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بسم هللا الرحمن
الرحيم
Dr Ahmed Esawy
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Dr. Ahmed Eisawy
MBBS M.Sc MD
Dr Ahmed Esawy
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HYPOTHYRIODISM
CONGENITAL
Hypoplasia & mal-descent Agenesis ,hemiagenesis Ectopia thyriod (sublingual thyriod) Familial enzyme defects Iodine deficiency (endemic cretinism) Intake of goitrogens during pregnancy Pituitary defects Idiopathic
Iodine deficiency(diffuse giotre) Hashimoto´s thyroiditis (autoimmune thyroiditis)
Subacute (De Quervein’s) thyroiditis
Thyroidectomy or RAI therapy TSH or TRH deficiency Medications (iodide & Cobalt,amiodarone)) Idiopathic Post partum amyliodosis
ACQUIRED
Dr Ahmed Esawy
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Thyriod Ultrasound in
hypothyriodism
Dr Ahmed Esawy
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Causes of Congenital
Hypothyroidism • Dysgenesis
ectopic thyriod (Sublingual thyroid)
Agenesis
Hypoplasia
Hemiagenesis
Dr Ahmed Esawy
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Causes of Acquired
Hypothyroidism
• Postoperative states
• Iodine deficiency (diffuse goitre which often becomes
nodular . The perfusion is normal. Enlargement of the
thyroid gland is an adaptive process in low iodine intake)
• Hashimoto´s thyroiditis (autoimmune thyroiditis)
• Subacute (De Quervein’s) thyroiditis
• Amiodarone-induced hypothyroidism
• Post partum
• Amyliodosis infiltration
Dr Ahmed Esawy
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Causes of Acquired
Hypothyroidism
• Postoperative states
• Iodine deficiency (diffuse goitre which often becomes
nodular . The perfusion is normal. Enlargement of the
thyroid gland is an adaptive process in low iodine intake)
• Hashimoto´s thyroiditis (autoimmune thyroiditis)
• Subacute (De Quervein’s) thyroiditis
• Amiodarone-induced hypothyroidism
• Post partum
• Amyliodosis infiltration
Dr Ahmed Esawy
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State of thyriod blood perfusion
Perfusion of the thyroid increases on several occasions:
• increased cardiac output (a stressed patient),
• in gravidity,
• during an active autoimmune inflammation – active Graves´ disease or
Hashimoto´s thyroiditis ((in active Graves´ disease “thyroid inferno”).
• hyperfunctioning nodules
• untreated primary hypothyroidism because of TSH stimulation.
decreased perfusion in breakdown of the thyroid tissue – as is the case of
• postpartum thyroiditis,
• De Quervain thyroiditis
• amiodarone-induced thyrotoxicosis type 2.
Dr Ahmed Esawy
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• PSV normal up to 25 cm/sec
• PSV at thyrotoxicosis more than 100 cm/sec
• PSV at hypothyriodism 50-60 cm/sec
Dr Ahmed Esawy
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Normal thyroid gland : US
Dr Ahmed Esawy
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TUS of a diffuse goitre in a
euthyroid patient
Dr Ahmed Esawy
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Normal TUS image of left thyroid lobe (euthyroid patient
with negative thyroid autoantibodies). Note the
low perfusion on the Doppler imaging (right).
Dr Ahmed Esawy
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Reference Standard for
Thyroid Size (cm) by Age
Dr Ahmed Esawy
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10-day-old girl with
sublingual thyroid gland.
.
Dr Ahmed Esawy
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14-day-old girl with thyroid agenesis.
Dr Ahmed Esawy
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7-day-old boy with thyroid hemiagenesis.
Dr Ahmed Esawy
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20-day-old girl with hemiagenesis and sublingual thyroid.
.
Dr Ahmed Esawy
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9-day-old boy with thyroid gland in normal location.
