Thyroid Disorders and RLN Injury Quiz
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Questions and Answers

Which of the following is NOT a glandular criterion for malignant transformation in thyroid tumors?

  • Pressure (more evident) (correct)
  • Onset of pain
  • Rapid growth
  • Edge is ill-defined

    • What is the incidence percentage of Papillary thyroid carcinoma among thyroid tumors?

  • 5-15%
  • 80% (correct)
  • 15%
  • 2-10%

    • Which familial syndrome is associated with Papillary Thyroid Carcinoma (PTC) and intestinal polyps?

  • Cowden syndrome
  • Tseng syndrome
  • Carney syndrome
  • Gardner syndrome (correct)

    • Which oncogene is commonly associated with Follicular thyroid carcinoma (FTC)?

    <p>Mutated RAS oncogene</p> Signup and view all the answers

    Which of the following is a poorly differentiated thyroid carcinoma?

    <p>Anaplastic thyroid carcinoma</p> Signup and view all the answers

    What characteristic is common to the presentation of malignant thyroid tumors?

    <p>Painless enlargement</p> Signup and view all the answers

    Which clinical feature is indicative of distant metastases in thyroid malignancy?

    <p>Unequal carotid pulsations</p> Signup and view all the answers

    Which type of thyroid tumor has the lowest incidence rate?

    <p>Lymphoma</p> Signup and view all the answers

    What imaging investigation is considered the most important for diagnosing thyroid nodules?

    <p>Ultrasound (US) neck</p> Signup and view all the answers

    Which of the following symptoms is indicative of a complete injury of the recurrent laryngeal nerve?

    <p>Aphonia</p> Signup and view all the answers

    Which type of goiter is typically caused by Grave's Disease?

    <p>Toxic Goiter</p> Signup and view all the answers

    What is the anatomical site characteristic of a thyroid swelling?

    <p>Lower anterior part of the neck</p> Signup and view all the answers

    What type of thyroid enlargement can occur as a result of a physiological response?

    <p>Simple Goiter</p> Signup and view all the answers

    Which of the following is NOT a routine investigation for thyroid issues?

    <p>Magnetic Resonance Imaging (MRI)</p> Signup and view all the answers

    What symptom might indicate a rapid increase in thyroid swelling size?

    <p>Sudden appearance</p> Signup and view all the answers

    Which clinical type of goiter is most likely to be malignant?

    <p>Neoplastic Goiter</p> Signup and view all the answers

    What is the primary difference in symptoms between primary and secondary thyrotoxicosis?

    <p>Primary symptoms appear simultaneously with swelling, while secondary symptoms follow swelling.</p> Signup and view all the answers

    Which physical examination finding is indicative of retro-sternal extension?

    <p>Non-visible lower border of the thyroid on swallowing.</p> Signup and view all the answers

    What is Berry's Sign associated with?

    <p>Displacement of the carotid artery backwards and outwards.</p> Signup and view all the answers

    What clinical test can be used to identify fine tremors in thyrotoxicosis?

    <p>Holding arms out in front with straight elbows and wrists.</p> Signup and view all the answers

    In the context of goiter, what would be a prominent physical sign of thyroid enlargement?

    <p>Impalpable lower border on palpation.</p> Signup and view all the answers

    Which of the following is NOT a complication of multinodular goiter?

    <p>Insomnia</p> Signup and view all the answers

    What is characteristic of the thyroid gland in primary thyrotoxicosis?

    <p>It is diffuse, smooth, and symmetrical bilateral.</p> Signup and view all the answers

    Which investigation is NOT typically performed for assessing thyroid issues?

    <p>MRI of the head</p> Signup and view all the answers

    What is the hallmark feature of papillary thyroid carcinoma?

    <p>Psammoma bodies</p> Signup and view all the answers

    What is the most common pattern of vascularity observed in the sonographic investigation of thyroid lesions?

