growth factor (EGF) receptor level and Epidermal growth factor (EGF) receptor level and various gene profilesvarious gene profiles


The extent of surgical resection The extent of surgical resection

ControversialControversial American recommondationAmerican recommondation

– Total or near total thyroidectomyTotal or near total thyroidectomy complication rate of less than complication rate of less than 2%2%

– Selective nodal resection Selective nodal resection

– Postoperative treatment with iodine-131 Postoperative treatment with iodine-131 Low-risk pts less than 1 cmLow-risk pts less than 1 cm

– thyroid lobectomy and isthmectomy OKthyroid lobectomy and isthmectomy OK

– Reoperation Reoperation multifocal, with nodal metastases, or with local invasionmultifocal, with nodal metastases, or with local invasion

Benefits of total thyroidectomyBenefits of total thyroidectomy

Postoperative radioiodine scanning and ablative Postoperative radioiodine scanning and ablative therapy can be effectivetherapy can be effective

Serum thyroglobulin levels are rendered more Serum thyroglobulin levels are rendered more sensitive for detecting recurrent or persistent sensitive for detecting recurrent or persistent diseasedisease

Intrathyroidal cancer that is present in more than Intrathyroidal cancer that is present in more than 50% of patients is removed50% of patients is removed

The small risk of a differentiated thyroid cancer The small risk of a differentiated thyroid cancer becoming an undifferentiated cancer is decreased.becoming an undifferentiated cancer is decreased.


The role of lymph node dissectionThe role of lymph node dissection

Also controversialAlso controversial Micrometastasis to cervical lymph nodes is Micrometastasis to cervical lymph nodes is

common (80%)common (80%) Prophylactic cervical lymph node dissection is Prophylactic cervical lymph node dissection is

not warranted not warranted Functional neck dissection and central neck Functional neck dissection and central neck

dissection should generally be performed dissection should generally be performed – only in pts with clinical or sonographic evidence of only in pts with clinical or sonographic evidence of

lymph node involvementlymph node involvement

Follicular Thyroid CarcinomaFollicular Thyroid Carcinoma

Approximately 10% of all thyroid malignanciesApproximately 10% of all thyroid malignancies Typically older than PTCTypically older than PTC Usually in the sixth decade of lifeUsually in the sixth decade of life The female-to-male ratio is between 2:1 and 5:1The female-to-male ratio is between 2:1 and 5:1 A slowly growing solitary thyroid noduleA slowly growing solitary thyroid nodule A tendency to spread hematogenouslyA tendency to spread hematogenously

– Rarely with symptoms of distant metastasis to the Rarely with symptoms of distant metastasis to the bone, lung, brain, and liver bone, lung, brain, and liver


Less than 6% metastasize to the cervical lymph Less than 6% metastasize to the cervical lymph nodesnodes

Approximately 25% of pts have extrathyroidal Approximately 25% of pts have extrathyroidal invasioninvasion

10% to 33% have distant metastasis at the time 10% to 33% have distant metastasis at the time of initial diagnosisof initial diagnosis

The prognosis of follicular cancer The prognosis of follicular cancer

Slightly worse than that for papillary cancerSlightly worse than that for papillary cancer Overall survival ranges from 43% to 95% at 10 Overall survival ranges from 43% to 95% at 10

yearsyears Lifelong surveillance is not necessaryLifelong surveillance is not necessary

The prognosis of follicular cancer The prognosis of follicular cancer

The important prognostic factorsThe important prognostic factors– Presence of metastatic disease Presence of metastatic disease

– Older age (usually >40 years)Older age (usually >40 years)

– Degree of invasion (microcapsular vs. angioinvasion Degree of invasion (microcapsular vs. angioinvasion with or without capsular and widely invasive)with or without capsular and widely invasive)

– Degree of tumor differentiationDegree of tumor differentiation


DiagnosisDiagnosis– The whole specimen must be evaluated for vascular The whole specimen must be evaluated for vascular

and capsular invasion.and capsular invasion.

