44 The thyroid gland and the thyroglossal tract

ZYGMUNT H. KRUKOWSKI Embryology The thyroid gland de elo!" #rom the median b$d o# the !haryn% &the thyroglo""al d$'t( )hi'h !a""e" #rom the #oramen 'ae'$m at the ba"e o# the tong$e to the i"thm$" o# the thyroid. The $ltimobran'hial body )hi'h ari"e" #rom a di erti'$l$m o# the #o$rth !haryngeal !o$'h o# ea'h "ide amalgamate" )ith the 'orre"!onding lateral lobe. *ara#olli'$lar 'ell" &+,'ell"( are deri ed #rom the ne$ral 're"t and rea'h the thyroid ia the $ltimobran'hial body. Re'ently- 'on"ideration ha" been gi en to the !o""ibility that "ome +,'ell" are o# endodermal rather than ne$ral 're"t origin. It i" do$bt#$l )hether the bran'hial a!!arat$" it"el# 'ontrib$te" to the thyroid #olli'$lar 'ell". S$rgi'al anatomy &.ig" //.0 and //.1( The normal gland )eigh" 12314 g. The #$n'tioning $nit i" the lob$le "$!!lied by a "ingle arteriole and 'on"i"ting o# 1/3/2 #olli'le" )hi'h are lined by '$boidal e!itheli$m. The re"ting #olli'le 'ontain" 'olloid in )hi'h thyroglob$lin i" "tored. The arterial "$!!ly i" ri'h- and e%ten"i e ana"tomo"e" o''$r bet)een the main thyroid arterie" and bran'he" o# tra'heal and oe"o!hageal arterie". There i" an e%ten"i e lym!hati' net)or5 )ithin the gland. 6ltho$gh "ome lym!h 'hannel" !a"" dire'tly to the dee! 'er i'al node"- the "$b'a!"$lar !le%$" drain" !rin'i!ally to the 7$%tathyroid node"- i.e. !retra'heal &8el!hi'(9 and !aratra'heal node"- and node" on the "$!erior and in#erior thyroid ein"- and then'e to the dee! 'er i'al and media"tinal gro$! o# node". E'to!i' thyroid and anomalie" o# the thyroglo""al tra't Some re"id$al thyroid ti""$e along the 'o$r"e o# the thyrogbo""al tra't i" not $n'ommon- and may be ling$al- 'er i'al or intrathora'i'. :ery rarely the )hole gland i" e'to!i'. ;ing$al thyroid Thi" #orm" a ro$nded ")elling at the ba'5 o# the tong$e at the #oramen 'ae'$m &.ig" //.< and //./( and itmay re!re"ent the only thyroid ti""$e !re"ent. It may 'a$"e dy"!hagia- im!airment o# "!ee'h- re"!iratory ob"tr$'tion or hemorrhage. It i" be"t treated by #$ll re!la'ement )ith thyro%ine )hen it "ho$ld get "maller- b$t e%'i"ion or ablation )ith radioiodine i" "ometime" ne'e""ary. Median &thyroglo""al( e'to!i' thyroid Thi" #orm" a ")elling in the $!!er !art o# the ne'5 &.ig. //./( and i" $"$ally mi"ta5en #or a thyroglo""al 'y"t. 6gain- thi" may be the only normal thyroid ti""$e !re"ent. ;ateral aberrant thyroid There i" no e iden'e that aberrant thyroid ti""$e e er o''$r" in a lateral !o"ition &Willi"(. =Normal thyroid ti""$e9 #o$nd laterally- "e!arate #rom the thyroid gland- m$"t be 'on"idered and treated a" a meta"ta"i" in a 'er i'al lym!h node #rom an o''$lt thyroid 'ar'inoma- almo"t in ariably o# !a!illary ty!e. Str$ma o arii i" not e'to!i' thyroid ti""$e- b$t !art o# an o arian teratoma. :ery rarely- neo!la"ti' 'hange o''$r" or hy!erthyroidi"m de elo!". Thyroglo""al'y"t Thi" may be !re"ent in any !art o# the thyroglo""al tra't &.ig. //.4(. The 'ommon "it$ation"- in order o# #re>$en'y- are beneath the hyoid- in the region o# the thyroid 'artilage- and abo e the hyoid bone. S$'h a 'y"t o''$!ie" the midline- e%'e!t in the region o# the thyroid 'artilage- )here the thyroglo""al tra't i" !$"hed to one "ide-

$"$ally to the le#t. It i" to be remembered that the ")elling mo e" $!)ard" on !rotr$"ion o# the tong$e a" )ell a" on ")allo)ing be'a$"e o# the atta'hment o# the tra't to the #oramen 'ae'$m. 6 thyroglo""al 'y"t "ho$ld be e%'i"ed be'a$"e in#e'tion i" ine itable- o)ing to the #a't that the )all 'ontain" nod$le" o# lym!hati' ti""$e )hi'h 'omm$ni'ate by lym!hati'" )ith the lym!h node" o# the ne'5. 6n in#e'ted 'y"t i" o#ten mi"ta5en #or an ab"'e"" and in'i"ed- )hi'h i" one )ay in )hi'h a thyroglo""al #i"t$la ari"e". Thyroglo""al #i"t$la Thyroglo""al #l"t$la &.ig. //.?a- b( i" ne er 'ongenital@ it#ollo)" in#e'tion or inade>$ate remo al o# a thyroglo""al 'y"t. +hara'teri"ti'ally the '$taneo$" o!ening o# "$'h a #i"t$la i" dra)n $!)ard" on !rotr$"ion o# the tong$e. 6 thyroglo""al #i"t$la i" lined by 'ol$mnar e!itheli$m- di"'harge" m$'$"- and i" the "eat o# re'$rrent atta'5" o# in#lammation. Treatment. Ae'a$"e the thyroglo""al tra't i" "o 'lo"ely related to the body o# the hyoid bone- thi" 'entral !art m$"t be e%'i"ed- together )ith the 'y"t or #i"t$la- or re'$rren'e i" 'ertain. When the thyroglo""al tra't 'an be tra'ed $!)ard" to)ard" the #oramen 'ae'$m- itm$"t be e%'i"ed )ith the 'entral "e'tion o# the body o# the hyoid bone- and a 'entral 'ore o# ling$al m$"'le &Si"tr$n59" o!eration(. *hy"iology. The hormone" tri,iodothyronine &T<( and thyro%ine &T/( &e%tra'ted by E.G. Kendall in 0B0?( are bo$nd to thyroglob$lin )ithin the 'olloid. Synthe"i" )ithin the thyroglob$lin 'om!le% i" 'ontrolled by "e eral enCyme"- in di"tin't "te!"@ Dtra!!ing o# inorgani' iodide #rom the bloodE Do%idation o# iodide to iodineE Dbinding o# iodine )ith tyro"ine to #orm iodotyro"ine"E D'o$!ling o# mono,iodotyro"ine" and di,iodotyro"ine" to #orm 0< and T/ D)hen hormone" are re>$ired the 'om!le% i" re"orbed into the 'ell and thyroglob$lin bro5en do)nE T< and T/ are liberated and enter the blood )here they are bo$nd to "er$m !rotein"@ alb$min and thyro%ine binding glob$lin &TAG( and !realb$min &TA*6(. 6 "mall amo$nt o# hormone remain" #ree in the "er$m in e>$ilibri$m )ith the !rotein,bo$nd hormone and i" biologi'ally a'ti e.The metaboli' e##e't" o# the thyroid hormone" are d$e to $nbo$nd #ree 0/ and 0< &2.2< !er 'ent and 2.< !er 'ent o# the total 'ir'$lating hormone"- re"!e'ti ely(. 0< i" >$i'5 a'ting &)ithin a #e) ho$r"( )herea" 0/ a't" more "lo)ly &/30/ day"(. 0< i" the more im!ortant !hy"iologi'al hormone and i" al"o !rod$'ed in the !eri!hery by 'on er"ion #rom 0/. Thera!e$ti' note"@ ;,thyro%ine &T/( i" the o##i'ial nameE trade name Eltro%inE tablet "iCe 2.0 mg and 2.24 mg. Tri,iodothyronine &T<(- o##i'ial name liothyronineE trade name" +ynomel- Tertro%inE tablet "iCe 12 .tg. Thyro'al'itonin See 'al'itonin- +ha!ter /4. The !it$itary thyroid a%i" Synthe"i" and liberation o# thyroid hormone" #rom the thyroid i" 'ontrolled by thyroid,"tim$lating hormone &TSH( #rom the anterior !it$itary. Se'retion o# TSH de!end" $!on the le el o# 'ir'$lating thyroid hormone" and i" modi#ied in a 'la""i' negati e #eedba'5 manner. In hy!erthyroidi"m- )here hormone le el" in the blood are high- TSH !rod$'tion i" "$!!re""ed )herea" in hy!othyroidi"m it i" "tim$lated. Reg$lation o# TSH "e'retion al"o re"$lt" #rom the a'tion o# thyrotro!hin,relea"ing hormone &TRH( !rod$'ed in the hy!othalam$". Thyroid."tim$lating antibodie" 6 #amily o# IgG imm$noglob$lin" bind" )ith TSH re'e!tor "ite" &TR6b"( and a'ti ate TSH re'e!tor" on the #olli'$lar 'ell membrane. They ha e a more !rotra'ted

a'tion than TSH &0?31/ ho$r" er"$" 0.43<ho$r"( and are re"!on"ible #or irt$ally all 'a"e" o# thyroto%i'o"i" not d$e to a$tonomo$" to%i' nod$le". Ser$m 'on'entration" are ery lo) and not ro$tinely mea"$red. Te"t" o# thyroid #$n'tion There i" a ariety o# te"t" o# thyroid #$n'tion a ailable- "ome o# )hi'h are no) only o# hi"tori' intere"t and other" in the !ro in'e o# the endo'rinologi"t rather than the endo'rine "$rgeon. The n$mber o# in e"tigation" re>$e"ted "ho$ld be the minim$m ne'e""ary to rea'h a diagno"i" and #orm$late a management !lan. Only a "mall n$mber o# !arameter" need" to be mea"$red a" a ro$tine altho$gh thi" may re>$ire "$!!lementation or re!eat )hen in'on'l$"i e. Ser$m thyroid hormone" Ser$m TSH. TSH le el" 'an be mea"$red a''$rately do)n to ery lo) "er$m 'on'entration" and i# the "er$m TSH le el i" in the normal range it i" red$ndant to mea"$re the T< and T/ le el". Inter!retation o# deranged TSH le el" ho)e er de!end" on 5no)ledge o# the T< and T/ al$e" &Table //.0(. In the e$thyroid "tateT<- T/and TSH le el" )ill all be )ithin the normal range. .lorid thyroid #ail$re re"$lt" in de!re""ed T< and T/ le el" )ith gro"" ele ation o# the TSH. In'i!ient or de elo!ing thyroid #ail$re i" 'hara'teri"ed by lo) normal al$e" o# T< and T/ and ele ation o# the TSH. In to%i' "tate" the TSH le el i" "$!!re""ed and $ndete'table. Thyro%ine &T/(and tri,iodothyronine &T<( are tran"!orted in !la"ma bo$nd to "!e'i#i' !rotein" &thyro%ine,binding glob$lin- TAG(. Only a "mall #ra'tion o# the total &2.2< !er 'ent o# T/ and 2.< !er 'ent o# T<( i" #ree and !hy"iologi'ally a'ti e. 6""ay" o# both total and #ree hormone are a ailable b$t the total al$e" de!end on the le el o# 'ir'$lating !rotein" )hi'h are a##e'ted by the le el o# 'ir'$lating oe"trogen. Th$"!regnant )omen and tho"e on the oral 'ontra'e!ti e !ill ha e ele ated total T/ and T< le el" )itho$t e iden'e o# to%i'ity. The #ree hormone le el" are $na##e'ted. Similarly "ome !atient" ha e lo) le el" o# TAG either a" a !rimary !henomenon or "e'ondary to a red$'tion in "er$m !rotein le el" a" a re"$lt o# "y"temi' or li er di"ea"e and the total le el o# 'ir'$lating hormone may be lo). .or the"e rea"on" the #ree le el" are more meaning#$l. Highly a''$rate radioimm$noa""ay" o# #ree T< and #ree T/ are no) ro$tine. T< to%i'ity &)ith a normal T/(i" a di"tin't entity and may only he diagno"ed by mea"$ring the "er$m T<- altho$gh a "$!!re""ed TSH le el )ith a normal T/ i" "$gge"ti e. :ario$" 'ombination" o# the"e te"t" are $"ed in di##erent laboratorie". 6n a!!ro!riate 'ombination i" to e"tabli"h the #$n'tional thyroid "tat$" at initial a""e""ment- )ith TSH "$!!lemented by #ree T/- and T< e al$ation )hen TSH i" abnormal. I"oto!e "'anning &.ig. //.F( The $!ta5e by the thyroid o# a lo) do"e o# either radiolabelled iodine &01<I( or te'hneti$m,BBm &BBGm9T'- )hi'h i" normally ta5en $! li5e 01<I()ill demon"trate the di"trib$tion o# a'ti ity in the )hole gland. Thi" te"t i" ina!!ro!riate #or di"ting$i"hing benign #rom malignant le"ion" be'a$"e the ma7ority &H2 !er 'ent( o# 'old ")elling" i" benign and "ome &4 !er 'ent( #$n'tioning or )arm ")elling" )ill be malignant. It" !rin'i!al al$e i" in the to%i' !atient )ith a nod$le or nod$larity o# the thyroid. ;o'ali"ation o# o era'ti ity in the gland )ill di##erentiate bet)een a to%i' nod$le )ith "$!!re""ion o# the remainder o# the gland and to%i' m$lti,nod$lar goitre )ith "e eral area" o# in'rea"ed $!ta5e )ith im!ortant im!li'ation" #or thera!y. Ro$tine i"oto!e "'anning i" $nne'e""ary. Whole body "'anning i" $"ed to demon"trate meta"ta"e" b$t the !atient m$"t ha e all normally #$n'tioning thyroid ti""$e ablated either by "$rgery or by ablation )ith high,

do"e radioiodine be#ore the "'an i" !er#ormed be'a$"e thyroid 'an'er 'annot 'om!ete )ith normal thyroid ti""$e in the $!ta5e o# iodine. Thyroid a$toantibodie" Ser$m titre" o# antibodie" again"t thyroid !ero%ida"e and thyroglob$lin are $"e#$l in determining the 'a$"e o# thyroid dy"#$n'tion and ")elling". 6$toimm$ne thyroiditi" may be a""o'iated )ith thyroid to%i'ity- #ail$re or e$thyroid goitre. Titre" o# greater than 0@022 are 'on"idered "igni#i'ant b$t a !ro!ortion o# !atient" )ith hi"tologi'al e iden'e o# lym!ho'yti' &a$toimm$ne( thyroiditi" i" "eronegati e. Hy!othyroidi"m 6 "'heme #or 'la""i#ying hy!othyroidi"m i" gi en in Table //.1. +retini"m &#oetal or in#antile hy!othyroidi"m( S!oradi' ' i" d$e to 'om!lete or near 'om!lete #ail$re o# thyroid de elo!ment &!artial #ail$re 'a$"e" 7$ enile my%oedema(@ the !arent" and other 'hildren may be !er#e'tly normal. In endemi' area"- goitro$" 'retini"m i" 'ommon- and i" d$e to maternal and #oetal iodine de#i'ien'y. Immediate diagno"i" and treatment )ith thyro%ine )ithin a #e) day" o# birth are e""ential i# !hy"i'al and mental de elo!ment are to be normal- or i# #$rther deterioration i" to he !re ented )hen damage ha" already o''$rred in $tero. Hy!othyroidi"m o''$r" in I in /222 li e birth" and #or thi" rea"on- in the UK- there i" ro$tine bio'hemi'al "'reening o# neonate" #or hy!othyroidi"m $"ing TSH a""ay on a "im!le heel,!ri'5 blood "am!le. Women $nder treatment )ith antithyroid dr$g" may gi e birth to a hy!othyroid in#ant. 6d$lt hy!othyroidi"m The term my%oedema "ho$ld be re"er ed #or "e ere thyroid #ail$re and not a!!lied to the m$'h 'ommoner mild thyroid de#i'ien'y. The "ign" o# thyroid de#i'ien'y are@ D brady'ardiaE D 'old e%tremitie"E D dry "5in and hairE D !eriorbital !$##ine""E D hoar"e oi'eE D brady5ine"i" 3"lo) mo ement"E D delayed rela%ation !ha"e o# an5le 7er5". The "ym!tom" are@ D tiredne""E D mental lethargyE D 'old intoleran'eE D )eight gainE D 'on"ti!ationE D men"tr$al di"t$rban'eE D 'ar!al t$nnel "yndrome. +om!ari"on o# the #a'ial a!!earan'e )ith a !re io$" !hotogra!h may be hel!#$l. Thyroid #$n'tion te"t"