    <p>Marked intrinsic hyper-vascularity</p> Signup and view all the answers

    In which patient group is a total thyroidectomy recommended for papillary thyroid carcinoma?

    <p>Patients older than 40 years for males and 50 years for females</p> Signup and view all the answers

    Which age group is most commonly affected by follicular thyroid carcinoma?

    <p>Mean age of 50 years</p> Signup and view all the answers

    What feature distinguishes the high-risk and low-risk groups for thyroid cancers?

    <p>Age and presence of distant metastasis</p> Signup and view all the answers

    Which surgical intervention is the first line of treatment for minimal papillary thyroid carcinoma?

    <p>Lobectomy with isthmectomy</p> Signup and view all the answers

    Which type of thyroid cancer is more frequent in iodine deficiency areas?

    <p>Follicular thyroid carcinoma</p> Signup and view all the answers

    What is the appropriate treatment for Hürthle cell tumors?

    <p>Lobectomy and isthmectomy</p> Signup and view all the answers

    What is the primary hormone secreted by medullary thyroid carcinoma (MTC) cells?

    <p>Calcitonin</p> Signup and view all the answers

    Which syndrome is associated with familial medullary thyroid carcinoma?

    <p>MEN II</p> Signup and view all the answers

    What is the common diagnostic tool used to identify medullary thyroid carcinoma?

    <p>FNAC</p> Signup and view all the answers

    What is the prognosis for familial non-MEN MTC compared to sporadic cases?

    <p>Better prognosis than sporadic cases</p> Signup and view all the answers

    Which of the following treatments is considered extremely difficult for anaplastic thyroid carcinoma?

    <p>Total thyroidectomy</p> Signup and view all the answers

    What is a key characteristic of thyroid lymphoma?

    <p>Non-Hodgkin B-cell lymphoma</p> Signup and view all the answers

    How does anaplastic thyroid carcinoma typically progress in terms of patient prognosis?

    <p>Poor prognosis with a mean life expectancy of 6-9 months</p> Signup and view all the answers

    What is a common complication associated with medullary thyroid carcinoma that should be screened for?

    <p>Pheochromocytoma</p> Signup and view all the answers

    Study Notes

    Injury of the Recurrent Laryngeal Nerve (RLN)

    • Dyspnea, stridor, hoarseness of voice and aphonia are all symptoms of RLN injury.
    • Unilateral injury leads to hoarseness.
    • Bilateral injury results in aphonia.

    Imaging

    • Plain X-ray of the neck and upper chest can reveal a soft tissue shadow indicating a retrosternal goiter.
    • Ultrasound: is used to differentiate cystic from solid nodules and detect clinically impalpable nodules.
    • CT scan of the neck can show retrosternal goiter and cervical lymph nodes.
    • Biopsy is used for suspected malignancy.
    • Indirect laryngoscopy is used to assess the vocal cords.

    Common Investigations

    • TSH, FT3, and FT4 are routinely conducted.
    • Thyroid auto-antibodies are tested to exclude Hashimoto’s thyroiditis.
    • Ultrasound and FNAC are considered essential.
    • Thyroid tumor markers like calcitonin are used to detect medullary cancer.

    Definition of Goiter

    • Goiter is an enlarged thyroid gland regardless of the cause or function.

    Clinical Features of a Thyroid Swelling

    • Goiters are typically located in the lower anterior part of the neck, deep to the sternomastoid muscle.
    • The shape is usually butterfly-like, but enlargement can be unilateral or asymmetrical.
    • A goiter moves up and down with deglutition.
    • A Thyroglossal cyst moves upwards with protrusion of the tongue.

