review of struma.doc

REVIEW OF STRUMA

PREPARED BY:

Stefano Leatemia

11.2012.031

SURGERY CLERKSHIP

AIR FORCE HOSPITAL OF DR.ESNAWAN ANTARIKSA

FACULTY OF MEDICINE UKRIDA

PERIOD MAY 6th – JULY 13th 2013

1

TABLE OF CONTENTS

Preface ……...................................................................................................................................i

Content ..........................................................................................................................................1

CHAPTER I Introduction ……………………………………………………………………….3

CHAPTER II Anatomy and Physiology of Thyroid .....................................................................4

CHAPTER III

3.1 Struma Difusa ……………………………………………………………………....9

3.2 Struma Nodosa Toxic ………………………….......................................................10

3.3 Struma Difusa ……………………………………………………………………...11

3.4 Struma Nodosa Non Toxic ………………………………………………………..12

3.5 Carcinoma …………………………………………………………………………14

3.6 Enforcement Measures Struma Diagnosis ...............................................................18

CHAPTER IV Conclusion …………………………………………………………………….. 22

REFERENCES ……………………………………………………………………………….. .23

2

CHAPTER I

INTRODUCTION

Struma is the enlargement of the thyroid gland caused by the addition of thyroid gland

tissue itself. Enlargement of the thyroid gland that causes changes in the body's functions and

some that did not affect function. Struma is a disease common day-to-day, with a history and a

thorough physical examination, struma with or without metabolic dysfunction can be diagnosed

accurately.

Epidemiological Survey for struma endemik often found in mountainous regions such as

the Alps, Himalayas, Bukit Barisan and other mountain areas. For toxic struma prevalence is 10

times more common in women than men. In the case of a woman found 1,000 women 20-27,

while the men 1-5 of 1,000 men.

3

CHAPTER II

Thyroid Gland Anatomy and physiology

To understand disease and thyroid disorders, to remember back about the anatomy of the

thyroid. Anatomy and normal physiologic must be known and remembered back before the

change of anatomy and physiology that may progress to a disease or disorder.

2.1 Anatomy of the Thyroid

The thyroid gland consists of three lobes, which dextra lobe, the left lobe and the

isthmus which lies in the middle. It can sometimes be found all four parts namely the pyramidal

lobe is located on the isthmus slightly to the left of the center line. This lobe is residual thyroid

tissue that remains embryonic.

The thyroid gland has a weight of about 25-30 grams and is located between the thyroid

and sixth tracheal rings. The entire thyroid tissue wrapped by a layer called the true capsule.

4

Vascularity of the thyroid gland derived from:

. 1) A. Superior thyroid which is a branch of A. Carotid externa

2) A. Inferior thyroid which is a branch of A. Subclavian

3) A. Ima thyroid which is a branch of the Arcus Aorta

Nerve that passes through the thyroid is the recurrent nerve. It is located in the dorsal

neural thyroid before entering the larynx.

5

2.2 Physiology of Thyroid

The thyroid gland is an endocrine gland that secretes hormones Thyroxine or T4,

triiodothyronine or T3 and calcitonin. In the blood of most of the T3 and T4 are bound by plasma

proteins are albumin, Thyroxin Binding Pre Albumin (TBPA) and Thyroxin Binding Globulin

(TGB). Fraction T3 and free T4 circulates in the blood and play a role in regulating the secretion

of TSH. HORMON thyroid is controlled by hyroid-stimulating hormone (TSH) produced by the

anterior lobe of the gland and release hypofise influenced by thyrotropine-releasing

hormone (TRH). Thyroid glands also secrete calcitonin of parafolicular cell, which can lower

serum calcium affect bone.

