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TREATMENT IN GOITER
Agung Pranoto
Division of Endocrinology & Metabolism
Department of Internal Medicine, Airlangga Faculty of Medicine
Dr.Soetomo Hospital
PERSENTATION OVERVIEW
Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis
INTRODUCTION
Definition: A goiter is an enlarged thyroid
gland, and it may be diffuse or nodular.
A goiter may extend into the retrosternal
space, with or without anterior enlargement.
may cause a variety of compressive
syndromes.
FREQUENCY
Whickham study United Kingdom: 16% of population
Framingham study (USG): Thyroid nodules
3% men > 60 years
36% women aged 49-58 years
History
Incidentally, as a swelling in the neck discovered
by the patient or on routine physical examination
A finding on imaging studies
Local compression causing dysphagia, dyspnea,
stridor, plethora or hoarseness
Pain due to hemorrhage, inflammation, necrosis,
or malignant transformation
Signs and symptoms of hyperthyroidism or
hypothyroidism
Thyroid cancer with or without metastases
PERSENTATION OVERVIEW
Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis
CAUSES OF GOITER
Iodine deficiency
Autoimmune thyroiditis: Hashimoto or
postpartum thyroiditis
Excess iodine (Wolff-Chaikoff effect) or lithium
ingestion
Goitrogens
Inborn errors of metabolism
Exposure to radiation
Deposition diseases
CAUSES OF GOITER
Silent thyroiditis
Riedel thyroiditis
Infectious agents
Acute suppurative: bacterial
Chronic: mycobacteria, fungal, and parasitic
Granulomatous disease
Thyroid malignancy
CAUSES OF GOITER
TOXIC GOITER
A goiter that is associated with
hyperthyroidism is described as a toxic
goiter.
diffuse toxic goiter (Graves disease),
toxic multinodular goiter,
and toxic adenoma (Plummer disease.)
PERSENTATION OVERVIEW
Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis
DIFFERENTIAL DIAGNOSIS
Lipomas
Thyroid Lymphoma
Thyroid Nodule
Thyroid, Anaplastic Carcinoma
Thyroid, Medullary Carcinoma
Thyroid,Papillary Carcinoma
Thyroiditis, Subacute
PERSENTATION OVERVIEW
Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis
Medical Care:
1. Small benign euthyroid goiters do not
require treatment.
2. The effectiveness of thyroid hormone for
benign goiters is controversial.
Medical Care:
3. Large and complicated goiters may
require medical and surgical treatment.
4. Malignant goiters require medical and
surgical treatment.
Medical Care
5. Levothyroxine suppressive therapy
a benign euthyroid goiter
Hashimoto's thyroiditis
6. Monitoring:
TSH in a low
avoid hyperthyroidism,
cardiac arrhythmias, and
osteoporosis.
7. Strategy:
Medical Care
Treatment of hypothyroidism or hyperthyroidism
often reduces the size of a goiter.
Thyroid hormone replacement is often required
following surgical and radiation treatment of a
goiter.
radioactive iodine for the therapy of nontoxic
goiter has been disappointing and is
controversial.
Medical therapy of autonomous nodules with
thyroid hormone is not indicated.
Ethanol infusion
PERSENTATION OVERVIEW
Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodules
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis
THYROID NODULES
The lifetime risk for palpable thyroid nodule 5-10%
5% are malignant, whereas the remainder
benign diagnoses, including colloid nodule,
degenerative cyst, hyperplasia, thyroiditis, or benign
neoplasm
Autonomously functioning thyroid nodules
suppressed TSH levels, whether with overt or
subclinical hyperthyroidism
iodine-131 treatment versus surgical
Medical therapy is not indicated.
PERSENTATION OVERVIEW
Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis
Diet
Iodine supplementation or levothyroxine may
reduce goiter size
avoidance of goitrogens
Cyanoglucosides
cassava, lima beans, maize, bamboo shoots,
and sweet potatoes
Thioglucosides are natural goitrogens found in
the Cruciferae family of vegetables and weeds
eaten by animals.
Thionamidelike passed to humans via milk ingestion.
PERSENTATION OVERVIEW
Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis
(Subacute Thyroiditis)
Thyrotoxicosis
PERSENTATION OVERVIEW
Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis
PERSENTATION OVERVIEW
Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis
Fever
Malaise
Anorexia
Fatigue
Muscle aches
Stage 1
Stage 2
Stage 3
Stage 4
Euthyroid
Hypothyroid
Euthyroid
(recovery)
Elevated
Normal
Decreased
Normal
Decreased
Normal
Elevated
Normal
Symptoms Hyperthyroid
T4, T3
TSH
Rare cases
levothyroxine 25-100 mcg/d life long
PERSENTATION OVERVIEW
Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis
TERIMA KASIH