Thyroid #$n'tion te"t" &Table //.0( "ho) lo) T/ and T< le el" )ith a high TSH &e%'e!t in the rare e ent o# !it$itary #ail$re(. High "er$m titre" o# antithyroid antibodie" are 'hara'teri"ti' o# a$toimm$ne di"ea"e. Treatment Oral thyro%ine &2.0232.12 mg( a" a "ingle daily do"e &be'a$"e o# it" !rolonged a'tion( i" '$rati e. +a$tion i" re>$ired in the elderly or tho"e )ith 'ardia' di"ea"e and the re!la'ement do"e i" then 'ommen'ed at 2.24 mg daily and 'a$tio$"ly in'rea"ed. I# a ra!id re"!on"e i" re>$ired- tri,iodothyronine &12 mg three time" a day( may be $"ed.The "ign" and "ym!tom" o# hy!othyroidi"m are a''ent$ated. The #a'ial a!!earan'e &.ig. //.00( i" ty!i'al- and there i"o#ten "$!ra'la i'$lar !$##ine""- a malar #l$"h and a yello) tinge to the "5in. My%oedema 'oma o''$r" in negle'ted 'a"e" and 'arrie" a high mortalityE the body tem!erat$re i" lo) and the !atient m$"t be )armed "lo)ly@0 g o# intra eno$" hydro'orti"one &in di ided do"e"( "ho$ld be gi en dailyand intra eno$" tri,iodothyronine in "lo)ly in'rea"ing do"e". 6$toimm$ne thyroiditi" The "o,'alled !rimary or atro!hi' my%oedema i" no) 'on"idered to be an a$toimm$ne di"ea"e "imilar to 'hroni' lym!ho'yti' &Ha"himoto9"( thyroiditi" &"ee belo)( b$t =)itho$t goitre #ormation #rom TSH "tim$lation. Ae'a$"e o# the delay in diagno"i" the hy!othyroidi"m i" $"$ally m$'h more "e ere than in goitro$" a$toimm$ne thyroiditi". 8y"hormonogene"i" and goitrogen" Geneti'ally determined de#i'ien'ie" in the enCyme" 'ontrolling the "ynthe"i" o# thyroid hormone"- i# "e ere- are re"!on"ible #or goitre #ormation )ith hy!othyroidi"m. I# o# moderate degree- a "im!le &e$thyroid( goitre re"$lt". Similarly goitrogen" may !rod$'e a goitre )ith- or )itho$t- hy!othyroidi"m. 6 n$mber o# nonendemi' goitro$" 'retin" ha" been born to a gro$! o# itinerant tin5er" li ing in S'otland )ho intermarry &H$t'hi"on- S'otland(. Thi" )a" d$e to a de#i'ien'y o# the enCyme dehalogena"e. When thyroglob$lin i" bro5en do)n- $n'o$!led iodotyro"ine" are liberated a" )ell a" T< and T/. They are bro5en do)n by the enCyme dehalogena"e and the iodine retained )ithin the thyroid. I# dehalogena"e i" de#i'ient- iodotyro"ine" !a"" into the blood- and are e%'reted in the $rine and thi" may re"$lt in iodine de#i'ien'y and goitre #ormation. 6nother 'la""i' e%am!le o# dy"hormonogene"i" i" *endred9" "yndrome- )here goitre i" a""o'iated )ith 'ongenital dea#ne"". Thi" i" d$e to a de#i'ien'y o# !ero%ida"e- the enCyme re"!on"ible #or organi#i'ation o# tra!!ed iodine. 8e#e't" in thyroglob$lin "ynthe"i" are al"o re'ogni"ed in dy"hormonogene"i". Thyroid enlargement The normal thyroid gland i" im!al!able. The term goitre &;atin- g$tt$r I the throat( i" $"ed to de"'ribe generali"ed enlargement o# the thyroid gland. 6 di"'rete ")elling &nod$le( in one lobe )ith no !al!able abnormality el"e)here i" termed an i"olated &or "olitary( ")elling. 8i"'rete ")elling" )ith e iden'e o# abnormality el"e)here in the gland are termed dominant. 6 "'heme #or 'ategori"ing thyroid enlargement i" gi en in Table //.<. Sim!le goitre 6etiology Sim!le goitre may de elo! a" a re"$lt o# "tim$lation o# the thyroid gland by TSHeither a" a re"$lt o# ina!!ro!riate "e'retion #rom a mi'roadenoma in the anterior !it$itary &)hi'h i" rare(- or in re"!on"e to a 'hroni'ally lo) le el o# 'ir'$lating thyroid hormone". The mo"t im!ortant #a'tor in endemi' goitre i" dietary de#i'ien'y

o# iodine &"ee belo)( b$t de#e'ti e hormone "ynthe"i" !robably a''o$nt" #or many "!oradi' goitre" &"ee belo)(.TSH i" not the only "tim$l$" to thyroid #olli'$lar 'ell !roli#eration and other gro)th #a'tor" in'l$ding imm$noglob$lin" e%ert an in#l$en'e. The heterogeneo$" "tr$'t$ral and #$n'tional re"!on"e in the thyroid re"$lting in 'hara'teri"ti' nod$larity may be d$e to the !re"en'e o# 'lone" o# 'ell" !arti'$larly "en"iti e to gro)th "tim$lation. Iodine de#i'ien'y The daily re>$irement o# iodine i" abo$t 2.032.04 mg. In nearly all di"tri't" )here "im!le goitre i" endemi'- there i" a ery lo) iodide 'ontent in the )ater and #ood. Endemi' area" are in the mo$ntaino$" range"- "$'h a" the Ro'5y Mo$ntain"- the 6l!"the 6nde" and the Himalaya". In Great Aritain endemi' goitre i" #o$nd in the Mendi!"- +hiltern"- +ot")old" and the *ennine 'hain o# 8erby"hire and Yor5"hire. Endemi' goitre i" al"o #o$nd in lo)land area" )here the "oil la'5" iodide or the )ater "$!!ly 'ome" #rom #ar a)ay mo$ntain range"- e.g. the Great ;a5e" o# North 6meri'athe *lain" o# ;ombardy- the Str$ma alley<- the Nile alley and the +ongo. +al'i$m i" al"o goitrogeni' and goitre i" 'ommon in lo),iodine area" on 'hal5 or lime"tone- e.g. 8erby"hire and So$thern Ireland. 6ltho$gh iodide" in #ood and )ater may be ade>$ate- #ail$re o# inte"tinal ab"or!tion may !rod$'e iodine de#i'ien'y &M'+arri"on(. 8e#e'ti e hormone "ynthe"i" EnCyme de#i'ien'yJdy"hormonogene"i". It i" !robable that enCyme de#i'ien'ie" o# arying "e erity are re"!on"ible #or many "!oradi' goitre"- i.e. in nonendemi' area". There i" o#ten a #amily hi"tory "$gge"ting a geneti' de#e't. En ironmental #a'tor" may 'om!en"ate in area" o# high iodine inta5e- #or e%am!le goitre i" almo"t $n5no)n in I'eland )here the #i"h diet i" ri'h in iodine. Similarly a lo) inta5e o# iodine en'o$rage" goitre #ormation in tho"e )ith a metaboli' !redi"!o"ition. Goitrogen". Well,5no)n goitrogen" are the egetable" o# the bra""i'a #amily &'abbage- 5ale and ra!e( )hi'h 'ontain thio'yanate- dr$g" "$'h a" !ara,amino"ali'yli' a'id &*6S( and- o# 'o$r"e- the antithyroid dr$g". Thio'yanate" and !er'hlorate" inter#ere )ith iodide tra!!ingE 'arbimaCole and thio$ra'il 'om!o$nd" inter#ere )ith the o%idation o# iodide and the binding o# iodine to tyro"ine. S$r!ri"ingly eno$gh- iodide" in large >$antitie" are goitrogeni' be'a$"e they inhibit the organi' binding o# iodine and !rod$'e an iodide goitre. The nat$ral hi"tory o# "im!le goitre Stage" in goitre #ormation are@ D!er"i"tent gro)th "tim$lation 'a$"e" di##$"e hy!er!la"iaE all lob$le" are 'om!o"ed o# a'ti e #olli'le" and iodine $!ta5e i" $ni#orm. Thi" i" a di##$"e hy!er!la"ti' goitre)hi'h may !er"i"t #or a long time b$t i" re er"ible i# "tim$lation 'ea"e"E Dlater- a" a re"$lt o# #l$'t$ating "tim$lation- a mi%ed !attern de elo!" )ith area" o# a'ti e lob$le" and area" o# ina'ti e lob$le"E Da'ti e lob$le" be'ome more a"'$lar and hy!er!la"ti' $ntil haemorrhage o''$r"'a$"ing 'entral ne'ro"i" and lea ing only a "$rro$nding rind o# a'ti e #olli'le"E Dne'roti' lob$le" 'oale"'e to #orm nod$le" #illed )ith either iodine,#ree 'olloid or a ma"" o# ne) b$t ina'ti e #olli'le"E D'ontin$al re!etition o# thi" !ro'e"" re"$lt" in a nod$lar goitre. Mo"t nod$le" are ina'ti e and a'ti e #olli'le" are !re"ent only in the internod$lar ti""$e. 8i##$"e hy!er!la"ti' goitre 8i##$"e hy!er!la"ia 'orre"!ond" to the #ir"t "tage" o# the nat$ral hi"tory. The goitre a!!ear" in 'hildhood in endemi' area" b$t- in "!oradi' 'a"e"- it $"$ally o''$r" at !$berty )hen metaboli' demand" are high 3!$berty goitre &.ig. //.01(. I# TSH

"tim$lation 'ea"e"- the goitre may regre""- b$t tend" to re'$r later at time" o# "tre"" "$'h a" !regnan'y. The goitre i" "o#t- di##$"e and may be'ome large eno$gh to 'a$"e di"'om#ort. 6 'olloid goitre i" a late "tage o# di##$"e hy!er!la"ia )hen TSH "tim$lation ha" #allen o## and )hen many #olli'le" are ina'ti e and #$ll o# 'olloid &.ig. //.0<(. Nod$lar goitre Nod$le" are $"$ally m$lti!le- #orming a m$ltinod$lar goitre. O''a"ionally- only one ma'ro"'o!i' nod$le i" #o$nd- b$t mi'ro"'o!i' 'hange" )ill be !re"ent thro$gho$t the gland@ thi" i" one #orm o# a 'lini'ally "olitary nod$le. Nod$le" may be 'olloid or 'ell$lar- and 'y"ti' degeneration and haemorrhage are 'ommon- a" i" "$b"e>$ent 'al'i#i'ation. Nod$le" a!!ear early in endemi' goitre and later &bet)een 12 and <2 year"( in "!oradi' goitre- altho$gh the !atient may be $na)are o# the goitre $ntil the late /2" or 42". 6ll ty!e" o# "im!le goitre are #ar more 'ommon in the #emale than in the male and the !re"en'e o# oe"trogen re'e!tor" in normal thyroid ti""$e and in nod$lar goitre i" rele ant. 8iagno"i" i" $"$ally "traight#or)ard. The !atient i" e$thyroid@ the nod$le" are !al!able and o#ten i"ibleE they are "mooth- $"$ally #irm and not hard- and the goitre i" !ainle"" and mo e" #reely on ")allo)ing. Hardne"" and irreg$larity- d$e to 'al'i#i'ation- may "im$late 'ar'inoma. 6 !ain#$l nod$le- "$dden a!!earan'e or ra!id enlargement o# a nod$le rai"e" "$"!i'ion o# 'ar'inoma b$t i" $"$ally d$e to haemorrhage into a "im!le nod$le. 8i##erential diagno"i" #rom a$toimm$ne thyroiditi" may be di##i'$lt. In e"tigation". Te"t" o# thyroid #$n'tion are ne'e""ary to e%'l$de mild hy!erthyroidi"m- and the e"timation o# titre" o# thyroid antibodie" to di##erentiate #rom a$toimm$ne thyroiditi". *lain radiogra!h" o# the 'he"t and thora'i' inlet may "ho) 'al'i#i'ation and tra'heal de iation or 'om!re""ion. +om!li'ation".Tra'heal ob"tr$'tion i" d$e to gro"" lateral di"!la'ement- or 'om!re""ion in a lateral or antero!o"terior !lane by retro"ternal e%ten"ion o# the goitre &.ig. //.0/(. 6'$te re"!iratory ob"tr$'tion may #ollo) haemorrhage into a nod$le im!a'ted in the thora'i' inlet. Se'ondary thyroto%i'o"i". Many !atient" )ith nod$largoitre" e%!erien'e tran"ient e!i"ode" o# mild hy!erthyroidi"m. The in'iden'e i" di##i'$lt to e"timate- b$t #ig$re" a" high a" <2 !er 'ent ha e been "$gge"ted. +ar'inoma-)hi'h i" $"$ally o# #olli'$lar !attern. It i" $n'ommon b$t an in'rea"ed in'iden'e ha" been re!orted #rom endemi' area". *re ention and treatment o# "im!le goitre In endemi' area"- e.g. S)itCerland- !art" o# the US6 and 6rgentina- the in'iden'e o# goitre ha" been "tri5ingly red$'ed by the introd$'tion o# iodi"ed "alt. In the early "tage" a hy!er!la"ti' goitre may regre"" i# thyro%ine i" gi en in a do"e o# 2.0432.1 mg daily #or a #e) month". The nod$lar "tage o# "im!le goitre i" irre er"ible. Mo"t !atient" )ith m$ltinod$lar goitre are a"ym!tomati' and do not re>$ire o!eration. O!eration may be indi'ated on 'o"meti' gro$nd" i# the goitre i" $n"ightly. Retro"ternal e%ten"ion )ith a't$al or in'i!ient tra'heal 'om!re""ion i" an indi'ation #or o!eration- a" i" the !re"en'e o# a dominant area o# enlargement )hi'h may be neo!la"ti'. There i" a 'hoi'e o# "$rgi'al treatment@ &a( total thyroide'tomy )ith immediate and li#e,long re!la'ement o# thyro%ineE or &b( "ome #orm o# !artial re"e'tion to 'on"er e "$##i'ient #$n'tioning thyroid ti""$e to "$b"er e normal #$n'tion )hil"t eliminating the ri"5 o# hy!o!arathyroidi"m )hi'h a''om!anie" total thyroide'tomy. *artial