Thyroid hormone function, among others:

1) increase the metabolic rate

2) cardiogenic effects

3) simpatogenik

4) growth and nervous system

6

CHAPTER III

DISCUSSION

Enlargement of the thyroid gland or struma classified according to its physiological effects

clinical, and changes in shape that occur. Struma can be divided into:

1) Toxic struma, struma which raises the clinical symptoms in the body, based on

changes in shape can be subdivided into

a. Diffusa, ie if the enlargement of the thyroid gland covering the entire lobe, like those found

in Grave's disease.

b. Nodosa, ie if the enlargement of the thyroid gland only on one lobe, like those found in

Plummer's disease.

2) Nontoxic struma, the struma that does not cause clinical symptoms in the body, based on the

change in shape can be subdivided into

a. Diffusa, such as those found in endemic struma

b. Nodosa, such as those found in thyroid malignancy

Enlargement of the thyroid gland can be caused by:

1) Hyperplasia and hypertrophy

Each organ is triggered when the work will have to compensate by increasing the

number of cells and multiply. Likewise, when the thyroid gland will be encouraged to

work pertumnuhan produce the hormone thyroxine and will have m embesar, such as

puberty and pregnancy.

2) Inflammation or infection

Processes such as inflammation of the thyroid gland in acute thyroiditis, subacute

thyroiditis (de Quervain) and chronic thyroiditis (Hashimoto)

7

3) Neoplasms

Benign and malignant

Struma cause clinical symptoms caused by changes in thyroid hormone levels in

the blood. The thyroid gland can result in excessive levels of thyroid hormone or

commonly called hyperthyroidism and in levels of normal or less than normal is called

hypothyroidism. Symptoms in hyperthyroidism are:

Increased appetite and weight loss

Can not stand the heat and hyperhidrosis

Palpitations, high systolic and diastolic pressure is low resulting in a high pulse

(pulsus celler) and in the long term could be atrial fibrillation

Tremor

Diarrhea

Infertility, amenorrhae in women and testicular atrophy in men

Exophtalmus

Symptoms in hypothyroidism is the opposite of hyperthyroidism:

Decreased appetite and weight gain

Can not stand the cold and dry scaly skin

Bradycardia, low systolic pressure and pulse pressure are weak

Gestures become sluggish and edema of the face, eyelids and limbs

8

3.1 Difusa Toxic Struma

3.1.1 Definition

Difusa toxic struma can be found in Grave's Disease. The disease is also called

Basedow. Trias Basedow include diffuse enlargement of the thyroid gland, and eksoftalmus

hipertiroidi. Disease is more common in younger people with symptoms such as excessive

sweating, hand tremors, decreased heat tolerance terhafap, weight loss, emotional instability,

menstrual disorders such as amenorrhea, and polidefekasi (often defecation). Clinical often

found in the thyroid gland enlargement, sometimes there is also a manifestation of the eye and

miopatia exophthalmus ekstrabulbi. Although the etiology of Graves' disease is not known for

sure, it seems there is a role of an antibody that can be captured TSH receptor, leading to

increased thyroid hormone stimulus. The disease is also characterized by increased absorption of

radioactive iodine by the thyroid gland.

Image: Graves disease

3.1.2 Pathophysiology

Grave's Disease is a disease caused by abnormalities in the body's immune system,

where there is a substance called Thyroid Receptor Antibodies. This substance occupies TSH

9

receptor in thyroid cells and stimulate them in berlebiham, so it can not occupy the TSH receptor

and thyroid hormone levels in the body is increased.

3.1.3 Clinical Symptoms

Symptoms and signs that arise is a manifestation of increased metabolism in all body

systems and organs that may be clinically apparent. Increased metabolism causes increased

caloric needs, and often intake (intake) insufficient caloric needs, causing drastic weight loss.

Increased metabolism in the cardiovascular system visible in the form of an increase in

blood circulation, among others, with an increase in cardiac output / cardiac output up to two-

three times normal, and also in a resting state. Rhythm pulse rise and pulse pressure increases, so

be pulsus Celer; patients will experience tachycardia and palpitations. Burden on myocardial,

and autonomic nerve stimulation can result in a heart rhythm disorder ektrasistol, atrial

fibrillation, and ventricular fibrillation.

