Goitre
Examination
Look and proceed, Look at the eyes/face (Grave’s ophthalmopathy)
Examine hands (thyroid signs)
Examine lower limbs (pretibial myxoedema)
Examine her neck (start from neck)
Assess her thyroid status (start from peripheries)
 General inspection – thin, fidgety and may have choreoathetoid movements
 ULs
o Both ULs up with dorsum facing upwards
 Tremors
 Acropachy (thyroid clubbing)
 Onycholysis (Plummer’s nails – especially ring finger)
 Skin for vitiligo
o Both ULs with palm facing upwards
 Sweaty palms
 Palmar erythema
o Proximal weakness
o Pemberton’s sign
o Measure pulse for ST or AF
o Reflexes
 Eyes
o Look
 Chemosis, keratitis, prominent caruncle and tarsorrhaphy
 Lid erythema and periorbital edema
 Exomphthalmos and lid retraction (Dalrymple’s sign)
o Move
 Lid lag (von Graefe’s sign)
 Ophthalmoplegia
 Order of muscles affected “I’M So Lazy”
o Inferior, medial, superior and lateral recti
 Neck
o Goitre – swallow water
o Look for scar (think of hypothyroid and hypoparathyroid) and distended
neck veins
o Walk to the patient’s back
 Observe for proptosis
 Palpate the goitre (soft, smooth vs nodular, large, tender)
 Palpate for Cx LNs, carotid pulsations
o Listen for bruit
o Palpate for tracheal deviation and SCM weakness on MNGs
o Percussion of sternum
 LL
o Pretibial myxedema
 Complete examination
o Reflexes for hyperreflexia
o Cardiovascular examination
 Wide pulse pressure (if clinically hyperthyroid) and systolic
hypertension
 ESM,CCF
 Gynaecomastia
o If there is a scar, request to perform Trousseau’s sign and Chvostek’s sign
for hypoparathyroidism, assessment for hoarseness of voice
o Abdominal examination may reveal hepatosplenomegaly in Grave’s
disease
Presentation
Grave’s disease
Sir, this patient has got Grave’s disease and is clinically hyperthyroid complicated
by Grave’s ophthalmopathy.
There is presence of a diffusely enlarged, smooth and firm goitre which is
associated with a bruit and is non-tender. There are no palpable LNs and tracheal is
central with no dullness to percussion of the sternum. Pemberton’s sign is negative.
There is evidence of hyperthyroidism. Patient is thin looking and is anxious and
fidgety with presence of fine tremors of the outstretched hands, sweaty palms, with
palmar erythema and a resting sinus tachycardia. I did not notice any thyroid acropachy
or onycholysis. There is also no evidence of proximal upper limb weakness.
Examination of the eyes reveals presence of lid retraction with a staring
appearance. There is no chemosis, keratitis or evidence of tarsorraphy. There is evidence
of exomphthalmos and proptosis. There is no ophthalmoplegia.
There is no evidence of pretibial myxedema.
Multinodular Goitre
Sir, this patient has MNG and is hyperthyroid complicated by atrial fibrillation.
There is presence of an enlarged goitre with multiple nodules bilaterally with a
dominant nodule in the right lobe of the thyroid gland. This is non tender. There is no
associated Cx LN and the carotid artery is palpable.
There are no signs of compression such as stridor, negative Pemberton’s sign with
no dullness to percussion of the sternum.
There are signs of hyperthyroidism.
The patient is in atrial fibrillation; did not notice any easy brusibility or obvious
hemiplegia
Questions
What is Grave’s disease?
 Autoimmune disease
 TSI binds to and stimulates the TSH receptor on the thyroid cell membrane
 Resulting in excessive synthesis and secretion of thyroid hormone
 2% in women and 0,2% in men; 2nd to 4th decades
What are the clinical signs specific to Grave’s disease?
 Grave’s ophthalmopathy
 Pretibial myxedema
 Thyroid acropachy
 Diffuse goitre
 Lymphoid hyperplasia
What is Grave’s Ophthalmopathy?
