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The thyroid gland affects many body systems and physiological processes, including fertility and reproduction. Disorders of the thyroid gland, such as hypothyroidism and hyperthyroidism, can affect fertility, miscarriage and pregnancy outcomes.

Subfertility is a term used to describe a state of reduced fertility; where it takes a longer time than expected to conceive. Subfertility affects around 1-5% of couples globally. Associations have been drawn between thyroid disorders and subfertility. Hyperthyroidism has an incidence of 1.5% amongst women in the general population; however, this rate may be as high as 2.3% in women affected by subfertility. Hyperthyroidism can cause problems with the menstrual cycle, such as menstrual irregularity and heavy bleeding. Despite the effect of hyperthyroidism on fertility, there is little evidence to suggest that treatments for hyperthyroidism improve ovulation.

Hypothyroidism can also affect fertility.  This is related to the hormonal control of ovulation. In hypothyroidism, the release of a hormone from the hypothalamus called gonadotrophin releasing hormone (GnRH). This hormone is usually released in bursts. When released in bursts, the GnRH stimulates the release of two hormones from the pituitary gland called follicle-stimulating hormone and luteinising hormone, which help to control ovulation. In hypothyroidism, GnRH is not released in bursts, which can affect the process of ovulation. Additionally, hypothyroid patients have high levels of thyroid stimulating hormone (TSH). High levels of TSH have been associated with disturbances to the menstrual cycle and an increase in the number of menstrual cycles in which ovulation does not occur (anovulatory cycles). There are higher rates of hypothyroidism amongst subfertile women, and also women who present with subfertility tend to have higher blood levels of TSH. Treatment with thyroxine can improve fertility in hypothyroid women.

Several autoimmune diseases have been associated with subfertility, including type 1 diabetes and lupus. Autoimmune thyroid disease and thyroid autoantibodies may also be associated with subfertility, as there is a higher prevalence of thyroid autoantibodies amongst subfertile patients than in the wider community.

Reference

Jefferys A, Vanderpump M, Yasmin E. Thyroid dysfunction and reproductive health. The Obstetrician & Gynaecologist, 2015, 17:39-45. http://onlinelibrary.wiley.com

 

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By Ashleigh Elkins

Background

A thyroglossal duct cyst is a congenital abnormality that results from a persistent thyroglossal duct. Thyroglossal cysts present as a neck swelling, generally in the midline or slightly to one side. They are generally smooth and painless. However, thyroglossal cysts are prone to infection and an infected cyst will often be quite painful.[1] Some patients may also experience other symptoms related to the cyst, including dysphagia and hoarseness.[2] Approximately 2/3 of patients with thyroglossal cysts have ectopic thyroid tissue within the cyst.[1]

Upon physical examination, a thyroglossal cyst can be differentiated from other neck lumps by observing the movement of the cyst/lump when the patient is swallowing or protruding their tongue. If the lump is a thyroglossal cyst, it will move upwards with swallowing or tongue protrusion.[1] The majority of thyroglossal cysts are detected during childhood. The location of a thyroglossal duct cyst can vary. Some are located above the hyoid bone, others are between the hyoid bone and thyroid cartilage and others are below the sternum. Cysts may also occur within the tongue.[2] The majority of thyroglossal cysts are located below the level of the hyoid bone, with approximately 60-80% of thyroglossal cysts being infrahyoid.[1]

Embryology

The thyroid gland initially develops on the base of the tongue and migrates to its final anatomical position during later stages of development. At approximately gestational week four, the foramen cecum develops as a result of an invagination of the pharyngeal membrane. The primitive thyroid originates from the foramen cecum, and descends into the neck via the thyroglossal duct, a tract running from the base of the tongue to the neck. After the thyroid cells have migrated, the thyroglossal duct regresses at approximately week 10. However, in some people, the thyroglossal duct does not regress completely, and parts of or the entire duct remains, giving rise to a thyroglossal cyst.[2]

Patients routinely undergo ultrasound studies prior to undergoing the Sistrunk procedure to determine whether there is a normally functioning thyroid gland in its anatomical position. Thyroid function tests are generally also ordered pre-operatively to determine whether or not the patient is euthyroid. If the patient does not have a functioning thyroid gland, then surgery is not usually performed, in order to minimise the risk of developing hypothyroidism.

