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Thyroid disease

Station 2 or Station 5:

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"This lady has been presented with...

  • Puffy / swollen eyes

  • Neck lump

  • Sweating / Palpitations / Anxiety / Tremor" 

    • (in other words - symptomatic thyrotoxicity)​

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History-taking:​

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Thyroid eye disease:

  • Visual loss or reduction in visual acuity

  • Eye pain, redness & swelling

  • Diplopia (double vision) - may be in pattern of complex ophthalmoplegia

  • Difficulty closing their eyes, when severe can lead to exposure keratitis in severe cases

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Red flag symptoms warrant an urgent, same day assessment by ophthalmology:

  • Diplopia / complex ophthalmoplegia

  • Significant visual loss

  • Red desaturation – suggestive of optic neuritis

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Neck lump:

  • Duration: chronic goitres tend to be benign, does not mean they don’t need treatment!

  • Size – has the lump changed in size since it was first noticed?

    • Malignant thyroid nodules tend to grow faster

  • Compressive symptoms: 

    • Difficulty swallowing or speaking

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Symptomatic thyroid disease:

  • Patients will volunteer their most obvious presenting symptom

  • Ask about most common presenting symptoms as per the table below:

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Key tip

With limited time in PACES, assessing thyroid status thoroughly is challenging

 

Have a systematic approach for thyroid assessment so you can quickly and fluently assess thyroid status

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Consider: 

  • ‘Top to toe’ approach

  • Systems-based approach – cardiovascular, respiratory, gastrointestinal etc.

Examination

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Thyroid eye disease

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Inspection from front, side and above

  • Exophthalmos

  • Lid retraction

  • Lid lag on rapid downward gaze

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  • Assess eye movements for ophthalmoplegia

    • Look for diplopia not in keeping with an isolated cranial nerve pathology e.g. CN III palsy

  • Assessment of visual acuity

    • Offer to use a Snellen chart 

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Neck lump

 

Inspection

  • For goitre or thyroidectomy scar

 

Palpation

  • From behind for goitre, size, shape, tenderness 

  • Swallow assessment

  • Regional lymph node examination

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Auscultate

  • For bruits – these occur due to increased blood flow to an enlarged, overactive thyroid in thyrotoxicosis patients, but are rare in clinical practice

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Thyroid status examination

 

  • Hands

    • Warm & sweaty

    • Fine tremor

    • Cold, dry skin

    • Thyroid acropachy (sometimes known as pseudo-clubbing)

  • Pulse

    • Heart rate or AF

  • Legs

    • Proximal myopathy (more often hyperthyroidism but difficult to differentiate from general fatigue from hypothyroidism)

    • Delayed deep tendon reflexes (hypo) 

    • Pretibial myxoedema (hypo

Key tip

Patients who have had a thyroidectomy are perfect for PACES.

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Don't forget that even if a patient has had a thyroidectomy in the past, often residual tissue may be left or not excised at the time of surgery.

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This remaining tissue can be the source of recurrent symptoms, so don't discount thyroid disease purely on the basis of a thyroidectomy in their past medical history

Investigations

  • Thyroid function tests (TFTs)

    • Thyrotoxicosis – low TSH, high T3/T4

    • Hypothyroidism – high TSH, low T3/T4

    • Subclinical hypothyroidism – high TSH, normal T3 and T4

    • Subclinical hyperthyroidism – low TSH, normal T3 and T4

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Subclinical hyperthyroidism is associated with an increased risk of developing atrial fibrillation and osteoporosis, and still warrants treatment. 

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  • TSH receptor antibodies (TRABs)

    • Positive in Graves’ disease

    • Can help to differentiate between Graves’ cisease and toxic multinodular goitre.

 

Management 

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Thyroid eye disease

  • Supportive management

    • Topical lubricants for patients at risk of exposure keratitis

    • Selenium may improve thyroid eye disease

  • Medical management​

    • High dose prednisolone (60mg) for thyroid eye disease

      • Can be started same-day in severe cases whilst awaiting urgent ophthalmology assessment

    • Immunotherapies e.g. rituximab

  • Specialist / surgical management 

    • Orbital radiotherapy

    • Orbital decompression surgery – often a ‘last resort’ however may be performed urgently if there are any sight-threatening features

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Hyperthyroidism

  • Symptomatic treatment with propranolol 

    • Weaned as symptoms improve

    • Helps to decrease conversion to T4 peripherally

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  • Definitive treatment: Carbimazole or Propylthiouracil​

    • Titration regime – High dose carbimazole or propylthiouracil is titrated to thyroid response

    • ‘Block + replace’ regime – the patient is given high dose carbimazole alongside thyroxine

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  • Patient counselling:

    • Carbimazole is relatively contraindicated in women of childbearing age, pregnancy or breastfeeding, therefore propylthiouracil is preferred

    • Risk of agranulocytosis with carbimazole. Patients should be advised to seek medical attention if they develop a severe sore throat

 

Graves disease

  • Approximately 33% of Graves’ Disease patients will only need one course of treatment

  • Relapses occur in 66% and are treated with radioactive iodine or surgical thyroidectomy

 

Toxic multinodular goitre:

  • Radioactive iodine

    • Radioactive iodine is taken up by the toxic nodules whilst the rest of the thyroid maintains normal function

    • Patients are required to isolate for two weeks post-treatment

    • Contraindicated in thyroid eye disease

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Hypothyroidism

  • Levothyroxine supplementation

    • Check lipid levels: cholesterol may be raised in hypothyroidism.

      • This often resolves once levothyroxine is started and thyroid function is optimised

      • Hypercholesterolaemia only requires treatment if lipids remain high after TFTs normalise

  • Patient counselling

    • Levothyroxine should be taken on an empty stomach, half an hour before food. This is due to its interaction with calcium (reduces absorption of levothyroxine). A common reason for persistence of symptoms despite levothyroxine therapy is concurrent use of a calcium supplement

Common examiner questions

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What are the possible causes of thyrotoxicosis?

  1. Graves’ Disease (autoimmune)

  2. Toxic multinodular goitre

  3. Single thyroid adenoma

  4. Thyroiditis (post-partum, post-viral illness)

  5. Drugs – amiodarone, lithium, over-the-counter drugs (seaweed/iodine)

 

What are the differential diagnoses for a thyroid neck lump?

  • Thyroid cancer – neck lump will usually grow faster, and may have malignant symptoms like fatigue, unintentional weight loss and night sweats, along with difficulty swallowing, a persistent sore throat and pain in the front of the neck.

    • Often not associated with systemic symptoms of thyrotoxicosis or hypothyroidism.

  • Multinodular goitre

  • Thyroid adenoma

  • Single nodule

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