 Characterised by
 edema and inflammation of the extraocular muscles
 increase in orbital connective tissue and fat
 edema is due to hydrophilic action of the glycosaminoglycans secreted by
fibroblast
 inflammation is due to infiltration by lymphocytes and macrophages
 Worst in
 Smokers, elderly males
 Post radio-iodine treatment
 Severe hyperthyroidism
 Can occur pre, during or post diagnosis of hyperthyroidism
How do you assess activity of the eye disease?
 Retrobulbar pain
 Pain on eye movement
 Eyelid erythema
 Conjunctival injection
 Chemosis
 Swelling of the caruncle
 Eyelid edema
Points system together with degree of proptosis (Hertel’s ophthalmometer), reduced VA
and eye movements
What is pretibial myxedema?
 Specific feature of Grave’s disease
 Types
o Lymphedema type
 Symmetrical, well defined, waxy and shiny peau d’orange
appearance
 Red but not inflamed, swollen but not edematous
o Nodular type
o Plague type
 Occurs on the shins, anterior lateral aspects
 Can also occur as localised dermopathy at sites of trauma
 Characterise by edema, accumulation of glycosaminoglycans and lymphocytic
infiltrates
 Usually after treatment of hyperthyroidism, especially after radioactive iodine
What are the signs of hyperthyroidism?
 Resting tachycardia (important)
 Sweaty palms
 Tremors
 Hyperreflexia
 Thyroid bruit
What are the causes of hyperthyroidism?
 Primary
 Grave’s disease
 Toxic MNG (Plummer’s disease)
 Toxic adenoma
 De Quervain’s thyroiditis
 Post partum thyroiditis (Characteristics: Reduced radionuclide uptake, low
T3/T4 ratio and raised Thyroglobulin level)
 Secondary
 Pituitary
 Struma ovarii, hydatidiform mole or choriocarcinoma (ectopic TSH)
 Exogenous
 Overtreatment (eg in thyroid cancer)
 Factitious
 Drug induced – Lithium, amiodarone (type 1 i.e. iodine induced and type 2 i.e.
inflammatory thyroiditis)
What are the differential diagnoses of swellings in the neck?
 Midline
o Thyroid gland which rises on swallowing
o Thryroglossal cysts which also rises on swallowing but also moves on
sticking out the tongue
o Submental LNs
 Lateral
o LNs
o Salivary Glands
o Skin – sebaceous cysts or lipoma
o Cystic hygroma
o Pharyngeal pouch
How would you grade the goitre?
WHO grading:
 Grade 0 : not palpable or visible
 Grade 1A: palpable goitre
 Grade 1B : palpable and visible only on neck extension
 Grade 2: Visible goitre at primary position
 Grade 3: Obvious goitre from a distance
What is Pemberton’s sign?
 Elicited by asking the patient to lift his arms above her head
 Development of plethora, cyanosis, inspiratory stridor and respiratory distress and
distension of neck veins
 Test for thoracic inlet obstruction due to a retrosternal mass
How do you differentiate between thyroid acropachy and HPOA?
 Radiographically
o Thyroid acropachy new bone formation has a soap bubbles appearance on
the bone surface with coarse spicules
o HPOA new bone formation in a linear distribution
What are the associated clinical conditions with Grave’s disease?
 Diabetes mellitus
 Vitiligo
 Pernicious anaemia
 Addison’s disease
 Myasthenia gravis
 Alopecia areata
How would you investigate this patient with Grave’s disease?
 Confirm the diagnosis
o Thyroid stimulating hormone levels (aka thyrotropin levels)
o Free thyroxine levels; KIV serum free tri-iodothyronine
o Autoantibodies such as TSH receptor Ab(TRAb), thyroid peroxidase
antibodies and thyroglobulin antibodies
o Occasionally, to differentiate between Graves and autoimmune thyroiditis,
radionuclide scan which shows diffuse uptake in Graves and no/low
uptake in autoimmune thyroiditis
 Ophthalmopathy
o CT or MRI orbits to rule out retrobulbar tumor or AVM especially in
unilateral exomphthalmos
How would you investigate this patient with MNG?
 Activity assessment – fT4 and TSH
 Imaging – CT neck to look for obstruction
 Radionuclide in a predominantly “hot nodule”
What is T3 thyrotoxicosis?
 Hyperthyroid symptoms and sign
 normal fT4 (thyroxine) level
 elevated T3 (triiodothyronine).