Surgical procedure

Thyroglossal cysts are managed by surgical removal. Surgical removal of the thyroglossal cyst is indicated because the cysts are prone to infection, and for cosmetic and aesthetic reasons. In rare instances, thyroglossal cysts may be malignant. This is thought to occur in less than 1% of all cases, and the underlying malignancy is usually papillary thyroid cancer.[2] Thyroglossal cysts are removed by a surgical procedure called the Sistrunk procedure. This operation is named for the surgeon who first described it. Prior to the development of the Sistrunk procedure, thyroglossal cysts were treated merely by incision and drainage, with recurrence being a key issue.

Due to the problems with recurrences, there was a move towards removing the cyst, along with part of the hyoid bone above it. Recurrence rates were lower with this type of operation compared to incision and drainage, but were still quite high. In 1920, Walter Sistrunk described an extended version of the previous operation. The Sistrunk procedure involved removing the cyst and part of the hyoid bone, as well as removing a small core of tissue from the hyoid bone all the way to the foramen cecum, resulting in a much lower rate of recurrence.[1]

How the Sistrunk Procedure is Performed

  1. A transverse incision is made along the neck is made at the level of the hyoid bone. The incision is approximately 5cm in length.
  2. The skin and the platysma muscle are reflected to expose the cyst, which is commonly found underneath the raphe which connects the sternohyoid muscles
  3. The cyst is then dissected away from the surrounding muscles and tissues up to the level of the hyoid bone
  4. At the hyoid bone, the muscles which attach to the centre of the bone are resected and separated, and then a section of the centre of the hyoid about 2cm is removed together with the cyst and tract.
  5. From the superior aspect of the hyoid bone up to the level of the foramen cecum, a core of tissue is then removed as needed. The diameter of the core of tissue surrounding the thyroglossal duct is approximately 1cm.
  6. In the original Sistrunk procedure the foramen cecum was removed, along with part of each genioglossus muscle and the raphe joining the mylohyoid muscles are also removed. This is now only performed as needed depending on the location of the cyst and path of the thyroglossal tract.
  7. If the tract extended to the tongue base and needed to be removed the opening into the mouth would be closed. Then the genioglossus muscles are sutured, and the tissues at the cut ends of the hyoid bone drawn together with sutures.
  8. A drain is inserted near the hyoid bone and the skin is closed over it.[3]

Extended Sistrunk Procedure

There are two main limitations of the Sistrunk procedure. Firstly, the procedure does not aim to resect the portion of the thyroglossal duct that lies below the hyoid bone. Secondly, the thyroglossal duct is not a simple, straight tube-like structure. It is often a tortuous structure, particularly between the tongue base and the hyoid bone. In some sections the duct may be incomplete. Furthermore, the duct has several side branches, which may not be resected by the standard Sistrunk procedure. Because the procedure originally described by Sistrunk may not result in complete resection of the entire thyroglossal duct, an extended Sistrunk procedure has been described which aims to surgically remove the entire thyroglossal duct.[4]

For the extended Sistrunk procedure, the skin incision is made lower, usually at the level of the thyroid isthmus. The site of the incision may vary if there are any neck swellings or fistulae that will also need to be resected. Starting at the superior aspect of the thyroid isthmus, a section of tissue which includes both the thyroglossal duct and part of the bordering strap muscles is dissected. The resection continues superiorly towards the hyoid bone, removing the thyroglossal duct and cyst. As with the original Sistrunk procedure, a section of the hyoid bone is removed in the extended procedure. Above the level of the hyoid, the thyroglossal duct and cyst are resected along with a wider core of normal tissue, to ensure that any branches of the thyroglossal duct are also removed. This resection continues until the level of the tongue base; however, the tongue base is ideally not breached by the surgeon. A drain is placed in the neck at the end of the procedure and the wound is closed.[4]

Complications

As with all surgical procedures, there are potential risks and complications associated with both the standard Sistrunk procedure and the extended Sistrunk procedure. Major complications associated with the Sistrunk procedure are rare. Potential major complications include nerve injury, airway injury, thyroglossal cyst recurrence, hypothyroidism, blood transfusion and the development of a haematoma or abscess which may require further surgical intervention.[5]