    Clinical Types of Goiter

    • Simple Goiter:
      • Diffuse:
        • Physiological
        • Colloidal
      • Multinodular
      • Solitary Nodule
      • Recurrent Nodular
    • Toxic Goiter:
      • Diffuse:
        • Grave's Disease
      • Multinodular:
        • Marine Lenhart Syndrome
      • Solitary Nodule:
        • Plummer's Disease
      • Recurrent Nodular
    • Special Goiter:
      • Thyroiditis
      • Neoplastic:
        • Benign: Adenoma
        • Malignant: 1 or 2
      • Autoimmune
      • Congenital (dyshormogenesis)

    Personal History in Goiter

    • Young patients between 25-40 years old are more likely to have physiological goiter, papillary carcinoma, and SNG (single nodular goiter).
    • Patients between 30-45 years old are more susceptible to thyrotoxicosis.
    • Elderly patients are at risk for cancer of the thyroid.
    • Women are more prone to goiter than men.
    • Males are more likely to develop retrosternal goiter and malignant solitary thyroid nodules.

    Symptoms of Goiter

    • Sudden appearance or rapid increase in size of the goiter can be due to Graves' disease.
    • Eye signs include exophthalmos, lid lag, and stare.
    • Other symptoms include tremors, chemosis, ophthalmoplegia, dilated congested conjunctival blood vessels, and tremors of the eyelids.
    • Dullness over the manubrium on percussion suggests retrosternal goiter.

    Signs of Retrosternal Extension

    • History: Postural dyspnea, stridor, cough, wheezing, choking, dysphagia.
    • Physical examination:
      • Dilated veins in front of the neck and sternum.
      • Enlarged thyroid with non-visible lower border on swallowing.
      • Impalpable lower border on palpation.
      • Dullness on percussion over the manubrium sterni.
      • Flushing of the skin and dilatation of the EJV during raising the arms or hyperextension of the neck (Positive Pemberton's Sign).

    Primary vs. Secondary Thyrotoxicosis

    • Age:
      • Primary thyrotoxicosis is common in young adults.
      • Secondary thyrotoxicosis is more prevalent in older age groups.
    • Onset of toxic symptoms:
      • Primary thyrotoxicosis: Symptoms appear simultaneously with the swelling.
      • Secondary thyrotoxicosis: Symptoms appear after the swelling.
    • Eye signs:
      • Primary thyrotoxicosis: Marked eye signs.
      • Secondary thyrotoxicosis: Mild eye signs.
    • Nervous manifestations:
      • Primary = +++
      • Secondary = +
    • Cardiovascular symptoms:
      • Primary = +++
      • Secondary = +
    • Gastrointestinal manifestations:
      • Primary = +++
      • Secondary = +
    • Increased BMR:
      • Primary= +++
      • Secondary = +
    • The Gland:
      • Primary: Diffuse, smooth, symmetrical, bilateral, and fleshy.
      • Secondary: Nodular, asymmetrical, and may be unilateral.

    Toxic (Grave's) vs. Colloid Goiter vs. Thyroiditis

    • Size:
      • Toxic (Grave's): Slight to moderate
      • Colloid Goiter: Moderate to gross
      • Thyroiditis: Small or moderate
    • Surface:
      • Toxic (Grave's): Smooth
      • Colloid Goiter: Bosselated
      • Thyroiditis: Smooth
    • Consistency:
      • Toxic (Grave's): Soft-Fleshy
      • Colloid Goiter: Fleshy
      • Thyroiditis: Hard
    • Tenderness:
      • Toxic (Grave's): -
      • Colloid Goiter: -
      • Thyroiditis: -
    • Bruit:
      • Toxic (Grave's): +
      • Colloid Goiter: -
      • Thyroiditis: -

    Complications of Multinodular Goiter

    • Toxicity
    • Malignancy
    • Retrosternal extension
    • Pressure
    • Cyst formation
    • Calcification
    • Hemorrhage
    • Infection (rare due to extensive vascularity)