Gastrointestinal secretion and peristalsis increases often resulting polidefekasi and

diarrhea.

Hipermetabolisme nervous system usually causes tremors, sleeplessness sufferers, often

waking in the night. Patients experience emotional instability, anxiety, thought disorder, and

unwarranted fear that very disturbing.

In the airways, causing dyspnea and tachypnea hipermetabolisme are not too

distracting. Muscle weakness mainly proximal muscles, usually quite disturbing and often appear

suddenly. This is caused by electrolyte disturbances triggered by the hipertiroidi.

Menstrual disorders can be secondary amenorrhoea or metrorhagia. Eye disorders

caused by an autoimmune reaction in the form of antibodies binding to receptors on muscle and

connective tissue in the eye socket ekstrabulbi. Connective tissue and fat tissue to hyperplastic so

eyeball pushed to the outer eye muscles and pinched. The result is eksoftalmus which can cause

eye damage due to keratitis. Impaired muscle movement will cause strabismus.

10

Figure: Schematic pathogenesis of Graves' disease

3.1.4 Treatment

Graves disease therapy aimed at controlling the state tirotoksisitas / hipertiroidi with

antithyroid administration, such as propyl-tiourasil (PTU) or karbimazol. Definitive therapy can

be selected between anti-thyroid medication long-term, detachments with radioactive iodine, or

thyroidectomy. Surgery of the Thyroid with hipertiroidi done especially if treatment with the

thyroid gland fails medikamentosa great.Surgery usually provides a good permanent cure

although sometimes encountered the hipotiroidi and minimal complications.

3.2 Struma Nodosa Toxic

3.2.1 Definition

Nodosa toxic struma is an enlarged thyroid gland on one lobe is accompanied by

signs of hyperthyroidism. Nodular enlargement occurs in young adulthood as a nontoxic

11

goiter. When untreated, in 15-20 years can be toxic. Was first distinguished from Grave's

disease by Plummer, then known as Plummer's disease.


The disease begins with the onset of nodular enlargement of the thyroid gland that

does not cause symptoms of toxicity, but if not treated immediately, within 15-20 years

can cause hyperthyroidism. The factors that affect the change of nontoxic be toxic

include these nodules turn out to be its own autonomous (associated with autoimmune

diseases), thyroid hormone from the outside, as the radioactive iodine treatment.


When history, it is difficult to distinguish between Grave's disease with

Plummer's disease because both showed symptoms of hyperthyroidism. The difference is

when a physical examination at the time of palpation where we can feel the enlargement

affects only one lobe.

3.2.4 Treatment

Therapy given to Plummer's Disease Grave's also the same as that aimed at

controlling the state tirotoksisitas / hipertiroidi with antithyroid administration, such as

propyl-tiourasil (PTU) or karbimazol. Definitive therapy can be selected between anti-

thyroid medication long-term, detachments with radioactive iodine, or

thyroidectomy. Surgery of the Thyroid with hipertiroidi done especially if treatment with

the thyroid gland fails medikamentosa great. Surgery usually provides a good permanent

cure although sometimes encountered the hipotiroidi and minimal complications.

3.3 Struma Difusa nontoxic

3.3.1 Definition

12

Endemic goitre endemic goitre is a disease that i signed with ti roid gland

enlargement that occurs in a population, and is expected to relate to deficiencies in the

daily diet. Endemic goiter epidemiology is estimated there are approximately 5% in a

population of primary school children / preadolescent (6-12 years), as is evident from

several studies. Endemic goitre occurs due to deficiency of iodine in the diet.Frequent

incidence of endemic goiter in derah pegnungan, such as in the Himalayas, alpens, areas

with the availability of natural iodine and iodine additional coverage has not done well