re"e'tion aim" to remo e the b$l5 o# the gland- lea ing $! to H g o# relati ely normal ti""$e in ea'h remnant. The te'hni>$e i" e""entially the "ame a" de"'ribed #or to%i' goitre- a" are the !o"to!erati e 'om!li'ation". More o#ten- ho)e er- the m$ltinod$lar 'hange i" a"ymmetri'ally di"trib$ted- )ith one lobe more "igni#i'antly in ol ed than the other. Under the"e 'ir'$m"tan'e" total lobe'tomy on the more a##e'ted "ide i" the a!!ro!riate management )ith either "$btotal re"e'tion or no inter ention on the le"" a##e'ted "ide. In many 'a"e" the 'a$"ati e #a'tor" !er"i"t and re'$rren'e i" li5ely. Reo!eration #or re'$rrent nod$lar goitre i" more di##i'$lt and haCardo$" and #or thi" rea"on many thyroid "$rgeon" #a o$r total thyroide'tomy in yo$nger !atient". When a $nilateral lobe'tomy alone ha" been !er#ormed #or a"ymmetri' goitre- reo!eration i" "traight#or)ard "ho$ld it be'ome ne'e""ary on the remaining lobe. 6#ter "$btotal re"e'tion itha" been '$"tomary to gi e thyro%ine to "$!!re"" TSH "e'retion )ith the aim o# !re enting re'$rren'e. Whether thi" i" either ne'e""ary or e##e'ti e i" $n'ertain- altho$gh the e iden'e o# bene#it in endemi' area" i" better than el"e)here. There i" "ome e iden'e that re'$rren'e a#ter "$rgery may red$'e in "iCe a#ter treatment )ith radioa'ti e iodine. +lini'ally di"'rete ")elling" 8i"'rete thyroid ")elling" &thyroid nod$le"( are 'ommon and are !re"ent in <3/ !er 'ent o# the ad$lt !o!$lation in the UK and US6. They are three to #o$r time" more #re>$ent in )omen than men. 8iagno"i" 6 di"'rete ")elling in an other)i"e im!al!able gland i" termed i"olated or "olitary)herea" the !re#erred term #or a "imilar ")elling in a gland )ith 'lini'al e iden'e o# generali"ed abnormality in the #orm o# a !al!able 'ontralateral lobe or generali"ed mild nod$larity i" dominant.6bo$t F2 !er 'ent o# di"'rete thyroid ")elling" are 'lini'ally i"olated and abo$t <2 !er 'ent dominant. The tr$e in'iden'e o# i"olated ")elling" i" "ome)hat le"" than the 'lini'al e"timate. +lini'al 'la""i#i'ation i" ine itably "$b7e'ti e and o ere"timate" the #re>$en'y o# tr$ly i"olated ")elling". When "$'h a gland i" e%!o"ed at o!eration or e%amined by $ltra"onogra!hy'om!$ted tomogra!hy &+T( or magneti' re"onan'e imaging &MRI(- 'lini'ally im!al!able nod$le" are o#ten dete'ted. The tr$e #re>$en'y o# thyroid nod$larity 'om!ared )ith the 'lini'al dete'tion rate by !al!ation i" "ho)n in &.ig. //.04(.E"tabli"hing the !re"en'e o# "$'h minor abnormality i" $nne'e""ary be'a$"e the management o# di"'rete ")elling"- be they i"olated or dominant- i" "imilar. The im!ortan'e o# di"'rete ")elling" lie" in the ri"5 o# neo!la"ia 'om!ared )ith other thyroid ")elling". Some 04!er 'ent o# i"olated ")elling" !ro e to be malignant- and an additional <23/2 !er 'ent are #olli'$lar adenoma". The remainder are non, neo!la"ti' largely 'on"i"ting o# area" o# 'olloid degeneration- thyroiditi" or 'y"t". 6ltho$gh the in'iden'e o# malignan'y or #olli'$lar adenoma in 'lini'ally dominant ")elling" i" a!!ro%imately hal# that o# tr$ly i"olated ")elling"- it i" "$b"tantial and 'annot be ignored. In e"tigation Thyroid #$n'tion. The thyroid #$n'tional "tat$" "ho$ld be e"tabli"hed by e"timation o# "er$m thyroid hormone" and TSH. I# hy!erthyroidi"m a""o'iated )ith a di"'rete ")elling i" 'on#irmed bio'hemi'ally- itindi'ate" either a =to%i' adenoma9 or a mani#e"tation o# to%i' m$ltinod$lar goitre. The 'ombination o# to%i'ity and nod$larity i" im!ortant and 'on"tit$te" the only indi'ation #or i"oto!e "'anning to lo'ali"e the area&"( o# hy!er#$n'tion. 6$toantibody titre". The a$toantibody "tat$" i" im!ortant in determining )hi'h ")elling" may be a mani#e"tation o# 'hroni' lym!ho'yti' thyroiditi".

I"oto!e "'an. I"oto!e "'anning $"ed to be the main"tay o# in e"tigation o# di"'rete thyroid ")elling" to determine the #$n'tional a'ti ity relati e to the "$rro$nding gland a''ording to i"oto!e $!ta5e. On "'anning- ")elling" are 'ategori"ed a" =hot9 &o era'ti e(- =)arm9 &a'ti e( or ='old9 &$ndera'ti e(. 6 hot nod$le i" one that ta5e" $! i"oto!e- )hile the "$rro$nding thyroid ti""$e doe" not. Here the "$rro$nding thyroid ti""$e i" ina'ti e be'a$"e the nod$le i" !rod$'ing "$'h high le el" o# thyroid hormone" that TSH "e'retion i" "$!!re""ed. 6 )arm nod$le ta5e" $! i"oto!e and "o doe" normal thyroid ti""$e abo$t it. 6 'old nod$le ta5e" $! no i"oto!e &.ig. //.F(. 6bo$t H2 !er 'ent o# di"'rete ")elling" are 'old b$t only 04 !er 'ent !ro e to be malignant and the $"e o# thi" 'riterion a" an indi'ation #or o!eration la'5" di"'rimination. Ro$tine i"oto!e "'anning ha" been abandoned e%'e!t )hen to%i'ity i" a""o'iated )ith nod$larity. Ultra"onogra!hy )a" #ormerly )idely $"ed a" a nonin a"i e "$!!lement to 'lini'al e%amination in determining the !hy"i'al 'hara'teri"ti'" o# thyroid ")elling". 6ltho$gh $ltra"onogra!hy 'an demon"trate "$b'lini'al nod$larity and 'y"t #ormation- the #ormer i" 'lini'ally irrele ant and the latter a!!arent at a"!iration- )hi'h "ho$ld be ro$tine in all di"'rete ")elling". .ine,needle a"!iration 'ytology &.N6+(. .N6+ ha" be'ome e"tabli"hed a" the in e"tigation o# 'hoi'e in di"'rete thyroid ")elling". .N6+ ha" e%'ellent !atient 'om!lian'e- i" "im!le and >$i'5 to !er#orm in the o$t,!atient de!artment and i" readily re!eated. Thi" te'hni>$e- de elo!ed in S'andina ia "ome <2 year" ago- ha" be'ome !o!$lar in the re"t o# E$ro!e and North 6meri'a in the la"t 12 year". Thyroid 'ondition" that may be diagno"ed by .N6+ in'l$de 'olloid nod$le" &.ig. //.0?(- thyroiditi"- !a!illary 'ar'inoma &.ig. //.0F(- med$llary 'ar'inoma- ana!la"ti' 'ar'inoma and lym!homa. .N6+ 'annot di"ting$i"h bet)een a benign #olli'$lar adenoma &.ig. //.0H( and #olli'$lar 'ar'inoma a" thi" di"tin'tion i" de!endent not on 'ytology b$t on hi"tologi'al 'riteria- )hi'h in'l$de 'a!"$lar and a"'$lar in a"ion. 6ltho$gh .N6+ ha" been re!orted a" highly a''$rate by ;o)hagen and hi" 'olleag$e" at the Karolin"5a Ho"!ital- )ho )ere it" !ioneer"- and by other a$thor"high a''$ra'y ha" not al)ay" been re!rod$'ible- e"!e'ially )hen re"$lt" are analy"ed 'riti'ally. There are ery #e) #al"e !o"iti e" )ith re"!e't to malignan'y b$t there i" a de#inite #al"e,negati e rate )ith re"!e't to both benign and malignant neo!la"ia. .N6+ i" le"" reliable in 'y"ti' than in "olid ")elling"- o#ten yielding only 'y"t #l$id )ith ma'ro!hage" and degenerate 'ell".6#ter a"!iration a #$rther "am!le "ho$ld be ta5en #rom the 'y"t )all- #or 'ytology. Relati ely #e) 'y"t" are !ermanently aboli"hed by one or more a"!iration" and- be'a$"e o# the ri"5 o# malignan'y- re'$rrent 'y"t" "ho$ld be remo ed. Radiology. +he"t and thora'i' inlet radiogra!h" are only ne'e""ary )hen there i" 'lini'al e iden'e o# tra'heal de iation or 'om!re""ion or retro"ternal e%ten"ion. Other "'an". +T and MRI "'an" gi e e%'ellent anatomi'al detail o# thyroid ")elling" b$t ha e no role in the #ir"t line o# in e"tigation. They are o''a"ionally $"e#$l in a""e""ing re'$rrent and retro"ternal ")elling". The in'rea"ed $"e o# the"e imaging modalitie" in other head and ne'5 ")elling" ha" 'reated a ne) 'lini'al 'on$ndr$m )hi'h ha" been termed the =Thyroid In'identaloma9. The"e are 'lini'ally $n"$"!e'ted and im!al!able thyroid ")elling" )hi'h )ith #e) e%'e!tion" re>$ire no #$rther in e"tigation or "$rgery. Indire't laryngo"'o!y to determine the mobility o# the o'al 'ord" i" )idely $"ed !reo!erati ely- altho$gh $"$ally #or medi'olegal rather than 'lini'al rea"on".

;arge,bore needle &Tr$'$t( bio!"y. Tr$'$t bio!"y ha" a high diagno"ti' a''$ra'y b$t ha" !oor !atient 'om!lian'e and may be a""o'iated )ith 'om!li'ation" "$'h a" !ainbleeding- tra'heal and re'$rrent laryngeal ner e damage. It ha" little a!!li'ation in ro$tine a""e""ment e%'e!t in lo'ally ad an'ed- "$rgi'ally $nre"e'table malignan'y &either ana!la"ti' 'ar'inoma or lym!homa( )hen Tr$'$t bio!"y may a oid o!eration. The main indi'ation #or o!eration i" the ri"5 o# neo!la"ia )hi'h in'l$de" #olli'$lar adenoma a" )ell a" malignant ")elling". The rea"on #or ad o'ating the remo al o# all #olli'$lar neo!la"m" i" that iti" "eldom!o""ible to di"ting$i"h bet)een a #olli'$lar adenoma and 'ar'inoma 'ytologi'ally. The di"tin'tion $"$ally de!end" on hi"tologi'al e iden'e o# 'a!"$lar or a"'$lar in a"ion and .N6+ 'annot ma5e thi" di"tin'tionaltho$gh on o''a"ion 'ell$lar n$'lear #eat$re" may be "o abnormal a" to "$gge"t malignant 'hange. On thi" ba"i"- "ome 42 !er 'ent o# i"olated and14 !er 'ent o# dominant ")elling" "ho$ld be remo ed on the gro$nd" o# neo!la"ia. E en )hen the 'ytology i" negati e- the age and "e% o# the !atient and the "iCe o# the ")elling may be relati e indi'ation" #or "$rgery- e"!e'ially )hen a large ")elling i" re"!on"ible #or "ym!tom". Some !atient" are ha!!ier to ha e a ")elling remo ed e en )hen 'ytology i" negati e. There are $"e#$l 'lini'al 'riteria to a""i"t in "ele'tion #or o!eration a''ording to the ri"5 o# neo!la"ia and malignan'y. Hard te%t$re alone i" not reliable "in'e ten"e 'y"ti' ")elling" may be "$"!i'io$"ly hard b$t a hard- irreg$lar ")elling )ith any a!!arent #i%ity- )hi'h i" $n$"$al- i" highly "$"!i'io$". E iden'e o# re'$rrent laryngeal ner e !araly"i"- "$gge"ted by hoar"ene"" and a nono''l$"i e 'o$gh- and 'on#irmed by indire't laryngo"'o!y- i" almo"t !athognomoni'. 8ee! 'er i'al lym!hadeno!athy along the internal 7$g$lar ein in a""o'iation )ith a 'lini'ally "$"!i'io$" ")elling i" almo"t diagno"ti' o# !a!illary 'ar'inoma. In mo"t !atient"- ho)e er- "$'h #eat$re" are ab"ent b$t there are ri"5 #a'tor" a""o'iated )ith "e% and age. The in'iden'e o# thyroid 'ar'inoma in )omen i" abo$t three time" that in men- b$t a di"'rete ")elling in a male i" m$'h more li5ely to be malignant than in a #emale and it i" "eldom 7$"ti#iable to a oid remo ing "$'h a ")elling in a man. The ri"5 o# 'ar'inoma i" in'rea"ed at either end o# the age range and a di"'rete ")elling in a teenager o# either "e% m$"t be !ro i"ionally diagno"ed a" 'ar'inoma. The ri"5 in'rea"e" a" age ad an'e" beyond 42 year"- and more "o in male". Thyroid'y"t" Ro$tine .N6+ &or $ltra"onogra!hy( "ho)" that o er <2 !er 'ent o# 'lini'ally i"olated ")elling" 'ontain #l$id and are 'y"ti' or !artly 'y"ti'. Ten"e 'y"t" may be hard and mimi' 'ar'inoma. Aleeding into a 'y"t o#ten !re"ent" )ith a hi"tory o# "$dden !ain#$l ")elling )hi'h re"ol e" to a ariable e%tent o er a !eriod o# )ee5" i# $ntreated. 6"!iration yield" altered blood b$t re a''$m$lation i" #re>$ent. 6bo$t 42 !er 'ent o# 'y"ti' ")elling" are the re"$lt o# 'olloid degeneration- or o# $n'ertain aetiologybe'a$"e o# an ab"en'e o# e!ithelial 'ell" in the lining. 6ltho$gh mo"t o# the remainder are the re"$lt o# in ol$tion in #olli'$lar adenoma" &.ig. //.0B( "ome 02304 !er 'ent o# 'y"ti' #olli'$lar ")elling" are hi"tologi'ally malignant &<2 !er 'ent in male" and 02 !er 'ent in #emale"(. *a!illary 'ar'inoma i" o#ten a""o'iated )ith 'y"t #ormation &.ig. //.12(. Mo"t !atient" )ith di"'rete ")elling"- ho)e er- are #emale" aged 123/2 year" in )hom the ri"5 o# malignan'y- altho$gh "igni#i'ant- i" lo) and the indi'ation" #or o!eration are not 'lear '$t. .N6+ i" the mo"t a!!ro!riate in e"tigation to aid "ele'tion. The indi'ation" #or o!eration in i"olated or dominant thyroid ")elling" are li"ted in Table //./.

