Non-cancerous Diseases of the Thyroid
What is hyperthyroidism? What are the reasons?
Hyperthyroidism is caused by excess thyroid hormone in the blood.
The most common;
Graves' disease,
Toxic nodular goiter,
Some drugs,
Some thyroid inflammations (thyroiditis)
It rarely occurs due to reasons such as thyroid cancer.
Of these, Graves' disease, toxic multinodular goiter (there is more than one nodule) and single toxic nodule are the most important for the surgeon.
Graves' disease
What are the causes of Graves' disease?
Graves' disease is a condition in which the thyroid increases in size (goiter) and secretes excess thyroid hormone (hyperthyoidism) without any nodules.
It occurs when the body damages its own thyroid tissue (autoimmune).
However, the exact reason why this process begins is unknown.
With this; conditions such as postpartum period, excess iodine in the body, use of lithium-containing drugs, and bacterial and viral infections have been suggested as possible triggers.
There may also be a genetic predisposition to Graves' disease.
Some Graves' patients may also have other autoimmune diseases such as type 1 diabetes, Addison's disease, pernicious anemia and myasthenia gravis.
What are the symptoms of Graves' disease?
Clinical manifestations of Graves' disease can be divided into those related to hyperthyroidism and those specific to Graves' disease.
Symptoms of hyperthyroidism include; These include heat intolerance, increased appetite and thirst, and weight loss despite adequate calorie intake.
Palpitations, irritability, fatigue, emotional lability, hyperactivity, and tremors may also occur.
Bowel movements may increase and diarrhea may occur.
In female patients, menstrual cessation, decreased fertility, and an increased risk of miscarriage are generally observed.
While children experience rapid growth with early bone maturation, elderly patients may experience cardiovascular problems such as palpitations and heart failure.
In examination; Thyroid size has increased enough to be noticed by eye.
Weight loss and facial flushing may be evident.
The skin is warm and moist.
Approximately 50% of patients with Graves' disease develop eye symptoms.
Gynecomastia is common in young men.
Some bone development anomalies may occur.
What tests are performed for Graves' disease?
For diagnosis, it is necessary to look at TSH, fT4 and T3 values.
In some cases, scintigraphy may also be needed.
Although not specific, anti-thyroglobulin and anti-thyroid peroxidase values are found to be elevated.
If necessary, magnetic resonance (MRI) or computed tomography (CT) may be performed to evaluate eye findings.
How is Graves disease treated?
In the treatment of Graves' disease, medications that suppress thyroid hormone secretion (antithyroid drugs), RAIA (Radioactive iodine ablation) or surgical removal of the thyroid gland (thyroidectomy) may be involved.
Which method to choose is decided according to various criteria.
When and how is drug treatment administered for Graves' disease?
Antithyroid medications are often given in preparation for RAI ablation or surgery.
These medications work by reducing the production of thyroid hormones or stopping the conversion of T4 to T3 in the body.
Commonly used drugs are propylthiouracil (PTU, between 100-300 mg per day) and methimazole (between 10-30 mg per day). Dosage adjustment varies from patient to patient.
Thyroid hormone levels usually return to normal within 2-6 weeks.
However, it is controversial how long the total duration of drug treatment will be.
After drug treatment is stopped, 40-80% of patients experience relapses within one or two years.
In addition to antithyroid drugs, palpitations etc. Patients with heart problems are also given beta-blocker drugs (20-40 mg per day).
Who can receive drug treatment for Graves' disease?
Antithyroid drugs;
In those with mostly small goiters,
slightly elevated hormone levels and
They are effective in goitres that rapidly shrink in size with medication.
All these drugs have some side effects and it is not right to use them without a doctor's supervision.
When and how is radioactive iodine ablation (RAIA) performed in Graves' disease?
The treatment, called radioactive iodine ablation, is performed by adjusting radioactive iodine in certain amounts and giving it to the patient along with liquid.
The most important advantages of this treatment are that it avoids surgery and surgery-related complications.
Additionally, treatment is easier and the overall cost of treatment is lower.
After standard treatment with RAIA, hormones return to normal levels (euthyroid) in most patients within two months.
However, only 50% of patients treated with RAIA still have normal hormone levels (euthyroid) six months after treatment.