Minor complications are more common than major complications after surgery. Minor complications are usually related to the wound, including superficial surgical site infections, small abscesses around the sutures, seromas and dehiscence of the wound. These minor complications are associated with very low morbidity and can be easily managed in an outpatient setting.[5]

The risk of developing major complications following the Sistrunk procedure is low for several reasons. The placement of a drain helps to reduce the risk of developing a haematoma and aseptic technique and antibiotic prophylaxis minimises the risk of infection. Furthermore, risk of injury to the airway and major vessels and nerves of the neck can be minimised by employing a meticulous surgical technique and by identifying key anatomical landmarks in order to reduce the risk of inadvertent injury to surrounding structures.[5]

Recurrence

Reported recurrence rates following the Sistrunk procedure are low, between 0 and 8%. In comparison, recurrence rates following incision and drainage of thyroglossal cysts exceeded 50%.[1] One study which has described the use of the extended Sistrunk procedure for primary excision of thyroglossal duct cyst reported a 0% recurrence rate at 3 years follow-up. When the extended Sistrunk procedure is implemented in revision cases, the recurrence rate is 7%.[4]

For more information about thyroglossal duct cyst and Sistrunk procedure click here.

References

[1] Wagner G, Medina JE. Excision of thyroglossal duct cyst: the Sistrunk procedure. Operative Techniques in Otolaryngology (2004); 15: 220-223

[2] Goldsztein H, Khan A, Pereira KD. Thyroglossal duct cyst excision—The Sistrunk procedure. Operative Techniques in Otolaryngology (2009); 20: 256-259.

[3] Sistrunk WE. The surgical treatment of cysts of the thyroglossal duct. Annals of Surgery (1920); 71:121-124.

[4] Ahmed J, Leong A, Jonas N, Grainger J, Hartley B. The extended Sistrunk procedure for the management of thyroglossal duct cysts in children: how we do it. Clinical Otolaryngology (2011); 36:252-279.

[5] Maddalozzo J, Venkatesan TK, Gupta P. Complications associated with the Sistrunk procedure. The Laryngoscope (2001); 111: 119-123.

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Thyroid dysfunction has thought to possibly contribute to memory disorders, such as Alzheimer’s disease and other types of dementia. Consequently, in patients who are experiencing memory problems, thyroid function tests are commonly ordered. A recent study aimed to see if elderly patients with hypothyroidism were more likely to suffer from mild cognitive impairment than elderly euthyroid individuals (those with normal thyroid function). Mild cognitive impairment is described as a state between normal age-related memory loss and dementia. It usually has minimal, if any, functional impact for the patient. Other studies on the topic have yielded conflicting results.

This study assessed cognitive function by face to face interviews and with detailed neurological and psychological tests. These tests looked at how well people performed in different areas of cognition, including memory, language, visuospatial, attention and executive function. In terms of thyroid function, patients were classified as either euthyroid, clinically hypothyroid or as having subclinical hypothyroidism. Clinical hypothyroidism was determined from medical records. Patients were deemed to have subclinical hypothyroidism if they had a thyroid stimulating hormone level of less than 10mIU/L, a free T4 level of 1.01 to 1.79ng/dL and were not on thyroxine therapy.

From the results of the cognitive testing, 316 of the 1904 participants in the study were found to have mild cognitive impairment, and the remaining 1588 patients were deemed to have normal cognitive function. Mild cognitive impairment was found in 16.3% of euthyroid participants, 17.2% of clinically hypothyroid patients and 17.7% of those with subclinical hypothyroidism. However, after the authors of this study accounted for other factors which were likely to influence the results (age, education, other medical conditions etc.), there was no significant influence of clinical or subclinical hypothyroidism on mild cognitive impairment.

A limitation of this study is that in the patients found to have mild cognitive impairment, there is no indication as to whether the hypothyroidism started before the onset of cognitive impairment or vice-versa. Additionally, the way the study was designed means that a cause-and-effect relationship cannot be determined.

Given the mixed results in other studies, more research is needed to determine the influence of hypothyroidism on cognitive function.

Reference

www.archneur.jamanetwork.com

Hypothyroidism and risk of mild cognitive impairment in elderly persons: A population-based study. JAMA Neurology; 71(2):201-207. Parsaik AK, et al. (2014).