Generally, the mechanism of occurrence of goiter caused by a

deficiency intake iodine by the body. In addition, goiter can also be caused by

congenital abnormalities of thyroid hormone synthesis or goitrogen (goiter-causing

agents such as intake Excessive calcium and Brassica family vegetables). Lack of

iodine causes a lack of thyroid hormone can be synthesized. This will lead to an increase

in the release of TSH (thyroid-stimulating hormone) into the blood as kompensatoriknya

effect. The effect causes hypertrophy and hyperplasia of thyroid follicular cells, resulting

in enlargement of the thyroid macroscopically. This enlargement can normalize body of

work, because on the kompensatorik effects of thyroid hormone needs are met. However,

in some cases, such as iodine deficiency is endemic, this enlargement will not be able to

compensate for the existing disease. The condition known as goiter hypothyroidism. The

degree of enlargement of the thyroid following levels and duration of thyroid hormone

deficiency that occurs in a person.

Diffuse Goiter

Diffuse Goiter is a form like piece that forms a visible enlargement without forming

nodules. Form is usually found with non-toxic properties (normal thyroid function), hence this

form is also called simple goiter. Can also be referred to as colloid goiter due to an enlarged

follicle cells are generally met by colloidal proficiency level. This disorder appears in endemic

and sporadic goiter.

13

Endemic goiter appeared in a soil, water, and food supply contains less iodine, so the

iodine deficiency is widespread in the area teresebut. Examples region is mountainous Alps, the

Andes or Himalayas.

Meanwhile, sporadic goiter appeared less frequently and can be caused by many things,

the consumption of which inhibit the synthesis of thyroid hormones or enzymes for impaired

thyroid hormone synthesis dropped hereditary.

On simple goiter, there are two phases of evolution, namely hyperplastic and colloid

involution. In the hyperplastic phase, the thyroid gland is diffusely enlarged and symmetrical,

although not too large magnifying power (up to 100-150 grams). Follicle-folikelnya coated by

columnar cells are numerous and crowded. Accumulation of these cells is not the same in the

whole gland. If after the consumption of iodine the body needs increased or decreased thyroid

hormone, follicle epithelial cell involution occurs, forming large follicles filled with

colloid. Thyroid would normally macroscopically visible brown and translucent, while

histologically will be seen that the follicles filled with colloid and epitelnya flattened and

cuboidal cells.


Most of the clinical manifestations associated with enlargement of the thyroid

gland. Most patients remained euthyroid state shows, but some circumstances having

hypothyroidism. Hypothyroidism is more common in children with biosynthetic defect as the

cause, including defects in the transfer of iodine.

3.3.4 Procedures

The goal of treatment is to shrink the goitre endemic goitre and hypothyroidism resolve

possible, namely by giving SoL Lugoli for 4-6 months. If there is improvement, treatment was

continued until a year and then tapering off in 4 weeks. When the 6 months after treatment of

goitre is not also shrink the medical treatment is not successful and should be operative action.

3.4 Struma nodosa nontoxic

14

3.4.1 Definition

Goitre nodosa is non toxic ti roid gland enlargement to the clinically palpable nodules

without one or more signs hypertiroidisme. The term struma nodosa indicates the existence of a

process, either physiological or pathological cause asymmetrical enlargement of the thyroid

gland. Because it is not accompanied by signs of toxicity in the body, it is referred to as

asymmetric enlargement nodosa nontoxic goiter.This disorder is very common everyday, and to

watch out for signs of possible malignancy.


SNNT can also be referred to as sporadic goiter. If endemic goitre occurs 10% of the

population in areas with iodine deficiency, the sporadic goiter occurs in someone who does not

live in an area endemic low iodine. The cause is as yet unknown, there can be interference

enzyme important in the synthesis of thyroid hormones or consumption of drugs containing

lithium, propiltiourasil, fenilbutazone, or aminoglutatimid.


