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Types of Goitres – Reidel’s, De Quervain’s, Hashimoto’s 

Goitres

  • Abnormal enlargement of the thyroid gland

Classification

  • Neoplastic
    • Benign
    • Malignant
  • Thyroid function
    • Hypothyroid – Hashmimoto’s
    • Euthyroid
    • Toxic – Graves’
  • Mass/size
    • Solitary – adenoma, cyst
    • Multinodular
    • Diffuse – Graves, Hashimoto’s

Clinical features

  • Patients are commonly asymptomatic
  • Altered hormone metabolism – features of hypo/hyperthyroidism
  • Obstructive symptoms
    • Compression of trachea – dyspnea, stridor, wheezing
    • Compression of oesophagus – dysphagia

Investigations

  • Palpation of thyroid gland – classify according to  WHO grading
  • Laboratory tests
    • TSH levels, antibody screen
    • Calcitonin if medullary carcinoma suspected
  • Imaging – US, CT, MRI
    • to see size, nodularity, consistency
  • Interventions – FNAC

Treatment

  • Non toxic – no treatment if asymptomatic
  • Large goitre – surgery and/or radioiodine therapy
  • Iodine deficiency – iodine supplement

Riedel’s Thyroiditis

  • Rare disease involving fibrosis of thyroid gland – this fibrous tissue infiltrates the capsule, surrounding muscles, paratracheal tissues and carotid sheath
  • Associated with retroperitoneal and mediastinal fibrosis and sclerosing cholangitis
  • Also affects parathyroid and recurrent laryngeal nerve

Clinical features

  • Swelling with irregular surface
  • Stony hard consistency
  • Stridor
  • Positive Berry sign – impalpable carotid pulse

Investigations

  • T3/T4 decrease due to hypothyroidism
  • Radioscan does NOT show any uptake
  • FNAC – to rule out carcinoma

Treatment

  • Isthmectomy to relieve compression on airway
  • Levothyroxine to treat hypothyroidism
  • High dose steroid
  • Thyroidectomy not necessary

De Quervain’s Thyroiditis

  • Subacute granulomatous thyroiditis
  • Due to viruses – mumps, coxsackie
    • Causes an inflammatory response, with infiltration of lymphocytes, neutrophils and multi-nucleated giant cells
  • More common in young females

Clinical features

  • Painful diffuse swelling in thyroid which is tender
  • Fever
  • Initially transient hyperthyroidism with elevated T3/T4, but poor radioiodine uptake
  • Self-limiting disease

Stages – within 6 months

  • 1. Thyroid gland becomes acutely congested, swollen, mildly tender (thyrotoxicosis)
  • 2. Gland remains enlarged, but not tender (euthyroid)
  • 3. Patient returns to hypothyroid stage (hypothyroid)
  • 4. Remission or recovery (euthyroid)

Investigations

  • High ESR
  • Anemia
  • Low TSH, high T3/T4
  • FNAC

Treatment

  • Prednisolone 30mg for 7 days
  • Salicylates and B-blockers
    • Propanolol inhibits conversion of T3 to T4

Hashimoto’s Thyroiditis

  • Painless diffuse goitre
  • Autoimmune disease – antibodies to TPO + TBG receptors
  • More common in females 30-50 years old
  • Genetic predisposition
  • Initially there is hyperplasia, then fibrosis and eventually infiltration with plasma and lymphyocytic cells

Clinical features

  • Painless diffuse enlargement of both lobes – firm, rubbery, tender, smooth
  • Initially toxic, later presents with features of hypothyroidism
    • Hyperplasia –hashitoxicosis
    • Fibrosis – hypothyroid

Investigations

  • High TSH, decreased T4
  • Antibodies – anti-TPO and anti-TBG

Treatment

  • Levothyroxine
  • Steroid therapy
  • Subtotal thyroidectomy
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