Retro"ternal goitre :ery #e) retro"ternal goitre" ari"e #rom e'to!i' thyroid ti""$eE mo"t ari"e #rom the lo)er !ole o# a nod$lar goitre. I# the ne'5 i" "hort and the !retra'heal m$"'le" are "trong- a" in men- the negati e intrathora'i' !re""$re tend" to dra) the"e nod$le" into the "$!erior media"tin$m. +lini'al #eat$re" 6 retro"ternal goitre i" o#ten "ym!tomle"" and i" di"'o ered on a ro$tine 'he"t radiogra!h. There may- ho)e er- be "e ere "ym!tom"@ dy"!noea- !arti'$larly at night- 'o$gh and "tridor &har"h "o$nd on in"!iration(. Many o# the"e !atient" may attend a 'he"t 'lini' )ith a diagno"i" o# a"thma be#ore the tr$e nat$re o# the !roblem i" di"'o eredE D dy"!hagiaE D engorgement o# ne'5 ein" and "$!er#i'ial ein" on the 'he"t )all. In "e ere 'a"e" there may be ob"tr$'tion o# the "$!erior ena 'a a &.ig. //.10(E D re'$rrent ner e !araly"i" i" rare. The goitre may al"o be malignant or to%i'. Radiogra!h" "ho) a "o#t,ti""$e "hado) in the "$!erior media"tin$m 3 "ometime" )ith 'al'i#i'ation 3 and o#ten 'a$"ing de iation and 'om!re""ion o# the tra'hea &.ig. //.0/(. Radio,gra!h" o# the thora'i' inlet gi e better de#inition than a 'he"t radiogra!h. Signi#i'ant tra'heal 'om!re""ion and ob"tr$'tion may be demon"trated ob7e'ti ely by a #lo)3 ol$me loo! !$lmonary #$n'tion te"t in )hi'h the rate o# #lo) i" !lotted again"t the ol$me o# air in"!ired and then e%!ired. 8eterioration in #lo) d$e to in'rea"e in tra'heal 'om!re""ion either a'$tely or in the long term may be $"ed to monitor !rogre""ion o# the di"ea"e and indi'ate the need #or "$rgery. The 'hange" are re er"ed by o!eration &.ig. //.11(. Treatment I# ob"tr$'ti e "ym!tom" are !re"ent in a""o'iation )ith thyroto%i'o"i" it i" $n)i"e to treat a retro"ternal goitre )ithantithyroid dr$g" or radioiodine a" the"e may enlarge the goitre. Re"e'tion 'an almo"t al)ay" be 'arried o$t #rom the ne'5 and a midline "ternotomy i" hardly e er ne'e""ary. The 'er i'al !art o# the goitre "ho$ld #ir"t be mobili"ed by ligation and di i"ion o# the "$!erior thyroid e""el"- and by ligat$re and di i"ion o# the middle thyroid ein" and the in#erior thyroid artery. The retro"ternal goitre 'an then be deli ered by tra'tion and #inger mobili"ation. Haemorrhage i" rarely a !roblem be'a$"e the goitre ta5e" it" blood "$!!ly )ith it #rom the ne'5. The re'$rrent laryngeal ner e "ho$ld be identi#ied i# !o""ible be#ore deli ering the retro"ternal goitre- a" it may be abnormally di"!la'ed and i" !arti'$larly $lnerable to in7$ry #rom tra'tion or tearing. I# a large m$ltinod$lar goitre 'annot be deli ered inta't #rom the retro"ternal !o"ition it may be bro5en )ith the #inger" and deli ered !ie'emeal- b$t thi" "ho$ld ne er he done i# the le"ion i" "olitary and there i" the !o""ibility o# 'ar'inoma. Hy!erthyroidi"m Thyroto%i'o"i" The term thyroto%i'o"i" i" retained be'a$"e hy!erthyroidi"m- i.e. "ym!tom" d$e to a rai"ed le el o# 'ir'$lating thyroid hormone"- i" not re"!on"ible #or all mani#e"tation" o# the di"ea"e. +lini'al ty!e" are@ D di##$"e to%i' goitre &Gra e"9 di"ea"e(E Dto%i' nod$lar goitreE Dto%i' nod$leE Dhy!erthyroidi"m d$e to rarer 'a$"e". 8i##$"e to%i' goitre

Gra e"9 di"ea"e 3 a di##$"e a"'$lar goitre a!!earing at the "ame time a" the hy!erthyroidi"m- $"$ally in the yo$nger )oman and #re>$ently a""o'iated )ith eye "ign". The "yndrome i" that o# !rimary thyroto%i'o"i" &.ig. //.1<(. The )hole o# the #$n'tioning thyroid ti""$e i" in ol ed- and the hy!ertro!hy and hy!er!la"ia are d$e to abnormal thyroid,"tim$lating antibodie" &T"6b(. To%i' nod$lar goitre 6 "im!le nod$lar goitre i" !re"ent #or a long time be#ore the hy!erthyroidi"m- $"$ally in the middle,aged or elderly and ery in#re>$ently a""o'iated )ith eye "ign". The "yndrome i" that o# "e'ondary thyroto%i'o"i". In many 'a"e" o# to%i' nod$lar goitre- the nod$le" are ina'ti e- and it i" the internod$lar thyroid ti""$e that i" o era'ti e. Ho)e er- in "ome to%i' nod$lar goitre"one or more nod$le" are o era'ti e and here the hy!erthyroidi"m i" d$e to a$tonomo$" thyroid ti""$e a" in a to%i' adenoma. To%i' nod$le Thi" i" a "olitary o era'ti e nod$le- )hi'h may be !art o# a generali"ed nod$larity or a tr$e to%i' adenoma. It i" a$tonomo$" and it" hy!ertro!hy and hy!er!la"ia are not d$e to T"6b. Ae'a$"e TSH "e'retion i" "$!!re""ed by the high le el o#'ir'$lating thyroid hormone"- the normal thyroid ti""$e "$rro$nding the nod$le i" it"el# "$!!re""ed and ina'ti e. Hi"tology The normal thyroid gland &.ig. //.1/( 'on"i"t" o# a'ini lined by #lattened '$boidal e!itheli$m and #illed )ith homogeneo$" 'olloid. In hy!erthyroidi"m &.ig. //.14( there i" hy!er!la"ia o#a'ini- )hi'h are lined by high 'ol$mnar e!itheli$m. Many o# them are em!ty and other" 'ontain a'$olated 'olloid. +lini'al #eat$re" The "ym!tom" are@ D tiredne""E D emotional labilityE Dheat intoleran'eE D )eight lo""E D e%'e""i e a!!etiteE D!al!itation". The "ign" o# thyroto%i'o"i" are@ D ta'hy'ardiaE D hot- moi"t !alm"E D e%o!hthalmo"E Dlid lagJretra'tionE DagitationE Dthyroid goitre and br$it. Sym!tomatology Thyroto%i'o"i" i" eight time" 'ommoner in #emale" than in male". It may o''$r at any age. The mo"t "igni#i'ant "ym!tom" are lo"" o# )eight in "!ite o# a good a!!etite- a re'ent !re#eren'e #or 'old- and !al!itation". The mo"t "igni#i'ant "ign" are the e%'itability o# the !atient- the !re"en'e o# a goitre- e%o!hthalmo"- and ta'hy'ardia or 'ardia' arrhythmia. The goitre in !rimary thyroto%i'o"i" i" di##$"e and a"'$lar- it may be large or "mall#irm or "o#t- and a thrill and a br$it may be !re"ent. The on"et i" abr$!t- b$t remi""ion" and e%a'erbation" are not in#re>$ent. Hy!erthyroidi"m i" $"$ally more "e erethan in "e'ondary thyroto%i'o"i" b$t 'ardia' #ail$re i" rare. Mani#e"tation" o#

thyroto%i'o"i" not d$e to hy!erthyroidi"m !er Se- e.g. orbital !ro!to"i"o!hthalmo!legia and !retibial my%oedema- may o''$r in !rimary thyroto%i'o"i". In "e'ondary thyroto%i'o"i" the goitre i" nod$lar. The on"et i" in"idio$" and may !re"ent )ith 'ardia' #ail$re or atrial #ibrillation. It i" 'hara'teri"ti' that the hy!erthyroidi"m i" not "e ere. Eye "ign" other than lid lag and lid "!a"m &d$e to hy!erthyroidi"m( are ery rare. +ardia' rhythm. 6 #a"t heart rate- )hi'h !er"i"t" d$ring "lee!- i" 'hara'teri"ti'. +ardia' arrhythmia" are "$!erim!o"ed on the "in$" ta'hy'ardia a" the di"ea"e !rogre""e"- and they are 'ommoner in older !atient" )ith thyroto%i'o"i" be'a$"e o# the !re alen'e o# 'oin'idental heart di"ea"e. Stage" o# de elo!ment o# thyroto%i' arrhythmia" are@ D m$lti!le e%tra"y"tole"E D !aro%y"mal atrial ta'hy'ardiaE D !aro%y"mal atrial #ibrillationE D !er"i"tent atrial #ibrillation- not re"!on"i e to digo%in. Myo!athy. Wea5ne"" o# the !ro%imal limb m$"'le" i" 'ommonly #o$nd i# loo5ed #or. Se ere m$"'$lar )ea5ne"" &thyroto%i' myo!athy( re"embling mya"thenia gra i" o''$r" o''a"ionally. Re'o ery !ro'eed" a" hy!erthyroidi"m i" 'ontrolled. Eye "ign". Some degree o# e%o!hthalmo" i" 'ommon &.ig. //.1<(. It may be $nilateral. Tr$e e%o!hthalmo" i" a !ro!to"i" o# the eye- 'a$"ed by in#iltration o# the retrob$lbar ti""$e" )ith #l$id and ro$nd 'ell"- )ith a arying degree o# retra'tion or "!a"m o# the $!!er eyelid. &;id "!a"m o''$r" be'a$"e the le ator !al!ebrae "$!eriori" m$"'le i" !artly inner ated by "ym!atheti' #ibre".( Thi" re"$lt" in )idening o# the !al!ebral #i""$re "o that the "'lera may be "een 'learly abo e the $!!er margin o# the iri" and 'ornea &abo e the =limb$"9(. S!a"m and retra'tion $"$ally di"a!!ear )hen the hy!erthyroidi"m i" 'ontrolled. They may be im!ro ed by <,adrenergi' blo'5ing dr$g"- e.g. g$anethidine eye dro!". Oedema o# the eyelid"- 'on7$n'ti al in7e'tion and 'hemo"i" are aggra ated by 'om!re""ion o# the o!hthalmi' ein" &.ig. //.1?(. Wea5ne"" o# the e%trao'$lar m$"'le"- !arti'$larly the ele ator" &in#erior obli>$e(- re"$lt" in di!lo!ia. In "e ere 'a"e"- !a!illoedema and 'orneal $l'eration o''$r. When "e ere and !rogre""i e- it i" 5no)n a" malignant e%o!hthalmo" &.ig. //.1F( and the eye may be de"troyed. Gra e"9 o!hthalmo!athy i" an a$toimm$ne di"ea"e in )hi'h there are antibody, mediated e##e't" on the o'$lar m$"'le". E%o!hthalmo" tend" to im!ro e )ith time. Slee!ing !ro!!ed $! and lateral tar"orrha!hy )ill hel! to !rote't the eye b$t )ill not !re ent !rogre""ion. Hy!othyroidi"m in'rea"e" !ro!to"i" by a #e) millimetre" and "ho$ld be a oided. Im!ro ement ha" been re!orted )ith ma""i e do"e" o# !redni"one. Intraorbital in7e'tion o# "teroid" i" dangero$" be'a$"e o# the eno$" 'onge"tion- and total thyroid ablation ha" not !ro ed e##e'ti e. When the eye i" in danger- orbital de'om!re""ion may be re>$ired &"ee 8y"thyroid e%o!hthalmo"(.*retibial my%oedema &.ig. //.1H( i" a thi'5ening o# the "5in by a m$'in,li5e de!o"it- nearly al)ay" a""o'iated )ith tr$e e%o!hthalmo"- !a"t or !re"ent hy!erthyroidi"m- and high le el" o# T"6b. 8iagno"i" o# thyroto%i'o"i" Mo"t 'a"e" are readily diagno"ed 'lini'ally. 8i##i'$lty i" mo"t li5ely to ari"e in the di##erentiation o# mild hy!erthyroidi"m #rom an an%iety "tate )hen a goitre i" !re"ent. In the"e 'a"e"- the thyroid "tat$" i" determined by the diagno"ti' te"t" de"'ribed earlier. 6 TRH te"t i" rarely indi'ated. T< thyroto%i'o"i" i" diagno"ed by e"timating the #ree T<. It "ho$ld be "$"!e'ted i# the 'lini'al !i't$re i" "$gge"ti e b$t ro$tine te"t" o# thyroid #$n'tion are )ithin the

normal range. 6 thyroid "'an i" e""ential in the diagno"i" o# an a$tonomo$" to%i' nod$le. Thyroto%i'o"i" "ho$ld al)ay" be 'on"idered in@ D 'hildren )ith a gro)th "!$rt- beha io$r !roblem" or myo!athyE Dta'hy'ardia or arrhythmia in the elderlyE D$ne%!lained diarrhoeaE D lo"" o# )eight. *rin'i!le" o# treatment o# thyroto%i'o"i" Non"!e'i#i' mea"$re" are re"t and "edation and- in e"tabli"hed thyroto%i'o"i"- "ho$ld be $"ed only in 'on7$n'tion )ith "!e'i#i' mea"$re" 3the $"e o# antithyroid dr$g""$rgery and radioiodine. 6ntithyroid dr$g" Tho"e in 'ommon $"e are 'arbimaCole and !ro!ylthio$ra'il. Aeta,adrenergi' blo'5er""$'h a" !ro!ranolol and nadolol- may al"o be $"ed. Iodide"- on'e tho$ght to red$'e the a"'$larity o# the thyroid- "ho$ld only be $"ed a" immediate !reo!erati e !re!aration in the 02 day" be#ore "$rgery. 6ntithyroid dr$g" are $"ed to re"tore the !atient to a e$thyroid "tate and to maintain thi" #or a !rolonged !eriod in the ho!e that a !ermanent remi""ion )ill o''$r- i.e. that !rod$'tion o# T"6b )ill dimini"h or 'ea"e. It "ho$ld be noted that antithyroid dr$g" 'annot '$re a to%i' nod$le. The o era'ti e thyroid ti""$e i" a$tonomo$" and re'$rren'e o# the hy!erthyroidi"m i" 'ertain )hen the dr$g i" di"'ontin$ed. 6d antage" No "$rgery and no $"e o# radioa'ti e material". 8i"ad antage" DTreatment i" !rolonged and the #ail$re rate a#ter a 'o$r"e o# 0.431 year" i" at lea"t 42 !er 'ent. Re'ently there ha" been a trend to)ard" the $"e o# "horter 'o$r"e" &?month"( o# the"e dr$g". DIt i" im!o""ible to !redi't )hi'h !atient i" li5ely to go into a remi""ion. K6ttem!t" ha e been made to !redi't )hi'h !atient" might rela!"e a#ter a ?,month 'o$r"e o# antithyroid dr$g" on the ba"i" o# h$man le$'o'yte antigen &H;6( "tat$" and the !re"en'e o# T"6b !rod$'tion.L DSome goitre" enlarge and be'ome ery a"'$lar d$ring treatment 3e en i# thyro%ine i" gi en at the "ame time. Thi" i" !robably d$e to T"6b "tim$lation d$ring the !rolonged 'o$r"e o# treatment and not a dire't e##e't o# the dr$g. D:ery rarely- there i" a dangero$" dr$g rea'tion- e.g. agran$lo'yto"i" or a!la"ti' anaemia. In the e ent o# agran$lo'yto"i"- the !atient "ho$ld be in"tr$'ted to di"'ontin$e treatment- i# a "ore throat de elo!"- $ntil the )hite 'ell 'o$nt ha" been 'he'5ed. Initially- 02 mg o# 'arbimaCole/ i" gi en three or #o$r time" a day- and there i" a latent inter al o# F30/ day" be#ore any 'lini'al im!ro ement i" a!!arent. It i" mo"t im!ortant to maintain a high 'on'entration o# the dr$g thro$gho$t the 1/ ho$r" by "!a'ing the do"e" at H, or ?,ho$rly inter al". When the !atient be'ome" e$thyroid- a maintenan'e do"e o# 4 mg t)o or three time" a day i" gi en #or another 0130H month". I# tri,iodothyronine &12 7ig$! to #o$r time" daily( or thyro%ine &2.0 mg daily( i" gi en in 'on7$n'tion )ith anti,thyroid dr$g"- there i" le"" danger o# !rod$'ing iatrogeni' thyroid in"$##i'ien'y or an in'rea"e in the "iCe o# the goitre &=blo'5 and re!la'ement treatment9(. S$rgery