In general, non-toxic struma nodosa had no complaints because there was no hypo-or

hyperthyroidism. SNNT diagnosis is important in the absence of toxic symptoms caused by

changes in thyroid hormone levels, and felt on palpation of the enlarged thyroid gland on one

lobe. Usually thyroid began to swell at a young age and developed into multinodular in

adulthood. Due to gradual growth, goitre may be asymptomatic unless large lump in the neck.

majority of patients with struma nodosa can live with strumanya without complaint.

Although most of struma nodosa does not interfere with breathing due to jut forward, others can

cause narrowing of the trachea when bilateral enlargement. Goitre nodosa unilateral

stimulation can lead the way into contra lateral direction. Thus may not lead to the promotion of

respiratory disorders. Significant narrowing cause respiratory until finally happened with stridor

inspiratoar dispn ea.

Complaints that there is a sense of weight in the neck. Trachea during swallowing to cover up the

15

larynx and epiglottis so heavy because fixed to the trachea.

3.4.4 Treatment

Operative action is still the main option on SNNT. Various techniques of operations

include:

a. Lobectomy, which is the lobe lift, when the gland is left subtotal weighing 3 grams

b. Isthmolobektomi, the removal of one lobe followed by the isthmus

c. Total thyroidectomy, which is removal of the entire thyroid gland

d. Bilateral subtotal thyroidectomy, the partial removal of the right lobe and the left part,

the rest of the network in the posterior 2-4 grams taken to prevent damage to the

parathyroid glands or N.Recurrent Laryngeus

3.5 Carcinoma of the Thyroid

3.5.1 Definition

Thyroid carcinoma is a malignancy (uncontrolled growth of cells) that occur in the

thyroid gland. Cancer is a depressing thyroid malignancy in thyroid which has 4 types:

papillary, follicular, medullary and anaplastic. Thyroid cancer rarely causes enlargement of the

gland, often causing small growth (nodule) in the gland. The majority of thyroid nodules are

benign, thyroid cancer usually can be cured

Thyroid Cancer often limit the ability to absorb iodine and limit the ability to produce

thyroid hormone, but sometimes produce enough thyroid hormone, causing hyperthyroidism.

3.5.2 Classification of thyroid carcinoma

2) Papillary carcinoma, This carcinomas derived from thyroid cells and is the most common

type of thyroid carcinoma. More often found in children and young adults and is more

common in females. Exposed to radiation during childhood helped to cause this

malignancy. First appeared in the form of a palpable lump in the thyroid gland as enlarged

16

lymph nodes or neck area. Metastases may occur via the lymph to other areas in the thyroid

or, in some cases, to the lungs.

3) Follicular carcinoma, carcinoma is derived from follicular cells and is 20-25% of thyroid

carcinoma. Follicular carcinoma primarily affects on age above 40 tahun.Karsinoma

follicular also attacked 2 women up to 3 times more often than men. Exposure to X-rays

during childhood increases the risk of this type of malignancy. This type is more invasive

than the papillary type.

4) Anaplastic carcinoma, This highly malignant carcinoma and constitute 10% of thyroid

cancers. Slightly more often in women than men. Metastasis occurs in rapid, early around

it and then other parts of the body. At first people were just complaining about the presence of

thyroid tumor area. With this cancer infiltration around, arising hoarseness, stridor, and

difficulty swallowing. Life expectancy after diagnosis is established, usually only a few

months.

5) Parafolikular carcinoma, carcinoma parafolikular or medul l er is unique among thyroid

cancer. This carcinoma more commonly in women than men and is most often over 50 years.

Carcinoma is rapidly metastasize, often to the place much like the lungs, bones, and liver. His

trademark is his ability to secrete calcitonin because of origin. Carcinoma is often said to be

hereditary.

