0:00 yes thank you everybody for attending today's session today we have with us two wonderful mentors uh professor raj kopal shannoy sir from kmc manipal author of the famous textbook manipal manual of surgery and professor srinivasansa from koyambutar government medical college thank you so much for taking your time and guiding us today i'll be presenting a case i'm neha i'll be presenting a thyroid a case of swelling on the neck today um so shall i start please please um 16 year old lady mrs x who hails from malaysia who is uh studied
0:47 after eighth standard and is a homemaker by occupation um present which is presented with the chief complaint uh good the next slide presented with the chief complete or swelling in front of her neck since 10 years patient was apparently well ten years back when her relatives noticed a swelling in front of her neck about two into two centimeters in size insidious and onset gradually progressing to the present size of around 12 into 10 centimeter there is no history of rapid increase in size of swelling and no history of pain over the swelling a patient doesn't uh complain of any history of palpitation loss of sleep excitability irritability appetite increase diarrhea heat intolerance hyperactivity hair loss
1:35 and unintentional loss of weight there's no history of increasing weight gain increased sleep constipation cold intolerance and mood changes there's no history of difficulty in breathing difficulty in swallowing and hoarseness of voice there are no other swellings there's no dyspnea no cough no jaundice and no history of bone pain our past history the there's no history of previous surgeries no history of long term drug intake no history of any radiation she's not a non case of diabetes hypertension tb asthma epilepsy or any other chronic conditions treatment history she's not on medication no history of use of thyroid related medications and
2:20 she has no allergy to any substances no known allergy personal history the patient's appetite is normal diet is predominantly non-vegetarian food she consumed iodized salt and does not consume much gytogenic food sleep sleep is adequate bowel habits is regular bladder is regular and there are no addictions menstrual history age of menarch is 12 years she had regular cycles of around 28 plus or minus 2 days and she attained menopause at 50. in family history no history of thyroid related diseases in the family no family history of cancers no history of thyroid swellings in the neighborhood
3:07 summary a 60 year old lady post-menopausal came with a complaint of painless progressive swelling in front of the neck since 10 years with no features suggestive of compression of adjacent structures hypo or hypothyroidism and no features suggestive of metastasis you go to the first slide yes you will stand we were going into the history let's ask you can i ask her please sir please please please you first ask then after that i will ask no problem tell me the basics of thyroid worry it is called thyroid what is the meaning of thyroid um uh it's a butterfly shame gland
3:55 uh so i don't know what is the meaning of no no the meaning okay now tell me there are two lobes you send connecting the two lobes yesterday is the mess right what does that correspond to the tracheal rings uh one two and three one two and three please modify [Music] right now what is the functioning unit of a thyroid so the thyroid has lobules which contain follicles the follicles have uh
4:42 the thyroid i mean the the circulating cells and in the center of the colloid and briefly tell me the arterial supply of the thyroid uh the thyroid is supplied by two main arteries one is superior thyroid artery which is a branch of external carotid artery uh it and it supplies from the upper pole and then there's the inferior thyroid artery which is a branch of the thyroid cervical trunk and uh yes sir and sometimes there is also a thyroidial emr artery which is an additional supply ins in some cases branches from the tracheal and these are vaginal branches also supply
5:30 the superior uh thyroid vein the middle thyroid vein and the inferior thyroid vein uh the superior thyroid brain gains into the internal jugular vein the middle thyroid wind also drains into the internal jugular vein it's short and uh it's the shortest one and the inferior thyroid veins uh in nominate vein there'll be two important nerves which are associated with thyroid so the external laryngeal knob and recurrent laryngeal nerve are closely associated with the thyroid the external laryngeal knob is a branch of the superior laryngeal now and uh it it yes and the recurrent laryngeal nerve is present at the tracheal esophageal groove and um now why does that
6:16 thyroid move up with deglite so the thyroid uh is enclosed in the pre-tracheal fascia and the pre-tracheal fascia has a condensation called berry's ligament which is connected to the cricoid uh since the uh the trachea and the thyroid and cricoid cartilage move up with declotation along with that even the thyroid gland uh because it's fixed i mean it's attached to the cricoid it moves up too how is the cricoid cartilage pulled up because the the the constrictor muscles like the inferior constricted muscles okay right all right you are enjoying your sir please take yourself yeah so dr neha you are answered well so good theory preparation
7:01 of two things you should know we need to definitely not put the identification of the patient that is a name but you can always tell this is a checklist for your name age address education occupation you know how you can present this 60 year old lady coming from malaysia bangalore 8th standard by whatever the educational status homemaker by occupation presented to the hospital with a swelling in front of the neck of 10 years duration yes sir clear so you never say mrs x and mr x etc is it clear yes sir it is simple these
7:47 are all the checklists even in the examination when you are asked to describe the spelling you don't have to tell size 6 centimeter surface smooth not like that surface is smooth borders around it make a continuous sentence and present the case i hope so 60 year old lady coming from malaysia bangalore is stranded by education homemaker by occupation presented to the hospital with following complaint right next slide yeah so this is how it is complaint of swelling in front of the neck 10 years duration so whenever you have a patient who comes with a swelling of 10 years duration
8:34 what is the first thing that you come to your mind first thing forget about thyroid and etc in general so the first thing is why hasn't this patient uh uh come before since the swelling has been presented present since 10 years what what do you think the reason in indian scenario uh so since maybe since she's a woman and uh maybe it was uh ignored and she didn't have any pain or any uh any uh any such um i agree with you but the what answer i wanted always to remember for any spelling for that matter is sir most probably we are dealing with benign swelling that is the first thing i want to understand is it clear yes very
9:22 very fact that she has been living with this dwelling for 10 years that means most probably see nobody can tell with 100 percent sure so when i ask you what do you think my first inference of 10 years your answer should be sir most probably benign then the second question we ask you is why she has come after 10 years for that you you just now told me many reasons like a women why women will come little late compared to men according to you so maybe maybe their complaints were not taken seriously in the house no that is why uh we are seeing uh more girls are taking up surgery now
