Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2693_Библиотеки_им_академика_М_И_Перельмана.pdf
31 G oiter
457
and chest. [Medeiros-Neto G.Chapter 3. In: Surks MI, editor. Volume 1: Thyroid
Diseases. 1 edition. Philadelphia: Current Medicine Group; 1999. (Korenman SG,
editor. Atlas of Clinical Endocrinology). ISBN: 0-632-04397-0]
• Horner’s syndrome. Horner’s syndrome results when the goiter causes compression of the cervical sympathetic nerve supply to the eye. Horner’s syndrome is rare, and it is especially rarely caused by goiter. The classic triad of
Horner’s consists of (all on the affected side);
• Miosis (constricted pupil).
• Partial ptosis, drooping eyelid from partial paralysis of the superior tarsal
muscle.
• Hemifacial anhidrosis, loss of sweating on the affected half of the face.
Photograph of the eyes showing the left ptosis and miosis of Horner’s syndrome.
[Mutalib M, Vandervelde C, Varghese A, Sallomi DF, Silva P de, Casey JMH,
Howlett DC.Horner’s syndrome secondary to asymptomatic pneumothorax in an
adolescent. Eur J Pediatr. 2006 Sep 19;166(5):507–8.] Caption from original
Primary Differential Considerations
• Patients who present with an exam consistent with goiter should be also be
evaluated for other possible diagnoses, including:
• Other thyroid pathology, such as nodules, thyroiditis, or malignancy
• Parathyroid cyst or malignancy
• Lipoma or broma
• Branchial cleft cyst or cystic hygroma
458
C. J. Rees et al.
History andPhysical Exam
Findings That Conrm Diagnosis
• The diagnosis can be conrmed by the direct palpation of the goiter. A goiter
can usually be distinguished from other anterior neck masses (such as fatty
tissue, redundant skin, etc.) as the thyroid will go up and down with swallowing. It is often helpful to ask the patient to swallow a sip of water and just
observe the anterior neck for this up and down motion.
Diffuse goiter: Hashimoto’s thyroiditis [Gharib H.Chapter 4. In: Surks MI, editor.
Volume 1: Thyroid Diseases. 1 edition. Philadelphia: Current Medicine Group;
1999. (Korenman SG, editor. Atlas of Clinical Endocrinology). ISBN: 0-632-043970] Caption adapted from original
Large goiter in a 57-year-old man. [Giovanella L.Nontoxic Multinodular Goiter. In:
Giovanella L, Treglia G, Valcavi R, editors. Atlas of Head and Neck Endocrine
Disorders [Internet]. Cham: Springer International Publishing; 2016 [cited 2015
Dec 17]. p. 67–72. Available from: http://link.springer.com/10.1007/978-3-319-
22276-9_10] Caption adapted from original
31 G oiter
• In patients with short and thick necks it can be difcult to adequately palpate
the thyroid. These patients may require some form of imaging to be certain a
goiter is present.
Factors That Suggest Diagnosis
• Patients with a family history of thyroid disease, recent immigrants from
areas of the world considered iodine-decient, those with a history of head
and neck irradiation, or other radiation exposure, should be considered to be
at higher risk for goiter.
• All patients in whom the diagnosis is being considered should be directly
questioned about the presence of hyper- or hypothyroid symptoms, and for
the presence or absence of obstructive symptoms.
• The presence of a substernal thyroid can be suggested by:
• The inability to directly palpate the inferior thyroid margin on either side.
• Pemberton’s maneuver. In this provocative physical exam test, the exam-
iner holds the patient’s arms directly above the head for about one minute.
This maneuver forces the thyroid into the thoracic inlet and can exacerbate
obstructive symptoms and signs. These include dyspnea, distension of the
neck veins, facial ushing or cyanosis, or the inability to swallow.
459
Pemberton’s sign. The presence of a retrosternal goiter causes facial ushing and
distended supercial veins. Mild ushing is noted with the arms by the side indicating some baseline obstruction at rest. [Sharma N, Watkinson JC.Retrosternal Goiter.
460
In: Watkinson JC, Scott-Coombes DM, editors. Tips and Tricks in Endocrine
Surgery [Internet]. London: Springer London; 2014 [cited 2015 Dec 17]. p.161–6.
Available from: http://link.springer.com/10.1007/978-1-4471-2146-6_20] Caption
from original
• Kocher’s test. This is a physical examination maneuver that can be used to
test for the presence of tracheal compression. In a positive test, compression of the lateral lobes of the thyroid will produce stridor from tracheal
compression.
C. J. Rees et al.
Factors That Exclude Diagnosis
• No historical or physical examination factors can adequately exclude the
diagnosis.
• In patients with short and thick necks it can be difcult to adequately palpate
the thyroid. These patients may require some form of imaging to be certain a
goiter is either present or absent.