In di##$"e to%i' goitre and to%i' nod$lar goitre )ith o era'ti e internod$lar ti""$e"$rgery '$re" by red$'ing the ma"" o# o era'ti e ti""$e. +$re i" !robable i# the thyroid ti""$e 'an be red$'ed belo) a 'riti'al ma"". Thi" may re"$lt in a red$'tion o# T"6b or it may be that 'ir'$lating T"6b- ho)e er high it" le el- 'an only !rod$'e limited hy!ertro!hy and hy!er!la"ia )hen the ma"" o# thyroid ti""$e i" "mall. In the a$tonomo$" to%i' nod$le- and in to%i' nod$lar goitre )ith o era'ti e a$tonomo$" to%i' nod$le"- "$rgery '$re" by remo ing all o# the o era'ti e thyroid ti""$e@ thi" allo)" the "$!!re""ed normal ti""$e to #$n'tion again. 6d antage" The goitre i" remo ed- the '$re i" ra!id and the '$re rate i" high i# "$rgery ha" been ade>$ate. 8i"ad antage" DRe'$rren'e o# thyroto%i'o"i" o''$r" in a!!ro%imately 4 !er 'ent o# 'a"e". DE ery o!eration 'arrie" a morbidity b$t )ith "$itable !re!aration and an e%!erien'ed "$rgeon the mortality i" negligible. D*o"to!erati e thyroid in"$##i'ien'y o''$r" in 123/4 !er 'ent o# 'a"e". D;ong,term #ollo),$! i" highly de"irable a" the #e) !atient" )ho de elo! re'$rren'e may do "o at any time in the #$t$re. In addition- altho$gh it i" $"$ally a!!arent )ithin a year or t)o- thyroid #ail$re may al"o he a late de elo!ment. D*arath roid in"$##i'ien'y@ thi" "ho$ld he !ermanent in le"" than 2.4 !er 'ent. Radioiodine Radioiodine4 de"troy" thyroid 'ell" and- a" in thyroide'tomy- red$'e" the ma"" o# #$n'tioning thyroid ti""$e to belo) a 'riti'al le el. 6d antage" No "$rgery and no !rolonged dr$g thera!y. 8i"ad antage" DI"oto!e #a'ilitie" m$"t be a ailable. DThere i" a high and !rogre""i e in'iden'e o# thyroid in"$##i'ien'y )hi'h may rea'h F43H2 !er 'ent a#ter 02 year". Thi" i" d$e to "$blethal damage to tho"e 'ell" not a't$ally de"troyed by the initial treatment and thi" e ent$ally 'a$"e" #ail$re o# 'ell$lar re!rod$'tion. DInde#inite #ollo),$! i" e""ential. There i" no 'on in'ing e iden'e that radioiodine ha" been re"!on"ible #or geneti' damage- le$5aemia- damage to the #oet$" i# gi en inad ertently in early !regnan'y- or 'ar'inoma in the ad$lt. In "ome 'lini'"- radioiodine i" gi en to almo"t all !atient" o er the age o# 14- i.e. )hen de elo!ment i" 'om!lete. .ollo),$! re>$irement" are red$'ed i# a total ablati e do"e o# radioiodine i" admini"tered #ollo)ed by ro$tine re!la'ement treatment )ith thyro%ine. In the UK- rel$'tan'e to !re"'ribe radioiodine $nder the age o# /4 ha" #aded. The do"e o# radioiodine arie" bet)een <22 and ?22 MA>. Re"!on"e i" "lo)- b$t a "$b"tantial im!ro ement i" to he e%!e'ted in H301 )ee5". 6''$rate do"age i" di##i'$lt and- "ho$ld there be no 'lini'al im!ro ement a#ter 01 )ee5"- a #$rther do"e i" gi en. T)o or more do"e" are ne'e""ary in 123< 2 !er 'ent o# 'a"e". +hoi'e o# thera!e$ti' agent Ea'h 'a"e m$"t be 'on"idered indi id$ally. Aelo) are li"ted g$iding !rin'i!le" on the mo"t "ati"#a'tory treatment #or a !arti'$lar to%i' goitre at a !arti'$lar ageE the"e m$"t ho)e er be modi#ied a''ording to the #a'ilitie" a ailable and the !er"onalityintelligen'e and )i"he" o# the indi id$al !atient- b$"ine"" or #amily 'ommitment" and any other 'oe%i"tent medi'al or "$rgi'al 'ondition. 8i##$"e to%i' goitre

O er /4@ radioiodine. Under /4@ "$rgery #or the large goitre- antithyroid dr$g" #or the "mall goitre. 6" mentioned abo e- radioiodine i" being in'rea"ingly $"ed in yo$nger !atient"- !arti'$larly )hen their #amilie" are 'om!lete. ;arge goitre" are $n'om#ortable and remi""ion )ith antithyroid dr$g" i" le"" li5ely than in the "mall goitre. To%i' nod$lar goitre S$rgery. To%i' nod$lar goitre doe" not re"!ond a" )ell or a" ra!idly to radioiodine or antithyroid dr$g" a" doe" a di##$"e to%i' goitre- and the goitre it"el# i" o#ten large and $n'om#ortable and enlarge" "till #$rther )ith antithyroid dr$g". To%i' nod$le S$rgery or radioiodine. Re"e'tion i" ea"y- 'ertain and )itho$t morbidity. Radioiodine i" a good alternati e o er the age o# /4 be'a$"e the "$!!re""ed thyroid ti""$e doe" not ta5e $! iodine and there i" th$" no ri"5 o# delayed thyroid in"$##i'ien'y. Re'$rrent thyroto%i'o"i" a#ter "$rgery In general radioiodine- b$t antithyroid dr$g" may be $"ed in yo$ng )omen intending to ha e 'hildren. .$rther "$rgery ha" no !la'e. .ail$reo# !re io$" treatment )ith antithyroid dr$g" or radioiodine. S$rgery or thyroid ablation )ith 01<I .In ad i"ing treatment- intelligen'e and 'om!lian'e are im!ortant@ $nintelligent !atient" 'annot be tr$"ted to ta5e dr$g" reg$larly i# they #eel )ell- and are $nli5ely to attend #ollo),$! 'lini'" inde#initely- )hi'h i" e""ential a#ter radioiodine or "$rgi'al thera!y. S!e'ial !roblem" in treatment *regnan'y. Radioiodine i" ab"ol$tely 'ontraindi'ated be'a$"e o# the ri"5 to the #oet$". The danger o# "$rgery i" mi"'arriageE and that o# anti,thyroid dr$g" i" o# ind$'ing thyroid in"$##i'ien'y in the mother- and be'a$"e both TSH and antithyroid dr$g" 'ro"" the !la'enta- o# the baby being born goitro$" &.ig. //.1B( and hy!othyroid. The ri"5 o# either "$rgery in the "e'ond trime"ter- in 'om!etent hand"- or 'are#$l admini"tration o# antithyroid dr$g"- i" ery "mall and the 'hoi'e i" e%a'tly a" in the $n'om!li'ated 'a"e. *o"t!art$m hy!erthyroidi"m. *regnan'y may lead to an e%a'erbation o# a ariety o# a$toimm$ne di"ea"e" in the !o"t!art$m !eriod. *o"t!art$m hy!erthyroidi"m may be a !roblem in a !atient !re io$"ly diagno"ed )ith hy!erthyroidi"m or may o''$r in a !atient )itho$t any !re io$" hi"tory o# thyroid di"ea"e. +hildren. Radioiodine i" 'ontraindi'ated be'a$"e o# the theoreti'al ri"5 o# ind$'ing thyroid 'ar'inoma. There i" an in'rea"ed ri"5 o# re'$rren'e a#ter thyroide'tomy be'a$"e thyroid 'ell" are highly a'ti e in the yo$ng. +hildren and adole"'ent" "ho$ld he treated )ith antithyroid dr$g" $ntil the late teen"- #ailing )hi'h total or near,total thyroide'tomy by an e%!ert "$rgeon "ho$ld be $nderta5en. Thethyro'ardia'. Thi" i" a !atient )ith "e ere 'ardia' damage d$e )holly or !artly to hy!erthyroidi"m. The !atient i" $"$ally middle aged or elderly )ith "e'ondary thyroto%i'o"i" and the hy!erthyroidi"m i" not ery "e ere. The 'ardia' 'ondition i" #ar more "igni#i'ant than the hy!erthyroidi"m- b$t thi" m$"t be ra!idly 'ontrolled to !re ent #$rther 'ardia' damage. Aetablo'5ade &!ro!ranolol( 'an a""i"t ra!id 'ontrol o# 'ardia' e##e't". Radioiodine i" the treatment o# 'hoi'e together )ith antithyroid dr$g" "tarted either be#ore or a#ter and 'ontin$ed $ntil the radioiodine ha" had an e##e't &$"$ally ? )ee5"(. High titre" o# thyroid antibodie". Their !re"en'e indi'ate" lym!hati' in#iltration o# the goitre- i.e. a di##$"e or #o'al thyroiditi"- and a liability to "!ontaneo$" remi""ion. The"e !atient" are be"t treated 'on"er ati ely b$t i# medi'al treatment #ail"- de#initi e treatment by o!eration or radioiodine i" not 'ontra,indi'ated. Steroid" may hel! to red$'e !ain and ")elling.

*ro!to"i" o# re'ent on"et. There i" a 'on entional ie) that to terminate thyroto%i'o"i" abr$!tly by thyroide'tomy or radioiodine )hen !ro!to"i" i" re'ent may ind$'e malignant e%o!hthalmo". Whil"t there i" no real !roo# o# thi" iti" rea"onable to treat the"e !atient" )ith anti,thyroid dr$g" $ntil the !ro!to"i" ha" been "tati' #or ? month" Hy!erthyroidi"m d$e to other 'a$"e" Thyroto%i'o"i" #a'titia. &U"$ally "een in health ='ran5"9 or tho"e gi en thyroid e%tra't a" =a toni'9.( Hy!erthyroidi"m may he ind$'ed by ta5ing thyro%ine- b$t only i# the do"age e%'eed" the normal re>$irement" o# 2.0432.14 mg a day. 8o"e" belo) the normal re>$irement" "im!ly "$!!re"" normal hormone !rod$'tion by the thyroid. 'retini"m Mod,Aa"edo) thyroto%i'o"i". &Mod IGerman #or iodineN Aa"edo). In E$ro!ean 'o$ntrie" di##$"e to%i' goitre i" o#ten 'alled Aa"edo)9" di"ea"e.( ;arge do"e" o# iodide gi en to a hy!er!la"ti' endemi' goitre )hi'h i" iodine a id may !rod$'etem!orary hy!erthyroidi"m- and ery o''a"ionally !er"i"tent hy!erthyroidi"m. In "$b a'$te or a'$te #orm" o# a$toimm$ne thyroiditi" or o# de O$er ain9" thyroiditi" &"ee later(- mild hy!erthyroidi"m mayo''$r in the early "tage" d$e to liberation o# thyroid hormone" #rom damaged ti""$e. 6 large ma"" o# "e'ondary 'ar'inoma )ill rarely !rod$'e "$##i'ient hormone to ind$'e mild hy!erthyroidi"m. Neonatal thyroto%i'o"i" o''$r" inbabie" hornto hy!erthyroid mother" or to e$thyroid mother" )hoha e had thyroto%i'o"i". High T"6b titre" are !re"ent in both motherand 'hild be'a$"e T"6b 'an 'ro"" the !la'ental barrier. The hy!erthyroidi"m grad$ally "$b"ide" a#ter <3/ )ee5"9 time a" the T"6b titre" #all in the baby9" "er$m. S$rgery #or thyroto%i'o"i" *reo!erati e !re!aration &.ig. //.<2( Traditional !re!aration aim" to ma5e the !atient e$thyroid or near e$thyroid at o!eration. Thethyroid "tate i"determined by'lini'al a""e""ment- i.e. by im!ro ement in !re io$" "ym!tom" and by ob7e'ti e "ign" "$'h a" gain in )eight and lo)ering o# the !$l"e rate- and by "erial e"timation" o# the thyroid !ro#ile. *re!aration i" a" an o$t,!atient and onlyrarely i" admi""ionto ho"!ital ne'e""ary on a''o$nt o#"e ere "ym!tom" at !re"entation or #ail$re to 'ontrolthe hy!erthyroidi"m. .ail$re to 'ontrol )ith antithyroid dr$g" i" $n$"$al b$t may bed$e to $ne en do"age-i.e. not ta5ing the dr$g at ?, or H,ho$rly inter al". +arbimaCole <23/2 mg a day i" the dr$g o# 'hoi'e #or !re!aration. When e$thyroid 3 a#ter H301 )ee5"3 the do"e may be red$'edto 4 mg H,ho$rly and the additiono# thyro%ine may #a'ilitate maintenan'e o# the e$thyroid "tate. The la"t do"e o# 'arbimaCole may he gi en on the e ening be#ore "$rgery. Iodide"?are not $"ed alone be'a$"e- i# the !atient need" !reo!erati e treatment- a more e##e'ti e dr$g "ho$ld be gi en. Iodide" may be gi en )ith 'arbimaCole #or 0230/ day" immediately be#ore o!eration b$t their $"e i" o# do$bt#$l al$e and ha" been gi en $! in many 'entre". 6n alternati e method o# !re!aration that a!!ear" to be "a#e i" to aboli"h the 'lini'al mani#e"tation" o# the to%i' "tate- $"ing beta,blo'5ing dr$g". Thi" re"$lt" in ery ra!id 'ontrol and o!eration may be arranged )ithin a )ee5 or t)o. The a!!ro!riate dr$g" are !ro!ranolol /2 mg three time" daily or- !re#erably- the longer a'ting nadolol 0?2 mg on'e daily. +lini'al re"!on"e to beta,blo'5ade i" ra!id and the !atient may be rea""e""ed )ithin day"@ i# 'lini'ally e$thyroid- an o!eration date may be arrangedE i# not- the do"e o# beta,blo'5er i" in'rea"ed )ith early rea""e""ment. O$ite o#ten larger do"e" are ne'e""ary.

Aeta,blo'5er" a't on the target organ" and not on the gland it"el#. *ro!ranolol inhibit" the !eri!heral 'on er"ion o# 0/ to0<. ;ong,a'ting betablo'5er"- e.g. nadolol- are no) al"o a ailable and are admini"tered on'e daily. They do not inter#ere )ith "ynthe"i" o# thyroid hormone"- "o that hormone le el" remain high d$ring treatment and #or "ome day" a#ter thyroide'tomy. Iti"- there#ore- im!ortant to 'ontin$e to gi e the dr$g #or F day" !o"to!erati ely. The addition o# iodine #or 02 day" be#ore o!eration gi e" an additional mea"$re o# "a#ety in 'a"e the early morning do"e o# beta,blo'5er on the day o# o!eration i" mi"ta5enly omitted &*l$mmer(. *ro!ranolol or nadolol 'ontrol "ym!tom" ery ra!idly and ha e additional al$e in 'ombination )ith 'arbimaCole in the immediate treatment o# !atient" )ith ery "e ere hy!erthyroidi"m. S$btotal thyroide'tomy *reo!erati e in e"tigation" to be 'arried o$t and re'orded are@ D thyroid #$n'tion te"t"E D indire't laryngo"'o!y 3it i" a matter #or lo'al !roto'ol" )hether thi" i" ro$tine. The o$t'ome "ho$ld ha e little im!a't on the o!eration be'a$"e e ery re'$rrent laryngeal ner e m$"t be ro$tinely and ob"e""ionally !re"er edE Dthyroid antibodie"E D"er$m 'al'i$m e"timationE Dan i"oto!e "'an be#ore !reo!erati e !re!aration i" ne'e""ary in !atient" )ith to%i' nod$lar goitre i# total thyroide'tomy i" not !lanned. The "$rgeon "ho$ld 5no) )hi'h nod$le"- i# any- are a$tonomo$" and a'ti e in order to en"$re their re"e'tion. 6 "'an i" o# no al$e in di##$"e to%i' goitre )hen $!ta5e- #or !ra'ti'al !$r!o"e"- i" $ni#orm. The diagno"i" o# a "ingle to%i' nod$le 'an only be made by demon"trating that the nod$le i" a'ti e and the remaining thyroid ti""$e "$!!re""ed. The e%tent o# the re"e'tion de!end" on the "iCe o# the gland- the age o# the !atient- the e%!erien'e o# the "$rgeon- the need to minimi"e the ri"5 o# re'$rrent to%i'ity and the )i"h to a oid !o"to!erati e thyroid re!la'ement. Th$" yo$ng !atient" )ith "mall gland" are at greate"t ri"5 o# re'$rren'e e en )ith ery "mall remnant "iCe". There i" an in'rea"ing trend to)ard" total thyroide'tomy )hi'h "im!li#ie" "$b"e>$ent management and ra!idly a'hie e" a !ermanent e$thyroid "tate on thyro%ine re!la'ement. In 'ontra"t- a !atient )ith a large goitre )ho )i"he" to a oid !o"to!erati e medi'ation i" "$itable #or "$btotal thyroide'tomy. Te'hni>$e. General anae"the"ia i" admini"tered thro$gh an endotra'heal t$be and good m$"'le rela%ation obtained. The !atient i" "$!ine on the o!erating table )ith the table tilted 04degree at the head end to red$'e eno$" engorgement. 6 "andbag i" !la'ed tran" er"ely $nder the "ho$lder" and the ne'5 e%tended &)ith 'are !arti'$larly in the elderly( to ma5e the thyroid gland more !rominent. 6 "5in 'rea"e in'i"ion i" made mid)ay bet)een the not'h o# the thyroid 'artilage and the "$!ra"ternal not'h. .la!" o# "5in- "$b'$taneo$" ti""$e and !laty"ma are rai"ed $!)ard" to the "$!erior thyroid not'h and do)n)ard" to the "$!ra"ternal not'h. The dee! 'er i'al #a"'ia i" di ided in the midline bet)een the "ternothyroid m$"'le" do)n to the !lane o# the thyroid 'a!"$le. The m$"'le" are not di ided a" a ro$tine b$t may be i# greater e%!o"$re i" re>$ired. The "ternothyroid m$"'le i" mobili"ed o## the thyroid lobe". In <2 !er 'ent o# !atient"- middle thyroid ein" !a""ing dire'tly into the internal 7$g$lar ein re>$ire ligation and di i"ion. The main blood "$!!ly i" the "$!erior thyroid artery )hi'h m$"t be ligated "e'$rely. The lobe i" then #ree to rotate o$t o# it" bed. The in#erior thyroid arterie" are not ro$tinely ligated to !re"er e !arathyroid blood "$!!ly. The re'$rrent laryngeal ner e "ho$ld be identi#ied in it" 'o$r"e in the