10:07 they are going to that is hundred percent true neha that is the women have to do a lot of responsibility in the house you know they have to look after children husband in-laws so many issues let us not divert that yes generally generally they come late maybe a financial considerations may be a literacy or maybe somebody has not not taken her to the hospital whatever be the reason is it clear yes right so that may be the reason that she has come she is a 60 year old lady and it has started at the age of 50. so does it make a difference to you when it is 20 year old lady
10:52 coming at 30 years of age uh yes so the age of uh the age is important in thyroid swellings like we can think of few etiologies like if they are young it could be iodine deficiency it could be a rare this hormoneogenesis uh it could be um like uh it could be puberty or pregnancy-related uh goiter uh at an older age the chances of um you know sorry at a younger age the chances of capillary carcinoma is also high uh at a middle age the chances of a colloidal goiter or a follicular carcinoma is higher at very old age there's a higher chance of anaplastic cancers um not not truly very volatile and all
11:39 that thing what you mentioned that is all right more or less what the answer i wanted was younger means they would have even worried about cosmetic is it clearly moment is 50 plus in the house you know there is a usual saying in indian madhya something like that so she is already married lady so that is the reason one reason they are coming late to the hospital right yes now shall we go sir further yeah now i i noticed that 2 into 2 centimeter see i accept it but some examiners you know they are little uh correct diameter etc so what you can tell is that it should can you see my hand now so you just said
12:27 sir she told me like this so i think it is 2 centimeter approximately small small 2 centimeter insidious onset and it has to attain the present size you can tell uh here to say 12 by 10 is becomes difficult you understand i know is a very large one people will jump on if you tell orange if you pineapple or if you tell the watermelon etc so you can tell cricket ball commonly people know so it has become large enough for a patient to show me sir that's why i said i guessed probably it is 10 centimeter that's all you can say yes sir why did you ask that rapid increase in the size of the swelling
13:13 so a rapid increase could indicate that there was hemorrhage or that there's a nuanced malignant transformation just hold on two things are different rapid increase means it is over a period of say few days few days maybe 10 days 20 days 30 days one month that is usually a malignant transformation yes whereas hemorrhage means it is sudden increase yes typically typically patient says i have been having this for a long period of time and suddenly yesterday i had even difficulty in breathing that is not a feature of malignancy that is a hemorrhage in a
13:58 nodule over the isthmus here what is the most common site of a nodule uh the is the the junction between the one lobule and the estimates ah so not lobular low low low so obviously when there is a sudden hemorrhage it causes compression of the tracheal cartilages so rapid increase suggests usually a malignant transformation sudden increase in the tracheal compression is it clear it happens in a hemorrhage in thyroid swellings you should bring this history of pain last is it clear yes however however big is the thyroid swelling pain is not at all a feature of thyroid
14:44 spellings is it clear because once you start initially only examiners will go on asking you about the different causes of pain and then you get stuck there and uh you know so so so let us come to the pain later we will not bring the because pain is the last symptom of thyroid diseases is it clear whether it is mng even if it is carcinoma thyrotoxicosis all that list which you give no adenoma this that uh it's very uncommon or rare bad things are rare so we'll discuss it later next slide please
15:32 yeah now what next you should have told at this juncture see you have written everything i agree with you now neha your thoughts have to be in some methodical way you know why i said this always first is the thyroid gland progress yes anytime it has a regressed in size small size when somebody takes it somebody has a disease for 10 years she might have gone to some local doctor general practitioner somebody would have given her even l thyroxine tablet with that it would have even become little smaller in size all this information you need to take that is one
16:17 now once that is done your that fifth line should come immediately after the swelling noise your difficulty in breathing difficulty in swallowing and hoarseness of the voice that should come first local compression issues both breathing and swallowing are due to local compression on the trachea and esophagus right what what is that called as 10-year swelling compressing on the trachea and patient feels a bit of you know difficulty in breathing why is that due to so it's because of the pressure effect of the enlarged gland see that's what i said if you say
17:04 pressure effect you will pass but if you tell pressure entropy and trach of malaysia you will get more marks yes see answers you know but in that limited time during the examination quickly you should come out sir compression of the tracheal cartilages can give rise to pressure entropy that's it softening softening of the technical cartilages even though trichomalacia manifests usually after thyroid is it clear is it clear once you remove that thyroid no the trachea loses the support and collapses that usually happens that is one any other reason for thyroid swelling to
17:51 have difficulty in breathing other than the trickle compression so if it's if it's extending like it could retrospec difficulty in breathing if there is a hyperthyroidism then that can cause cardiovascular uh like side effects which can cause dyspnea and cardiovascular side effects again correct yourself and tell a good sentence good word so uh hyperthyroidism can cause um like congestive cardiac failure that can lead to dyspnea so you know the answer so you need to spell out in the exam first so that the question is asked be specific and what is that called as in a
18:36 long-standing goiter like this multi-node logoider or whatever causing congestive cardiac failure what is this uh what is this thyrotoxic force is called as oh yes yes i'm not sure what it's called the secondary paratoxico system also called plummer's disease yes you know what is primary theratoxicosis oh yes so it's because of graves disease uh there's mostly cns side effects in primary yeah we'll stop it primary called as graves disease secondary is called as plummer's disease also it is secondary thyrotoxic process right cardiac involvement is more common and later if you don't treat it then
19:23 only they will go for a congestive cardiac failure similarly in primary if you don't treat it as a as a severe manifestation you know what happens to the eyes even if blindness also can occur progressive of thoughts so these are the two extremes nowadays we are not seeing much but you should remember a patient who has got a multi-node laboratory complaints of difficulty in breathing consider a tracheal compression possible to consider a retrosternal extension yes consider also a secondary thyrotoxic process right so what i am trying to tell is breathing swallowing hoarseness should come top in the list
20:08 yes why difficulty in swallowing uh so that's an uh more advanced stage of compression because it because of compression of the which structure is more anterior the trachea so esophagus is posterior it's a posterior lobe laterally compressing may cause esophageal compression esophagus is a muscular tube so it doesn't you know collapse but definitely some amount of discomfort or difficulty in swallowing they may complain on that they will never complain so it is possible even in a patient who has got large swelling and