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By Ashleigh Elkins

There are many different tests that can be used to help confirm the diagnosis of a thyroid problem. Based on taking a history and performing a physical examination, if your doctor suspects you have a problem with your thyroid gland, he or she will most likely order one or more tests to help confirm or rule out the diagnosis of a thyroid disorder.

Common tests include blood tests to check the thyroid function, fine needle aspiration biopsy to evaluate lumps and nodules, and scans to obtain imaging of the thyroid gland.

Thyroid Function Tests

Thyroid function tests are a very common investigation performed when a thyroid problem is suspected. Thyroid function tests require a blood test. They are also used to monitor the effectiveness of treatment. Thyroid function tests assess the levels of thyroid stimulating hormone (TSH) and the two thyroid hormones – thyroxine (T4) and v (T3). These tests can be used to determine if the thyroid has a normal level of activity (euthyroid), if the thyroid is underactive (hypothyroid) or if the thyroid is over-active (hyperthyroid). The table below shows the results for the different states of thyroid activity:

Thyroid State TSH Free T4 Free T3
Euthyroid Normal Normal Normal
Hyperthyroid Decreased Increased Increased
Hypothyroid Increased Decreased Decreased

Due to Medicare restrictions in Australia, TSH needs to be tested alone first. If the TSH is found to be abnormal, then levels of thyroid hormone can be tested. This restriction does not apply to people who have already been diagnosed with a thyroid problem.

Thyroid Autoantibodies

Thyroid autoantibodies are another type of blood test that can be ordered in the investigation of thyroid problems. This test is used to rule in or rule out an autoimmune disease as the cause of thyroid problems. There are three main autoantibodies that can be tested for:

  1. Thyroid peroxidase antibodies (TPO); these are antibodies towards thyroid peroxidase, an enzyme that is needed in the process of producing T3 and T4. TPO antibodies are positive in most patients with Hashimoto’s thyroiditis and in most patients with Graves’ disease. TPO antibodies may also be elevated in patients with other autoimmune diseases, such as rheumatoid arthritis.
  2. Thyroglobulin antibodies; these antibodies are markers of autoimmune thyroid diseases. They are positive in almost all patients with Hashimoto’s thyroiditis and are positive in most people with Graves’ disease
  3. TSH receptor autoantibodies; these are antibodies that bind to the TSH receptor and cause it to activate. TSH receptor autoantibodies are positive in the majority of people with Graves’ disease.

Other Thyroid Blood Tests

There are a few other blood tests that may be ordered to investigate suspected thyroid disease. Calcitonin is a hormone made by the C cells of the thyroid and is released when levels of blood calcium are high. Calcitonin levels may be ordered in the investigation of people with thyroid nodules or suspected medullary thyroid cancer. Blood levels of calcitonin may be elevated in medullary thyroid cancer, and may be used in monitoring following treatment for medullary thyroid cancer. In addition, another blood test called carcinoembryonic antigen, or CEA, is also used in addition to calcitonin for monitoring and follow up after treatment of medullary thyroid cancer. CEA is also used for monitoring following treatment of other types of tumours, such as colorectal cancers.

Fine Needle Aspiration Biopsy

Fine needle aspiration biopsy is most commonly used in the investigation of thyroid nodules. The procedure involves inserting a needle into the nodule in order to remove a sample of cells which can then be analysed under a microscope to assist in diagnosis. There are usually several samples taken from different parts of the nodule to ensure that the samples that are taken are representative of the cells and tissues within the nodule. This test helps to determine whether or not the nodule requires surgical removal or further monitoring.

Fine needle aspiration can also be used to help evaluate thyroid cysts. This involves inserting a needle into the cyst and draining the fluid within the cyst. The fluid that is collected can be evaluated in the lab to see if there are any suspicious changes.

Fine needle aspiration biopsy is used to guide the treatment and management of patients with thyroid nodules. Thyroid fine needle aspiration cytology results are classified according to the Bethesda classification system which is a six-category system used to guide management of thyroid nodules.

The six categories of this system are:

  1. Unsatisfactory sample/Non-diagnostic
  2. Benign
  3. Atypia of undetermined significance
  4. Follicular neoplasm/suspicious for follicular neoplasm
  5. Suspicious for malignancy
  6. Malignant

Fine needle aspiration cytology cannot help to differentiate between benign and malignant follicular neoplasms. Ultrasound guidance can be used to visualise the nodule when performing the fine needle biopsy to make sure that the samples are being taken from within the nodule and not the surrounding thyroid tissue.