    Criteria of Malignant Transformation

    • Glandular criteria:
      • Rapid growth
      • Fixation
      • Hard consistency
      • Ill-defined edge
      • Onset of pain
    • Extraglandular criteria:
      • Pressure
      • Vocal cord paralysis
      • Horner syndrome
      • Cervical lymph nodes
      • Unequal carotid pulsations
      • Distant metastases

    Benign Tumors of the Thyroid

    • Epithelial Tumors:
      • Papillary adenoma (fetal or microfollicular adenoma)
      • Follicular adenoma (cystadenoma or colloid adenoma)
    • Mesenchymal Tumors:
      • Lipoma
      • Leiomyoma
      • Hemangioma
    • Other Tumors:
      • Teratoma (mainly in children)

    Malignant Tumors of the Thyroid

    • A painless enlarging lesion with one or more of the following should raise suspicion of malignancy:
      • Radiation exposure
      • Male gender
      • Older age
      • Younger age
      • Rapid increase in size
      • Previous thyroid cancer
      • Lymphadenopathy
      • Evidence of local invasion (vocal cord paralysis, dysphagia or firm, fixed nodules)

    Familial Syndromes Associated with Thyroid Cancer

    • Familial non-medullary thyroid cancer:
      • Gardner Syndrome: PTC (intestinal polyps, osteomas, fibromas, lipomas)
      • Cowden Syndrome: PTC - FTC (breast cancer, hamartomas, pigmented adrenal nodules, Schwannoma)
      • Carney Syndrome: PTC (myoma, pituitary adenomas, testicular tumors)

    Thyroid Cancer Incidence

    • Papillary: 80%
    • Follicular: 15%
    • Medullary: 2-10%
    • Anaplastic: 5-15%
    • Lymphoma: Rare
    • Metastatic: Rare

    Thyroid Cancer Classification

    • Differentiated tumors of follicular origin (90-95%):
      • Papillary carcinoma
      • Follicular carcinoma
      • Hürthle cell carcinoma
    • From parafollicular cells (2-10%):
      • Medullary thyroid carcinoma (MTC)
    • Poorly differentiated (5-15%):
      • Anaplastic thyroid carcinoma (ATC)

    Oncogenes Associated with Thyroid Carcinoma

    • RET oncogene: Papillary (PTC) & MTC
    • Mutated RAS oncogene: Follicular thyroid carcinoma (FTC)
    • Mutated p53 gene: Anaplastic thyroid carcinoma (ATC)

    Papillary Thyroid Carcinoma (PTC)

    • Most common type of thyroid malignancy (80%)
    • Predominant thyroid cancer in children
    • May be due to radiation exposure of the neck
    • Age: Peak incidence is in the third decade of life
    • Gender (Female: male = 3:1)

    Pathology of PTC

    • Complex papillary projections with a fibrovascular core.
    • Hallmarks of PTC:
      • Psammoma bodies (laminated calcified spheres)
      • Orphan Annie eye Nuclei or ground glass nuclei (nuclei with finely dispersed chromatin, optically clear or empty appearance)
    • Incidence of multi-focality is 80%
    • Spread to lymph nodes occurs in 30-50% of patients (no effect on survival).
    • Hematogenous spread is rare, occurs late to lung and bones.

    Investigations of PTC

    • Ultrasonography (US)
      • Calcifications (thyroid microcalcifications, = Psammoma bodies)
      • Local invasion + LN metastases (irregular margins + heterogeneous echo-texture)
      • Shape: Taller than it is wide
      • Vascularity (color or power Doppler US): marked intrinsic hyper-vascularity
      • Hypoechoic solid nodule
    • FNAC (specific and sensitive for PTC, MTC and ATC)
    • CT / MRI for extensive local or sub-sternal extension

    Surgery of PTC

    • Hemithyroidectomy (lobectomy with isthmectomy) for minimal PTC
    • Total thyroidectomy:
      • Size >4cm
      • Age (male >40 y, female >50y)
      • Angio-invasion
    • Total thyroidectomy + Neck dissection: Metastatic cervical LNs.