20:54 hoarseness is due to a recurrent laryngeal nerve when when that is damaged then there's hoarseness of voice don't say damage what is the word to be used compression no it's a invitation of the recurrent laryngeal in all i have assessed you know already by your presentation you know the answer but it will not come first time a congestive cardiac failure you said side effects of cardiovascular system infiltration of recurrent land general so every word is important here tracheomalacia or suffering you just have to even say softening of the tracheal cartilages so
21:41 this will come first once that is done again see here you have written a history of palpitation then you are written loss of sleep excitability then fatigue weight gain sleep constipation all that thing if they are present you tell or you can say write us one sentence here so no history suggest you of toxicosis it gives a examiner to active question and when the examiner asks you a question you again tell it in a methodical way for example primary theratoxicosis you start with the cns symptoms all that you are written know that how
22:26 will know that patient is irritable has it has she told you that i am not i'm not irritable you are written what do you mean by irritable irritable means restless basically they are restless primary i'm talking primary so what answers you need to ask your questions is first is cns symptoms next comes the gastrointestinal symptoms right so in that order you take one by one they can also have skeletal system for example myopathy difficult to getting and you already clearly mentioned she is a post so we will not ask that question for her about menstrual irregularity in a young
23:12 patient if you follow one method one order so no history suggest you have toxicosis what is that history you asked sir in the form of cns i asked this this this in the form of menstrual i asked this in the form of this i asked similarly why did you ask that increased fatigue ability weight gain to look for symptoms of hypothyroidism very important so one no history of toxicosis no history suggest you of hypothyroidism one sentence is enough if let the give give a chance to the examiner to ask questions no other swellings what is that you are
23:59 looking for so um for example in follicular carcinoma uh many times we see like uh swellings like in the skull or uh in the sternum and other places which uh which are like pulsatile swellings so i've just ruled out that there's no other swellings what is the more common thyroid malignancy the most common is papillary carcinoma what is the method of presentation of papillary carcinoma thyroid it's a generally a solitary uh they'll have a solitary knockout and with or without lymph node metastasis so when we ask you know what other swelling first is
24:45 other neck nodes yes if patient is intelligent or if she's careful you can always tell after that after that see don't go on telling at a once pulsatile second is in the scalp and sternum etcetera you just bony swelling it gives an examiner to ask a question which bones see you know the answer so which bones so you say flat bones like that what is the nature pulsating so that means you have asked you you drawn the examiner towards you by five questions which you know the answer is it clear to you yes sir for the benefit of all the undergraduates here just remember fbs fps means follicular
25:31 blood spread it it does not mean exclusive but i just want you to understand commonly it is blood spread again fbs is follicular bone spread bone again fbs is flat bone spread see easy to remember so that you will never forget because other way is papillary spread by lymphatics follicles from blood spread so easy way to remember and another thing i would like to tell you at this junctures nice that you mentioned as well thyroid malignancy malignancies like follicle will not produce that uh back ache and all that you know bony pain and all they all produce like this swelling
26:18 if you have a bone pains there's more destruction and it is a feature of female means think of carcinoma or the breast you know in ca breast we ask you we ask a low back ache back ache we don't we don't ask the bone spellings we ask backache lumbar area or thoracic so see a breast produces more backache and follicular carcinoma produces more bony swellings synovial sensor please know that she has told that you have told everything she's using 10 years duration in years duration you say what type of toxic causes you can develop they can can the patient be having primary thyroid oxygen for 10 years
27:04 so primary thyroid toxic toxicosis will generally have like uh eye symptoms and uh science everything is having ten years if we develop if we develop toxic symptoms what's what is the give me a secondary hereditary it'll be secondary yes so you should mention that first okay is there a difference between thyrotoxicosis and hyperthyroidism and hypersonic toxic causes uh hyperthyroidism is a type of thyroid toxicosis thyrotoxicosis doesn't have to be because of the thyroid gland it can even be like factitious uh intake of thyroxine it can even be stroma over some ectopic production of thyroid hyperthyroidism is specific to when the
27:50 thyroid gland is producing more thyroxin [Music] you can just mention noise any toxic symptoms or hypothyroid symptoms if they ask you you bring in or if they'll start asking you what is the reason for excitability what is the reason for irritability so if the patient has got any symptoms you mentioned that one that uh oh is your last sentence swelling is all right um cough jaundice bony pain remember each each malignancy has certain different behavior so thyroid malignancies even they take one year two year
28:37 metastases in the bone metastases in the lymph nodes they ragley rarely i have not seen producing jaundice is it clear okay so there should not be any reason for you to ask that uh and write in the case okay so please do not mention jaundice because the day you mentioned john day immediate question is why jaundice what did you have in mind also i thought like for like cough dyspnea was for lung metastasis like that jaundice i thought would be if there's liver metastasis again liver metastasis do not produce jaundice for your inflammation because it is normal liver
29:23 unless significantly where seventy to eighty percent is damaged you don't get jaundice number one and notes at the habit quota hepatitis and all see don't go to too much imagination like uh no history of jaundice somebody's asked no issue of epilepsy no histocoma cerebral metastasis there's no end for it is it clear yes sir in in thyroid spelling very specific next valley neck swelling and bone swelling enough if it is papillary carcinoma it will indirectly tell lymph nodes if it is a follicle it will tell probably a hepatogen has spread enough anaplastic is more of a hoarseness of
30:10 the voice and medullary is a different situation sporadic cases what we see it can be associated with the endocrine me and syndromes they are different so let us not worry too much about that i think we can go to the next slide yes why did you ask history of previous surgery so if there's if it's like a recurrent condition in case she has had any thyroid surgery before that is all right because if you have a exam there may be a patient who has undergone total thyroidectomy and one case is given to you with the neck nose that gives you a clue that old case can be papillary customer thyroid is it