Ancillary Studies
Laboratory
• Thyroid stimulating hormone (TSH). All patients with goiter should have
their thyroid function evaluated by measurement of their serum TSH.Serum
TSH is often normal (euthyroid), but can also be low (suppressed) with hyperthyroidism, and high with hypothyroidism.
• If the TSH is low, the serum-free thyroxine (T4) and total triiodothyronine
(T3) should also be measured to assess for an autonomously functioning
multinodular goiter or Graves’ disease.
• If the TSH is high, free T4 should be measured as part of the evaluation for
likely Hashimoto’s disease.
• Thyroid peroxidase antibodies (TPO). Patients with Hashimoto’s (autoimmune) thyroiditis almost always have elevated TPO.Patients with goiter and hypothyroidism in the United States will most likely have
Hashimoto’s thyroiditis as the cause of their goiter. This can be confirmed
by elevated TPO.
• TSH receptor antibodies. These should be measured when Graves’ disease is
being considered in the differential diagnosis of the goiter. This is mostly in
the setting of a goiter associated with hyperthyroidism.
31 G oiter
Imaging
• Thyroid ultrasound should be obtained in most patients with goiter. Thyroid
ultrasound can be used to evaluated thyroid size and volume; it can also
help assess thyroid function. Thyroid ultrasound can also help in the evaluation of a goiter with features that may be consistent with thyroid cancer.
These “worrisome” features include a rapidly growing goiter, asymmetric
thyroid enlargement, rm consistency to focal areas of the thyroid, and
tenderness to palpation.
• Chest x-ray. Substernal goiters are often found incidentally on a CXR being
performed for other reasons. They can appear as a mass that causes tracheal
deviation or narrowing, or as superior mediastinal widening, or a mediastinal
mass.
461
Chest radiograph in substernal goiter. There is an anterior mediastinal mass,
which was thought to be compatible with a substernal goiter. Note the deviation
of the trachea to the left and the presence of a mass in the upper anterior mediastinum. [Singer P.Chapter 12. In: Surks MI, editor. Volume 1: Thyroid Diseases. 1
edition. Philadelphia: Current Medicine Group; 1999. (Korenman SG, editor.
Atlas of Clinical Endocrinology). ISBN: 0-632-04397-0] Caption adapted from
original
• CT scan. Goiters may be incidentally noted on CT scans of the neck and chest
being performed for other reasons, but a CT chest can also be an important
test in the evaluation of large cervical goiters and suspected substernal goiters.
CT can help delineate the extent of the goiter. To fully evaluate the goiter, a
CT of the neck and chest may be necessary.
462
C. J. Rees et al.
Computed tomography in substernal goiter. Note the predominantly right-sided mass
with tissue to the left of the trachea as well. The trachea is not signicantly narrowed.
[Singer P.Chapter 12. In: Surks MI, editor. Volume 1: Thyroid Diseases. 1 edition.
Philadelphia: Current Medicine Group; 1999. (Korenman SG, editor. Atlas of
Clinical Endocrinology). ISBN: 0-632-04397-0] Caption adapted from original
Substernal goiter Substernal goiter (SG) leading to signicant tracheal deviation and
compression with symptomatic dyspnea on exertion[Wilhelm SM. Multinodular
Goiter. In: Pasieka JL, Lee JA, editors. Surgical Endocrinopathies [Internet]. Cham:
31 G oiter
463
Springer International Publishing; 2015 [cited 2015 Dec 17]. p.57–63. Available from:
http://link.springer.com/10.1007/978-3-319-13662-2_11] Caption from original
Image from a computed tomography of a patient with a massive intrathoracic goiter.
The goiter is clearly below the aortic arch[Rolighed L, Rønning H, Christiansen
P.Sternotomy for substernal goiter: retrospective study of 52 operations. Langenbeck’s
Archives of Surgery. 2015 Apr;400(3):301–6.] Caption from original
• Thyroid radionuclide imaging may be necessary to identify any nodules or
areas of autonomous functioning within the thyroid.
Other
• Flow-Volume Loop. Any patient with symptoms or signs consistent with an
obstructive goiter should have pulmonary function tests with a ow-volume loop.
If another imaging study reports a tracheal diameter less than 10 mm, the patient
should also have a ow-volume loop performed. A xed, mechanical obstruction
in the trachea will show a blunted or “notched” ow-volume loop. A positive owvolume loop may inuence treatment and suggest the need for surgery.
• Fine needle aspiration (FNA) biopsy. FNA biopsy may be necessary to evaluate suspicious areas of goiter, or suspicious nodules for cancer. Suspicious
ndings include:
• Rapid growth of the goiter
• Pain or tenderness
• Asymmetry in the consistency of the thyroid on examination
464
C. J. Rees et al.
Special Populations
Age
• Goiter is most common in the middle-aged to older adult population. The
incidence of goiter rises with age.