o!erati e #ield. It "ho$ld #ir"t he "o$ght belo) the le el o# the in#erior thyroid artery a" it !a""e" obli>$ely $!)ard" and #or)ard". Thi" 'o$r"e &.ig. //.<0(- obli>$e to the tra'hea and oe"o!hag$"- i" a''ent$ated by mobili"ation o# the thyroid lobe. I# not immediately "een- the ner e 'an $"$ally be !al!ated a" a ta$t "trand. 6t a higher le el the ner e lie" bet)een the bran'he" o# the in#erior thyroid artery. The ner e !a""e" into the laryn% immediately behind the in#erior e$ro o# the thyroid 'artilage )hi'h i" there#ore a ery im!ortant landmar5. I# the right ner e 'annot he #o$nd in it" $"$al 'o$r"e- an anomalo$" &nonre'$rrent( ner e- !re"ent in 0 !er 'ent o# 'a"e"- "ho$ld he "$"!e'tedE thi" ari"e" #rom the ag$" tr$n5 and $"$ally !a""e" #rom behind the 'arotid "heath- '$r ing medially- #or)ard" and $!)ard"- and may be mi"ta5en #or the in#erior thyroid artery. The !arathyroid gland" are !rote'ted by identi#i'ation on 'are#$l in"!e'tion o# the goitre be#ore re"e'tion and by a oiding ligat$re" and "$t$re" 'lo"e to the hil$m o# identi#ied gland". The $"e o# diathermy in thi" area "ho$ld he a oided a" heat 'ond$'tion may de a"'$lari"e the !arathyroid" or damage the re'$rrent laryngeal ner e" &.ig. //.01(. I# a !arathyroid gland i" inad ertently e%'i"ed or de a"'$lari"edit "ho$ld he a$totran"!lanted in "e eral #ragment" )ithin the "ternoma"toid m$"'le. S$btotal re"e'tion o# ea'h lobe i" 'arried o$t- lea ing a remnant o# bet)een / and 4 g on ea'h "ide. 6b"ol$te haemo"ta"i" i" "e'$red byligation o# indi id$al e""el" and by"$t$re o# the thyroid remnant" to the tra'heal #a"'ia. The !retra'heal m$"'le" amid 'er i'al #a"'ia are "$t$red and the )o$nd i" 'lo"ed )ith or )itho$t "$'tion drainage to the dee! 'er i'al "!a'e. *o"to!erati e 'om!li'ation" Haemorrhage. 6 ten"ion haematoma dee! to the 'er i'al #a"'ia &.ig. //.<<( i" $"$ally d$e to "li!!ing&I#a ligat$re on the "$!erior thyroid artery@ o''a"ionally haemorrhage #rom a thyroid remnant or a thyroid ein may he re"!on"ible. It may- on rare o''a"ion"- be ne'e""ary to re o!en the )o$nd inthe )ard to relie e ten"ion be#ore ta5ing the !atient to theatre to e a'$ate the haematoma and to tie o## a bleeding e""el. 6 "mall "$b'$taneo$" haematoma or 'olle'tion o# "er$m may #orm $nder the "5in #la!" and "ho$ld he e a'$ated or a"!irated in the #ollo)ing F1 ho$r". Thi" "ho$ld not be 'on#$"ed )ith the !otentially li#e,threatening dee! ten"ion haematoma. Re"!iratory ob"tr$'tion. Thi" i" ery rarely d$e to 'olla!"e or 5in5ing o# the tra'hea. Mo"t 'a"e" are d$e to laryngeal oedema. The mo"t im!ortant 'a$"e o# laryngeal oedema i" a ten"ion haematoma. Ho)e er- tra$ma to the laryn% by anae"theti' int$bation and "$rgi'al mani!$lation i" an im!ortant 'ontrib$tory #a'tor" 3 !arti'$larly i# the goitre i" ery a"'$lar 3and may 'a$"e laryngeal oedema )itho$t a ten"ion haematoma. Unilateral or bilateral re'$rrent ner e !araly"i" )ill not 'a$"e immediate !o"to!erati e re"!iratory ob"tr$'tion $nle"" laryngeal oedema i" al"o !re"ent- b$t they )ill aggra ate the ob"tr$'tion. I# relea"ing the ten"ion haematoma doe" not immediately relie e air)ay ob"tr$'tionthe tra'hea "ho$ld he int$bated at on'e. 6n endotra'heal t$be 'an he le#t in !la'e #or "e eral day"E "teroid" are gi en to red$'e oedema and a tra'heo"tomy i" rarely ne'e""ary. Int$bation in the !re"en'e o# laryngeal oedema may be ery di##i'$lt and "ho$ld be 'arried o$t by an e%!erien'ed anae"theti"tE re!eated $n"$''e""#$l attem!t" may in'rea"e ob"tr$'tion and 'a$"e "erio$" 'erebral ano%ia &Wade(. In an emergen'yiti" #ar "a#er #or the ine%!erien'ed "$rgeon to !er#orm a needle tra'heo"tomy a" a tem!orary mea"$reE a Medi'$t 01G needle &diameter 1.< mm( i" highly "ati"#a'tory. Re'$rrent laryngeal ner e!araly"i" may be $nilateral or bilateral- tran"ient or !ermanent &+ha!ter /<(. Tran"ient !araly"i" o''$r" in abo$t < !er 'ent o# ner e" at

ri"5 and re'o er" in < )ee5" to < month". *ermanent !araly"i" i" e%tremely rare i# the ner e ha" been identi#ied at o!eration. Thyroid in"$##i'ien'y. Thi" $"$ally o''$r" )ithin 1 year"- b$t it i" "ometime" delayed #or 4 year" or more. It i" o#ten in"idio$" and di##i'$lt to re'ogni"e. The in'iden'e i" 'on"iderably higher than $"ed to he tho$ght and #ig$re" o# 123/4 !er 'ent ha e been re!orted a#ter o!eration" on di##$"e to%i' goitre" and to%i' nod$lar goitre" )ith internod$lar hy!er!la"ia. It re!re"ent" a 'hange in the a$toimm$ne re"!on"e #rom "tim$lation to de"tr$'tion o# thyroid 'ell". There i"- ho)e er- a de#inite relation"hi! bet)een the e"timated )eight o# the thyroid remnant and the de elo!ment o# thyroid #ail$re a#ter "$btotal thyroide'tomy #or Gra e"9 di"ea"e. Thyroid in"$##i'ien'y i" rare a#ter "$rgery #or a to%i' adenoma be'a$"e there i" no a$toimm$ne di"ea"e !re"ent. *arathyroid in"$##i'ien'y i" d$e to remo al o# !arathyroid gland"- or in#ar'tion thro$gh damage to the !arathyroid end,arteryE o#ten both #a'tor" o''$r together. :a"'$lar in7$ry i" !robably #ar more im!ortant than inad ertent remo al. The in'iden'e o# thi" 'ondition "ho$ld be le"" than 2.4 !er 'ent and mo"t 'a"e" !re"ent dramati'ally 134 day" a#ter o!eration- b$t ery rarely the on"et i" delayed #or 13< )ee5" or a !atient )ith mar5ed hy!o'al'aemia i" a"ym!tomati'. Thyroto%i' 'ri"i" &"torm( i" an a'$te e%a'erbation o# hy!erthyroidi"m. It o''$r" i# a thyroto%i' !atient ha" been inade>$ately !re!ared #or thyroide'tomy- and i" no) e%tremely rare. :ery rarely- a thyroto%i' !atient !re"ent" in a 'ri"i" amid thi" may #ollo) an $nrelated o!eration. Sym!tomati' and "$!!orti e treatment i" #or dehydration- hy!er!yre%ia and re"tle""ne"". Thi" re>$ire" the admini"tration o# intra eno$" #l$id"- 'ooling the !atient )ith i'e !a'5"- admini"tration o# o%ygendi$reti'" #or 'ardia' #ail$re- digo%in #or $n'ontrolled atrial #ibrillation- "edation and intra eno$" hydro'orti"one. S!e'i#i' treatment i" by 'arbimaCole 02312 mg ?, ho$rly- ;$gol9" iodine 02 dro!" H,ho$rly by mo$th or "odi$m iodide 0 g intra eno$"ly &i. .(. *ro!ranolol /2 mg ?,ho$rly orally )ill blo'5 ad er"e beta, adrenergi' e##e't". Thi" agent may be gi en by 'are#$l intra eno$" admini"tration &0 31 mg( $nder !re'i"e ele'tro'ardiogra!hi' 'ontrol. Wo$nd in#e'tion. 6 "$b'$taneo$" or dee! 'er i'al ab"'e"" "ho$ld he drained. Hy!ertro!hi' or 5eloid "'ar i" more li5ely to #orm i# the in'i"ion o erlie" the "tern$m. Intradermal in7e'tion" &I#'orti'o"teroid "ho$ld he gi en at on'e and re!eated monthly i# ne'e""ary. Stit'h gran$loma. Thi" may o''$r )ith or )itho$t "in$" #ormation and i" "een a#ter the $"e o# nonab"orbable "$t$re material. 6b"orbable ligat$re" and "$t$re" m$"t be $"ed thro$gho$t thyroid "$rgery. Some "$rgeon" $"e a "$b'$ti'$lar ab"orbable "5in "$t$re rather than the traditional "5in 'li!" or "ta!le". S5in "ta!le" "ho$ld be remo ed in le"" than /H ho$r". *o"to!erati e 'are Indire't laryngo"'o!y ha" been ad i"ed a" a ro$tine be#ore lea ing ho"!ital. 6lternati ely- it may he a oided )hen the oi'e i" normal and the 'o$gh o''l$"i e.6bo$t 14 !er 'ent o# !atient" de elo! tran"ient hy!o'al'aemia and- i# a""o'iated "ym!tom" are "e ere- intra eno$" 'al'i$m gl$'onate or oral 'al'i$m may be ne'e""ary- altho$gh thi" i" $n$"$al. To "'reen #or !arathyroid in"$##i'ien'y- the "er$m 'al'i$m "ho$ld be mea"$red at the #ir"t re ie) attendan'e /3? )ee5" a#ter o!eration 6#ter o!eration- "tability in term" o# thyroid #$n'tion ta5e" time. It i" im!ortant that bio'hemi'al &"$b'lini'al( thyroid #ail$re "ho$ld not he aim indi'ation #or treatment d$ring the #ir"t year a" the ma7ority o# !atient" )ith early "$b'lini'al #ail$re- )hi'h i" 'ommon- $ltimately regain" normality. E en )hen there are 'lini'al #eat$re" o#

#ail$re- thyro%ine "ho$ld he )ithheld i# !o""ible d$ring the #ir"t ? month". Mo"t !atient" )ho de elo! thyroid #ail$re do "o )ithin the #ir"t 1 year"- b$t there i" a 'ontini$ing in'iden'e therea#ter. Re'$rrent thyroto%i'o"i" may o''$r at any time a#ter o!eration. .ollo),$! "ho$ld there#ore he #or li#e. On'e a "table "it$ation ha" been a'hie ed- #ollo),$! a#ter thyroid "$rgery may be 'arried o$t by an a$tomated 'om!$ter,a'ti ated "y"tem. S$'h "y"tem" in S'otland and Wale" ha e been "ho)n to be e%tremely 'o"t,e##e'ti e and dramati'ally red$'e the n$mber o# !atient attendan'e" at the thyroid 'lini'. The in'iden'e" >$oted #or thyroid #ail$re &123/4 !er 'ent( and re'$rrent thyroto%i'o"i" &4 !er 'ent( a#ter "$btotal thyroide'tomy #or Gra e"9 di"ea"e re#er to UK e%!erien'e arid may be di##erent el"e)here in the )orld. In i'eland- #or e%am!lean area o# high dietary iodine inta5e- the in'iden'e o# thyroid #ail$re i" m$'h lo)er amid that o# re'$rrent to%i'ity m$'h higher than in the UK. Neo!la"m" o# the thyroid Thyroid neo!la"m" are 'la""i#ied in Table //.4. Aenign t$mo$r" .olli'$lar adenoma" !re"ent a" 'lini'ally "olitary nod$le" and the di"tin'tion bet)een a #olli'$lar 'ar'inoma and an adenoma 'an only be made by hi"tologi'al e%amination@ in the adenoma there i" no in a"ion o# the 'a!"$le or o# !eri'a!"$lar blood e""el". Treatment i"- there#ore- by )ide e%'i"ion 3!re#erably a lobe'tomy. The remaining thyroid ti""$e i" normal "o that !rolonged #ollo) $! i" $nne'e""ary. It i" do$bt#$l )hether there i" "$'h an entity a" a !a!illaryadenoma and all !a!illary t$mo$r" "ho$ld be 'on"idered a"malignant e en i# en'a!"$lated. Malignant t$mo$r" The a"t ma7ority o# !rimary gro)th" i" 'ar'inoma" &Table //.?(. 8$nhill 'la""i#ied them hi"tologi'ally a" di##erentiated and $ndi##erentiated@ and the di##erentiated 'ar'inoma" are no) "$bdi ided into #olli'$lar and !a!illary. Se'ondary gro)th" are rare b$t blood,borne meta"ta"e" o''$r &.ig" //.</ and //.<4(.Alood borne meta"ta"e" more $"$ally o''$r #rom !rimary 'ar'inoma" o# brea"t- 'olon and 5idney and #rom melanoma". 6etiology o# malignant thyroid t$mo$r" 8i##erentiated thyroid 'ar'inoma- !arti'$larly !a!illary- #re>$ently #ollo)" a''idental irradiation o# the thyroid in 'hildhoodF. The in'iden'e o# #olli'$lar 'ar'inoma i" high in endemi' goitro$" area"- !o""ibly o)ing to TSH "tim$lation. Malignant lym!homa" 'an !re"ent in a !atient 5no)n to ha e a$toimm$ne thyroiditi"- "o that the lym!ho'yti' in#iltration in the a$toimm$ne !ro'e"" may be an aetiologi'al #a'tor. Indeed- iti" li5ely that all lym!homa" o# the thyroid ari"e in gland" a##e'ted by "$'h thyroiditi". +lini'al #eat$re" o# thyroid neo!la"m" The ann$al in'iden'e i" abo$t <.F !er 022 222 o# the !o!$lation and the "e% ratio i" three #emale" to one male. The mortality "ho$ld only be o# the order o# 13< !er 'ent. The 'ommone"t !re"enting"ym!tom i" a thyroid ")elling &.ig. //.<?( and a 4,year hi"tory i" #ar #rom $n'ommon indi##erentiated gro)th". Enlarged 'er i'al lym!h node" may be the !re"entation o# !a!illary 'ar'inoma. Re'$rrent laryngeal ner e !araly"i" may be a !re"enting #eat$re o# lo'ally ad an'ed di"ea"e. 6na!la"ti' gro)th" are $"$ally hard- irreg$lar and in#iltrating. 6 di##erentiated 'ar'inoma may be "$"!i'io$"ly #irm and irreg$lar- b$t i" o#ten indi"ting$i"hable #rom a benign ")elling. Small!a!illary t$mo$r" may be im!al!able &o''$lt 'ar'inoma( 3

