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Thread: Thyroid Swelling- viva questions

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    Default SIMPLE NODULAR GOITRE- Viva voce

    Case 1. SIMPLE NODULAR GOITRE


    Q. What is your diagnosis ?
    A. Simple nodular goitre.


    Q. Why this is a goitre ?
    A. Because there is a swelling in the lower part of
    the front of the neck which is the anatomical site
    of the thyroid gland, having the shape of the
    thyroid gland (butterfly) and this swelling moves
    up and down with deglutition.


    Q Why does a goitre move up and down with
    deglutition ?

    A. Because the thyroid gland is enclosed within
    the pretracheal fascia which is attached to the
    thyroid cartilage and hyoid bones.


    Q. Mention other swellings that move up and
    down with deglutition.

    A. Subhyoid bursitis, prelaryngeal L.Ns.,
    thyroglossal cyst, ectopic thyroid gland,
    pretracheal L.N., cold abscess of the larynx,
    parathyroid gland tumours, laryngocoele and
    tracheocoele.


    Q. When doesn't the goitre move up and
    down with deglutition ?

    A. In 1) Huge goitre, 2) Malignant goitre and 3)
    Retrosternal goitre.

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    Q Why this is a simple goitre ?
    A. Because there are no manifestations suggestive
    of thyrotoxicosis, no manifestations suggestive of
    malignancy and no manifestations suggestive of
    inflammation.


    Q. What are the manifestations suspicious of
    malignancy in a goitre ?

    A.
    From history : Short duration or long
    duration with recent rapid enlargement in
    size, pain referred to the ear, hoarseness of
    voice, symptoms of distant metastases.
    From examination : Hardness, fixity to the
    trachea, fixity to sternomastoid, attachment
    to the skin overlying, absent carotid pulse
    (Berry's ), enlarged deep cervical lymph
    nodes, signs of distant metastases.



    Q. How would you elicit fixity to the trachea ?
    A. By fixing the trachea by one hand and trying to
    move the gland up and down with the other hand,
    normally there is a slight range of movement.


    Q. How do you elicit fixity to the
    sternomastoid ?

    A. By asking the patient to swallow while pinching
    the relaxed sternomastoid, normally I do not feel
    something pulling on the sternomastoid between
    my fingers.


    Q. Can the cervical L.Ns. develop secondaries
    from a thyroid carcinoma while the 1ry is not
    felt clinically ?

    A. Yes, in occult papillary carcinoma of the thyroid
    gland. This was thought in the past as some form
    of ectopic thyroid gland and was called "lateral
    aberrant thyroid".

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    Q. What are the manifestations suspicious of
    an inflammatory goitre ?

    A.
    In acute and subacute thyroiditis : Short
    duration, pain, may be fever (with or without
    chills), warmth and tenderness over the
    gland.
    In Hashimoto thyroiditis : Locally the gland is
    very similar to S.N.G. but the course of the
    disease is characteristic; early there is
    thyrotoxicosis which is followed by
    hypothyroidism.
    In Riedle's thyroiditis : The gland is
    irregularly enlarged, hard, fixed to skin,
    trachea, and sternomastoid i.e. very similar
    to anaplastic carcinoma of the thyroid gland.


    Q. What is the aetiology of simple goitre ?

    A. Simple goitre is due to stimulation of the
    thyroid gland by increased level of circulating
    T.S.H. secondary to low levels of circulating
    thyroid hormones secondary to either iodine
    deficiency or defective synthesis of thyroid
    hormones.

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    Q. What are the causes of iodine deficiency ?
    A.
    1) Decreased intake as in endemic areas,
    2) Increased demands as in periods of stress
    in the females (puberty, pregnancy,
    lactation),
    3) Decreased absorption from the G.I.T.


    Q. What are the causes of defective synthesis
    of thyroid hormones ?

    A. 1) Enzymatic deficiency, and 2) Goitrogens
    (Cabbage, P.A.S., antithyroid drugs and iodides in
    large amounts "iodide goitre")


    Q. What is Pendred's syndrome ?

    A. This is a cretinoid goitre associated with
    deafness.


    Q. What is the cause of this goitre ?
    A. Congenital deficiency of peroxidase enzyme.


    Q. What are the types of simple goitre ?
    A. 1. Simple diffuse goitre (Physiological goitre)
    2. Simple nodular goitre (S.N.G.).


    Q. Which of them is reversible ?
    A. Physiological goitre can be reversible if the
    cause of iodine defeciency is eliminated.

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    Q. What are the complications of simple
    nodular goitre ?

    A. 1) Pressure on surrounding structures
    (dyspnoea and dysphagia), 2) Disfigurement, 3)
    2ry toxic goitre (30%), 4) Haemorrhage in a cyst,
    and 5) Malignant transformation (1/2%),
    {Follicular Type}.


    Q. How does a patient with a haemorrhage in
    a cyst present ?

    A. Sudden onset of dyspnoea.


    Q. What is the cause of dyspnoea in such
    cases ?

    A. Sudden enlargement of the gland and more
    important is the reflex spasm of the pretracheal
    muscles.


    Q. How do you manage such a patient ?
    A. Emergency needle aspiration.


    Q. What investigations do you want to do for
    this patient with a goitre ?

    A. In addition to the routine laboratory
    investigations, we do thyroid function tests.

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    Q. What are the complications of subtotal
    thyroidectomy for S.N.G.?

    A. Complication of subtotal thyroidectomy for
    S.N.G. include :
    1. Tension haematoma (due to slipped
    ligature from the superior thyroid artery),
    2. Dyspnoea
    3. Injury to the related nerves : 1) recurrent
    laryngeal nerve, and 2) external laryngeal
    nerve
    4. Hypoparathyroidism (due to accidental
    removal of the parathyroid glands),
    4. Hypothyroidism (if the gland was removed
    near totally and no postoperative
    replacement by thyroxin was given),
    5. Recurrent goitre (if no postoperative
    thyroxin was given),


    Q. What is the danger of haematoma after
    thyroidectomy ?

    A. It can lead to suffocation as it is enclosed
    within the pretracheal muscles.


    Q. How do you treat it ?
    A. First, urgently, while the patient is in bed, the
    sutures are cut to relieve the tension and the
    patient is taken to the theatre to deal with the
    bleeder.


    Q. What are the causes of dyspnoea after
    thyroidectomy ?

    A. 1) Tension haematoma, 2) Laryngeal oedema
    due to rough manipulations during the operation,
    3) Bilateral recurrent laryngeal nerve injury, and 4)
    Tracheomalacia (very rare).


    Q. What are the effects of RLN injury ?
    A.
    &Unilateral RLN injury -------------> hoarseness of
    voice which is improved by time due to
    compensatory crossing of the contralateral cord to
    the other side.
    &Bilateral RLN injury -------------> Suffocation
    which should be treated at once by emergency
    tracheostomy.
    Q. What is the effect of external laryngeal
    nerve injury ?

    A. Loss of high pitched voice due to paralysis of
    cricothyroid muscle..

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    I enjoyed very much reading your writing on the thyroid topic and many thanks. I would suggest you enlarge on the recurrent laryngeal nerve injury as unilateral or bilateral complete or partial.

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