goitre,powet point presentation-teresia lutufyo,shija charles,mkindi hamisi
TRANSCRIPT
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GOITREPRESENTERS: HAMISI MKINDI,MD5 SHIJA CHARLES,MD5 THERESIA LUFYO,MD5
MODERATORS Dr.FASSIL G. Dr.MAYOKA R. Dr.Fr.GINGO
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Learning objectives
Definition Surgical anatomy
and embryology of thyroid gland
Etiology Classification Pathophysiology Clinical
presentation
Workup Treatment Complications Prevention
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DEFINITION
Goiter can be defined as enlargement of the thyroid gland irrespective of its pathology
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THYROID
Derives its name from thyroid cartilage Anterior part of neck 20-25gm Functional unit=lobule Each lobule =24-40 follicles
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SURGICAL ANATOMY
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BLOOD SUPPLY
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NERVE SUPPLY
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ARTERIES AND NERVES
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EMBRYOLOGYDv from TGD(median bud of pharynx)which
passes from foramen caecum at base of the tongue to thyroid isthmus
First of the body's endocrine glands to develop, on approximately the 24th day of gestation.
2 main structures: the primitive pharynx and the neural crest.
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EMBRYOLOGY
The inferior parathyroid glands arise from the dorsal wing of the third pharyngeal pouch.
The initial descent of the thyroid gland follows the primitive heart and occurs anterior to the pharyngeal gut. At this point, the thyroid is still connected to the tongue via the thyroglossal duct.
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PHYSIOLOGY
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THYROID HORMONES
Mental growth and developmentPhysical growthBMRSensitivity to catecholamines
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ETIOLOGY OF GOITRE
Factors associated with goiter formation can be classified as follows:-Hereditary factorsHormonal factorsDietary factorsPharmacological factorsPhysiological factorsEnvironmental factorsPathological factors
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Hereditary factorsInherited defect of thyroid hormone
synthesis Enzymatic defect deficiencyDyshormonogenesis
Familial goitre
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Hormonal factorsThyroid hormone dysfunction
Hyperthyroidism (overproduction of thyroid hormones)
Hypothyroidism (underproduction of thyroid hormones)
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Dietary factors
Dietary iodine deficiencyGoitrogens:-
Cabbage endemic goitre
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Pharmacological factorsUse of goitrogen drugs like para-
aminosalicylic acid (PAS), thiocyanate and antithyroid drugs [e.g. thiouracil, carbimazole] hypothyroidism
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Physiological factorsIncreased metabolic demand of
thyroid hormones e.g. during pregnancy or puberty physiological goitre
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Environmental factors
Exposure to radiations Thyroid cancer
Hypothyroidism
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Pathological factorsIntrinsic thyroid gland diseases
Inflammatory goitresNeoplastic goitres-Benign adenoma(follicular adenoma)-MalignantA.Primary
Well differentiated, Poorly differentiated, Arising from parafollicular cells
B.Secondary
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CLASSIFICATION
Etiological classificationEpidemiological classificationAnatomical classificationPathological classificationFunctional classificationMorphological classification
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Etiological classificationPhysiological goitre
Goitres resulting from increased metabolic demand of thyroid hormones e.g. during pregnancy or puberty
Pathological goitreGoitres resulting from diseases
affecting the thyroid gland e.g. Neoplastic or inflammatory conditions
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Epidemiological classificationFamilial goitres
goitres that run in families as a result of Inherited defect of thyroid hormone synthesis
Endemic goitresdefined as thyroid enlargement affecting
a significant number of inhabitants of a particular locality
Sporadic goitresgoitres that run sporadically
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Anatomical classification
Cervical goitreGoitre situated on the anterior aspect of
the neckRetrosternal goitre
Goitre extends downward and get situated behind the sternum
Intrathoracic goitreThe type of goitre which extends into
thoracic cavity
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Pathological classificationSimple goitresToxic goitres Neoplastic goitresInflammatory goitresMiscellaneous (Other rare types)
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Functional classificationToxic goitre
Type of goitre associated with thyroid hyperfunction (hyperthyroidism)
Non-toxic Type of goitre associated with thyroid
hypofunction (hypothyroidism) or normal thyroid function (Euthyroid)
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Morphological classificationAccording to the texture of the
glandDiffuse goitreNodular goitre
Solitary nodular goitreMultinodular goitre
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PATHOPHYSIOLOGY
The pathophysiological consequences of goitres results from one of the following:-The effect of thyroid hormone
dysfunctionThe effect of enlarged thyroid glandThe effect of primary disease causing
goitre
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Effect of thyroid hormone dysfunction
Thyroid hyperfunction (hyperthyroidism)
Features of hyperthyroidism
Thyroid hypofunction (hypothyroidism)
Features of hypothyroidism
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Effect of enlarged thyroid gland
Effect on the trachea dyspneaEffect on the esophagus
dysphagiaEffect on the superior venacava
distended neck veinsEffect on the recurrent laryngeal
nerve horsiness of voice
