MULTINODULAR GOITRE Dr PERVEZ MS GENERAL SURGERY Embryology
MULTINODULAR GOITRE -Dr . PERVEZ -MS (GENERAL SURGERY)
Embryology & Surgical Anatomy n n n Develops as a midline diverticulum in the floor of the pharynx (cells are endodermal in origin) Descends to the neck as a bilobed solid organ which later develops into mature thyroid gland Enclosed in pretracheal fascia and lies next to the thyroid cartilage in a position anterior and lateral to junction of larynx & trachea Comprises of 2 lateral lobes joined by an isthmus located at or just below cricoid cartilage 20 -25 gm, lobule supplied by arteriole containing 25 -40 follicles which in turn contain colloid
Blood supply & Drainage Superior thyroid artery (ext. Carotid) n Inferior thyroid artery (thyrocervical trunk) n Drained by superior, middle & inferior thyroid veins( > IJV & brachiocephalic) n L. N : pretracheal, paratracheal (deep cervical & mediastinal L. N) n
Nerve supply & Attachments n n Ext. laryngeal N(runs far from superior thyroid artery – ligate nearby) Rec. laryngeal N(runs in between inferior thyroid artery – ligate far away) Thyroid gland has 2 important attachments Attached to hyoid bone by levator glandulae thyroideae and attached to cricoid cartilage by suspensory ligament of Berry.
Definitions & classification Goitre – generalised enlargement of thyroid n Types : 1. Diffuse(puberty, colloid, iodine deficiency) 2. Hyperplastic 3. nodular(MNG either in euthyroid or toxic state) n
MNG is end stage of hyperplastic goitre n Stages of MNG formation 1. Persistent TSH stimulation 2. Diffuse hyperplasia & hypertrophy 3. Fluctuating TSH 4. Nodule formation(center of nodule is inactive but internodular tissue is active) n
Aetiology Iodine deficiency n Dyshormonogenesis( enzyme defect) n goitrogens n
Clinical Features n n Female predominance(20 -40 years) Swelling in midline of neck, long standing, multiple visible nodules(bosselated surface, firm consistency, hard areas signify calcification and soft areas denote necrosis) Initial complaint is mainly for cosmesis Recent increase in size with pain indicates hemorrhage in a nodule
Later features (due to mass effect) 1. Dyspnoea 2. Dysphagia 3. Dysphonia Usually MNG is euthyroid. it can however turn toxic due to secondary thyrotoxicosis with CVS symptoms being predominant. n
Complications Calcification n Hemorrhage in a nodule n Stridor with respiratory obstruction n Secondary thyrotoxicosis n Follicular CA of thyroid n
Investigations n n n n TFT Indirect laryngoscopy Isotope scan X-Ray (neck) – AP & Lateral USG (subclinical nodule, lymph node & cyst detection, adjunct to cytology) FNAC -> True-cut Biopsy 2 nd line of investigations-CT, MRI, PET scan
Treatment Surgery is treatment of choice n Procedures : 1. Total thyroidectomy (2 * total lobectomy + isthmusectomy) n 2. Near-total thyroidectomy (total lobectomy + isthmusectomy + subtotal lobectomy) 3. Sub-total thyroidectomy (2 * subtotal lobectomy + isthmusectomy) Followed by 0. 1 to 0. 2 mg of T. Levothyroxine for 1 -2 years.
Total vs Sub-total thyroidectomy Entire gland is diseased – total thyroidectomy(no risk of recurrence but impaired thyroid function) n Better chance of thyroid function but increased chances of recurrence – near-total or sub-total thyroidectomy n
THANK YOU n 1. 2. References : Bailey & Love (25 th edn) Sabiston text book of surgery (18 th edn)
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