Nodules that are removed surgically undergo histopathological analysis to provide a definitive diagnosis.

Thyroid Imaging

Thyroid Ultrasound

Ultrasound is a safe, accurate, non-invasive, inexpensive and readily available imaging modality that can be used to assess the thyroid gland. Ultrasound is usually the first type of imaging ordered for the investigation of thyroid problems. Ultrasound uses sound waves transmitted through a hand-held transducer probe. A gel is placed over the neck which helps to transmit the ultrasound waves from the probe. There is no radiation used in an ultrasound. Thyroid ultrasounds are particularly useful for imaging thyroid cysts, nodules, goitre (enlargement of the thyroid gland) and suspected tumours. Ultrasounds can also be used to assess the blood flow in the thyroid. Ultrasound can also be used to guide fine needle aspiration biopsy of nodules or growths in the thyroid.

There are several ultrasound features which suggest that a thyroid nodule is likely to be benign. These include:

  • Sharp, well-defined borders around the entire nodule
  • Fluid within the nodule is indicative of the nodule being a cyst
  • Numerous nodules throughout the thyroid; this generally indicates a benign multinodular goitre
  • Minimal or no blood flow through the nodule indicates that the nodule is likely to be a cyst

Thyroid Scan/Thyroid Isotope Scans

An isotope scan of the thyroid is used to determine thyroid function because the scan measures how much of a substance similar to iodine is taken up by the gland. The thyroid uses iodine to produce thyroid hormones, so the thyroid normally absorbs iodine. For the scan, technetium (Tc- 99m) pertechnetate is injected. This is a substance that behaves similarly to iodine. Radioactive iodine has been used in the past, but technetium pertechnetate is now preferred because there is less radiation exposure and it is more cost-effective than radioactive iodine. After about 20 minutes, a scan is performed to identify the pattern of uptake in the thyroid.

This type of thyroid scan is particularly useful in helping to determine if the thyroid is over-active, such as in conditions like Graves’ disease, subacute thyroiditis and toxic multinodular goitre. All three conditions have different patterns of uptake:

Graves’ disease

  • Diffuse increased uptake

Subacute Thyroiditis

  • Low iodine uptake

Toxic Multinodular Goitre

  • Patchy uptake; areas of increased uptake and areas of decreased uptake

Thyroid isotope scans are helpful in the investigation of thyroid nodules. Thyroid nodules are generally classified as cold, warm or hot. A cold nodule does not take up any pertechnetate and is non-functioning, a warm nodule is functioning normally, and a hot nodule takes up more pertechnetate than the surrounding thyroid tissue and is said to be hyper-functioning. Isotope scans are particularly helpful for investigating patients with low levels of TSH. If a patient has low TSH and the isotope scan identifies a hot nodule, it is likely that the nodule is benign. Overall, the majority of thyroid nodules scanned are cold nodules, approximately 80%. However, only about 20% of cold nodules are found to be malignant after further investigation.

Thyroid CT Scan

Computed tomography, or CT scans can also be used to investigate suspected thyroid pathologies. It is not as good as ultrasound for identifying pathology within the thyroid gland itself, but CT is useful for investigating lymph nodes in the neck, chest and thyroid region. It is also used in the investigation of goitre to determine if the goitre has extended behind the sternum and into the mediastinum (retrosternal extension). CT may also be used if thyroid cancer is suspected to see if the tumour has spread to other surrounding organs. CT scans use x-rays to create cross-sectional images of the thyroid and surrounding structures. In some cases, a contrast medium may be injected to help define anatomical structures more clearly. A limitation of CT scans is that there is radiation exposure associated with the scan, unlike MRI and ultrasound.

Thyroid MRI Scan

Another type of investigation which may be ordered to investigate problems with the thyroid is a magnetic resonance imaging (or MRI) scan. Just like a CT scan, MRI is also not as good as ultrasound for detecting pathology within the thyroid gland itself. MRI scans might be ordered to assess surrounding lymph nodes and other neck and chest structures. It is useful to help determine if a suspected thyroid cancer has spread to surrounding organs. MRI can also be used to evaluate retrosternal goitre extension. MRI is also helpful to determine the size and shape of the thyroid. MRI may be recommended instead of a CT scan because there is no radiation exposure associated with an MRI, and an MRI scan of the thyroid does not usually require the administration of a contrast medium. CT and MRI are similar in terms of evaluating lymph nodes and spread to the surrounding tissues.

