Makindo Medical Notes

Pemberton's sign refers to faintness with evidence of facial congestion and cyanosis due to external jugular venous obstruction when the arms are raised above the head, a manoeuvre that draws the thyroid into the thoracic inlet.

About

• Goitre refers to an enlarged thyroid
• WHO definition "a thyroid gland whose lateral lobes have a volume greater than the terminal phalanges of the thumbs of the person being examined"
• May be diffuse or composed of one or more nodules

Goitre Causes

• Idiopathic, Hashimoto's thyroiditis
• Graves disease, Puberty, Iodine deficiency
• Subacute thyroiditis
• Goitrogens (Lithium, Amiodarone, smoking)

Types

• Diffuse enlargement of the thyroid occurs in the absence of nodules and hyperthyroidism, it is referred to as a diffuse nontoxic goitre.
• Nodular/Multinodular goitre. An enlarging gland may also produce pressure symptoms on the trachea and the oesophagus

Grade Characteristics

• 0 No palpable or visible goitre.
• 1 A goitre that is palpable but not visible when the neck is in the normal position (i.e. the thyroid gland is not visibly enlarged). Nodules in a thyroid that is otherwise not enlarged fall into this category.
• 2 A swelling in the neck that is clearly visible when the neck is in a normal position and is consistent with an enlarged thyroid gland when the neck is palpated

Malignancy high risk

• High risk history includes head and neck irradiation,
• Thyroid cancer in a first degree relative
• Radiotherapy or radiation exposure as a child
• Uptake on F18 fluorodeoxyglucose positron emission tomography,
• multiple endocrine neoplasia type 2, elevated calcitonin

Clinical: Examine from the front and then behind

• Inspect from in front in vertical position
• Appearance. Position. Any respiratory compromise.
• Patients with goitre may be asymptomatic and cosmetic
• Compressive symptoms such as cough or dysphagia.
• Associated hypothyroidism or hyperthyroidism
• Look for the type of goitre and local lymph nodes
• Listen for hoarseness and Pemberton sign
• Ask the patient to drink and swallow as the thyroid should move with swallow

Investigations

• FBC, U&E, CRP, CXR may show goitre
• TFTs: TSH and T4. Elevated TSH drives thyroid enlargement in Hashimoto's
• Low TSH get radionuclide scan
• Thyroid ultrasound has become an extension of physical examination and should be performed in all patients with goitre. Ultrasound can determine what nodules should be biopsied. It is key to diagnosing cancer.
• Antibodies to thyroperoxidase (anti-TPO) and thyroglobulin (anti-TG) is recommended
• CT thoracic inlet may help. CT scans should be ordered as non-contrast due to the risk of contrast-induced hyperthyroidism or hypothyroidism in patients with nodular thyroid disease

Nodules to Biopsy

• High risk history and nodules = 5 mm
• All Nodules if cervical lymph nodes enlarged
• Micro calcification nodule >1 cm
• Solid nodule >1 cm
• Mixed cystic solid >1.5-2 cm
• Spongiform >2 cm
• Purely cystic FNA not indicated

Management

• Treatment options for goitre depend on the cause and the clinical picture
• Exclude a malignant process through USS and biopsy
• Treat cause may need simple observation, iodine supplementation
• Thyroxine suppression, thionamide medication (Carbimazole or propylthiouracil)
• Some may need radioactive iodine ablation and surgery.