Alright, here's a summary of the video, presented in a way that should be easy to follow.
Brief Summary
This video by Dr. Ghanashyam Vaidya presents a case study of a thyroid swelling. It covers everything from the patient's history and physical examination to diagnosis, investigations, and treatment options. Key takeaways include:
- Importance of detailed history taking to differentiate between various thyroid conditions.
- Thorough physical examination techniques for assessing thyroid swellings.
- Understanding the significance of different investigations in diagnosing thyroid disorders.
- Knowledge of various treatment modalities for different types of thyroid swellings, including surgical and non-surgical options.
Introduction: Patient Presentation
Dr. Ghanashyam Vaidya introduces a case of a 60-year-old Hindu female, a housewife named Kamala from a village in Thane district, who presents with a swelling in her neck for the past two years. The swelling started gradually in the midline of her neck, near the hyoid bone, without any associated pain or fever. There's no history of the swelling decreasing in size, rapid increase with pain, or new swellings in the neck.
History Taking: Ruling Out Complications and Toxicosis
The patient denies any difficulty in swallowing (dysphagia), change in voice (hoarseness), or breathing difficulties (dyspnea). There's no history of recent weight loss, bone pains, or swelling in the supraclavicular region. The patient also denies symptoms of thyrotoxicosis like palpitations, chest pain, excessive sweating, increased appetite with weight loss, diarrhea, or mental disturbances.
Menstrual and Family History
The patient had menarche at 13 years, with regular menstrual cycles of 4/28 days and moderate flow. While a detailed menstrual history isn't always necessary, it's important to ask about recent irregularities as thyroid hormones can play a role in menstrual cycle regulation. There's no family history of similar swellings, but a family history of goiters could suggest iodine deficiency in the area.
Past History and Inspection
The patient has no history of taking anti-thyroid treatment or radiation exposure in childhood, which is significant as radiation can lead to thyroid carcinoma later in life. On inspection, a single oval swelling of 3x2 cm is noted on the right side of the midline of the neck, 3 cm from the midline and 1 cm above the medial end of the clavicle. The swelling has a smooth surface and well-defined margins.
Surface Characteristics and Differential Diagnosis
The smooth surface suggests it's not a multinodular goiter, which typically has an uneven surface. Single nodules can be associated with toxic adenomas, cysts, or papillary carcinoma. If only a single nodule is palpable, it's considered a solitary nodule unless the rest of the thyroid gland can be felt, indicating a multinodular goiter with a dominant nodule.
Palpation: Techniques and Findings
The swelling rises with deglutition, confirming it's thyroid in origin. This is because the thyroid is closely related to the laryngeal cartilage. Other swellings that rise with tongue protrusion are thyroglossal cysts. Several palpation techniques are discussed, including standing behind the patient, flexing the neck to relax the sternocleidomastoid muscle, and Lahey's method for palpating the postero-medial surface of the thyroid.
Consistency, Borders, and Retrosternal Extension
On palpation, there's no local rise in temperature or tenderness. The swelling has a smooth surface, firm consistency, and well-defined borders. Firm consistency is typical of nodular goiters and primary toxic goiters, while hard consistency suggests carcinoma or long-standing calcified nodules. The lower border is 1 cm above the clavicle, and the trachea can be palpated in the suprasternal notch, ruling out retrosternal extension.
Types and Implications of Retrosternal Goiters
Knowing about retrosternal extension is important because it's a relative contraindication to medical treatment, as initial swelling from anti-thyroid drugs can compress the trachea. Types of retrosternal goiters include substernal, plunging, and intrathoracic. The video explains how to differentiate between a solitary nodule and a multinodular goiter.
Skin Fixation and Thrills
There's no skin fixation or platysma sign, which indicates infiltration by the swelling. A thrill, characteristic of primary thyrotoxicosis due to increased vascularity, is also absent. The video explains how to palpate for a thrill.
Carotid Pulsations and Malignancy Signs
Carotid pulsations are felt equally on both sides but are slightly displaced backward on the right side. Displacement of carotid vessels suggests malignancy. Clinical signs indicative of malignancy include rapid growth, painless nodule, new nodules after 40 years, hard consistency, fixation, difficulty feeling carotid pulsations, tracheal deviation, hoarseness, Horner's syndrome, and hard lymphadenopathy.
Tracheal Deviation and Kocher's Test
The trachea is slightly deviated to the left, and Kocher's test is negative. Kocher's test involves compressing the thyroid from both sides while the patient extends their neck and takes a deep breath. A positive test, indicated by tracheal obstruction, suggests a tight goiter. The video also discusses saber-sheath trachea, where the trachea is compressed laterally in long-standing goiters.
Anterior vs. Posterior Growth and Percussion
The video explains why goiters tend to grow posteriorly due to the weaker posterior layer of the pretracheal fascia. Percussion over the manubrium is not dull, ruling out retrosternal goiter. Auscultation may reveal a systolic bruit over the swelling, especially in vascular goiters.
Signs of Thyrotoxicosis and Myxedema
The patient shows no signs of thyrotoxicosis, such as tremors, lid lag, or exophthalmos. The video details how to examine for lid lag (Graefe's sign) and exophthalmos. It also differentiates between true exophthalmos and apparent proptosis due to lid retraction. Signs of myxedema, such as thinning of skin, edema, and hoarseness of voice, are also absent.
Retrosternal Extension and Metastasis
There are no signs of retrosternal extension, such as dilated veins on the chest wall or inability to palpate the trachea in the suprasternal notch. Horner's syndrome, resulting from compression of the cervical sympathetic chain, is also absent. Finally, there are no signs of metastasis, such as enlarged cervical lymph nodes or bony tenderness.
Diagnosis and Investigations
The diagnosis is a non-toxic solitary thyroid nodule without retrosternal extension or exophthalmos. Investigations include complete blood count, blood sugar, urea, creatinine, ECG, chest X-ray, neck X-ray, ultrasonography, thyroid function tests (T3, T4, TSH), and fine needle aspiration cytology (FNAC).
Specific Investigations and Sleeping Pulse Rate
Specific investigations include a sleeping pulse rate to assess for thyrotoxicosis, laryngoscopy to check vocal cord movement, and a thyroid scan (I-131 study) to determine if the nodule is functioning or non-functioning. The video explains how to check the sleeping pulse rate accurately.
Treatment Options and Surgical Considerations
For a clinically euthyroid solitary nodule, surgery (right hemithyroidectomy) with frozen section biopsy is advised. If malignancy is found, a total thyroidectomy is performed. For multinodular goiters, a subtotal thyroidectomy is preferred, leaving behind some normal thyroid tissue.
Management of Thyrotoxicosis and Thyroid Cancer
Mild thyrotoxicosis is managed with rest and anti-thyroid drugs (carbimazole). If drugs are ineffective or cause side effects, surgery or radioiodine ablation is considered. For papillary carcinoma, total thyroidectomy with removal of involved lymph nodes is performed, followed by lifelong thyroxine supplementation. Follicular carcinoma requires total thyroidectomy followed by a bone scan to detect metastasis. Anaplastic carcinoma is treated with radiotherapy, but total thyroidectomy may be justified if the capsule is not infiltrated. Medullary carcinoma requires total thyroidectomy with resection of involved lymph nodes.
Conclusion
Dr. Vaidya concludes the presentation, summarizing the key aspects of the case study.