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Thyroid Conditions in Children

Whilst most people associate thyroid conditions with adults, children are also susceptible to thyroid issues. There are essentially two different types of thyroid problems found in children: congenital hypothyroidism and childhood onset hypothyroidism.

Congenital Hypothyroidism

This thyroid condition is present at birth, and is detected through the heel prick that all children undergo. Current statistics show that around one in 3,500 babies are born with hypothyroidism in the UK, and most of these cases are due to the thyroid gland failing to develop fully while in the womb. The cause of this condition is not fully understood, but treatment is necessary due to the dangers for the child.

Hypothyroidism is a condition that is marked by low levels of thyroid hormones in the body. One of these hormones, thyroxine, is an essential component in growth and development in children. During pregnancy, babies receive adequate amounts of this hormone through the mother’s production. However, after birth, babies who suffer from this condition are not able to produce enough thyroxine to properly support development.

Proper thyroxine levels are required throughout life, but they are much more important for an infant. This hormone is responsible for the healthy growth and development of every organ system in the body, which is why the heel prick test is so important. If congenital hypothyroidism is not treated within the first weeks after delivery, it can result in serious complications for the child, including brain damage. However, nearly every child that does receive proper treatment for this condition in a timely manner goes on to live a healthy life.

Neonatal screening for hypothyroidism

The neonatal heel prick or Guthrie test is a screening test done on newborns. It consists of making a pinprick puncture in one heel of the newborn and soaking the blood into pre-printed collection cards known as Guthrie cards. The blood samples can be used for a variety of metabolic test to detect genetic conditions, including congenital hypothyroidism.

If your baby is born with hypothyroidism, he or she will need to have thyroxine administered on a daily basis. The exact amount of the medication needed will change over time, depending on the results of frequent blood testing.

Childhood Onset Hypothyroidism

There is also hypothyroidism that occurs later in childhood. Childhood onset hypothyroidism is broken down into two forms; one is called Hashimoto’s thyroiditis, and the other is atrophic thyroiditis. Both forms are generally due the body’s immune response forming antibodies that destroy the function of the thyroid gland.

Hashimoto’s thyroiditis affects children by causing swelling and enlargement of the thyroid gland, which is often referred to as goiter. This form of hypothyroidism causes symptoms such as dry skin and hair, slow pulse, and changes in the facial features, much as they do in adults. However, these symptoms typically show up much later in the disease.

The second form, which is called atrophic thyroiditis, occurs without any signs of swelling, but results in the thyroid gland being completely destroyed. Children suffering from this form of acquired hypothyroidism show noticeable changes in their growth due to the lack of thyroxine in their bodies.

It is also possible for children to acquire Hashimoto’s thyroiditis, but end up with atrophic thyroiditis. No matter which form a child is suspected to have, diagnosing the thyroid problem requires blood testing to measure the amount of TSH and thyroxine.

Children who are diagnosed with hypothyroidism require treatment with oral thyroxine therapy. Once this treatment is started, most children experience excellent results. Children who have suffered growth issues due to decreased thyroxine levels are also able to quickly catch up with their growth, allowing them to return to normal. While children suffering from any form of childhood hypothyroidism will require oral thyroxine for the rest of their lives, they are still able to function normally with no adverse side effects.

Another thyroid related problem commonly seen in children is a thyroglossal cyst. Thyroglossal duct cyst often presents as a lump in the neck which may be painful. The thyroglossal duct is a structure which is important in the development of the thyroid gland in the embryo, and generally regresses in the majority of people. Thyroglossal duct cysts are most commonly diagnosed in patients before the age of 20; however, they can occur at any age.

Hypothyroidism in children can be very serious, so it is important that you speak to your child’s paediatrician or endocrinologist if you have any questions or concerns.

If you have questions about thyroid conditions in children contact your local doctor who will arrange for you to see a thyroid surgeon.

References

The post Thyroid Conditions in Children appeared first on Thyroid Clinic Sydney.

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