– Diagnosis of follicular cancer cannot be made on Diagnosis of follicular cancer cannot be made on FNABFNAB


TreatmentTreatment– The recommended initial operation is lobectomy and The recommended initial operation is lobectomy and

isthmectomyisthmectomy

– Lymph node dissection is rarely warranted because Lymph node dissection is rarely warranted because nodal metastases are uncommonnodal metastases are uncommon

Medullary Thyroid CarcinomaMedullary Thyroid Carcinoma

7% of thyroid cancers 7% of thyroid cancers 15% of all thyroid cancer–related deaths15% of all thyroid cancer–related deaths Approx 75% sporadicApprox 75% sporadic 零星的零星的 , 25% hereditary, 25% hereditary From c cells or parafollicular cells From c cells or parafollicular cells Located laterally at the junction of the upper two Located laterally at the junction of the upper two

thirds of the thyroid gland at approximately the thirds of the thyroid gland at approximately the level of the cricoid cartilagelevel of the cricoid cartilage


In the sporadic formIn the sporadic form– Usually a single focus of malignancy Usually a single focus of malignancy – Unilateral disease in 85% of casesUnilateral disease in 85% of cases

In the hereditary formIn the hereditary form– Multifocal and bilateral in 90% of cases Multifocal and bilateral in 90% of cases – C-cell hyperplasiaC-cell hyperplasia

The hereditary forms of MTCThe hereditary forms of MTC


Tumor markerTumor marker

Serum markers for calcitonin Serum markers for calcitonin – support the diagnosissupport the diagnosis

– correlate with tumor bulk, nodal, and distant correlate with tumor bulk, nodal, and distant metastasismetastasis

High CEA levels correlate with a poorer High CEA levels correlate with a poorer prognosisprognosis

Flushing and diarrhea also have a worse Flushing and diarrhea also have a worse prognosisprognosis


Lymph node metastasesLymph node metastases

Positive in 70% of patients Positive in 70% of patients 81% of patients had central node disease81% of patients had central node disease 81% had ipsilateral cervical node disease81% had ipsilateral cervical node disease 44% had contralateral cervical nodal disease44% had contralateral cervical nodal disease

Prevention or cure of MTCPrevention or cure of MTC

By surgeryBy surgery– mainly dependent on the initial stage and the mainly dependent on the initial stage and the

adequacy of the initial operationadequacy of the initial operation

IndicationIndication– RET-positive patients with familial disease before the RET-positive patients with familial disease before the

age of possible malignant progressionage of possible malignant progression

– total thyroidectomy before age 6total thyroidectomy before age 6

Surgical management for MTC Surgical management for MTC

Depends on the presentation of the diseaseDepends on the presentation of the disease– Thyroidectomy and central node dissectionThyroidectomy and central node dissection

Central lymph node dissections increase Central lymph node dissections increase – the risk of recurrent laryngeal nerve injury and the risk of recurrent laryngeal nerve injury and

hypoparathyroidismhypoparathyroidism

Anaplastic Thyroid CarcinomaAnaplastic Thyroid Carcinoma

Rare, 1% to 2% of thyroid malignancies Rare, 1% to 2% of thyroid malignancies More than half of the deaths from thyroid cancerMore than half of the deaths from thyroid cancer Survival is measured in monthsSurvival is measured in months Commonly in patients older than 60 years Commonly in patients older than 60 years Usually presents as a rapidly expanding thyroid Usually presents as a rapidly expanding thyroid

mass mass


Lymph node enlargement Lymph node enlargement – Frequent (84%) and earlyFrequent (84%) and early

Local tumor extension cause Local tumor extension cause – Fixation of the larynx, esophagus, and carotid vesselsFixation of the larynx, esophagus, and carotid vessels

Dysphagia, dysphonia, and dyspnea are commonDysphagia, dysphonia, and dyspnea are common Systemic metastases occur in 75% of pts, Systemic metastases occur in 75% of pts,

– Usually involving the lungs, bone, brain, and adrenal Usually involving the lungs, bone, brain, and adrenal glandsglands


The diagnosis The diagnosis – Be established by FNABBe established by FNAB

– Differentiated from that of lymphoma and poorly Differentiated from that of lymphoma and poorly differentiated medullary carcinomadifferentiated medullary carcinoma


