Surgical Treatment of Goiter and

Hyperthyroidism

Haben11111
10/29/2010

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 Assessment of thyroid nodules
History
 Rapid painless growth suggests malignancy
 Sudden painful growth suggests haemorrhage into
degenerating colloid nodule
 Family history - 20% medullary carcinomas are familial
associated with MEN 2 Syndrome
 History of radiation exposure
Used in treatment of tonsillar hypertrophy, acne, thymic
enlargement
 Increased incidence of thyroid malignancy - usually papillary
 Most occult (<1.5 cm diameter) and multifocal

Usually good prognosis

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 Examination
 80% solitary thyroid nodules occur in women
 The risk of malignancy is increased three fold in men
 Malignancy more common in children and >60 years
 Assess whether true solitary or dominant nodule within
goitre
 True solitary nodule have 10% risk of malignancy
 Dominant nodule in multinodular goitre has 2-5% risk of
malignancy

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 Evidence of fixation or nodal involvement
suggests malignancy
 Most patients will be clinically and biochemically
euthyroid
 Obstructive signs - stridor, tracheal deviation,
neck vein engorgement
 Hoarseness and vocal cord paralysis suggests
recurrent laryngeal nerve palsy
 50% solitary thyroid nodules in children are
cancers

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 Investigation
Biochemical assessment
 Thyroid functional status - Free T4 and TSH
 Thyroid Antibodies - anti-thyroglobulin and anti-
microsomal
 If positive family history and possibility of
medullary carcinoma - calcitonin
 If suspicion of MEN2 Syndrome will need 24 hr
urinary catecholamine estimations to exclude
phaeochromocytoma prior to surgery

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 Standard radiography
 Chest radiography and thoracic inlet views
if obstructive symptoms
Isotope scanning
 131I , 123I or 99Tch scanning provides
functional assessment of thyroid
 Nodules classified as cold, warm or hot

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 Unable to differentiate benign and
malignant nodules
 Most solitary thyroid nodules are cold
 Most cancers arise in cold nodules
 Risk of cancer in a cold nodule is 10-15%
 Risk of tumour in a hot nodule is negligible

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 Ultrasound
 Will define solitary and dominant nodules
 Will distinguish solid and cystic lesions
 Most sonographically solid lesions are
benign
 Cancer can occur in the wall of a cystic
lesion
 No reliable criteria to distinguish benign
and malignant lesions
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 Fine needle aspiration cytology
 Should be first line investigation of the solitary
thyroid nodule
 With experienced cytologist diagnostic accuracy
can be >95%
 Possible cytopathological diagnoses are:
 Benign

 Malignant

 Indeterminate

 Inadequate

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 Can distinguish benign and malignant
tumours except follicular neoplasms
 Diagnosis of follicular carcinoma depends
on the visualisation capsular invasion
 If follicular neoplasm on FNA lesion will
require surgical excision
 False negative rate less than 5% in most
institutions

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 Indications for surgery after FNA cytology
 All proven malignant nodules
 All cytologically diagnosed follicular neoplasms
 All lesions exhibiting an atypical but non-
diagnostic cellular pattern on cytology
 Cystic nodules which recur after aspiration
 When on clinical grounds the index of suspicion
of malignancy is high even if the cytology report
suggests it is benign

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 Hyperthyroidism
Causes
Graves’ disease
Toxic nodular goiter
Toxic thyroid adenoma
CNS disorders

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 Grave’s Disease
Diffuse toxic goiter
Women
20-40 years
Immunoglobulins
Genetic susceptibility
Hyperplasia of the follicular cells

Diagnosis------

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 Treatment
.
1 Radioiodine treatment
131I

Euthyroid for 3-4 weeks

Advantage-----90%
Risks---hypothyroidism(10-15%)
Pregnancy
2.Antithyroid Medications
PTU, Methimazole,Carbimazole
inhibition of organification of intrathyroid
iodine
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 Toxic nodular goiter

Plummer’s disease
Endemic goiter
Autonomous nodule
Mild course
Older patient
Treatment :-Surgical

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 Multinodular Goiter
Endemic/Sporadic
Endemic=IDD---10%
Diffuse enlargement
Heterogenous
Asymmetrical nodularity
Iodine deficiency/ Goiterogens
(cyanoglucosides,thioglycosides)
Euthyroid, Hyperthyroidism
Carcinoma---5-10%

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Classification of goiter (WHO)

• Grade 0: No palpable or visible goiter

• Grade 1: Mass consistent with enlarged
thyroid that is palpable but not visible when the
neck is in the neutral position; it also moves
upwards in the neck as the subject swallows.
• Grade 2: Swelling visible in a neutral position
of neck and is consistent with an enlarged
thyroid when the neck is palpated

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 Prevention and Medical treatment
Medical Treatment
Iodine/ Thyroxine
Prevention
Iodisation of salt

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 Surgery is indicated for:
1. Increase in size while on TSH
suppression
2. Pressure Symptoms
3. Toxic changes
4. Suspected or proven malignancy
5. Cosmetic reasons

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 Substernal Goiter
Secondary
Primary(1%)
Compressive symptoms
Cervical approach

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 Solitary Thyroid Nodule
Mostly benign
F:M=4:1
Suspect Malignancy
male
>50yrs
Children
Rapid Growth
local invasion
Clinical
Radiologic

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Indications for Surgery of thyroid nodule
 Proven or suspected cancer
 Obstructive symptoms
 Patient anxiety
 Hyperfunctioning nodules resulting in
hyperthyroidism
 Cosmesis

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 Thyroid Cancers
Well Differentiated
Papillary Carcinoma(70-75%)
multicenteric
<1.5cm---lobectomy with isthmusectomy
>1.5cm---Total thyroidectomy
postop. Radioiodine treatment
Follicullar carcinoma(10-15%)
<2cm---

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Medullary Carcinoma
Non Familial
Inherited/Familial—MEN I/II
Total thyroidectomy
poorer prognosis
Anaplastic carcinoma
very aggressive

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 Complications of thyroidectomy
 Haemorrhage
 Wound Complications
 Sepsis
 Hypertrophic scarring
 Respiratory Obstruction
 Laryngeal mucosal oedema
 Clot deep to strap muscles
 Bilateral incomplete recurrent laryngeal nerve palsies
 Tracheomalacia

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 Nerve Damage
 Recurrent laryngeal nerve palsy
 Incomplete - cord moves to midline
 Complete - cord in cadaveric position
 Preoperative cord inspection is essential
 3% population have asymptomatic recurrent laryngeal
nerve palsy
 Hypocalcaemia
 Pneumothorax
 Air Embolism

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 Thyroid Crisis
 Fulminating hyperthyroidism
 Hyperpyrexia
 Arrhythmia
 Cardiac Failure
 Recurrent hyperthyroidism
 Hypothyroidism

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