In the rest, it is either still overactive (hyperthyroid) or no longer producing any hormones (hypothyroid).
Who can undergo radioactive iodine ablation (RAIA) in Graves' disease?
RAIA is mostly used in elderly patients with small or medium-sized goiters.
It is also preferred in patients who have relapsed after treatment with medication or goiter surgery.
RAIA treatment is preferred in patients for whom antithyroid medication or surgery is not appropriate.
Who cannot undergo radioactive iodine ablation (RAIA) in Graves' disease?
It is absolutely wrong to use it in women who are pregnant or planning to become pregnant with 6-month treatment and in women who are breastfeeding.
It should also not be preferred, especially in young patients such as children and adolescents, those with thyroid nodules, and patients with developed eye symptoms.
The lack of an experienced surgeon who can perform Graves' disease surgery is a situation that necessitates drug or RAIA.
What are the side effects of radioactive iodine ablation (RAIA) in Graves' disease?
Although rare, RAIA treatment may have complications such as nodular goiter, thyroid cancer and hyperparathyroidism.
Although there is no definitive scientific evidence for radioactive iodine ablation treatment, the possibility of pregnancy may decrease in women whose thyroid hormones are underactive.
For patients scheduled for surgery for Graves' disease, antithyroid medications are continued until the day of surgery.
In other words, patients must be made euthyroid before surgery.
How and when is Graves' disease treated with surgery?
Three types of surgery are generally preferred in Graves' disease:
Concomitant thyroid cancer,
Refuses RAIA treatment,
have serious eye symptoms or
In patients with life-threatening reactions to antithyroid drugs, all thyroid tissue must be removed completely (total thyroidectomy), or very little thyroid tissue must be left (near-total thyroidectomy).
For all other cases, the third option, leaving approximately 4-7 grams of thyroid tissue (subtotal thyroidectomy), is appropriate.
All three methods have their own advantages and disadvantages.
For this reason, the surgeon and the patient should decide jointly on the type of surgery.
If the level of thyroid hormones increases again after surgery, RAIA treatment is generally preferred.
Who can have Graves' disease treated with surgery?
The purpose of surgery in Graves' disease is to achieve complete and permanent control of the disease with the least amount of problems.
Therefore, surgery in Graves' disease recommended;
In the presence of cancerous or suspected cancerous thyroid nodules,
In young patients,
In patients who want to become pregnant immediately after treatment (<6 months),
Those who have severe reactions to antithyroid drugs,
Those with large goiters (goiters over 80 grams) that cause difficulty in swallowing and speaking and hoarseness, and
Patients who are unwilling to receive RAIA treatment.
Moreover;
Those who have moderate or severe eye symptoms due to Graves and who smoke,
Those who want rapid control of hyperthyroidism and
Those who are poorly compliant with antithyroid medications can also undergo surgery.
Is surgery performed for Graves' disease during pregnancy?
For Graves' patients who are pregnant, surgery is performed only when rapid control is needed and antithyroid medications cannot be used.
If necessary, the ideal time is the second trimester of pregnancy (months 4-6).
Toxic multinodular goiter
What is toxic multinodular goiter? What are the symptoms?
Toxic (excessive hormone secreting) multinodular (more than 1 nodule) goiters are usually seen in elderly individuals with a previous history of non-toxic multinodular goiter.
Over several years, enough thyroid nodules cause hyperthyroidism.
The onset is usually insidious and may not cause any symptoms.
Some patients have excess T3.
In some patients, it may occur only with palpitations or heart failure.
Hyperthyroidism can also be accelerated by some medications.
Its signs and symptoms are like Graves (click for Graves). However, they may not cause any symptoms other than goiter.
What tests are performed in toxic multinodular goiter?
In blood tests, TSH levels are low while free T4 or T3 levels are high. With these features, it is similar to Graves' disease.
In scintigraphy, iodine retention increases and many nodules are seen in the thyroid.
How is toxic multinodular goiter treated?
The main goal of treatment is to adequately control hyperthyroidism (excess hormone secretion).
For this purpose, atom (RAI) treatment or surgery can be applied.
In the surgical option, near-total or total thyroidectomy is recommended to avoid recurrence and therefore increased complication rates as a result of repeat surgery.
Toxic adenoma
What is toxic adenoma? How is it detected?