e en )hen lym!hati' meta"ta"e" are !re"ent &"o,'alled lateral aberrant thyroid(. *aino#ten re#erred to the ear- i" #re>$ent in in#iltrating gro)th". 8iagno"i" o# thyroid neo!la"m" 8iagno"i" i" ob io$" on 'lini'al e%amination in mo"t 'a"e" o# ana!la"ti' 'ar'inomaaltho$gh Riedel9" thyroiditi" &"ee later( i" indi"ting$i"hable. The lo'ali"ed #orm" o# gran$lomato$" thyroiditi" and lym!hadenoid goitre may "im$late 'ar'inoma. It i" not al)ay" ea"y to e%'l$de a 'ar'inoma in a m$ltinod$lar goitre- and "olitary nod$le"!arti'$larly in the yo$ng male- are al)ay" "$"!e't. .ail$re to ta5e $! radio,iodine i" 'hara'teri"ti' o# almo"t all thyroid 'ar'inoma" Konly ery rarely )ill di##erentiated 'ar'inoma &!rimary or "e'ondary( ta5e $! 01<0in the !re"en'e o# normal thyroid ti""$eL- b$t o''$r" al"o in degenerating nod$le" and all #orm" o# thyroiditi". Thyroid antibody titre" are o#ten rai"ed in 'ar'inoma. The role o# .N6+ in !reo!erati e diagno"i" ha" already been di"'$""ed. No diagno"ti' te"t i" ab"ol$tely 'ertain- and e%!loration )ith e%'i"ion in the #orm o# lobe'tomy i" e""ential )hen indo$bt. In'i"ional bio!"y may 'a$"e "eeding o# 'ell" and lo'al re'$rren'e- and i" mo"t inad i"able ina re"e'table 'ar'inoma. In an ana!la"ti' and ob io$"ly irremo able 'ar'inoma- ho)e er- in'i"ional or needle bio!"y i" 7$"ti#ied. *a!illary 'ar'inoma Mo"t !a!illary t$mo$r" 'ontain a mi%t$re o# !a!illary and 'olloid,#illed #olli'le"- and in "ome the #olli'$lar "tr$'t$re !redominate". Ne erthele""- i# any !a!illary "tr$'t$re i" !re"ent- the t$mo$r )ill beha e in a !redi'table #a"hion a" a !a!illary 'ar'inoma. Hi"tologi'ally the t$mo$r "ho)" !a!illary !ro7e'tion" and 'hara'teri"ti' !ale- em!ty n$'lei &Or!han 6nnie,eyedH n$'lei( &.ig. //.<F(. *a!illary 'ar'inoma"are ery "eldom en'a!"$lated.M$lti!le #o'i may o''$r in the "ame lobe a" the !rimary t$mo$r or- le"" 'ommonly- in both lobe". They may be d$e to lym!hati' "!read in the ri'h intrathyroidal lym!h !le%$"- or to m$lti'entri' gro)th. S!read to the lym!h node" i" 'ommon b$t blood,borne meta"ta"e" are $n$"$al $nle"" the t$mo$r i" e%trathyroidal. The term e%trathyroidal indi'ate" that the !rimary t$mo$r ha" in#iltrated thro$gh the 'a!"$le o# the thyroid gland. O''$lt 'ar'inoma *a!illary 'ar'inoma may !re"ent a" an enlarged lym!h node in the 7$g$lar 'hain )ith no !al!able abnormality o# the thyroid. The !rimary t$mo$r may be no more than a #e) millimetre" in "iCe and i" termed o''$lt. S$'h !rimary #o'i o# !a!illary 'ar'inoma may al"o be di"'o ered in thyroid ti""$e re"e'ted #or other rea"on"- e.g. Gra e"9 di"ea"e. The term o''$lt i" no) a!!lied to all !a!illary 'ar'inoma" le"" than 0.4 'm in diameter. The"e ha e an e%'ellent !rogno"i" and are regarded a" o# little 'lini'al "igni#i'an'e. .olli'$lar 'ar'inoma The"e a!!ear to be ma'ro"'o!i'ally en'a!"$lated b$t mi'ro"'o!i'ally there i" in a"ion o# the 'a!"$le and o# the a"'$lar "!a'e" in the 'a!"$lar region &.ig. //.<H(. M$lti!le #o'i are "eldom "een and lym!h node in ol ement i" m$'h le"" 'ommon than in !a!illary 'ar'inoma. Alood,borne meta"ta"e" are almo"t t)i'e a" 'ommon and the e ent$al mortality rate i" t)i'e a" high &.ig. //.<B(. H$rthle 'ell t$mo$r" are a ariant o# #olli'$lar neo !la"m in )hi'h o%y!hil &H$rthle- 6"5anaCy( 'ell" !redominate hi"tologi'ally. It i" do$bt#$l )hether H$rthle 'ell neo!la"m" are e er benign and they may be a""o'iated )ith a !oorer !rogno"i". 8i##eren'e" bet)een !a!illary and #olli'$lar 'ar'inoma The ma7or di##eren'e" bet)een !a!illary &in'l$ding mi%ed !a!illary and #olli'$lar( and #olli'$lar 'ar'inoma ha e been "et o$t by +ady on the ba"i" o# an analy"i" o# /2 year"9 e%!erien'e at the ;ahey +lini' &Table //.F(.

*rogno"i" in di##erentiated thyroid 'ar'inoma The !rogno"i" o# di##erentiated thyroid 'ar'inoma - altho$gh in#l$en'ed byhi"tologi'al ty!e- i" m$'h more de!endent onage- the !re"en'e o# e%trathyroidal "!read or ma7or 'a!"$lar tran"gre""ion &in #olli'$lar 'ar'inoma(- and the "iCe o# the t$mo$r. Re'ently"e eral "'oring "y"tem" ba"ed on m$lti,#a'torial analy"i" o# ri"5 #a'tor" #rom retro"!e'ti ely gathered data ha e been de i"ed. On the ba"i" o# age- t$mo$r "!read"iCe and hi"tology- the"e allo) "e!aration o# !atient" into lo),and high,ri"5 gro$!" )ith 14,year mortality rate" o# 1 !er 'ent and /? !er 'ent- re"!e'ti ely. With regard to age- the !rogno"i" i" m$'h )or"e in male" o er the age o# /2 year" and in #emale" o er 42 year". 8i"tant meta"tati' di"ea"e i" ob io$"ly an ad er"e !rogno"ti' #a'tor b$t lym!h node meta"ta"e" are not a""o'iated )ith )or"e !rogno"i". 8e#inition" o# lo), and high,ri"5 gro$!" ba"ed on data #rom the ;ahey +lini' are gi en in Table //.H. *atient" in the lo),ri"5 gro$! a''o$nt #or B2 !er 'ent o# 'a"e" o# di##erentiated thyroid 'ar'inoma. S$rgi'al treatment There i" 'ontin$ing di"agreement on the mo"t a!!ro!riate o!eration #or di##erentiated thyroid 'ar'inoma. The 'on"er ati e a!!roa'h ad o'ate" lobe'tomy )ith i"thm$"e'tomy in mo"t !atient" )ith total thyroide'tomy re"er ed #or "!e'i#i' indi'ation" & iC- tho"e )ith bilateral di"ea"e or 7$dged to be in a high,ri"5 'ategory(. The more radi'al a!!roa'h ad o'ate" ro$tine total thyroide'tomy o#ten a" a "taged !ro'ed$re de!ending on the !athologi'al #inding" o# the initial lobe'tomy. The 'a"e #or a !oli'y o# total thyroide'tomy i" theoreti'ally ba"ed on the !re alen'e o# m$lti#o'ality in !a!illary 'ar'inoma and on the #ea"ibility therea#ter o# $"ing radioiodine "'anning to dete't meta"ta"e"- the thyroid ha ing been ablated &.ig. //./2(. Ho)e er- the 'lini'al "igni#i'an'e o# m$lti#o'ality i" lo) a" lo'al re'$rren'e i" in#re>$ent a#ter $nilateral re"e'tion. In addition- in tho"e "ele'ted !atient" in )hom "'anning may be indi'ated- the remaining thyroid ti""$e may be ablated "a#ely )ith a !reliminary do"e o# radioiodine. Mo"t im!ortantly there i" no e iden'e that the long, term re"$lt" o# ro$tine total thyroide'tomy a" a !oli'y are better than tho"e o# more 'on"er ati e o!eration"- and there i" a "$b"tantial ri"5 o# !ermanent hy!o!arathyroidi"m. +learly the ri"5 o# !arathyroid damage arie" a''ording to e%!erti"e and the #re>$en'y )ith )hi'h the o!eration i" done b$t- e en at the Mayo +lini'- )here thyroid "$rgery i" #re>$ently and e%!ertly done- the rate o# hy!o!arathyroidi"m i" "igni#i'ant &Hay(. The large ma7ority o# !atient" )ith di##erentiated 'ar'inoma- !arti'$larly "in'e B2 !er 'ent #all into a gro$! )ith a 1 !er 'ent mortality rate- i" a!!ro!riately treated by lobe'tomy )ith i"thm$"e'tomy on the a##e'ted "ide. 6t the "ame time 'lini'ally ob io$" node"- )hi'h may be !retra'heal- !aratra'heal or in the 7$g$lar 'hain- are remo ed. I# the 7$g$lar node" are e%ten"i ely in ol ed- a modi#ied ne'5 di""e'tion )ith !re"er ation o# the a''e""ory ner e and "ternoma"toid m$"'le may be 'arried o$t thro$gh e%ten"ion o# the thyroide'tomy in'i"ion. :ery o''a"ionally it may be ne'e""ary to "a'ri#i'e the re'$rrent laryngeal ner e i# it i" 'om!letely en'ir'led andon e en more rare o''a"ion"- e%trathyroidal "!read may re>$ire re"e'tion o# !art o# the tra'hea. When there i" 'lini'ally ob io$" bilateral di"ea"e at o!eration- bilateral re"e'tion i" 'learly indi'ated and bilateral re"e'tion may al"o be indi'ated in the #e) !atient" 'la""i#ied a" high ri"5- altho$gh the e iden'e at !re"ent #or im!ro ed !rogno"i" i" rather )ea5. Retro"!e'ti e analy"i" o# o$t'ome in H?2 !atient" )ith !a!illary 'ar'inoma treated at the Mayo +lini' bet)een 0B/? and 0BF2 "ho)ed im!ro ed

"$r i al in high,ri"5 !atient" $ndergoing bilateral re"e'tion- 'om!ared )ith lobe'tomy alone- altho$gh the di##eren'e )a" not "tati"ti'ally "igni#i'ant &Hay(. There )a" no ad antage #or total 'om!ared )ith near,total thyroide'tomy in )hi'h 031 g o# thyroid ti""$e i" !re"er ed on the 'ontralateral "ide to !rote't the blood "$!!ly to one or more !arathyroid gland". S$rgi'al o!eration" I"thm$"e'tomy. S)elling" 'on#ined to the thyroid i"thm$"- in'l$ding "mall di##erentiated 'ar'inoma"- may be a!!ro!riately remo ed by re"e'tion o# the i"thm$" alone. I"thm$"e'tomy i" al"o an e##e'ti e method o# relie ing tra'heal ob"tr$'tion and obtaining ti""$e #or diagno"i" in ana!la"ti' 'ar'inoma and lym!homa. Thyroid lobe'tomy. Total lobe'tomy on the, a##e'ted "ide together )ith i"thm$"e'tomy i" the a!!ro!riate o!eration #or remo al o# a di"'rete thyroid ")elling and #or mo"t !atient" )ith di##erentiated 'ar'inoma. The !ro'ed$re- i# !er#ormed meti'$lo$"ly by an e%!erien'ed "$rgeon- i" a""o'iated )ith ery little ri"5 o# !o"to!erati e 'om!li'ation" "$'h a" re'$rrent laryngeal ner e in7$ry. The !arathyroid gland" "ho$ld be "een and !re"er ed in "it$ i# !o""ibleE altho$gh the inta't gland" on the 'ontralateral "ide )ill en"$re normal #$n'tion- remo al o# the 'ontralateral lobe may o''a"ionally be ne'e""ary in the #$t$re. It i" $nne'e""ary to ligate the main tr$n5" o# the in#erior thyroid arterie". In"tead- the indi id$al arterial bran'he" "$!!lying the thyroid gland "ho$ld be ligated 'lo"e to the thyroid- !re"er ing the !arathyroid blood "$!!ly. The re'$rrent laryngeal ner e i" 'are#$lly e%!o"ed thro$gho$t the di""e'tion. It i" !arti'$larly $lnerable 'lo"e to )here it ang$late" !o"teriorly to enter the laryn%at )hi'h "ite it i" intimately related to the lateral thyroid ligament &ligament o# Aerry(. Near,total thyroide'tomy. Thi" 'on"i"t" o# total thyroid lobe'tomy on the a##e'ted "ide- )ith 'on"er ation o# 031 g o# thyroid ti""$e on the 'ontralateral "ide- )hi'h !re"er e" the blood "$!!ly to one or both !arathyroid". Total thyroide'tomy. The te'hni>$e i" e""entially that o# bilateral lobe'tomy and- i# meti'$lo$"- the ri"5 o# 'om!li'ation" i" ery lo) e%'e!t #or !ermanent hy!o!arathyroidi"m. The ri"5 o# hy!o!arathyroidi"m i" ariable b$t may be a!!re'iable e en in e%!erien'ed hand". 6dditional mea"$re" Thyro%ine. It i" "tandard !ra'ti'e to !re"'ribe thyro%ine in a do"e o# 2.032.1 mg daily- to "$!!re"" endogeno$" TSH !rod$'tion- #or all !atient" a#ter o!eration #or di##erentiated thyroid 'ar'inoma on the ba"i" that "ome t$mo$r" are TSH de!endent. S$!!re""ion o# the TSH le el "ho$ld be 'on#irmed by mea"$rement. .ail$re o# "$!!re""ion to a le el o# P2.0 i.tJlitre may indi'ate an inade>$ate do"e o# thyro%ine or more $"$ally that the !atient i" non'om!liant. Ho)e er- "$!!re""i e thyro%ine i" !robably not o# al$e in #olli'$lar 'ar'inoma- and i" $nli5ely to be o# bene#it in lo), ri"5 !atient" treated by lobe'tomy.Thyroid hormone re!la'ement i" ob io$"ly ne'e""ary a#ter total thyroide'tomy and in the ma7ority o# !atient" a#ter near,total thyroide'tomy- and i" $"$ally gi en in the #orm o# thyro%ine. *atient" )ith !otential or a't$al di"tant meta"ta"e" )ho may re>$ire re!eated radioiodine admini"tration #or "'anning and thera!y "ho$ld be gi en tri,iodothyronine &?23H 2 mgJday( be'a$"e it i" m$'h "horter a'ting- and on "to!!ing it- in'rea"ed TSH "e'retion and thyroid a idity #or iodine re'o er >$i'5ly "o that radioiodine may be gi en a#ter "e eral day". The !atient i" thereby "!ared )ee5" o# de elo!ing thyroid in"$##i'ien'y a#ter "to!!ing thyro%ine be#ore radioiodine may be gi en. Radioiodine. I# meta"ta"e" ta5e $! radioiodine they may be dete'ted by "'anning and may be treated )ith large do"e" o# radioiodine. .or e##e'ti e "'anning- all thyroid ti""$e m$"t ha e been ablated by either "$rgery or !reliminary radioiodine and the