30:57 clear so no issue of surgery in the past why did you ask a history of radiation and what radiation why so radiation for like conditions like lymphoma will increase the risk radiation in this area increases the risk of papillary thyroid cancer yes that's why i asked if she had any history of radiation i i agree with you that uh if at all a childhood childhood lymphoma so if this in this grade it it is possible because when i say childhood means this is about 50 years back for this lady and now she is 60 so yes lymphoma one situation but what you should
31:43 understand today is more than lymphoma there are many head and neck malignancy children can develop more than lymphoma not just lymphoma nasopharyngeal carcinomas or maybe a lymph non hodgkin's lymphoma even anywhere so child who have been treated with the with radiation that is one any other source of radiation for a any other source of radiation accidental radiation i was i think historically like the chernobyl accident uh historically means effects may be still there once any other
32:36 many conditions especially for children to see the head and neck uh you know even though it is uh for 15 seconds or 20 seconds to the fast cd they have what a significant uh radiation hazards is it clear so that's what you should need to know so radiation given for lymphoma radiation given for a childhood malignancies of the head and neck multiple ct scans of the head and neck taken for different conditions they are accidental source these are the various sources of radiation what is that long-term drug intake so there are some goitrogenic drugs so i like like
33:22 thiocyanates then para amino salicylates then anti-thyroid drugs what is this late so i'm not sure so again for for all undergraduates all anything which you are not sure please do not mention in the examination pas is i have seen that i have given that you know with my hand only in a badari medical college when i was a intern but it is no longer used anti-tuberculosis treatment okay pass it stopped almost uh i think uh 30-40 years back para amino salicylic acid so more than two things i would have
34:10 been happy if you were to tell what is that anti-hypertensive drug you know the answer does it contain iodine oh yes amiodarone uh yes sir i am adorable is the one and another another drug is lithium okay yes lithium so at least one or two drugs you should know rather than pas okay tuberculosis epilepsy chronic condition we need to take it for the sake of management of the patient is there any questions
35:00 medication so i asked her if she was if she had gone to a doctor specifically for that and if she was prescribed any medication for that and if she's been taking anything but she didn't have any history of that how do you know whether the patient is taking anti-thyroid drugs or thyroid supplements uh patients no all patients are educated so the dosing i think like um thyroid supplements is taken once a day i think so and uh early morning empty stomach yes is thyroid supplement yes two times two drugs or three times
35:48 is anti-thyroid okay that is how you exit the history not on any medication the allergic history go to the next slide you have to go for the clinical examination again here don't say does not consume too much goitrogenic food and all all that is the old story of the cabbage etc okay yes so again consume iodized salt today every salt is iodized for your information so diet say normal diet or say non-vegetarian okay wanted to add that doesn't matter you can say don't have to really go on telling iodized salt etc okay
36:35 insomnia insomnia also called a slip disturbance is predominantly a feature of which condition so insomnia happens in hypothyroidism but a hyperthyroidism patient can also have sleep disturbance because of the they'll be uh you are telling me i think wrong what did you tell insomnia happens in hyperthyroidism so insomnia is a very very important feature of again to give you more marks you should use the word primary theratoxicosis is it clear yes insomnia is a very strong feature of a primary paratoxicosis the metabolic activity is so much high
37:22 sympathetic activity tachycardia palpitation it doesn't keep the patient you know he is all the time anxious anxious awareness the beat some kind of a dehydration also so it doesn't get the sleep is it fair that's it whereas hypothyroid means they like sleeping okay i think we can go to the next slide what is the importance of family history uh sir there's some um family history in thyroid uh like um there can be some genetic conditions like men's syndrome where there's an increased chance of medullary carcinoma like in men to a and 2b
38:07 and there can be some familial syndromes like cowden syndrome and where there are multiple uh and there can be uh this hormone or genesis um and uh uh yes sir all that you know yeah but what you should have mentioned is always endemicity endemic what do you mean by endemic water so sometimes in certain neighborhoods uh the the there are many cases of goiter in that neighborhood
38:55 you are from karnataka state do you know one or two endemic goiter areas in our state i know only that one sir maybe i i do know much about that but see the suckles for belt you know those are the patients mostly either they go to mysore or mangalore so wherever the hilly areas you know hilly area and then there's a low lying area but again the incidence is coming down now so that is what is endemicity either when the neighborhood what that you are written there family members so all that other things what you mentioned is not common is it clear not common okay go ahead with the next slide okay you go to you can go to clinical
39:41 examinations then yeah sir at this juncture if they ask you what is your diagnosis what is that you tell at this stage at this link goiter and eu thyroid state without any metastatic symptoms i fully agree with you when you have a no hypothyroidism and no hyperthyroidism when there is no future suggestion of more than telling metastasis malignancy that is the better word rather than straight away there's no word about malignancy the most common of a 10 years duration either it's a colloidal colloid water you know the correct word which is used you know canada yes sir telegram that is the word which used to be used
40:27 lord or mighty not labor that's all two things that's all it's been more looking like a benign swelling correct history wise yes the patient consent was taken and examined under adequate lighting exposure in the presence of an attender um physical examination an elderly lady conscious well oriented to time place and person cooperative moderately built and well-nourished sitting comfortably on the bedded examination there's no parallel actress lymphadenopathy pre-trivial mixed edema and clubbing normal hair luster there are no eye
41:14 signs oral cavity is good hygiene upper limbs is warm there's no uh tremors lower limb is normal skin is normal yeah just hold on hold on we have one minute um whenever you are presenting you also need to know uh what looking for this related to your case why you are looking for lymphadenopathy in this patient so lymph node enlargement happens in uh malignancy so is it is it an important feature of a thyroid examination also to look for lymph nodes yes sir so it is not required or you should not mention that during your
42:02 general physical examination is it clear okay your answer should be that i look for pallet because we want to know she may be six grams seven grams so we we need to take her for surgery or something icterus has no relevance in this patient sir i will i will mention the lymph nodes later is it clear similarly for all the benefit of post graduates or undergraduates in a thyroid swelling again no eye signs you can always mention if it is there you mentioned otherwise i will describe it later in a case of primary thyroid toxicosis is it clear this oral cavity is okay upper limb warm no tremors that's all fine but lymph nodes need a separate