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Effect of primary disease causing goitre
The effect depends on the underlying disease
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CLINICAL PRESENTATION
History (Symptoms)Physical examination (Signs)
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History (Symptoms)Age SexMain complaints
Anterior neck swellingDurationMode of onsetRate of growthAssociated pain
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History (Symptoms)… Pressure-related symptoms
Dysphagia, dyspnoea, hoarseness of voice, neck vein engorgement etc
Review of systems to assess toxicityCNS- tremors, irritability, mental
disturbance CVS- palpitation, dyspnoea, orthopnoeaGI- change of appetite, constipation,
diarrhoeaMSS- bone pain, weight change, heat or
cold preference, excessive sweating
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History (Symptoms)…….. Past medical history
Previous medication, previous h/o irradiation
Family and social historyH/o goitre in the family or in the
community
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Physical examination General examinationLocal examinationSystemic examination
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General examinationLook for four cardinal features of
toxicity namely:-ExophthalmosisTachycardiaTremorMoist skin
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Local examinationInspectionPalpationPercussionAuscultation
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Systemic examinationCentro nervous system Cardiovascular SystemRespiratory system
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WORK UP
Laboratory studiesImaging studies Endoscopic studiesHistopathology
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Laboratory studiesSerum TSH(0.3-5IU/ml)Serum T3(1.5-3.5nmol/l)Serum T4(55 – 150nmol/l)Disease T3 T4 TSH
Thyrotoxicosis Increased Increased Supressed
T3 toxicosis 2X Normal Suppressed
Hypothyroidism Low/normal Low Increased
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Labs cont…
Serum thyroglobulinSerum cholesterolThyroid autoantibody levelsThyroid scintigraphy
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Imaging studiesPlain x-ray of the neckThyroid ultrasoundThyroid radioisotope scanCT scan/MRIBarium swallow
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Plain x-ray of the neckPlain radiography of the neck may
reveal the following:-Tracheal deviation or
compressionCalcification within the goitre
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Thyroid ultrasound Help to determine the
physical characteristics of the goitre and used to:- distinguish solid from
cystic nodules assess whether more
than one nodule exists to assess the exact size
and shape of the thyroid gland
Aid in ultrasound guided FNAC
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Thyroid radioisotope scan Used to determine the functional activiity by
distinguishing a nodule as hot, warm, or cold, based on the relative amount of uptake of radioactive isotope Hot nodules take up excessive amounts of
isotope and indicate autonomously functioning nodules
Cold nodules does not radioactive isotope and therefore indicate hypofunctional or nonfunctional thyroid tissue
Warm nodules appear gray and suggest normal thyroid function
The radioactive isotopes that are most commonly include 123-Iodine, 99m-Technetium and 131-Iodine
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CT scan/MRIGive excellent anatomical detail of
thyroid swelling but have no role in the first line of investigation
Help to assess recurrence and intrathoracic or retrosternal goitres
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Barium swallowTo assess compression of the
esophagus
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Endoscopic studiesIndirect laryngoscopy
To assess the mobility of the vocal cord
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HistopathologyFine needle aspiration cytology (FNAC)Open biopsy
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TREATMENT
Medical treatmentRadioiodine Surgery
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Medical treatmentLugol’s iodine
thyroid hormone synthesis vascularity
Antithyroid drugs eg CarbimazoleUsed to restore the patient to a euthyroid
state -adrenergic blockers E.g. propranolol
tachycardia & palpitation Used to restore the patient to a euthyroid It also vascularity
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RadioiodineThyroiodine destroys thyroid cells
and as in thyroidectomy reduces the mass of functioning
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SurgeryIndicationsPreoperative careIntraoperative care Postoperative care
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IndicationsCosmetic purposeSuspected malignancyToxic goitrePressure symptoms
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Preoperative careCorrect anemia, mobilize blood donor Treatment of intercurent disease or
infectionsThe thyroid functional status should be
determinedThe patient should be made euthyroid
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Preoperative care……Admit the patient a day before
operationAnesthetic visitAn informed written consent for
operation and anaesthesia
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Intraoperative careTypes of surgery (Thyroidectomy)
Subtotal thyroidectomyNear-total thyroidectomyTotal thyroidectomyThyroid nodulectomy
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Postoperative careIv fluidAnalgesicsAntibiotics Monitor vital signs
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COMPLICATIONS
Complications related to enlarged glandComplications related to thyroidectomy
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Complications related to enlarged gland
Tracheal obstruction airway obstruction
Secondary thyrotoxicosisMalignant transformation
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Complications related to thyroidectomy
Haemorrhage Respiratory obstruction Recurrent laryngeal nerve palsy Thyroid storm Thyroid insufficiency Parathyroid insufficiency Wound infection Hypertrophic scar Keloids
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PREVENTION
PrimarySecondaryTertiary