What is “sick euthyroid”?
 Occurs in patient’s with severe illness or physical trauma
 Alterations of peripheral transport and metabolism of thyroid hormones
 Low fT4 and T3 and inappropriately low TSH
How would you manage this patient?
(1) Grave’s disease:
 Medical therapy
o Symptomatic treatment with propranolol
o Carbimazole, methimazole and propylthiouracil
o All inhibit thyroid peroxidase and hence thyroid hormone synthesis
o PTU also inhibit conversion of fT4 to fT3, useful in crisis
o CMZ and MTZ useful as fewer tablets and once daily dosing
o Treated for 12-18 months and 30-40% will remain euthyroid
o If it recurs, likelihood of remission on medications is low
o Minor adverse effects (5%)
 fever, rash, urticaria and arthralgia
o Major adverse effects (0.5%) (CMZ and MTZ are dose related and PTU is
not)
 agranulocytosis
 Advised to stop the drug if develop fever, sorethroat or
mouth ulcers
 Severe hepatotoxicity
 Vasculitis
 Lupus-like syndrome
 Radio-iodine (131-I at dose 5 to 15 mCi)
o 90% will become euthyroid within 2 months.
o Contraindicated in pregnant and breast-feeding mothers, children and
adolescent
o Side effects
 Almost all will become hypothyroid
 Neck pain
 Worsened thyrotoxicosis for several days post treatment
 Prevented with CMZ/MTZ pre-treatment for 1-2 months
and stopped 3-5 days before treatment; try not to use PTU
as this decrease efficacy of I -131 treatment
 Observed if mild or treat with beta blockers
 Should not give antithyroid medications unless severe or
expected to be severe due to poor control at the time of I131 administration
 Worsening of ophthalmopathy
 especially in smokers and severe hyperthyroidism
 Administration of glucocorticoids can prevent worsening
 Thyroidectomy
o Indications includes “Cs”: Cancer (dominant nodule), cosmesis,
compression
o
o
o
o
Effective in 90%
Not a/w worsening of Grave’s ophthalmopathy
Side effects : recurrent laryngeal nerve, hypoparathyroidism (1-2%)
Medications given prior to surgery and Lugol’s iodine given 7-10 days
prior to surgery
(2) MNG
 Render euthyroid with thionamide
 As spontaneous remission does not occur, ablative therapy required
 No obstruction – Radio-iodine
 Obstruction – Surgical
(3) Toxic Adenoma
 Render euthyroid with thionamide
 Radio-iodine – hypothyroidism side effect is less compared to Grave’s disease
as the toxic adenoma suppresses the other thyroidal tissue
 Surgical – Lobectomy
(4) Subacute thyroiditis
 Should not Rx with thionamides
 Rx with propranolol, aspirin, NSAIDs and glucocorticoids
How would you counsel a young woman with thyrotoxicosis who wishes to be pregnant?
 Ideally, pregnancy should be avoided until hyperthyroidism is adequately treated
because the rate of fetal loss is high
 If it occurs or recurs during pregnancy, then
o Treat with PTU
 Lowest dose possible such that fT4 is at the upper range of normal
 Combination therapy contraindicated because PTU passes the
placenta but thyroxine doesn’t, resulting in fetal hypothyroidism
 PTU better because of better binding to proteins and therefore less
transplacental transfer theoretically; also CMZ a/w rare side effects
of aplasia cutis congenita, esophageal and choanal atresias
o Can also be safely treated with surgery in the second trimester with almost
no risk of death in experienced hands
o In the 3rd trimester, TSI levels declines and remission of hyperthyroidism
occurs; stopping medications is possible then
o 1-5% of fetuses may be hyperthyroid resulting in IUGR and tachycardia
o up to 750mg/d PTU or 20mg CMZ can be safely used in lactating mothers
How do you treat Graves ophthalmopathy?
 General measures
o Maintenance of euthyroidism
o Stop smoking
o Sleep with head raised
o Use of artificial tears
o Diuretics
o Tinted glasses
 Specific measures (for severe disease)
o Glucocorticoids – 40-80mg OM then taper over 3 months
o Radiotherapy
o Surgical decompression
 Stable disease
o Surgery for lid retraction, exomphthalmos or diplopia