3.5.3 Differences Benign and Malignant Thyroid Nodules

Approximately 5% had malignant struma nodosa. In the clinic should be differentiated

thyroid nodules are benign and malignant nodules that have these characteristics:

1. Consistency hard on some parts or the whole nodules and hard-driven, although malignant

nodules may undergo cystic degeneration and then become soft.

2. In contrast to the consistency of soft nodules more often benign, although calcified

nodules can be found in adenomatous hyperplasia longstanding.

3. Infiltration into the surrounding tissue nodules merupaka sign of malignancy, although not

always malignant nodules infiltrating. If found ptosis, miosis, and enoftalmus a sign of

infiltration into surrounding tissue

17

4. 20% are malignant solitary nodules whereas multiple nodules are rarely malignant.

5. Nodules that appear suddenly or rapidly growing needs, especially malignant suspicion

that is not accompanied by pain. Or nodules old suddenly enlarged progressively

6. Suspected malignant nodules when accompanied by regional lymph node enlargement or

change in voice became hoarse.

7. Carotid artery pulsation is palpable from the rear edge of the sternocleidomastoid

muscular enlargement due to pressure nodules (Berry's Sign)

3.6 Enforcement Measures Diagnosis Struma

3. 5. 1 Anamnesis

On history, major complaints expressed by the patient may be a lump in the neck that

has lasted a long time, and the symptoms of hyperthyroidism or hipotiroidnya. If the patient

complained of a lump in the neck, then it should be further explored whether or progressive

enlargement occurs very slowly, accompanied with swallowing disorders, impaired breathing

and voice changes. After that asked whether or not there symptoms of hyper and hypofunction of

thyroid kelenjer. Need a place to stay were also asked patients and salt intake to see if there are

trends towards endemic goitre. Conversely, if patients present with symptoms towards hyper or

hypofunction of the thyroid, should be explored further to hyper or hypo and whether there is a

lump in the neck.

3. 5. 2 Physical Examination

On physical examination localist status at the anterior region coli, the most first carried

out an inspection, symmetrical enlargement seen whether or not, arise respiratory signs or not,

part moves while swallowing or not.

On palpation it is important to determine whether the right is bejolan thyroid gland or

lymph nodes. The difference was at the time the patient is asked to swallow. If true then enlarged

thyroid lumps will also move when swallowing, while if not moving then to think about the

possibility of enlarged cervical lymph nodes. Palpable enlargement should be described:

Location: right lobe, left lobos, isthmus

18

Size: in centimeters, length diameter

The number of nodules: one (uninodosa) or more than one (multinodosa)

Consistency: cystic, soft, chewy, hard

Pain: there is pain or not at the time of palpation

Mobility: no or no attachment to the trachea, muscular sternokleidomastoidea

Lymph nodes around the thyroid: no enlargement or not

3.5.3 Examination Support

Laboratory tests used in the diagnosis of thyroid disease is divided into:

1. Examination to measure thyroid function. Examination to determine levels

of T3 and T4 and TSH most often using radioimmunoassay technique (RIA)

and ELISA in serum or blood plasma. Normal levels of total T4 in adults is

50-120 ng / dl. Normal levels of T3 in adults is 0.65 to 1.7 ng / dl.

2. Examination to indicate the cause of thyroid disorders. Antibodies to various

thyroid antigens found in the serum of patients with autoimmune thyroid

disease. Such as thyroglobulin antibodies and thyroid stimulating hormone

antibodies

3. Radiological examination

X-rays can clarify the deviation of the trachea or retrosternal goitre

enlargement is generally clinically was to be expected. X-ray neck AP and

lateral position is usually an option.

Thyroid ultrasound is useful to determine the number of nodules,

differentiate between solid and cystic lesions, detect the presence of

cancerous tissue that does not capture iodine and can be seen by scanning

the thyroid.

