In this MRCS Part B scenario are the SHO in ENT clinic. Your next patient is Mrs Johnston who has noticed a lump in her neck.

Please take a history.

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Key Information

Differential diagnosis for a swollen thyroid:

Simple goitres:

They can be physiological secondary to increased physiological demand during puberty or pregnancy or pathological secondary to iodine deficiency, the most common cause of an enlarged thyroid gland worldwide.
These goitres can be simple diffuse goitres or multinodular goitres.

Thyroid cancer:

Papillary – 70%
Follicular – 15%
Medullary – 8%
Anaplastic – 5%
Lymphoma – 2%

Inflammatory goitres:

Also known as thyroiditis. Examples include Hashimoto’s, Riedel’s and de Quervain’s thyroiditis

Toxic goiters:

Graves’ disease
Solitary toxic adenoma
Thyroxine producing multinodular goitre – Plummer’s disease

Hyperthyroid signs and symptoms:

Patients tend to be restless and anxious. They may sweat a lot and prefer to be in the cold. A fine tremor may be evident. On examination, you may see signs of thyroid acropachy (in Graves’ disease), palmar erythema, pretibial myxoedema (in Graves’ disease) and they may have brisk reflexes and be tachycardic.

Hypothyroid signs and symptoms:

Patients tend to be slow and have a flattened affect. They are intolerant to the cold. On examination, you may notice brittle hair with loss of the outer third of the eyebrow, dry palms, periorbital puffiness and slow reflexes. It is associated with carpal tunnel syndrome.

Graves’ eye disease:

Grave’s disease is caused by a polyclonal immunoglobin that targets and stimulates the TSH receptor producing hyperthyroidism and an enlarged thyroid gland. Thyroid eye disease is classically seen with exophthalmos and ophthamopelgia (abnormal eye movements) secondary to retro-orbital inflammation and lymphocytic infiltration of the occulomotor muscles causing oedema, and lid lag and lid retraction due to a restrictive myopathy of the levator palpebrae superioris muscle.

It is associated with other autoimmune conditions like type 1 diabetes and pernicious anaemia.

Treatment is with carbimazole or propylthiouracil to inhibit thyroid peroxidase, and radio-iodine to damage the thyroid follicular cells. Total or subtotal thyroidectomy is an option for pregnant women and others who are unable to take radio-iodine.