Thyroiditis Symptoms and Treatment

Thyroiditis

• Bacterial infection of the thyroid is very rare because of the rich blood supply.
• Thyroiditis is broadly classified into granulomatous, autoimmune and Riedel’s thyroiditis.

Granulomatous Thyroiditis

• It is also called subacute thyroiditis or de Quervain’s disease.
• This occurs due to viral infection and usually follows sore throat. (Mumps virus has been incriminated in a few cases.)
• Patients present with fever, body aches, and painful enlargement of the thyroid gland. The gland is enlarged, tender to touch, soft to firm and a few symptoms of hyperthyroidism occur initially.
• ESR is increased.

Granulomatous Thyroiditis Treatment

The majority of the patients respond to conservative treatment in the form of analgesics and a short course of prednisolone. There are no permanent sequelae of this condition.

Read And Learn More: Clinical Medicine And Surgery Notes

Autoimmune Thyroiditis

• Hashimoto’s thyroiditis is the main component of thyroiditis.
• Autoimmune aetiology is characterised by extensive lymphocytic infiltration resulting in the destruction of thyroid follicles with variable degrees of fibrosis.
• Females in the perimenopausal group (40–50 years) are commonly affected. Initially, symptoms of mild hyperthyroidism (hashitoxicosis) may be present. Later, extensive intrathyroidal fibrosis results in permanent hypothyroidism.
• The thyroid follicles are destroyed by significant fibrosis. The deep eosinophilic-staining thyroid follicular cell, Askanazy cell, is characteristic.
• The gland can be firm to hard and sometimes rubbery in consistency, smooth or irregular and can involve a lobe or the entire gland.
• In many cases, thyroid antibodies are raised, suggesting an autoimmune disorder.

Autoimmune Thyroiditis Treatment

1. Thyroxine 0.2 mg/day is given as a supplementary dose.
2. If there is compression on the trachea, an isthmusectomy is done to relieve compression.
3. If the goitre is big and causing discomfort, subtotal thyroidectomy can also be done.

Complications of Hashimoto’s thyroiditis

1. Permanent hypothyroidism
2. Papillary carcinoma of the thyroid
3. Malignant lymphoma.

Riedel’s Thyroiditis

• This is a very, very rare cause of a goitre which is supposed to be a collagen disorder.
• It can be associated with mediastinal fibrosis, retroperitoneal fibrosis sclerosing cholangitis.
• In this condition, there is intrathyroidal fibrosis but extrathyroidal fibrosis is more common.
• Involvement of trachea, oesophagus, internal jugular vein, carotid artery, etc., results in dysphagia and dyspnoea.
• As a result of fibrosis, all the thyroid follicles are replaced by fibrous tissue.
• By the time patients present at the hospital, it is an advanced stage and excision is very difficult.

Riedel’s Thyroiditis Treatment

• Treatment with thyroxine may be necessary to treat hypothyroidism.
• In selected difficult cases, isthmusectomy can be tried to relieve compression on the trachea. Three types of thyroiditis

Complications Of Thyroidectomy

1. Haemorrhage can be a primary haemorrhage which occurs on the table.

• Reactionary haemorrhage is more dangerous and occurs within 6–8 hours after surgery.
• This is due to slipping of ligature because of straining, coughing, hypertension, etc.
• It is a tension haematoma which develops deep to deep fascia, compressing the larynx.
• Re-exploration of the neck under GA, control of bleeding points and evacuation of
  haematoma should be done immediately.
• Without evacuating haematoma, an attempt to intubate the patient may result in cardiac arrest (as such patient will be struggling).

2. Respiratory obstruction can be due to tension haematoma resulting in compression of the larynx, collapse, and tracheal cartilage softening (tracheomalacia).

• Endotracheal intubation and a dose of steroid is necessary.