42:47 examination last method is pretabial mixed edema and clubbing why did you suddenly bring that word pre-tbl mix edema who asked you to examine that now is your patient toxic patient no no so don't get into trouble they will go on asking you about pre-tribal mixed edema yes mentioning no edema of the fate is fine at this juncture yes edema can be due to nutritional you only said no women means generally they i don't say they're neglected but they come late to the hospital so no editing of the fate is fine she is not in congestive cardiac failure or she is not nutritionally
43:33 deprived of but don't mention this pre-tbl mixed edema at this change yes let again give a chance to the examiner ask you in primary theratoxicosis what do you look in the limb what do you look in the lymph in primary thyroid toxicosis your answer should be treated yes do you know what do you know how how it looks like and what it is unilateral or bilateral what is this pre-table mixed edema fitting non-pitting so i think um you think yes i'm not fully sure sir okay this is exactly it happens it's more symmetrical you know bilateral symmetrical you know museum like deposition which is
44:19 non-pitting in nature so and also you don't look for that pitting just about the medial malleolus etc it's a pre tbl the shin is area these are the area skin is looking like bit of a coarse you know so that's what a thick and light tissue so that's what i am trying to say just say no edema other way of putting the same question what what other examination you do in hypothyroidism if this question is asked in the leg in the limb do you have any idea ankle jerk slow relaxation yes somebody has put that aminoglycans correct that is the answer
45:05 for a deposition of the tissue in the primary third occurs yeah i think you go ahead for the thyroid straight away yes pulse rate is 78 beats per minute regularly regular rhythm blood pressure is 130 by 80 millimeters mercury respiration is 14 cycles per minute and temperature is 98.8 degrees currently um examination of the neck uh inspection a single overhead swelling size 12 into 10 into 8 centimeters approximately in the anterior neck in thyroid region extending from the upper border of thyroid cartilage to sternal notch and lateral border are under sternocleidomastoid surface looks nodular the skin on the swelling
45:52 appears normal the swelling moves with deglotation and the lower border is seen uh palpation there's no local rise of temperature uh it is non-tender uh the consistency is uh cystic to form uh the size is around 50 the size is 15 to 10 into 8 centimeters extending from the upper border of thyroid cartilage superiorly to sternal notch inferiorly lateral extent not made out as swelling extends under the sternocleidomastoid carotid pulse palpable on both sides a lower border of the swelling is felt the surface is nodular consistency is variable firm over most areas and cystic over few areas multiple nodules palpated largest being
46:39 around three into two centimeters on the left side trachea is central uh auscultation no brewing hormone the brain of the spelling plane of the swelling is important is it not i say it's deep to the deep cervical you've been you mentioned left hand kindly added okay yes reign of the swelling is born yes uh auscultation no brewery heard in the superior pole system just stopped for some time go to the first slide of the inspection okay simple question you know this is a very big fighter like elephant size nobody can listen if there's a very small swelling and how to make it prominent
47:25 to do the good inspection this is a very common problem commonly asked question yes uh sorry yes so if we if they extend the neck then because it's deep to the deep cervical fascia uh so in the book it was given that it becomes more prominent but i i had a doubt shouldn't it become less prominent because uh just told them i will give the answer so when you ask the patient to stretch the neck like this next time if you happen to go to the ward maybe by number december sometimes you see it's a cervical lordosis that happens is it clear you know lordosis means
48:10 what the natural curvature of the spine when that cervical lordosis happens it pushes the thyroid gland anteriorly is it clear to you yes and your second question you are telling that uh what is that second you were telling you had a doubt what is the doubt you had it got cleared so that was the doubt like uh because it's when you extend it becomes prominent but however when it's deep to deep cervical fascia how does it become less prominent
48:57 one important word many of you forget is contraction should be against resistance is it against resistance you want to check for stunner mastery don't say just turn the neck like that no you always push it to the other side correct so when you when you extend the neck are you really doing any contraction here you are just passive stretching is it clear it is you are not contracting at all against resistance you are only extending the neck by extending the neck there is a cervical ordos is pushing the thyroid gland anteriorly so it becomes more prominent i hope it is clear yes sir second important thing
49:44 oh why do you have written and 12 whatever 12 10 8 oh whatever it is i always make a habit to mention firstly there is a swelling in the region of thyroid is very good anterior neck is good whether you say anterior or front of the neck and anterior that is also fine extension you are told nicely upper body the thyroid cartilage the external notch and laterally that is also fine but what is this diameter transversely and what is the diameter vertically that has to be made clear yes when you say 12 by 10 i don't know are you referring to vertical 12 and horizontal 10 is it like that no so it's
50:33 horizontally over 12 is the horizontal and 10 is vertical so horizontally extension you mean to say horizontal it is more than vertical yes so what what do you think why it is like that why it is not butterfly because your statement is correct yes it's not butterfly shape because there are many different nodules and the shape of the gland has been lost uh and what i what i what i can guess is if it is 12 centimeter horizontally and vertically eight means left lobe is enlarged and right side the entire lobe is not unlocked that's the only way i can think
51:18 uh can you show the picture one just one left side is more enlarged than the right side show the front yeah left is more compared to the right that is why sir she is telling is horizontally horizontally oval she is including the portion of the right lobe and left anyway so go ahead go ahead when you ask the patient to swallow i agree in indian scenario we just ask them to swallow but remember she goes on swallowing her saliva she has hardly any saliva at the end by the time you come and ask her to swallow make a habit to give a glass of water fellowship examinations and all they may
52:04 consider these are the points for your whatever results or good marks so asking the patient to drink a glass of water and people mentioned swelling with the degrees already initially srivasan sir has asked you why it moves with the degradation invariably you people tell various ligament according to me it should come last you understand your answer should be thyroid is very nicely enclosed with the pre-tracheal fascia so with the attachment of the various ligament and also also pharyngeal muscles constrictor muscles and even a digastric muscles they all act in a
