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Surgical Thyroid Disease. Surgical Thyroid disease. Presentation and assessment Indications for surgery Risks of surgery Thyroid cancer / RAI protocol Discussion session. Surgical Thyroid Disease. Anatomical abnormality : goitre / nodule Functional abnormality : over /under active

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surgical thyroid disease1
Surgical Thyroid disease
  • Presentation and assessment
  • Indications for surgery
  • Risks of surgery
  • Thyroid cancer / RAI protocol
  • Discussion session
surgical thyroid disease2
Surgical Thyroid Disease
  • Anatomical abnormality : goitre / nodule
  • Functional abnormality : over /under active
  • Both : toxic nodule

graves with big goitre

common presenting symptoms
Common presenting symptoms
  • Lump in neck
  • Feeling of pressure
  • Feeling of discomfort
  • Feeling of choking
  • Feeling of having to ‘double swallow’
  • Don’t like the appearance and want to know what it is
lump in neck
Lump in neck
  • Examination
    • Lymph node
    • Thyroid
    • Other
suggested pathway for lymph node in neck present for 3 6 52 2cm or increasing in size
Suggested pathway for lymph node in neck:present for 3-6/52, >2cm or increasing in size
  • With associated systemic symtoms ; fast track haematology referral
  • Asymptomatic : rapid access neck lump clinic ; same day panedoscopy, USS, FNA, Core cut
if thought to be a thyroid abnormality
If thought to be a thyroid abnormality
  • Helpful if USS requested at same time
  • Single nodule / multinodular / diffuse
  • Likely Benign or Malignant ?
  • What is it that is bothering the patient ?
discrete palpable nodule
Discrete palpable nodule
  • FNA
    • Cyst : if resolves : discharge
    • Solid : Benign ;

asymptomatic and <4cm : review

symptomatic, >4cm or clinical anxiety : lobectomy

    • Solid : Follicular ;

Lobectomy

discrete palpable nodule1
Discrete palpable nodule
  • FNA
  • Solid : Suspicious :
      • lobectomy
  • Solid : likely Malignant
      • thyroidectomy
indications for surgery
Indications for surgery
  • Diagnostic uncertainty (clinical or cytology)
  • Discrete lump over 4 cms
  • Cosmetic benefit
  • Relief of pressure symptoms
  • Correction of tracheal deviation /compression
  • Retrosternal extension
  • Thyroid eye disease (graves)
thyroid surgery
Thyroid Surgery
  • Thyroid lobectomy (including isthmus and pyramidal lobe)
  • Total thyroidectomy
thyroid surgery1
Thyroid Surgery
  • Sup laryngeal nerves
  • Cutaneous sensory nerves
  • Recurrent laryngeal nerves
  • Para-thyroid glands
  • Post-operative thyroxine
  • Post-operative calcium replacement
thyroid cancer
Thyroid cancer
  • 8-10 cases per year in Swindon
  • <1% of cancers
  • If managed early favourable prognosis
  • Most symptomatic nodules are not cancer (value of screening?)
  • Following surgery, MDT discussion but further treatments at Churchill Oxford
rai treatment protocol and fu
RAI Treatment protocol and FU
  • After surgery pt on T3; stop 10/7 before admission (ideally TSH >30mU/L)
  • 131I 3.1Gbq (5.5Gbq if known mets)
  • Day 3 uptake scan to check 131I safe for home
  • Home on T3 20mU/l tds
  • 6/52 GP to check TSH (<0.5mU/l)
  • 3 months later ; stop T3 for 10/7
  • Iodine uptake scan 150Mbq 131I
rai treatment protocol and fu1
RAI Treatment protocol and FU
  • If no uptake or <0.05% and thyroglobulin undetectable start T4 (150 – 200 microg /day
  • If uptake >0.25% ; residual thyroid tissue/disease further therapeutic/ ablative dose of 131I and repeat uptake scanning process
summary
Summary
  • Sound bites on some common functional and anatomical thyroid issues.
  • Discussion
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