3. Laryngeal nerve paralysis

• Unilateral recurrent laryngeal nerve (RLN) palsy produces a whispering voice, the opposite vocal cord compensates. There will not be problems of aspiration or airway obstruction.
• Bilateral recurrent nerve palsy: It is also known as bilateral abductor paralysis. Both the vocal cords come to be in the median or paramedian position, and the airway is inadequate causing dyspnoea and stridor but the voice is good.
  • Treatment: Tracheostomy is required as an emergency procedure. Following
    tracheostomy, the patient is followed up on an outpatient basis for a period of 8–9 months.
  • This period is required for any spontaneous recovery. No recovery may be expected after this period and would require a permanent solution.
  • The choice is between a permanent tracheostomy with a speaking valve or surgery to lateralise the cord which can be done by the endoscopic method.
  • The former relieves stridor and preserves good voice but has the disadvantage of a tracheostomy in the neck.
  • The latter relieves airway obstruction but at the expense of good voice. However, there is no tracheostomy hole in the neck.
• Superior laryngeal nerve paralysis: This results in paralysis of the cricothyroid muscle, a consequence of which is the weak and husky voice and the inability to raise the pitch of the voice (this is of particular importance in singers).
• Combined (complete paralysis)

1. Unilateral

• This results in paralysis of all muscles of the larynx on one side. The vocal cord will be in a cadaveric position.
• The healthy cord is unable to approximate the paralysed cord, thus causing glottic incompetence. This results in hoarseness of voice and aspiration of liquids through the glottis.
• The cough is ineffective due to air wastage.
• Treatment includes the procedures to medialise the cord and speech therapy.

Bilateral:

• This is an uncommon condition. This results in paralysis of all the intrinsic muscles of the larynx. Both vocal cords assume a cadaveric position. There is also total anaesthesia of the larynx.

4. Permanent hypothyroidism can develop slowly after thyroid surgery, especially after subtotal thyroidectomy for Graves’ disease. It takes 2–3 years for manifestation of hypothyroidism.

5. Permanent hypoparathyroidism is managed with calcium tablets or with 1,25-dihydroxy cholecalciferol.

6. Thyrotoxic crisis (storm)

• The thyrotoxic storm occurs in patients with primary thyrotoxicosis who are improperly treated or prepared for surgery. At surgery, due to the handling of the gland, the sudden release of thyroxine into the systemic circulation results in a thyrotoxic crisis.
• Hyperpyrexia above 105°F, severe sweating, gross dehydration, hypovolemic shock, and tachycardia are the diagnostic features.
• It is treated by the following measures
  1. Correction of dehydration by rapid I.V. fluids.
  2. Cold tepid sponging, to control the temperature.
  3. 4 propranolol 2–4 mg with ECG monitoring and oral propranolol. In spite of the above treatment, mortality is high.

Thyrotoxic Storm Prevention

• Euthyroid before surgery
• β blockers, Carbimazole
• Lugol’s iodine
• Good anaesthesia
• Perfect haemostasis
• Gentle manipulation

7. Wound infection: It is not common to get a wound infection after thyroid surgery. However, antibiotics are started if there is evidence of local erythema or tenderness and if the patient has a fever.

8. Scar hypertrophy and keloid

9. Stitch granuloma: This may occur with/without sinus formation and is seen after the use of nonabsorbable suture material.

• Absorbable ligatures and sutures (Vicryl) can be used throughout thyroid surgery except for skin closure where silk is still appropriate.

Miscellaneous Lingual Thyroid

• Occasionally, a patient presents with a small swelling in the middle of the tongue at the junction of anterior 2/3 and posterior 1/3 of the tongue.
• It could be lingual thyroid —an aberrant thyroid tissue found in the region of foramen caecum on the tongue.
• Foramen caecum represents the junction of the epithelial floor of the mouth with the proximal portion of the thyroglossal duct.
• Even though lingual thyroid is rare, it can give rise to significant complications.