52:51 whole larynx if upwards to block the respiratory passage so because of these reasons thyroid mostly the degradation so my question to you is when thyroid does not move with the degradation so it may not move if it's very large or if it's infiltrated like the strap muscles or if it's infiltrated like in a carcinoma like anaplastic carcinoma in these two conditions it won't move and if it's very large and like retrosternal also you may not be able to appreciate it moving it but it moves with limited mobility
53:39 there will be a restricted movement okay that is the word don't tell infiltration to strap muscles and all it's it's they're all complex their best is to say infiltration especially in malignancies to the pre vertebral fascia is it clear if that module module in the lobes the immediate posterior structure is prevertable fissure once it infiltrates the preventable fascia it doesn't move the dignitation that is the reason why most of the anaplastic becomes inoperable it's not just the question of recurrent langener you can sacrifice it in malignancy if it
54:26 is infiltrating of course i use the word infiltrating but preventable facial so you you cannot move it in such situations it doesn't move rotation okay go to the next surface modular skin over the swelling you have written normal uh yes possible but sometimes see carefully large void is skin may be stretched skin may be shiny or even in veins you may be able to see over the large thyroid swelling uh no local release of temperature and non-tender initially when that history of pain you know i i wanted to ask that question to you that why you ask a history of pain in
55:13 thyroid thyroid swellings uh your answer should be for to rule out thyroiditis is it clear thyroidite whether they do courage steroids otherwise bacterial thyroiditis thyroid axis is not at all common why right however with the thyroid you don't get a tenderness is it clear that you don't get tenderness and localizer temperature may be seen only in a very vascular vascular tumor at this juncture you need to tell the examiners that you
56:01 go behind the patient you go behind the patient and i have started palpating is it clear yes somebody has asked that anaplastic carcinoma thyroid can it give rise to pain yes whenever there's a very hard tumor infiltrating paravertebral uh paravertable space there vertical fascia growth itself is very rapid and sudden rapid so it can produce some kind of a dull acting pain so i just wanted to tell you pain is feature of anaplastic carcinoma and also lymphoma of the thyroid i don't want you people to get into trouble in the exam keep that pain separate if they ask you just say dear current thyroid that is the most common cause of pain in the
56:47 thyroid is it clear okay yeah so now um you need to tell sir i have gone behind the patient and i gently flex the neck gently flex the neck too so that you are relaxing this muscles also strap muscles or even sternum asteroid fascia and start palpating with your two hands you don't say i'll pulp it with one hand both hands just like rolling movements of your hand both hands you start palpating on inspection swelling is moving up with the degradation you have swelling in front so you already made up a diagnosis it is thyroid now it is thyroid so you don't have to have
57:33 any hesitation now sir i went behind the patient i started palpating and what is that you are palpating strenuous sensor i asked in the initial stage thyroid has got two lobes and esthemous so i need to examine both lobes and is the mass so you start palpating and then you say what is palpable that is what i have not made out in this your slides so i can make out that from your figure i will say both left and right lobes are palpable that is number one is it correct yes sir left and right lobes are powerful see you're not mentioned there number one number two isthamas is also palpable how do you know is possible
58:20 um yes simple if you run your finger beneath your uh thyroid adam's apple you can all of you can feel your tracheal cartilages yes correct if any one of you say sir my tracheal cartilage not felt means yogurt is the mass enlargement simple very simple yes sir so you are going to say left lobe is pulpable right lobe is palpable is palpable however left lobe is seems to be much bigger you have to have a measuring tape that's what i can understand now 15 centimeter or whatever and then you are going to describe surface you are written here swelling extends
59:05 under the sterno mastered muscle and next your jump to carotid pulse without giving any details about surface borders consistency that which you have put in the next slide should come here here carotid pulse should come later yes sir you know that you know the schematic schematic presentation of very swelling those 10 points are there which you should not miss that local razor temperature tenderness you mentioned measuring tape see variable systicks will come later size shape surface borders skin over the swelling consistency mobility fixity plane of the swelling
59:52 surrounding area about any other features like fellow processes means you will tell moment on protrusion of that time in addition to movement is falling so please uh correct this case sheet so no locator is temperature non-tender then measurements so can you present this again now this in a correct way oh yes sir um no local uh so no local rise of temperature non-tender uh the size is 15 into 10 into 8 centimeters extending from the upper border of thyroid cartilage superiorly to sternal notch inferiorly lateral extend not made out as swelling accidents under the
1:00:38 sternocleidomastoid the surface is the surface is nodular um the surface is nodular uh the borders are well made out um the skin above the swelling is normal um the consistency is a variable uh firm on most areas stick in a few areas um so i will sorry i will stop you for two things here one swelling is firm equipment how did you make out that one area artistic uh so it was not formed throughout a few areas uh felt system i i agree with you
1:01:24 madam this is a scientific way of proof that it has to contain fluid whenever you have a small swelling by doing the packets test so examiner may ask you what is private's test what is private's test uh sir it in order to elicit fluctuation it is in a small swelling we do a paget's test uh since it's small we can't use uh more fingers so we just use one press it in the center and see expansion with the other one sorry not expansion so i meant uh since this fluid the fluctuation test no no no no no don't get into trouble if is swelling will feel soft in the center firm at the
1:02:09 peripheral yes it happens when there is a tumor necrosis i'm sorry tumor necrosis cystic degeneration that's what happens in such a large goiter you know those pathophysiology of multinode levitator stimulation a few areas which become ultimately necrosis necros lobules together which forms a nodule and in between the nodules thyroid issue may be normal also is it clear so i need to mention that if the examiner asks you how did you make of cystic your answer should be sir i have done pilots test again you are not mentioned to be which side is a lobe is big left or right that has to be made clear
1:02:55 and also is the mass these are the details expected from you when you have a nodule which is much bigger much bigger say beyond 2.5 centimeter like that you can use the word oscillated one look will tell you surface such a big swelling is called as oscillated surface is firm few areas show cystic few areas are showing cystic and consistency is over once that is done you any swelling which moves up with the deglutation you don't have to mention chin test all that neck flexion test etc because any swelling which moves with the