!atient m$"t be hy!othyroid to im!ro e $!ta5e. The indi'ation" #or "'anning a#ter o!eration" #or di##erentiated 'ar'inoma are di"!$ted- b$t it i" !robably only indi'ated in !atient" )ith $nre"e'table lo'al re'$rren'e or meta"tati' di"ea"e- high,ri"5 !atient"and in tho"e )ith a ri"ing "er$m thyroglob$lin le el. In addition- i# meta"ta"e" ta5e $! radioiodine they are li5ely to be "$!!re""ed a" e##e'ti ely by treatment )ith thyro%ine a" by radioiodine. +a"e" in )hi'h "$!!re""ion ha" #ailed and radioiodine ha" gi en !ermanent 'ontrol a!!ear to be $n'ommon. I# meta"ta"e" ha e been treated- the "'an "ho$ld be re!eated at ann$al inter al" and #$rther thera!e$ti' do"e" o# radioiodine gi en a" ne'e""ary. Solitary di"tant meta"ta"e" may be treated by e%ternal radiothera!y. Thyroglob$lin. The mea"$rement o# "er$m thyroglob$lin i" o# al$e in the #ollo),$! and in the dete'tion o# meta"tati' di"ea"e in !atient" )ho ha e $ndergone "$rgery #or di##erentiated thyroid 'an'er. Thi" mea"$rement may ob iate the need #or "erial radioa'ti e iodine "'anning b$t )hen a ri"e o''$r"- a "'an )ill be indi'ated to 'on#irm and lo'ate the meta"tati' di"ea"e. Thyroglob$lin le el" are- ho)e er- only an ad7$n't to 'are#$l 'lini'al !al!ation o# the ne'5 be'a$"e lo'al re'$rren'e dete'table 'lini'ally may be !re"ent )ith a lo) thyroglob$lin. Undi##erentiated &ana !la"ti'( 'ar'inoma Thi" o''$r" mainly in elderly )omen and i" m$'h le"" o#ten diagno"ed no) than in the !a"t )hen many thyroid lym!homa" )ere mi"ta5enly 'la""i#ied hi"tologi'ally a" ana!la"ti' 'ar'inoma". ;o'al in#iltration i" an early #eat$re o# the"e t$mo$r" )ith "!read by lym!hati'" and by the blood"tream. They are e%tremely lethal t$mo$r" and "$r i al #or more than 031 year" a#ter !re"entation i" mo"t $n$"$al. In mo"t 'a"e" death o''$r" )ithin month" rather than )ithin year". 6n attem!t at '$rati e re"e'tion i" only 7$"ti#ied i# there i" no in#iltration thro$gh the thyroid 'a!"$le and no e iden'e o# meta"ta"e". Many o# the"e aggre""i e le"ion" !re"ent in an ad an'ed "tage )ith tra'heal ob"tr$'tion and re>$ire $rgent tra'heal de'om!re""ion. The tra'hea may be de'om!re""ed and ti""$e obtained #or hi"tology by i"thm$"e'tomy. Tra'heo"tomy i" be"t a oided. Radiothera!y "ho$ld be gi en in all 'a"e" and may !ro ide a )orth)hile !eriod o# !alliation a" may 'ombination 'hemothera!y Kin'l$ding do%or$bi'in &6driamy'in(L. Med$llary 'ar'inoma The"e are t$mo$r" o# the !ara#olli'$lar &+(,'ell" deri ed #rom the ne$ral 're"t and not #rom the 'ell" o# the thyroid #olli'le a" are other !rimary thyroid 'ar'inoma". The 'ell" are not $nli5e tho"e o# a 'ar'inoid t$mo$r and there i" a 'hara'teri"ti' amyloid "troma &.ig. //./0(. High le el" o# "er$m 'al'itonin &Q2.2H ngJml( are !rod$'ed by many med$llar t$mo$r". The"e le el" #all a#ter re"e'tion o# a t$mo$r and )ill ri"e again i# the t$mo$r re'$r". Thi" i" a al$able t$mo$r mar5er in the #ollo),$! o# !atient" )ith thi" di"ea"e. 8iarrhoea i" a #eat$re in <2 !er 'ent o# 'a"e" and thi" may be d$e to 4,hydro%ytry!tamine or !ro"taglandin" !rod$'ed by the t$mo$r 'ell". Some t$mo$r" are #amilial and may a''o$nt #or 02312 !er 'ent o# all 'a"e". Med$llary 'ar'inoma may o''$r in 'ombination )ith adrenal !haeo'hromo'ytoma and hy!er!arathyroidi"m &$"$ally d$e to hy!er!la"ia( in the "yndrome 5no)n a" m$lti!le endo'rine neo!la"ia ty!e ha &MEN IIa(. The #amilial #orm o# the di"ea"e #re>$ently a##e't" 'hildren and yo$ng ad$lt" )herea" the "!oradi' 'a"e" o''$r at any age )ith no "e% !redominan'e. When the #amilial #orm i" a""o'iated )ith !rominent m$'o"al ne$roma" in ol ing the li!"- tong$e &.ig. //./1( and inner a"!e't o# the eyelid"- )ith o''a"ionally a Mar#anoid hahit$"- the "yndrome i" re#erred to a" MEN ty!e IIb.

In ol ement o# lym!h node" o''$r" in 423?2 !er 'ent o# 'a"e" o# med$llary 'ar'inoma and blood,borne meta"ta"e" are 'ommon. 6" )o$ld be e%!e'ted- t$mo$r" are not hormone de!endent and do not ta5e $! radioa'ti e iodine. The 'o$r"e o# the t$mo$r i" $n!redi'tableE in general- li#e e%!e'tan'y i" e%'ellent i# the t$mo$r i" 'on#ined to the thyroid gland- good a" long a" meta"ta"e" are 'on#ined to the 'er i'al lym!h node" and !oor on'e blood,borne meta"ta"e" are !re"ent. Treatment i" by total thyroide'tomy and re"e'tion o# in ol ed lym!h node" )ith either a radi'al or modi#ied radi'al ne'5 di""e'tion. .amilial 'a"e" are no) dete'ted by geneti' "'reening #or the RET on'ogene m$tation" )hi'h identi#ie" indi id$al" )ho )ill de elo! med$llary 'an'er later in li#e &.ig. //./<(. The geneti' te"t" are "$!!lemented by e"timating "er$m 'al'itonin le el" in the ba"al "tate and a#ter "tim$lation by either 'al'i$m or !entaga"trin. 6 ri"e in 'al'itonin le el" $nder the"e 'ir'$m"tan'e" "ho$ld lead to a !ro!hyla'ti' thyroide'tomy b$t e en then the di"ea"e may be beyond the !rein a"i e +,'ell hy!er!la"ia "tage &.ig. //.//(. *haeo'hromo'ytoma m$"t be e%'l$ded by mea"$rement o# $rinary 'ate'holamine le el" &+ha!ter /4(in all 'a"e" be#ore embar5ing $!on thyroid "$rgery to a oid the !otential haCard" a""o'iated )ith thi" 'ondition. Malignant lym!homa In the !a"t- many malignant lym!homa" )ere diagno"ed a" "mall ro$nd,'ell ana!la"ti' 'ar'inoma". Re"!on"e to irradiation i" good &.ig. //./4( and radi'al "$rgery i" $nne'e""ary on'e the diagno"i" i" e"tabli"hed by bio!"y. 6ltho$gh the diagno"i" may be made or "$"!e'ted on .N6+- "$##i'ient material i" "eldom a ailable #or imm$no'yto'hemi'al 'la""i#i'ation- and large,needle &Tr$'$t( or o!en bio!"y i" $"$ally ne'e""ary. In !atient" )ith tra'heal 'om!re""ion- i"thm$"e'tomy i" the mo"t a!!ro!riate #orm o# bio!"y. The !rogno"i" i" good i# there i" no in ol ement o# 'er i'al lym!h node". Rarely the t$mo$r i" !art o# )ide"!read malignant lym!homa di"ea"e- and the !rogno"i" in the"e 'a"e" i" )or"e. Thyroiditi" +hroni' Iym!ho'yti' &a$toimm$ne( thyroiditi" Thi" 'ommon 'ondition i" $"$ally a""o'iated )ith rai"ed titre" o# thyroid antibodie". Not in#re>$ently there i" a #amily hi"tory o# other a$toimm$ne di"ea"e. It 'ommonly !re"ent" a" a m$ltinod$lar goitre )ith e"tabli"hed or "$b'lini'al thyroid #ail$realtho$gh it may !re"ent a" a di"'rete ")elling. .eat$re" o# 'hroni' lym!ho'yti' &#o'al( thyroiditi" are 'ommonly !re"ent on hi"tologi'al e%amination in a""o'iation )ith other thyroid di"ea"e 3 notably to%i' goitre. *rimary my%oedema )itho$t dete'table thyroid enlargement re!re"ent" the end "tage o# the !athologi'al !ro'e"". +lini'al #eat$re" 6" might be e%!e'ted #rom the aried hi"tologi'al !i't$re &abo e(- the on"et- the thyroid "tat$" and the ty!e o# goitre ary !ro#o$ndly #rom 'a"e to 'a"e. The on"et may be in"idio$" and a"ym!tomati'- or "o "$dden and !ain#$l that it re"emble" the a'$te #orm o# gran$lomato$" thyroiditi". Mild hy!erthyroidi"m may be !re"ent initially- b$t hy!othyroidi"m i" ine itable and may de elo! ra!idly or e%tremely "lo)ly. The goitre i" $"$ally lob$lated- and may be di##$"e or lo'ali"ed to one lobe. It may be large or "mall- and "o#t- r$bbery or #irm in 'on"i"ten'y 3 de!ending $!on the 'ell$larity and the degree o# #ibro"i". The di"ea"e i" 'ommone"t in )omen at the meno!a$"e- b$t may o''$r at any age. *a!illary 'ar'inoma and malignant lym!homa are o''a"ionally a""o'iated )ith a$toimm$ne thyroiditi". 8iagno"i"

Aio'hemi'al te"t" o# thyroid #$n'tion ary )ith the thyroid "tat$" and are o# diagno"ti' al$e only i# hy!othyroidi"m i" !re"ent. Signi#i'antly- rai"ed titre" o# one or more thyroid antibodie" are !re"ent in o er H4 !er 'ent o# 'a"e". Ne erthele""di##erential diagno"i" #rom nod$lar goitre- 'ar'inoma and malignant lym!homa o# the thyroid i" not al)ay" ea"y. .N6+ i" the mo"t a!!ro!riate in e"tigation altho$gh ab$ndant lym!ho'yte" may ma5e the 'ytologi'al di"tin'tion bet)een a$toimm$ne thyroiditi" and lym!homa di##i'$lt &.ig. //./?(. When there i" do$bt abo$t neo!la"ti' di"ea"e- )hi'h may 'oe%i"t )ith thyroiditi"- o!eration i" ne'e""ary. Treatment .$ll re!la'ement do"age o# thyro%ine "ho$ld be gi en #or hy!othyroidi"m and i# the goitre i" large or "ym!tomati'- be'a$"e "ome &$nder TSH "tim$lation( may "$b"ide )ith hormone thera!y. More minor mani#e"tation" o# the 'ondition "$'h a" a "mall goitre )ith rai"ed antibody titre"- or hi"tologi'al e iden'e o# thyroiditi" in a""o'iation )ith other thyroid di"ea"e- do not 7$"ti#y thyro%ine re!la'ement i# thyroid #$n'tion i" bio'hemi'ally normalE ho)e er- long,term "$r eillan'e i" ne'e""ary be'a$"e o# the ri"5 o# late thyroid #ail$re. O''a"ionally the goitre in'rea"e" in "!ite o# hormone treatment and in the"e 'ir'$m"tan'e" there may be a #a o$rable re"!on"e to "teroid thera!y. Thyroide'tomy may be ne'e""ary i# the goitre i" large and 'a$"e" di"'om#ort. The 'lini'ian m$"t- ho)e er- be 'a$tio$" )hen a lym!ho'yti' goitre in'rea"e" in "iCe and be'ome" $nre"!on"i e to thyro%ine a" thi" may be d$e to the de elo!ment o# malignant lym!homa. Gran$lomato$" thyroiditi" &"$ba'$te thyroiditi" 3de O$er ain9" thyroiditi"( Thi" i" d$e to a ir$" in#e'tion. &6n e!idemi' re!orted #rom I"rael )a" d$e to a m$m!" ir$".( In a ty!i'al "$ba'$te !re"entation there i" !ain in the ne'5- #e ermalai"e and a #irm- irreg$lar enlargement o# one or both thyroid lobe". There i" a rai"ed erythro'yte "edimentation rate and ab"ent thyroid antibodie"- the "er$m T/ i" high- normal or "lightly rai"ed- and the01< I $!ta5e o# the gland i" lo) The 'ondition i" "el#,limiting and in a #e) month" the goitre ha" "$b"idedE "$b"e>$ent hy!othyroidi"m i" rare. In 02 !er 'ent o# 'a"e" the on"et i" a'$tethe goitre ery !ain#$l and tender- and there may be "ym!tom" o# hy!erthyroidi"m. Thirty,#i e !er 'ent o# 'a"e" are a"ym!tomati' b$t #or the !re"en'e o# the goitre. I# diagno"i" i" in do$bt- it may be 'on#irmed by .N6+- radioa'ti e iodine $!ta5e and by a ra!id "ym!tomati' re"!on"e to !redni"one. The "!e'i#i' treatment #or the a'$te 'a"e )ith "e ere !ain i" to gi e !redni"one 02312 mg daily #or F day" and the do"e i" then grad$ally red$'ed o er the ne%t month. Riedel9" thyroiditi" Thi" i" ery rare- a''o$nting #or 2.4!er 'ent o# goitre". Thyroid ti""$e i" re!la'ed by 'ell$lar #ibro$" ti""$e )hi'h in#iltrate" thro$gh the 'a!"$le into ad7a'ent m$"'le"!aratra'heal 'onne'ti e ti""$e and the 'arotid "heath". It may o''$r in a""o'iation )ith retro!eritoneal and media"tinal #ibro"i" and i" mo"t !robably a 'ollagen di"ea"e. The goitre may be $nilateral or bilateral and i" ery hard and #i%ed. The di##erential diagno"i" #rom ana!la"ti' 'ar'inoma 'an only be made )ith 'ertainty by bio!"y- )hen a )edge o# the i"thm$" "ho$ld al"o be remo ed to #ree the tra'hea. I# $nilateral- the other lobe i" $"$ally in ol ed later and "$b"e>$ent hy!othyroidi"m i" 'ommon. .$rther reading +ohn- K.H.- Aa'5dahl- M.- .or""l$nd- +. et al. &0BH/( Aiologi' 'on"ideration" and o!erati e "trategy in !a!illary thyroid 'an'er@ arg$ment" again"t the ro$tine !er#orman'e o# total thyroide'tomy. S$rgery- B?-

B4F3F2. +$"i'5- E.;.- Kr$5o)"5i- Z.H. and Mathe"on- N.6. &0BHF( O$t'ome o# "$rgery #or Gra e"9 di"ea"e re i"ited. Ariti"h Mo$rnal o# S$rgery- F/- FH23<. Harne""- M.K.- .$ng- ;.- Thom!"on- N.W et al. &0BH?( Total thyroide'tomy@ 'om!li'ation" and te'hni>$e. World Mo$rnal o# S$rgery- 02- FH 03H. Hay- I.8.- Grant- +.S.- Taylor- W.. and M'+onahey- WM. &0BHF( I!"ilateral lobe'tomy er"$" bilateral lobe re"e'tion in !a!illary thyroid 'ar'inoma@ a retro"!e'ti e analy"i" o# "$rgi'al o$t'ome $"ing a no el !rogno"ti' "'oring "y"tem. S$rgery- 021- 02HH3B4. Mathe"on- N.6. &0BH4( 6 +olo$r 6tla" o# Thyroid ;obe'tomy- Wol#e Medi'al;ondon. MaCCa#erri- E.;. &0BB<( Management o# a "olitary thyroid nod$le. Ne) England Mo$rnal o# Medi'ine- <1H- 4 43B. Wheeler- M.H. and ;aCar$"- M.H. &0BB/( 8i"ea"e" o# the Thyroid. *atho!hy"iology and Management- +ha!man R Hall- ;ondon.