Dr Ahmed Esawy
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Congenital hypothyroidism
Ultrasound
Aplasia
Hemiagenesis
Lingual thyroid
Dr Ahmed Esawy
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Dr Ahmed Esawy
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Hashimotos thyroiditis
• Destructive autoimmune disorder which
leads to chronic inflammation of gland
• Enlargment not necessarly symmetric
• Young Middle aged female
Dr Ahmed Esawy
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Hashimotos thyroiditis
• Three stages
• -Acute : enlarged in size and decreased
vascularity
• Chronic : enlarged with multiple linear
bright echoes throuhout parenchyma with
multiple hypoechioc nodules
• Atrophic : end stage small atrophic gland
,avascular with heterogenous echoes
Dr Ahmed Esawy
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Hashimotos thyroiditis
• Sonographic features :
• diffusle enlarged and coarse parenchyma
• heterogenous texture
• Multiple hypoechioc nodules in both lobes
Dr Ahmed Esawy
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Hashimotos thyroiditis
Dr Ahmed Esawy
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Hashimotos thyroiditis (late stage):
Heterogeneous and coarse parenchyma
• Multiple small hypoechoic nodules surrounded by an echogenic rim of fibrosis
• Vascularity : Variable; increased early in the disease and decreased later in
the disease course
Dr Ahmed Esawy
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diffusely coarse echotexture with
innumerable tiny hypoechoic nodules
that may become confluent,
interspersed with echogenic fibrous
bands. Vascularity may be increased,
decreased, or normal, and FNA is
usually not necessary for diagnosis.
painless enlarged thyroid usually
in a hypothyroid state .few in
hyperthyriod state
Hashimotos thyroiditis
Dr Ahmed Esawy
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Nodular Hashimotos thyroiditis
Homogeneously echogenic nodule with a hypoechoic rim: “white knight”
Dr Ahmed Esawy
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Typical TUS image of Hashimoto´s
thyroiditis (TSH 17 mIU/l, highly positive
thyroid autoantibodies). Note
the inhomogenous and hypoechogenic
thyroid texture.
Dr Ahmed Esawy
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TUS image of the right thyroid lobe in a patient with Hashimoto´s thyroiditis with a
large goitre.
Dr Ahmed Esawy
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Graves disease
Diffusely enlarged, hypoechoic, increased vascularity (thyroid inferno)
Dr Ahmed Esawy
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Graves disease
• PSV HIGH
Dr Ahmed Esawy
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Graves disease / Hashimotos thyroiditis
Thyroid
inferno Graves disease: 4 hour uptake of 40%
Dr Ahmed Esawy
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Absent thyroid gland in a patient after total thyroidectomy due to papillary thyroid
carcinoma. Note fibrous tissue without residual thyroid parenchyma in the thyroid beds. Dr Ahmed Esawy
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atrophic
thyroiditis
TUS of atrophic thyroiditis (a patient with
mild hypothyroidism: TSH 9.43 mIU/l,
highly positive anti-TPO antibodies).
Dr Ahmed Esawy
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Subacute (De Quervein’s)
thyroiditis • The inflammation do not involve entire
glan but infiltrates gland in non-
homogenous patteren
• Sonographic feature (hypoechioc and
hypervascular areas)
Dr Ahmed Esawy
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TUS image of subacute thyroiditis in the
hyperthyroid phase (FT3: 10.7 pmol/l, FT4:
33.1 pmol/l, TSH: 0.039
mIU/l, antibodies negative). Note the low
perfusion as shown by the Doppler imaging
(right).
Dr Ahmed Esawy
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amiodarone
TUS image in a 69-year-old patient who
developed hypothyroidism after treatment
by amiodarone.
Dr Ahmed Esawy
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Post
partum
TUS of the left thyroid lobe of patient
with PPT which occurred two months
after delivery .
Four months after delivery, the patient
developed hypothyroidism
Dr Ahmed Esawy
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euthyroid
woman
TUS image in a young
euthyroid woman with
negative antithyroid
antibodies
Dr Ahmed Esawy
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amyloidosis
TUS image of thyroid amyloidosis
confirmed by cytology
Dr Ahmed Esawy
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THANK YOU
Dr Ahmed Esawy