1:03:40 rotation it means it is deep to you know the deep cervical fascia also is a part of that yes so that's how it is trachea is in the center is it a normal in your patient this finding is it uh do you expect it to be get shifted if it is which side so since the left lobe is larger it could be shifted a little bit to the right how did you examine patrick yeah so the trial sign uh the trail sign up so the side which the trachea is shifted the clavicle head
1:04:26 of sternocleidomastoid is more prominent on that side uh we can also palpate uh and check and another way to know is uh by auscultation so ideal idp palpate the prominent part of the thyroid cartilage come down uh a case like this where is grossly enlarged you cannot do the test so either a mention trail sign or auscultatory method okay yes next actually now carotid should come
1:05:12 here in this slide okay everything about the swelling should finish only after that that's why it's called loco regional examination it's not called a loco regional thyroid trachea carotid lymph nodes in that order right yes where did you feel the keratin uh so it's felt uh against the uh the transverse process of the sixth cervical vertebra and so correct in a large swelling like this do you think you can feel that in that area c6 area i know in a large swelling it is shifted
1:05:57 a bit like pushed a bit laterally benign swellings tend to push it right beyond c6 is also the area of the pharynx becoming dash mcq question what uh the pharynx continues as the esophagus very good phallics becomes the esophagus at that level okay so c6 so ideally you what happens at the upper body of thyroid cartilage uh yes this is a common question uh the carotid artery the common carotid artery splits into the external and internal carotid artery don't say split you know anatomical word is not splitting yes
1:06:57 you know fork of the common keratin oracle or temporal nerve goes through that you know fork it's called a fork all right so uh you need to examine for the carotid i think we'll proceed lower you didn't mention about the lymph nodes because i was not able to palpate the lymph nodes or lymph nodes were able to be palpated what is the importance of palpating the lower border if the lower body is not palpable then we should think that it might i mean we should suspect that there's a retro tunnel uh extension of the goiter yes what are the types of retrosternal goiter you know so it could be um it could be extending from the
1:07:43 thyroid and going downwards uh or it could be a plunging type which is the entire goiter is present in the retrostenal area and on increasing pressure like on coughing it comes back up and or yes is enough if they ask you what is plunging what is external you explain okay please always be brief with the examiners okay because we are trying to force more ask one question if you answer more and 25 students per day examiners are really tired and you are
1:08:30 trying to answer them you make the examiner more sleepy if you say like this the examiners will be happy yes external plunging that is believed to be better okay right next slide yes why why you want to ascertain the brewery is a common question yes sir when there is increased vascularity like in thyrotoxicosis or in certain malignancies we can hear a brewery in the superior pool so the superior thyroid artery is more superficial and it doesn't branch out unlike the inferior third artery so it's better
1:09:16 better heard in the superior force branches close to the upper pole okay um maybe the the pressure is more in the actual carotid artery right this is a subclavian artery giving rise to thyroid cervical strength and thyroid cervical strength gives rest of these three most of the blood supply comes from the superior thyroid okay so inferior thyroid arteries not only suppress thyroid it is also important to supply for one important organ yes next i think we will not waste our time at this gym
1:10:02 respiratory cvs abdomen all that you need to examine like any other compression if it is if your case is a primary thyroid toxicity they ask you muscular you are written there musculoskeletal so primary what thyrotoxicos is just p for p pretibial mixed edema you need to know and proximal optimal myopathy right and uh you also should remember pachi pacqui means thyroid acropachy another p you know pachi thyroid acrobatic all this is in primary paratoxicosis yes go ahead next you may not read all this thing what is
1:10:47 your final diagnosis we will read it uh the problem the diagnosis is multi-nodular goiter in you thyroid state multi-nautical goiter in euthyrone what is your plan of management first one minute at this juncture whenever you give a diagnosis they will ask you two things your diagnosis is perfect here multi-node located eu thyroid state you can also write non-malignant i'm only talking about the clinical angle yeah anatomically why do you say it is thyroid gland this is the question so firstly the location of the swelling secondly because it's moving because
1:11:32 with deglutation very good so it's um it's deep to the pre-trigger fascia yes what are the parts it has all the parts lobes slopes right lobe is the mass all that move with the degradation together examiners want to know why not they are lymph nodes or any other for that matter so anatomically you think it is thyroid swelling why did you tell pathologically multinodular vitamin uh so the uh they were on palpation many nodules uh were present so based on that uh both lobes are enlarged is enlarged
1:12:20 and multiple nodules are present scattered all over so you say mulch nodular water in your patient non non-malignant mulching nodule or vital so one common right the error has got three diagonals three things you should bring one is anatomical anatomical means is a diffuse or modular if it is nodular is it solitary or multi-nautical okay now physiological is it hyper hypothyroid no pathological benign or malignant that's all okay it's neoplastic or inflammatory if it is neoplastic it's better so you bring the anatomical the physiological and the pathological so now you now you tell me the diagnosis has said wanted
1:13:06 non-toxic non-malignant multi-nautical vital common common question which is asked at this juncture is in your patient in your if what symptoms or signs if they were present you would have suspected malignant just answer the to the question uh so if there was a sudden ink if she had a sudden ink uh wrap it right here rapid size she had a rapid increase in size of swelling number two yes if there was uh any um if there was hoarseness or voice or uh compression symptoms don't say complications don't don't say compression symptoms compression no no no hoarseness enough if there was
1:13:53 hoarseness or voice please remember compression will not tell it is malignant yes it is infiltration that uh rln so in the history wise rapid increase and hoarseness to the voice yes don't say loss of weight loss of hepatitis they do not occur in thyroid malignancies very very late very very advanced and clinically history wise two points then palpation-wise sorry what are the findings if present it will suspect it could be carcinoma or malignancy so if it was hard uh swelling correct um if we could palpate lymph nodes hard irregularity and fixity yes you
1:14:39 can't even move even movement with the degradation is also affected restricted you can't even move enough plastic as i mentioned to you fixed to the trachea and they when the tumor is fixed infiltrating to the prevertable fascia it won't move yes 10 lymph nodes and no other bony swellings is it clear yes yes so now what investigations you would like to ask so in uh to confirm the diagnosis uh i like to do thyroid function test uh usg and uh if needed then uh usg guided fn ac and an x-ray neck uh ap lateral view uh along with that some routine investigations like uh hemoglobin that is fine yes whenever investigation