SurgeySurgey

Usually not curative, with distant metastasesUsually not curative, with distant metastases Multimodality treatment, slightly improved Multimodality treatment, slightly improved

outcomesoutcomes– Indicate local control in 22% to 76% of ptsIndicate local control in 22% to 76% of pts

Median survival ranges from 2.5 to 9 months, Median survival ranges from 2.5 to 9 months, with 2-year survival of less than 20%with 2-year survival of less than 20%

Subacute ThyroiditisSubacute Thyroiditis

Painless ThyroiditisPainless Thyroiditis Painful ThyroiditisPainful Thyroiditis

– RareRare

Painless ThyroiditisPainless Thyroiditis

Also called lymphocytic thyroiditisAlso called lymphocytic thyroiditis Spontaneously resolving hyperthyroidismSpontaneously resolving hyperthyroidism An autoimmune disorderAn autoimmune disorder

– Typically elevated thyroid peroxidase antibody levels Typically elevated thyroid peroxidase antibody levels

– Lymphocytic infiltration of the thyroidLymphocytic infiltration of the thyroid



Ages of 30 and 60 yearsAges of 30 and 60 years 40% pts with the classical a four-stage clinical 40% pts with the classical a four-stage clinical

coursecourse– (1)Destruction-induced thyrotoxicosis, (2) euthryoidism, (3) (1)Destruction-induced thyrotoxicosis, (2) euthryoidism, (3)

hypothyroidism, and (4) return to euthyroidismhypothyroidism, and (4) return to euthyroidism

Usually, firm gland and non-tender with Usually, firm gland and non-tender with symmetrical, modest enlargement symmetrical, modest enlargement

Nearly one third of pts, permanently hypothyroidNearly one third of pts, permanently hypothyroid


Clinical ManagementClinical Management

Many patients do not require therapyMany patients do not require therapy Thyroidectomy is rarely indicated Thyroidectomy is rarely indicated

Painful ThyroiditisPainful Thyroiditis

Also called de Quervain's disease, Also called de Quervain's disease, granulomatous thyroiditis, granulomatous thyroiditis,

A viral etiologyA viral etiology Preceded by upper respiratory infectionPreceded by upper respiratory infection

Painful ThyroiditisPainful Thyroiditis

Clinical ManagementClinical Management

Usually self-limitedUsually self-limited Beta-blockade is indicated to treat the symptoms Beta-blockade is indicated to treat the symptoms

of hyperthyroidismof hyperthyroidism Nonsteroidal anti-inflammatory medications and Nonsteroidal anti-inflammatory medications and

prednisone may also be used for painprednisone may also be used for pain

Chronic ThyroiditisChronic Thyroiditis

Hashimoto's thyroiditisHashimoto's thyroiditis

The most common inflammatory diseaseThe most common inflammatory disease Autoimmune, chronic, progressive lymphocytic Autoimmune, chronic, progressive lymphocytic

thyroiditisthyroiditis Up to 95% of cases occur in womenUp to 95% of cases occur in women Elevated levels of circulating antibodies to Elevated levels of circulating antibodies to

thyroglobulin, thyroid peroxidase, and thyroglobulin, thyroid peroxidase, and thyrotropin receptorthyrotropin receptor



Usually asymptomaticUsually asymptomatic 20% with hypothyroidism20% with hypothyroidism

– The most common cause of hypothyroidism in USThe most common cause of hypothyroidism in US Usually symmetrical, firm glandUsually symmetrical, firm gland


ManagementManagement

Thyroid hormone replacement therapy Thyroid hormone replacement therapy – HypothyroidismHypothyroidism

– Elevated TSHElevated TSH


Indication of surgeyIndication of surgey

Malignancy is suspected from FNA biopsyMalignancy is suspected from FNA biopsy Compressive symptoms from a large goiter Compressive symptoms from a large goiter Cosmetic purposesCosmetic purposes

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anatomy of thyroid

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historyasymptomatic

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iodine deficiencyespecially

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