    Follicular Thyroid Carcinoma (FTC)

    • It is the 2nd most common thyroid cancer (10%).
    • More frequent in iodine deficiency areas (nodular goiter →neoplasm).
    • Age: Mean age is 50 y.
    • Gender: (Female: male = 3:1).

    Features of FTC

    • Occasional tumors are dominated by cells with abundant granular, eosinophilic cytoplasm (Hürthle cells).
    • Requires extensive sampling of the tumor-thyroid capsule → capsular or vascular invasion.
    • Hematogenous spread is more common (bone, lung and liver).

    Diagnosis and Treatment of FTC

    • FNAC is not helpful: Requires lobectomy and isthmectomy.

    Follicular Thyroid Cancer Subgroups

    • Low-risk group:
      • Younger patients
      • Without distant metastasis
      • Intra-thyroid follicular / papillary tumors
      • Tumors < 4cm in diameter
    • High-risk group:
      • Older patients
      • Distant metastasis
      • Extrathyroid papillary/follicular tumors
      • Tumors >4 cm

    Hürthle Cell Thyroid Tumor

    • More common in males.
    • Derived from oxyphilic cells of the thyroid gland.
    • Spreads by lymphatics.
    • Diagnosis: FNAC (20% malignant) - Often multifocal and bilateral.
    • Treatment: Total thyroidectomy + Modified radical neck dissection (if with palpable cervical LNs).

    Medullary Thyroid Carcinoma (MTC)

    • Age: The peak incidence is at 50-60 years.
    • Origin: parafollicular or C cells of the thyroid (neuroectodermal).
    • Secrets calcitonin (95%); 85% secrets carcinoembryonic antigen (CEA).
    • Sporadic 90%: Uni-focal, usually at 45y, worse prognosis.
    • Familial 10%: Multifocal, usually 35 y, better prognosis, associated with:
      • MEN IIA or Sipples' syndrome (MTC, hyperplastic parathyroid and pheochromocytoma)
      • MEN IIB (MTC, pheochromocytoma, ganglioneuromatosis and Marfan's syndrome)
    • Can secrete: Calcitonin (95%), СЕА (85%).
    • Spread:
      • Lymphatics (neck and superior mediastinum)
      • Blood → liver, bone (osteoplastic) and lung
      • Local invasion
    • Diagnosis: Serum calcitonin, CEA
    • Treatment:
      • FNAC: characteristic amyloid stroma
      • Total thyroidectomy
      • MRND (Palpable cervical LN, tumor >2cm →chance of 60% nodal metastasis)
      • Screen for pheochromocytoma (MEN II) which should be resected first.
    • Follow Up: Serum Calcitonin / CEA level
    • Prognosis:
      • Best → worst prognosis: Familial non-MEN MTC → ΜΕΝ ΙΙΑ → sporadic cases → MEN IIB

    Anaplastic Thyroid Carcinoma (ATC)

    • Incidence: Uncommon, affecting older patients
    • Origin: May arise in a well differentiated thyroid carcinoma
    • 80% a history of a long-standing goiter with sudden and rapid growth
    • Treatment:
      • Tracheostomy and total thyroidectomy (difficult due to injury risk)
      • External radiation (temporarily controls local effects)
      • Chemotherapy (limited effect)
    • Prognosis is extremely poor + mean life expectancy of 6-9 months.
    • Death occurs from local invasion of vital cervical structures + airway compression

    Thyroid Lymphoma

    • Non-Hodgkin B-cell lymphoma
    • Hashimoto's thyroiditis is a risk factor
    • Treatment: Chemotherapy / Radiotherapy

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    Description

    Test your knowledge on recurrent laryngeal nerve injuries, imaging techniques, and common investigations related to thyroid disorders. This quiz also covers the definition of goiter and pertinent symptoms associated with thyroid issues. Enhance your understanding of how these conditions are diagnosed and managed.

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