1:15:28 is asked yes your aim is definitely to confirm the diagnosis no doubt about it and in case of a thyroid yes physiologically functions you need to know and if there is a malignancies there you need to do a metastatic workout and general fitness i just want you to you you can't say wrong if you say tpp all that is fine but urine albumin sugar and all is nowadays it is not done you understand blood urine blood urea sugar grouping ecg flexible laryngoscope why you want to do flexible laryngus so for medical legal purposes because since you're going to operate her and a very small portion of the population like two to three percent have a recurrent laryngeal
1:16:15 nerve uh that i mean uh um fever might have happened during childhood maybe your generation has not seen you have not been affected when we were small there are so many examples fever ramp and diphtheria laryngeal laryngitis so many causes of the different examples so they would have caused some kind of a changes so one vocal cord paralyzed so the reason why it is done but yes medial laryngoscopy are flexible yes what answer expected from you today after that blood test and t3 t4 tsh is
1:17:03 imaging and why do you want to do ultrasound guided if it's a good answer why do you want to do fnac and which module you would like to defense so since this is a large swelling with variable consistency of both uh for firm and specific we would need usd to make sure we're taking the sample from a solid swelling and not this is very good so you should always remember all its swelling you need to do a final aspiration psychology okay so at this juncture they may ask you terah's criteria it's for post graduates just like a bio arts you know what is means yes a breast imaging uh reporting uh
1:17:49 data system like that's half for thyroid and prostate and a few other yeah so that that's fine so if you know it well and good otherwise we'll not ask theory now so what your answer expected is why do you want to do the thyroid number one it will tell you more or less anatomical area like for example this is thyroid there's no doubt about in this patient second is we are not interested to know five nodules are there six or eight or ten but solid area hypervascular area that may be eight ten nodules one of the nodules is more vascular one of the nodules is pretty regular one of the nodules may have micro
1:18:35 calcification is it clear my hypervascular solid nodule irregular nodule and you can also use a ultrasound doppler to know the vascularity also that area need to undergo fns is it clear so it depends upon the fnac it may be malignancy it may be benign or whatever it is again do you know any criteria here fnac criterias any criterias you heard of bethesda criteria so that i think taiwan yeah you read that you read that you don't want to go into the theory you know you know uh yes i don't remember it no study
1:19:23 now my question one question is we is there any role of any troop and biopsy in terror and military important question because of the risk of hemorrhage it's not done but i think so in lymphoma it is done lymphoma and whereas it won't operate you can do if it is okay carcinoma thyroid usually you know inoperable array sorry to say hopeless cases most of it you need to have some histology before you brand somebody having a malignancy and a plastic carcinoma yes and also the only cinema sensor has given you lymphoma of the thyroid if you have any slightest suspicion
1:20:13 then only otherwise don't mention true cut biopsy understand so we'll come to your case now yeah you're right and give you the diagnosis your tft is normal ultrasound shows multi-nautical greater your refinancy shows kids colloidal the ecg everything is fine tracheal narrowing is not there vocal cords are fine what is your plan of management is it medical or surgical if it is surgical why do you want to do surgical management uh so surgical management because the swelling is uh very big and there's a chance that it can become uh toxic like
1:21:00 and there's also a small risk that it can have follicular carcinoma in the future yes so go for surgical management cosmetic compression or complication and carcinoma remember three c's even if uh even if this patient has a no say let us say she is not worried about cosmetic because she is married and all 16. even if there is no complication according to nothing nothing but she has come to you uh there are very high chances of such a large big nodules four centimeter etc what you mentioned definitely more than 20 to 30 percent chance of malignancy may come after fnac do you understand yes
1:21:48 it may it may come to you as a surprise so it may turn out to be a fantasy does it tell you follicular carcinoma uh no sir because we can't see the capsular invasion so we can't differentiate adenoma and follicular carcinoma so so efferency may suggest could be a follicular adenoma but it can tell papillary carcinoma correct this is such a large nodule before you post it in this list i want you to put a ct scan is it clear yes especially in this patient because i forgot to mention ultrasound one more advantage in this patient especially is look for the lymph nodes
1:22:33 specially level two three four see five you can make out in the poster triangle five five and uh you can't make out behind the sternum that you need a ct scan but at least two three four two three four is the jiggler trunk they're originally called a jiggle or diagnostic but better to say now two three four lymph nodes so that's the advantage with the ultrasound ct scan is done because any reason so there's better resolution we can see the lymph nodes better and we can see if there's any uh retrospec [Music] seen here more importantly various neck is you know neck is a very
1:23:19 small area relatively with so many structures you would like to know how much thyroid has gone behind how much it is infiltrate rather how much it has pushed the carotid artery jugular vein a recurrent engineer and even vegas carotid sheath so because you are going to do the surgery for this patient such a big goiter so better to know where exactly this vital structures are present this information can be made out by ct scan right okay so if this is a let us say non-toxic multi-nodule or water what is the plan you have prepared or well you have prepared her well this is the
1:24:06 picture so what is the treatment so uh surgical management or total thyroidectomy so i think there is no controversy today most of the time your answer what you should tell is total thyroidectomy which means can you tell it completely which means so sorry so the last one uh it just got blocked some notification came up can you repeat that no no what do you mean by total thyroidectomy uh sir uh the entire uh the entire gland is removed we don't leave behind uh any portion like sub total thyroidectomy a little uh again i told you again you're answering to you can very well say
1:24:51 removing both the lobes and the entire lobes with these tumors is total thyroid there yes maybe you want to go in for subtotal and other thing then they will start asking what is subtotal where do you keep why do you keep that and what is daniel's procedure all this you can say removing both the lobes along with isthmus is totally thyroidectomy yes okay so another reason what i have told you elderly lady 60 year lady you have all the reason more chances of actually having a malignancy in this space which may come as histological so that is why you call it as histological surprise is it clear yes sir so you do a subtotal
1:25:38 and the report comes as say papillary carcinoma thyroid what will you do then so then we'll uh have to do a completion thyroid activity so second surgery yes if you do a subtotal it comes as follicular carcinoma thyroid what will
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