It is a condition of hyperthyroidism caused by a single nodule that produces too much hormone.
It mostly occurs when young patients who already have symptoms of hyperthyroidism notice nodules on their necks. The size of the nodule can reach 3 cm in diameter.
In scintigraphy, a "hot" nodule is detected even though the rest of the thyroid gland is normal.
These nodules are rarely cancerous.
How is toxic adenoma treated?
Smaller nodules can be treated with antithyroid medications and RAI.
Surgery (lobectomy and isthmusectomy) is preferred to treat younger patients and patients with larger nodules.
Although percutaneous ethanol injection (PEI) has been reported to have reasonable success rates, it has not been directly compared to surgery.
Smaller nodules can be treated with antithyroid medications and atom (RAI).
Solitary thyroid nodule
What is a solitary thyroid nodule? Why is it important?
The average incidence of a single nodule in the thyroid is 4%.
The importance of a single nodule stems from the risk of developing cancer. However, cancer does not develop in every single nodule.
Therefore, it is very important to evaluate the patient very carefully and determine which patient will benefit from surgery.
What are the examination findings in solitary (single) thyroid nodule?
A hard mass with irregular borders is felt in the front of the neck, adhering to the trachea and surrounding tissues.
Enlargement of the lymph nodes on both sides of the neck may also be noticed.
In what cases is cancer suspected in the presence of a solitary nodule?
Pain in solitary nodules is an uncommon complaint. If there is pain, there may be bleeding into a benign nodule. Additionally, pain may occur in cases of thyroid inflammation (thyroiditis) and cancer.
If cancer reaches the nerve that moves the vocal cords, hoarseness may develop.
If the patient has a history of previous exposure to radiation in the neck area, there is a risk of developing cancer.
Having members in the patient's family with cancer of the thyroid or other organs is also risky for cancer.
What tests are performed on solitary thyroid nodule? How is it treated?
First of all, the characteristics of the nodule are determined by ultrasonography and the levels of thyroid hormones in the blood are checked.
Then, a fine needle biopsy is performed from the nodule under ultrasonography guidance. If there is cancer or suspicion of cancer as a result of the biopsy, surgery is planned.
If there is a cyst, it can be drained with a needle.
In other cases, the path to be followed is determined according to the condition of each patient. Accordingly, the biopsy may be repeated or the patient is followed up.
Computed tomography, magnetic resonance examination and scintigraphy can be performed when necessary.
Inflammation of the thyroid (thyroiditis)
How many types of thyroiditis are there?
Inflammations of the thyroid (thyroiditis) are generally classified into acute, subacute and chronic forms.
The symptoms and treatment of each are different.
ACUTE (SUPURATIVE) THYROIDITIS
What is acute (suppurative) thyroiditis? What are the reasons?
Normally, the thyroid gland is resistant to infection. However, it can be infected by bacteria for various reasons.
It is more common in children.
It can often occur after an upper respiratory tract infection or middle ear infection.
What are the symptoms of acute (suppurative) thyroiditis?
Acute thyroiditis is characterized by severe neck pain radiating to the jaws or ear, fever, chills, earache, and hoarseness.
If left untreated, it can cause very serious problems.
How is acute (suppurative) thyroiditis diagnosed?
Acute thyroiditis is diagnosed by increasing the number of white blood cells in the blood, bacterial growth in the culture, and biopsy with a fine needle when necessary.
Computed tomography may be performed to determine the extent of infection and detect abscesses if present.
How is acute (suppurative) thyroiditis treated?
Antibiotics administered intravenously or intramuscularly are used to treat acute thyroiditis.
If there is an abscess, drainage is performed.
In the presence of recurrent abscess or if there is no improvement despite surgical drainage, surgical removal of the thyroid (thyroidectomy) may be required, although rarely.
Nowadays, a lighted device (fiberoptic laryngoscope) inserted through the nose is also used for treatment.
PAINFUL SUBACUTE THYROIDITIS
What causes painful subacute thyroiditis?
Although the exact cause is unknown, it is thought that the cause of painful thyroiditis is viruses, not bacteria.
Sometimes it may develop as a result of another viral upper respiratory tract infection.
Some patients also have a genetic predisposition.