Thyroid scanning is essentially a presentation of I 131 uptake thyroid

distributed. Uptake can be determined from the impression the size, shape

19

and location of the main parts is thyroid function (distribution within the

gland). Normal uptake of 15-40% within 24 hours. From the results of

thyroid scanning can distinguish three forms, namely cold nodule uptake

when nil or less than normal compared with the surrounding region, this

suggests that the function of low and often occurs in neoplasms. The second

form is when uptakenya warm nodule with surrounding, showing the

function of the thyroid nodule with other parts. If the latter is the hot nodule

uptake more than normal, meaning excessive activity and rarely in

neoplasms.

4. FNAB. Histopathologic examination of 80% accuracy. It is worth

remembering that not to determine the only definitive therapy based

on the results of FNAB alone.

3.5.4 Measures Surgery

Indications operations on goitre is:

1. Toxic diffuse goiter who fail to medical therapy

2. Struma uni or multinodosa with the possibility of malignancy

3. Struma with compression disorders

4. Cosmetics

Contraindicated in goiter surgery:

1. Struma toksika that have not prepared in advance

2. Goitre with cardiac decompensation and other systemic diseases that have not

been controlled

3. Large goitre which cling tightly to the neck tissues that are normally difficult

to move because of carcinoma. Such carcinomas are usually of poor prognosis

anaplastic type. Attachment to the trachea or larynx or trachea may well

20

dilakukanreseksi laringektomi, but attachment with extensive soft tissue neck

excision is difficult to do well.

First clinical examination for menentuka n whether the suspected malignant

thyroid nodules or suspected to be benign. When the suspected malignant nodules, it is

distinguished whether the case is operable or inoperable.

When the case at hand is inoperable then performed an act of incisional biopsy for

histopathological examination purposes. Debulking followed by action and external

radiation or chemoradiotherapy. When suspected malignant thyroid nodules or suspected

benign operable can be taken isthmolobektomi or lobectomy. If after the PA results prove

that the lesion is benign then the operation is complete, but if malignant it must be

determined beforehand which type of carcinoma occurred.

Complications of thyroid surgery:

a. Bleeding from A. Superior thyroid

b. Dispneu

c. Paralysis N. Recurrent Laryngeus. Consequently oto-laryngeal muscle

weakness occurs

d. Paralysis N. Laryngeus Superior. As a result, patients become lenih

sound weak and difficult to control the high pitch sound, due to the

shortening of the vocal cords due to relaxation of

M. Cricothyroid. Possibility terligasi nerve during surgery

21

CHAPTER IV

CONCLUSION

Goitre is a disease that often we encounter daily. It's important to do a history and

physical examination are thorough and meticulous to determine the presence or absence of signs

of toxicity caused by changes in thyroid hormone levels in the body. So also with signs of

malignancy that can be detected in time.

Next is to determine the appropriate tests to determine the exact diagnosis of the

existing types of goitre. With a definite diagnosis then we can mnentukkan appropriate for

treatment of goitre experienced by pasie. Does it require surgery, or simply given treatment

within a certain period.

22

REFERENCES

1. Widjosono, Garitno, Endocrine System: Textbook of Surgery. Editor Syamsuhidayat

R.Jong WB, Revised Edition, EGC, Jakarta, 1997: 925-952.

2. Kariadi KS Sri Hartini, Sumual A., Struma nodosa Non Toxic & Hyperthyroidism:

Textbook of Pneyakit In, Keiga Edition, Publisher Faculty of Medicine, Jakarta,

1996: 757-778.

3. Schteingert David E., Thyroid Disease, Pathophysiology, Fourth Edition, Book Two,

EGC, Jakarta, 1995: 1071-1078.

4. Liberty Kim H, Thyroid Glands: Textbook of Surgery, Volume One, Publisher

Binarupa script, Jakarta, 1997: 15-19.

23

review of struma.doc

Documents

physiology of thyroid

inferior thyroid

ima thyroid

thyroid disorders

superior thyroid

residual thyroid tissue

entire thyroid tissue

dorsal neural thyroid