In partial fulfillment of the requirements for NCM 202 O.R. ward
NON-TOXIC NODULAR GOITER (sporadic goiter)
Submitted by : Antas, Wilson Bumatay, Jaffrabel Chua, Kayshel Christine Corpuz, Jessielyn Cabalo, Joelyode De Lima, Ginnalyn Estella , Ann-marvie
Brief anatomy and physiology of the thyroid gland The thyroid gland is a butterfly-shaped organ and is composed of two conelike lobes or wings, lobus dexter (right lobe) and lobus sinister (left lobe), connected via the isthmus. The organ is situated on the anterior side of the neck, lying against and around the larynx and trachea, reaching posteriorly the esophagus and carotid sheath. It starts cranially at the oblique line on the thyroid cartilage (just below the laryngeal prominence, or 'Adam's Apple'), and extends inferiorly to approximately the fifth or sixth tracheal ring It is difficult to demarcate the gland's upper and lower border with vertebral levels because it moves position in relation to these during swallowing.
Definition of non-toxic nodular goiter
Nontoxic Nodular Goiter or sporadic goiter; simple goiter; nodular enlargement of the Thyroid Gland A nontoxic goiter is a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function. Endemic goiter is defined as thyroid enlargement that occurs in more than 10% of a population, and sporadic goiter is a result of environmental or genetic factors that do not affect the general population.
Diffuse—enlarging the whole thyroid gland Nodular—enlargement caused by nodules, or lumps, on the thyroid
The development of nodules marks a progression of the goiter. It should be evaluated by your doctor.
Nodular goiter
Pathophysiology
The histopathology varies with etiology and age of the goiter.
uniform follicular epithelial hyperplasia (diffuse goiter) is present, with an increase in thyroid mass.
As the disorder persists, the thyroid architecture loses uniformity
development of areas of involution and fibrosis interspersed with areas of focal hyperplasia.
results in multiple nodules (multinodular goiter).
nontoxic goiter growth, nodule production and functional autonomy
thyrotoxicosis
Causes The exact causes of nontoxic goiter are not known. In general, goiters may be caused by too much or too little thyroid hormones. There is often normal thyroid function with a nontoxic goiter. Some possible causes of nontoxic goiter include:
Heredity (family history of goiters)
Regular use of medications such as lithium , propylthiouracil , phenylbutazone, or aminoglutethimide
Regular intake of substances (goitrogens) that inhibit production of thyroid hormone—common goitrogens include foods such as cabbage, turnips, brussel sprouts, seaweed, and millet
Iodine deficiency—Iodine deficiency is very rare in the US and other developed countries, due to the use of iodized table salt; this is a primary cause of goiter in other parts of the world, particularly in mountainous areas, or areas that experience heavy rainfall or flooding
Hashimoto’s thyroiditis - an autoimmune disease in which the thyroid gland is gradually destroyed by a variety of cell- and antibody-mediated immune processes
Risk Factors
Sex: nodular goiter is more common in women than in men. According to the best estimate, the incidence of goiter in women is 1.2-4.3 times as great as that in men
Age: Sporadic goiter from dyshormonogenesis, a genetic error in proteins that are necessary for thyroid hormone synthesis, occurs during childhood. Endemic goiter due to iodine deficiency occurs during childhood, with the goiter's size increasing with age. Other causes of
sporadic goiter rarely occur before puberty and do not have a peak age of occurrence. Thyroid nodules increase in incidence with age.:
Family history of goiter
History of radiation therapy to head or neck, especially during childhood
Symptoms Nontoxic goiters usually do not have noticeable symptom.
Swelling on the neck Breathing difficulties, coughing, or wheezing with large goiter Difficulty swallowing with large goiter Feeling of pressure on the neck Hoarseness
Diagnosis Your doctor will ask about your symptoms and medical history. A physical exam will be done. Your doctor may recommend a specialist. An endocrinologist focuses on hormone related issues. Tests may include the following: Examination of the neck—to assess any thyroid enlargement Ultrasound —a test that uses sound waves to identify nodules of the neck and thyroid Blood tests—to assess levels of thyroid hormones (eg, thyroid stimulating hormone); thyroid autoantibodies tests may also be done Thyroid scan (scintigraphy)—a picture of your thyroid gland taken after you have been given a shot or drink of a radioisotope to show how your thyroid is functioning and exclude thyroid cancer
Fine needle aspiration biopsy —a tissue sample is taken with a small needle to determine if it is benign or malignant (cancer); 50%-60% are noncancerous Barium swallow —a test to determine if the enlarged goiter is compressing the esophagus, thus causing swallowing difficulty X-ray of neck and chest for large goiters—to see if the trachea is compressed
Treatment Nontoxic goiters usually grow very slowly. They may not cause any symptoms. In this case they do not need treatment. Treatment may be needed if the goiter grows rapidly, affects neck or obstructs breathing . If a nontoxic goiter progresses to the nodular stage, and the nodule is found to be cancerous, you will need treatment. Talk with your doctor about the best plan for you. Treatment options include the following: Hormone Suppression Therapy Thyroid hormone medication is used to suppress secretion of thyrotropin (TSH). TSH is the thyroid-stimulating hormone that causes growth. This therapy is most effective for early stage goiters that have grown due to impaired hormone production. It is less effective for goiters that have progressed to the nodular stage. Radioactive Iodine Radioactive iodine treatment is used to reduce the size of large goiter. It is used in the elderly when surgical treatment is not an option. Thyroidectomy A surgery to remove a portion or all of the thyroid gland. It is the treatment of choice if the goiter is so large to cause difficulty in breathing or swallowing.
Prevention Be sure that diet contains enough iodine.
Interventions
Measure the patient's neck circumference to check for progressive thyroid gland enlargement.
Check for hard nodules in the gland, which may indicate cancer.
emphasize the importance of iodized salt and medications
Provide preoperative teaching and postoperative care if subtotal thyroidectomy is indicated. Preoperatively
Provide information about the surgical procedure and relieve patient anxiety.
Explain patient the temporary impairment of verbal capability.
Postoperatively
Relieve pain
Prevent infection
Asses for stridor , ronchi , patient cyanosis as it may indicate tracheal obstruction/laryngeal spasm
Place patient on a semifowler position and place pillow at the back of the neck to prevent hyperextension of the neck.
Instruct patient not to bend the neck as it reduces the likelihood of tension in the incision site.
Investigate reports of difficulty swallowing or drooling of oral secretions as it may indicate edema/sequestered bleeding in tissues surrounding the operative site.
Thyroid self-examination may be taught to patients, allowing them to monitor their own body for early changes in gland size
Advise patient to always include iodine in meals.
Bibliography
http://emedicine.medscape.com/article/120392-overview#showall http://en.wikipedia.org/wiki/Goiter http://www.upmc.com/healthatoz/pages/HealthLibrary.aspx?chunkiid=96739 http://library.med.utah.edu/WebPath/ENDOHTML/ENDO021.html
