Follicular cell
Secretes 90% T4 and 10%T3
TBG binds 75% of t4
Thyroid Exam
Anterior
Midline
Neck
Structure
Below
Thyroid
Cartilage
Observe
Observe neck
Note any pulsation,
asymmetry, or scars
Skin changes
erythema, edema
Observe
Observe deglutition
(swallowing)
Thyroid will move up
and down due to
action of inferior
pharyngeal constrictor
muscles
Useful to evaluate
nodules/masses from
lipoma
Ausculation
Ausculation bruit
Palpation
Palpate both lobes and
isthmus
Note texture, shape,
density of
nodules/masses,
tenderness
Mobility palpate
movement with
deglutition
Thyroid Exam
Palpate carotid pulse
Tracheal Deviation
Palpate for thrill/ bruit
Multiple nodules vs
single vs goiter
Eye
Exam
Lid
retraction
Exopthalm
os
Observe for tremor,
palmar hyperhidrosis
or erythema
Observe nail beds for
clubbing, onycholysis
Pembertons sign
https://
www.youtube.com/wat
ch?v=r1dkasbE7v8
Hyperthyroidism will
have tachycardia
Thyroid Disease
Hypothyroidism (too little thyroid hormone)
Hyperthyroidism (too much thyroid hormone)
Thyroid nodule/thyroid cancer
Hypothyroidism
Hypothyroidism
In US, 0.3% overt have hypothyroidism and
4.3% subclinical hypothyroidism
More common in women with age over 60
years
Signs and Symptoms of
Hypothyroidism
Signs and Symptoms of
Hypothyroidism
Slowing of metabolic causes
Symptoms:
Fatigue and weakness, Cold intolerance,
Weight gain, Cognitive dysfunction,
Constipation
Signs: slower movement/ speech,
delayed relaxation of tendon reflexes,
bradycardia
Signs and Symptoms of
Hypothyroidism
Accumulation of Matrix Substances
Symptoms: Dry skin, hoarseness, edema
Signs: coarse skin, puff facies, loss of
eyebrows, periorbial edema, tongue
enlargement
Signs and Symptoms of
Hypothyroidism
Other
Symptom: decreased hearing, myalgia,
depression, menorrhagia, arthralgia,
puberty delay
Signs: diastolic hypertension, Plural and
pericardial effusions, ascites,
galactorrhea
Causes of Hypothyroidism
Primary (defect at end organ, thyroid),
99%
Secondary (defect at pituitary, TSH),
Tertiary (defect at Hypothalamus, TRH)
Central Hypothyroidism
Peripheral (extrathyroidal)
Reduced action of thyroid hormone
Consumptive hypothyroidism
Causes of Hypothyroidism
Iodine deficiency (worldwide most
common)
Autoimmune Thyroid Disease
Hashimotos thyroiditis (most common in
US)
Autoimmune Disease
Medications
lithium, interferon alpha, amiodarone, or excessive iodine
ingestion (Kelp), tyrosine kinase inhibitors (Sunitinib)
Post RAI therapy, thyroid nodular disease, external
beam radiation for neck/head cancer
Central Hypothyroidism from pituitary or
Hashimotos Thyroiditis
5-10x more common in females than males
Diagnosed via elevated anti-thyroid antibodies:
TPO Ab
Elevated TPO Ab titers help predict progression
to overt hypothyroidism
Autoimmune disease
Autoimmune disease such as type 1 diabetes and
Addisons disease associated with hypothyroidism
Type I Polyglandular autoimmune syndrome
Hypoparathyroidism, Addisons disease,
mucocutaneous candidasis caused by defective AIRE
gene; autoimmune thyroid disease in 15%
Type II Polyglandular Autoimmune syndrome
(Schmidts Syndrome)
Addisons disease, autoimmune thyroid disease,
and DM1
Central Hypothyroidism
(secondary & tertiary)
May be congenital or acquired insufficient
production of TSH
Causes include
pituitary or hypothalamic tumors
Caused by
Inflammatory (lymphocytic or granulomatous
hypophysitis)
Infiltrative disease
Hemorrhagic necrosis (Sheehan s syndrome)
Surgery or treatment of pituitary or
hypothalamic disease
Diagnostic Tests
TSH is best diagnostic test then check free t4
anti TPO antibodies
Total cholesterol, LDL
NHANES III
Iodine Sufficient population
1.3% or 2.6 million people had thyrotoxicosis
4-5% of older women
Signs and
Symptoms
of
Hyperthyroidism
Signs and Symptoms
Classic Symptoms:
Nervousness, fatigue, weakness, Heat
intolerance/excessive sweating, Palpitations,
Anxiety, increased bowel frequency,
Shortness of breath, poor concentration,
oligomenorrhea
Signs:
Weight loss, hair loss, tachycardia, proximal
myopathy, moist skin, stare/lid
lag/exophthalmos, emotional lability,
hyperactive reflexes, thyroid enlargement,
Thyroid Gland
Large thyroid = goiter
Graves eye disease
Signs: Exophthalmos, lid retraction, stare, lid lag,
and conjunctiva injected
Chronic pretibial
Pretibial myxedema
Hyperthyroid
manifestations
Cardiac: Heart rate increased, Systolic
hypertension, and Atrial fibrillation
Metabolic : Hyperglycemia, amenorrhea,
hypercalcemia
Gastrointestinal : weight loss, increased gut
motility, malabsorption, dysphagia
Bone: thinning of bone, increased calcium in
blood
Neuropsychiatric: insomnia, anxiety, poor
concentration, confusion
Causes of
Thyrotoxicosis
Thyrotoxicosis Etiologies
with normal to elevated
uptakes
Autoimmune Thyroid Disease
Graves Disease (most common)
Hashitoxicosis
Autonomous Thyroid Tissue
Toxic Adenoma
Toxic Multinodular Goiter
TSH Mediated Hyperthyroidism
TSH secreting pituitary adenoma
HCG Mediated Hyperthyroidism
Hyperemesis gravidarum
Trophoblastic disease
Thyrotoxicosis with low
uptake
Thyroiditis
Painless/Silent/Post partum thyroiditis
Subacute Thyroiditis
Amiodarone induced
Radiation thyroiditis
Exogenous thyroid intake
Too much exogenous thyroid hormone
Too much suppressive ATD
Factious hyperthyroidism
Ectopic Hyperthyroidism
Struma ovarii
Metastatic follicular cancer
Work up for
Thyrotoxicosis
Tests to order
TSH
Free T4
Free or total T3
TSI,TSH receptor antibody
ESR if pain present
Tg if suspecting exogenous intake
So you have low TSH with
elevated T3/T4
Do not order RAI if patient is pregnant or nursing!
(I 123 used not I 131)
Hamburger Thyrotoxicosis
An unusual form of exogenous thyrotoxicosis
occurred in the midwestern portion of the
United States in 1984 and 1985. The source
was the inclusion of large quantities of bovine
thyroid in ground beef preparations
Treatment
Considerations
Surgery: Risks of infections, parathyroid injury,
vocal cord injury, lifelong levothyroxine
therapy