Session 10: Thyroid Disorders

Question 1

Different ways to examine thyroid and investigate.

(Not blood tests)

Answer 1

Palpate it. If the size of the thyroid is normal you will not be able to feel it.

Thyroid ultrasound

Radio-isotope scan (Scintography) with technetium-99m

Question 2

What is lingual thyroid?

Answer 2

Since the embryological origin of the thyroid is in the foramen cecum in the tongue (middle of the tongue).

If embryology fails you might end up with a lingual thyroid which is a sort of ectopic thyroid gland.

Question 3

Treatment of hypothyroidism.

Answer 3

Usually levothyroxine (T4) for life

The starting does depends on levels of T3, T4 and the symptoms severity.

Question 4

Side-effects of levothyroxine treatment.

Answer 4

You might induce hyperthyroidism.

Also in elderly patients and patients with heart disease the levothyroxine can be harmful in large doses due to its sympathomimetic effects. This can cause tachycardia and increased inotropy.

Question 5

What is myxoedema coma?

Answer 5

Severy hypothyroidism which usually occur in the elderly if it occurs at all as it is really rare.

This can lead to hypothermia and fluid overload in heart causing pericardial effusion.

The mortality of myxoedema coma is 50% so requires high dependency treatment.

Question 6

Symptoms of hyperthyroidism.

Answer 6

Weight loss

Irritability

Restlessness

Insomnia

Malaise

Icthing

Sweating

Palpitations

Tremor

Muscle ache

Diarrhoea

Question 7

Signs of hyperthyroidism

Answer 7

Tremor

Hyperkinesis

Tachycardia

Atrial fibrillation

Warm peripheries

Hypertension

Proximal myopathy

Lid lag

Lid retraction

Question 8

Explain lid lag and lid retraction

Answer 8

Due to the sympathomimetic effects of T3 and T4 lid lag and lid retraction occurs.

This is because there is a sympathetic branch of levator palpebrae superioris in the eye which under sympathetic influence will pull the eye lid upwards.

Question 9

Specific signs of Grave’s disease.

Answer 9

Grave’s opthalmopathy

Pretibial myxoedema also called Grave’s dermopathy

Question 10

Briefly explain thyroiditis.

Give causes.

Answer 10

Inflammation of thyroid causing release of thyroxine into circulation.

This can be caused by viral infection

After childbirth

Medication like amiodarone

Question 11

How does acute and chronic thyroiditis differ?

Answer 11

Acute can manifest signs of hyperthyroidism even though it is not an overactive thyroid. Better word is thyrotoxicosis.

Chronic will manifest signs of hypothyroidism. And it is also hypothyroidism.

Question 12

Treatment of hyperthyroidism.

Answer 12

Medication:

Carbimazole or propylthiouracil to treat the thyroid issue.

Betablockers to treat the symptoms (tachycardia and heart palpitations)

Surgery:

Removal of thyroid gland

Misc:

Radioactive iodine

Question 13

Side effects of Carbimazole.

Answer 13

Rare side effect but it can cause agranulocytosis -> neutropenia.

So risk of infection and patient might get rashes and fever.

Question 14

Complications of surgery.

Answer 14

Cosmetics although usually minor

Small risk of laryngeal nerve palsy and hypocalcaemia if there is damage to parathyroid glands.

Question 15

What is thyroid storm/thyroid crisis?

Answer 15

A rare condition with 10% mortality where the patient becomes hyperpyrexic, tachycardic, cardiac failure and liver dysfunction.

This needs urgent treatment of beta blockers and carbimazole

Question 16

What is neonatal Grave’s disease?

Answer 16

If a mother has Grave’s disease she can give of antibodies (the TSI) to the child in utero. This can cause the child to have hyperthyroidism when they are born. However it goes into remission as the mother’s antibodies disappear.

They are treated as an infant though.

Question 17

Types of goitre.

Answer 17

Diffuse goitre:

Simple goitre
Auto-immune thyroid disease like Hashimoto’s and Grave’s
Thyroiditis

Nodular goitre:

Multinodular goitre which is the most common in the UK
Solitary nodule (*_Red flag for cancer_*)

Fibrotic goitre:

Riedel’s thyroiditis which is rare

Iodine deficiency:

Common worldwide but rare in the UK

Question 18

Red flag symptoms of thyroid cancer

Answer 18

Very young or old patient

Rapid enlargement of lump in neck

Hoarse voice and dysphagia

Family history of thyroid cancer

Hard irregular thyroid mass

Fixed to surrounding structures meaning it won’t move on swallowing

Cervical lymph nodes

Question 19

Investigation of suspected thyroid cancer

Answer 19

Thyroid ultra-sound

CT scan thorax and mediastinum

Fine needle aspiration

Thyroid scintology