What are the symptoms of painful subacute thyroiditis?
Painful thyroiditis is most common in women between the ages of 30 and 40.
It is usually characterized by sudden or gradual onset of neck pain that may radiate towards the lower jaw or ear.
The thyroid gland is enlarged and sensitive.
During the disease, increases and decreases are observed in the secretion of thyroid hormones.
How is painful subacute thyroiditis treated?
Painful thyroiditis usually does not progress very far. For this reason, treatment is primarily aimed at eliminating complaints (symptomatic).
Aspirin and other nonsteroidal anti-inflammatory drugs are used to relieve pain.
However, in more severe cases, steroids can be used.
If thyroid hormones are decreased in the blood (hypothyroidism), thyroid hormone can be given as a supplement for a short time.
In cases that do not respond to these measures, last a long time, or recur, surgical removal of the thyroid (thyroidectomy) may be required.
PAINLESS SUBACUTE THYROIDITIS
What is the cause of painless subacute thyroiditis?
Painless thyroiditis is considered to be primarily the result of an attack by the body against its own thyroid tissue (autoimmune).
It may occur for no reason, or it may occur during the puerperium.
What are the symptoms of painless subacute thyroiditis?
Painless thyroiditis is more common in women between the ages of 30 and 60.
On examination, the thyroid gland may be found to be normal sized or slightly enlarged.
Its hardness has increased slightly and there is no sensitivity.
Blood tests and the course of the disease are similar to painful thyroiditis.
How is painless subacute thyroiditis treated?
Patients with complaints may require beta-blockers and thyroid hormone support.
In cases that recur and disrupt the comfort of life, surgery (thyroidectomy) or atom (RAI) application may be tried, although rarely.
LYMPHOCYTIC (HASHIMOTO) THYROIDITIS
What is the cause of lymphocytic (Hashimoto) thyroiditis?
Hashimoto is the most common inflammatory disease of the thyroid.
Today, it is the leading cause of hypothyroidism (low thyroid hormones).
Hashimoto, an autoimmune process, is a hereditary disease.
What are the symptoms of Hashimoto's thyroiditis?
Hashimoto's thyroiditis is more common in women between the ages of 30 and 50.
20% of the patients present with hypothyroidism and 5% with hyperthyroidism complaints.
On examination, a slightly or moderately enlarged, hard, painless mass is detected in the neck.
In Hashimoto's thyroiditis with classic goiter, a widely enlarged, hard and lobulated gland is detected on examination.
How is Hashimoto's thyroiditis diagnosed?
Elevated TSH in the blood and the presence of thyroid autoantibodies usually confirm the diagnosis.
If there is a single suspicious nodule or rapidly growing goiter, a fine needle biopsy is performed under ultrasound guidance.
The possibility of lymphoma increases in the presence of Hashimoto's.
How is Hashimoto's thyroiditis treated?
Thyroid hormone replacement therapy is necessary in patients with severe hypothyroidism to maintain normal TSH levels.
Drug therapy is also recommended in middle-aged patients and pregnant patients, especially those with cardiovascular risk factors such as hyperlipidemia or hypertension.
Surgery (thyroidectomy) may sometimes be performed for suspected cancer, goiter causing pressure symptoms or cosmetic defects.
RIEDEL THYROIDITIS
What causes Riedel's thyroiditis?
Riedel thyroiditis (Riedel struma) is a rare type of thyroiditis that is characterized by the replacement of all or part of the thyroid tissue with fibrous tissue and spreads to neighboring tissues.
The reason is controversial.
It has been reported to occur in patients with other autoimmune diseases.
What are the symptoms of Riedel's thyroiditis?
The disease is predominantly seen in women between the ages of 30 and 60.
It typically presents with symptoms of compression such as difficulty swallowing, difficulty breathing, choking, and hoarseness that progress over weeks or years.
Patients may present with symptoms of hypothyroidism and hypoparathyroidism.
On examination, a hard, "woody" thyroid gland is palpable, adhering to the surrounding tissues.
The diagnosis is confirmed by surgical biopsy.
How is Riedel's thyroiditis treated?
Treatment is primarily surgery (thyroidectomy).
The aim is to relieve the pressure of the mass and make tissue diagnosis.
Hypothyroid patients are treated with thyroid hormone support.