Thyroid Examination

Question 1

Present and differentials

Answer 1

On general inspection, the patient appears comfortable and euthyroid. There are no features of thyroid eye disease, tremor, or pretibial myxedema.”

“On examination of the neck, there is a midline swelling in the lower neck which moves with deglutition but not with tongue protrusion, consistent with a thyroid swelling.”

“The swelling is located just below the thyroid cartilage, extends across the midline, has smooth surface and regular borders. It is firm in consistency, non-tender, and moves freely on swallowing.”

“There is no retrosternal extension on percussion, no bruit on auscultation, and no palpable cervical lymphadenopathy.”

• Simple multinodular goiter
• Thyroid neoplasm
• Toxic nodular goiter
Thyroiditis

Question 2

How would you manage this patient?

If the patient come back with pain on swallowing, difficulty in breathing few months later, does it change your management?

Her FNA comes back showing a follicular cell tumor. The report says “unable to differentiate carcinoma from adenoma”. Why is this?

What is the next step in the patient’s management following this histological result?

5-year survival rate of follicular carcinoma?

Answer 2

I would perform a triple assessment, taking a history as well as my examination, arrange an ultrasound and a fine needle aspiration or a biopsy. Also, I have to check thyroid functions

Yes, these are obstructive symptoms requiring thyroidectomy

Follicular carcinomas are differentiated from follicular adenomas as they invade the tumor capsule or surrounding vessels. Therefore, histology rather than simply cytology is needed.

This lady needs to be discussed in the MDT and worked up for a total or thyroidectomy

More than 90%

Question 3

indications for thyroidectomy:

what invex to do for retrostetnal extension?

what is the role of USS?

Answer 3

-failed medical ttt in thyrotoxicosis
-Neoplasm
-obstructive Sx
-cosmotics

-CxR(thoracic inlet/lateral)
-CT chest
-Radio iodine 131

-differentiate b/w cystic and solid
-assess number and size of nodule
-if there ,calcification, hemorrhage
-Us guided FNA

Question 4

Classification of thyroid disease

Answer 4

1. Simple (Euthyroid) Goitre
   • Diffuse hyperplastic goitre (physiological – puberty, pregnancy)
   • Multinodular goitre

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2. Toxic (Hyperthyroid) Conditions
   • Diffuse toxic goitre → Graves’ disease
   • Toxic multinodular goitre
   • *Toxic adenoma (Plummer’s disease)

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3. Neoplastic
   • Benign: follicular adenoma
   • Malignant: papillary, follicular, medullary, anaplastic carcinoma; lymphoma

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4. Inflammatory
   • Autoimmune: Hashimoto’s (chronic lymphocytic thyroiditis)
   • Granulomatous: De Quervain’s (subacute)
   • Fibrosing: Riedel’s thyroiditis

Question 5

Principles of Treatment of Thyrotoxicosis

Answer 5

1. Antithyroid Drugs

(Carbimazole, Propylthiouracil)
• Used to restore and maintain euthyroid state until spontaneous remission occurs (↓ TSH-R antibodies).
• Ineffective for toxic nodules (autonomous tissue).
• Duration: 6 months – 2 years.
• Advantages: Non-invasive, no radiation or surgery.
• Disadvantages: Long treatment, ~50 % relapse rate.

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2. Surgery

(Subtotal or total thyroidectomy)
• Mechanism: Removes/reduces overactive thyroid tissue.
• Indicated for:
• Diffuse toxic goitre (after medical control)
• Toxic multinodular goitre
• Toxic adenoma
• Advantages: Rapid cure, removes goitre, high success rate.
• Disadvantages:
• Risk of hypoparathyroidism, recurrent laryngeal nerve injury.
• Hypothyroidism (especially after total).
• Scar (cosmetic concern).
• 5 % recurrence with subtotal resection.

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3. Radioiodine Therapy (I¹³¹)
   • Mechanism: Destroys overactive thyroid cells → reduces function below critical mass.
   • Advantages: Non-surgical, single-dose cure in many.
   • Disadvantages:
   • Needs isotope facility, radiation precautions.
   • Avoid pregnancy and close contact post-therapy.
   • May worsen eye signs (Graves’).