• Although rare, goiters can occur in infants and children. They can be congenital or acquired.
• Congenital Goiter. Goiters can occur in infants from congenital causes.
Congenital goiters may not be evident at birth, but will usually develop
over the rst several months of life. The causes of congenital goiter include:
• Inborn errors of thyroid hormone production
• Mother’s with Hashimoto’s or Graves’ can have transplacental transfer
of maternal antibody leading to goiter
• Maternal ingestion of antithyroid drugs
• Inborn mutations of thyroid hormones and receptors
• Thyroid tumors
• Acquired Goiter. Acquired goiters in children follow a similar distribution
as adults. In iodine-decient parts of the world, iodine-decient goiters are
the most common cause. In areas of the world where iodine-deciency is
uncommon, common causes of goiter include:
• Hashimoto’s Thyroiditis
• Graves’ Disease
• Colloid Goiter. This is a unique form of goiter that occurs in adolescent girls.
The cause is unknown. Thyroid function is usually normal. It usually improves
over time with no treatment.
Co-morbidities
• Goiters can occur in patients with multiple other co-morbid illnesses.
Signicant cardiac and pulmonary disease can complicate the management of
goiters. As one of the primary treatments for goiter may be surgical, patients
with multiple co-morbid conditions may not be good candidates for surgery.
31 G oiter
Pitfalls inDiagnosis
Critical Steps Not toMiss
• It is critical to take a complete history, including a family history and exposure to radiation history, to help determine the cause for a goiter and to guide
the appropriate work-up and treatment.
• It is critical to assess for a substernal goiter, by asking about obstructive symptoms,
performing a thorough examination, and ordering appropriate imaging studies.
Mimics
• There are no signicant mimics of goiter.
• There are other causes of anterior neck masses, but thorough physical examination, and/or an appropriate imaging study, can determine the etiology of
the mass.
Time-Dependent Interventions
465
• Goiters are usually very slow-growing and can be dealt with over time.
• Substernal goiters may cause acute symptoms from tracheal compression.
This can be due to continued growth of the thyroid, acute hemorrhage into a
large nodule, or from acute swelling from thyroiditis. These symptoms usually include dyspnea, associated with wheezing or stridor.
• In these situations, an adequate airway must be obtained. Temporary measures can include humidied oxygen, positive pressure ventilation such as
continuous positive airway pressure (CPAP), and use of heliox (a helium/
oxygen mixture). All of these are temporizing measures however, and a secure
airway will need to be obtained. This usually requires the involvement of a
surgeon with experience in these matters.
Overall Principles ofTreatment
• The treatment goals for goiters differ based upon the cause of the goiter,
whether the goiter is symptomatic or asymptomatic, and whether the goiter is
cervical or substernal.
466
• Goiters that are not associated with hyperthyroidism and are non-
obstructive (such as Hashimoto’s): The primary goals are to treat any
underlying hypothyroidism, decrease the size of the goiter, and prevent
further growth. If there is signicant hypothyroidism, treatment with thyroid replacement hormone can decrease the size of the goiter. If the
patient is asymptomatic, the goiter can be followed. If the goiter is large,
surgery or radioiodine ablation (RIA) may be appropriate. Surgery is
indicated for large goiters, especially those that are continuing to grow
over time. RIA can be an alternative to surgery for those patients that are
not good surgical candidates.
• Substernal (or cervical) Goiter with obstructive symptoms:
• Once obstructive symptoms occur, the patient requires treatment. There
is a small incidence of spontaneous hemorrhage into an enlarged thyroid. This can cause an acute increase in thyroid size leading to acute
compression that can be fatal.
• The usual treatment is surgical resection of the thyroid gland.
• If the patient is unable or unwilling to have surgery, RIA can be
considered.
• Asymptomatic Substernal Goiter:
• These patients can be observed over time for the development of
obstructive symptoms.
• These patients can also be offered denitive surgical treatment.
• Early, denitive surgical treatment should be considered, for the following reasons:
C. J. Rees et al.
• Most goiters will continue to enlarge.
• Surgery will become more technically difcult as the goiter
enlarges.
• A signicant minority (up to 40%) of patients with asymptomatic
substernal goiter have abnormal ow-volume loops.
• There is a small risk of cancer developing in the goiter. The risk of
cancer developing in a goiter is about the same as the risk of cancer
developing in any thyroid nodule.
• There is a small risk of acute hemorrhage into the thyroid with
potentially fatal acute airway obstruction.
• Patients are considered safe to observe, rather than to undergo surgery,
when any of the following conditions is met:
• They have a normal ow-volume loop.
• The substernal component ends at or above the brachiocephalic vein.
• The patient is a poor surgical candidate.
• Patients being observed should be followed closely for the development
of obstructive symptoms, and should have a CT scan every year until
stability is documented.