Swelling Clinical Features

• Swelling of the tongue in the classical location. It is firm in consistency and can be irregular.
• There may be impaired speech, dysphagia and haemorrhage.

Ectopic Thyroid Tissue

• Lingual thyroid
• Thyroglossal ectopic thyroid—in the upper part of the neck
• Struma ovarii—malignant ovarian teratoma containing thyroid tissue

Ectopic Thyroid Tissue Treatment

The lingual thyroid may be the only thyroid tissue present in a patient. Hence, a thyroid scan is done to confirm the presence of normal thyroid tissue.

A small dose of thyroxine may decrease the size of the swelling (similar to a puberty goitre). Large swelling with significant symptoms needs to be excised.

Clinical Examination Of Thyroid Swelling

Diseases of the thyroid are very common and thyroid swellings are very often common cases in an undergraduate and postgraduate clinical examination. Hence, before discussing the various diseases of the thyroid gland, various aspects of the “CLINICS” are discussed in detail below.

Dyspnoea In Goitre—Causes

• Infiltration into trachea Anaplastic carcinoma
• Lower border not seen Retrosternal goitre
• Tracheomalacia Long standing MNG
• Cardiac failure Secondary thyrotoxicosis

Complaints-History

1. Swelling: Long duration of thyroid swelling indicates benign condition, e.g. multinodular goitre (MNG), colloid goitre, etc.
   • Short duration with rapid growth indicates malignancy, such as anaplastic carcinoma. The majority of thyroid swellings do not produce pain.
2. Rate of growth: Usually slow growing in benign disease.
   • If it is a rapid growth, it can be de novo malignancy or malignancy developing in a benign lesion, e.g. follicular carcinoma in MNG.
   • The sudden increase in the size of swelling with pain indicates a haemorrhage in the MNG (multinodular goitre).
3. Dyspnoea: Difficulty in breathing can be due to the following reasons
   1. Small goitre, rapid growth—anaplastic carcinoma infiltrating the trachea
   2. When the lower border is not seen, retrosternal goitre.
   3. Long-standing MNG compresses on tracheal cartilages and produces pressure atrophy of tracheal cartilages. This is called tracheomalacia.
4. Dysphagia is relatively uncommon because the oesophagus is a posterior structure and it is a fibromuscular tube.
5. Hoarseness of voice indicates malignancy. It always occurs in carcinoma thyroid infiltrating the recurrent laryngeal nerve (never in benign diseases of the thyroid).
6. Toxic features suggestive of hyperthyroidism
   1. CNS symptoms are predominantly seen in Graves’ disease (primary thyrotoxicosis
      • Tremors of the hand
      • Waiting
      • Intolerance to heat
      • Preference to cold
      • Excitability
      • Irritability
      • Promise
   2. Cardiovascular symptoms (CVS) are predominantly seen in secondary thyrotoxicosis. Even though both forms of thyrotoxicosis produce palpitations, it is a significant complaint in multinodular goitre with thyrotoxicosis (secondary thyrotoxicosis). Precordial chest pain and dyspnoea on exertion are the late manifestations of secondary thyrotoxicosis.
   3. Gastrointestinal tract (GIT) symptoms such as increased appetite, diarrhoea, and weight loss despite a good appetite are commonly seen in primary thyrotoxicosis.
      • It is mandatory to consider the diagnosis of primary thyrotoxicosis in a young girl who presents with GIT symptoms and thyroid swelling.
   4. Menstrual disturbance Oligomenorrhoea is common.
7. Symptoms of hypothyroidism Poor appetite, abnormal deposition of fat in the supraclavicular region, intolerance to cold, failing memory, deep hoarse voice, and lethargy are typically seen in myxoedema. Snt eyes are observed by other persons. Double vision and oedema of the conjunctiva can be the presenting complaints.
8. Sudden pain, thyroid swelling and fever suggest autoimmune thyroiditis. Bacterial thyroiditis is a very rare cause of goitre.