PK x2\_rels/PK x2\ docProps/PK x2\ppt/PK x2\ ppt/_rels/PK x2\ ppt/charts/PK x2\ppt/charts/_rels/PK x2\ppt/embeddings/PK x2\ ppt/media/PK x2\ppt/slideLayouts/PK x2\ppt/slideLayouts/_rels/PK x2\ppt/slideMasters/PK x2\ppt/slideMasters/_rels/PK x2\ ppt/slides/PK x2\ppt/slides/_rels/PK x2\ ppt/theme/PK x2\ppt/notesMasters/PK x2\ppt/notesMasters/_rels/PK x2\ppt/notesSlides/PK x2\ppt/notesSlides/_rels/PK x2\V'$'$[Content_Types].xml PK x2\]] _rels/.rels PK x2\A4docProps/app.xml 0 0 Microsoft Office PowerPoint On-screen Show (16:9) 0 17 17 0 0 false Fonts Used 2 Theme 1 Slide Titles 17 Arial Calibri Office Theme Slide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15Slide 16Slide 17 PptxGenJS false false false 16.0000 PK x2\F7docProps/core.xml Multinodular Goiter - Surgical Lecture PptxGenJS Presentation Prof. Zahid Mahmood Prof. Zahid Mahmood 1 2026-06-18T06:19:48Z 2026-06-18T06:19:48Z PK x2\c ppt/_rels/presentation.xml.rels PK x2\Oݨ ppt/theme/theme1.xmlPK x2\jppt/presentation.xml PK x2\Xppt/presProps.xml PK x2\ppt/tableStyles.xml PK x2\D >00ppt/viewProps.xml PK x2\H7t!ppt/slideLayouts/slideLayout1.xml PK x2\ђ77,ppt/slideLayouts/_rels/slideLayout1.xml.rels PK x2\Ul""ppt/slides/slide1.xml MNGMULTINODULAR GOITERGeneral Surgery | Thyroid Disorders | Final Year MBBSProf. Zahid MahmoodUHS / CPSP Aligned CurriculumPK x2\3 ppt/slides/_rels/slide1.xml.rels PK x2\.ppt/notesSlides/notesSlide1.xml 1PK x2\:A*ppt/notesSlides/_rels/notesSlide1.xml.rels PK x2\+::ppt/slides/slide2.xml 02Learning Outcomes 1Define multinodular goiter and classify its clinical types 2Describe etiology and pathophysiology of nodule formation 3Outline clinical features, investigations and complications 4Discuss indications and surgical management of MNGProf. Zahid Mahmood | Learning OutcomesPK x2\2- ppt/slides/_rels/slide2.xml.rels PK x2\ppt/notesSlides/notesSlide2.xml 2PK x2\xշ*ppt/notesSlides/_rels/notesSlide2.xml.rels PK x2\ڱ&::ppt/slides/slide3.xml 03Definition 1Thyroid enlargement with multiple discrete palpable nodules 2Results from chronic, TSH-driven follicular cell hyperplasia 3Most common cause of thyroid swelling worldwide 4May present as euthyroid (non-toxic) or hyperthyroid (toxic) stateProf. Zahid Mahmood | DefinitionPK x2\W/ ppt/slides/_rels/slide3.xml.rels PK x2\K |Őppt/notesSlides/notesSlide3.xml 3PK x2\9 Y*ppt/notesSlides/_rels/notesSlide3.xml.rels PK x2\0 ::ppt/slides/slide4.xml 04Classification 1Non-toxic (simple) MNG — euthyroid, no thyrotoxicosis 2Toxic MNG — autonomous nodules causing hyperthyroidism 3Endemic goiter — seen in iodine-deficient regions 4Sporadic goiter — goitrogens, dyshormonogenesis, idiopathic causesProf. Zahid Mahmood | ClassificationPK x2\` ppt/slides/_rels/slide4.xml.rels PK x2\vsppt/notesSlides/notesSlide4.xml 4PK x2\J *ppt/notesSlides/_rels/notesSlide4.xml.rels PK x2\W::ppt/slides/slide5.xml 05Types / Variants 1Colloid nodular goiter — degenerated, colloid-filled nodules 2Plummer's disease — toxic MNG with thyrotoxicosis 3Retrosternal goiter — extends into superior mediastinum 4Dominant nodule MNG — raises suspicion of malignancyProf. Zahid Mahmood | Types / VariantsPK x2\5 ppt/slides/_rels/slide5.xml.rels PK x2\W8ppt/notesSlides/notesSlide5.xml 5PK x2\Qe*ppt/notesSlides/_rels/notesSlide5.xml.rels PK x2\`::ppt/slides/slide6.xml 06Etiology / Causes 1Iodine deficiency — the commonest cause worldwide 2Goitrogens — cassava, brassica vegetables, lithium therapy 3Dyshormonogenesis — inherited thyroid hormone synthesis defects 4Female sex, puberty and pregnancy increase riskProf. Zahid Mahmood | Etiology / CausesPK x2\ج+ ppt/slides/_rels/slide6.xml.rels PK x2\zppt/notesSlides/notesSlide6.xml 6PK x2\=|*ppt/notesSlides/_rels/notesSlide6.xml.rels PK x2\%J3::ppt/slides/slide7.xml 07Pathophysiology 1Reduced T4 raises TSH via negative feedback 2Persistent TSH drives diffuse follicular cell hyperplasia 3Heterogeneous cellular response produces focal nodules 4Hemorrhage, necrosis and calcification occur within nodulesProf. Zahid Mahmood | PathophysiologyPK x2\F ppt/slides/_rels/slide7.xml.rels PK x2\)lppt/notesSlides/notesSlide7.xml 7PK x2\|g*ppt/notesSlides/_rels/notesSlide7.xml.rels PK x2\"b::ppt/slides/slide8.xml 08Clinical Features 1Painless, slow-growing swelling in the anterior neck 2Swelling moves upward on swallowing, confirming thyroid origin 3Pressure symptoms — dyspnea, dysphagia, occasional stridor 4Retrosternal extension may cause SVC obstruction signsProf. Zahid Mahmood | Clinical FeaturesPK x2\6 ppt/slides/_rels/slide8.xml.rels PK x2\iސppt/notesSlides/notesSlide8.xml 8PK x2\pO*ppt/notesSlides/_rels/notesSlide8.xml.rels PK x2\TÊ::ppt/slides/slide9.xml 09Investigations 1TSH and free T4 — assess functional status 2Ultrasound neck — nodule number, size and characteristics 3FNAC — Bethesda system, excludes underlying malignancy 4CT / MRI — assesses retrosternal extension, tracheal compressionProf. Zahid Mahmood | InvestigationsPK x2\>$ ppt/slides/_rels/slide9.xml.rels PK x2\qppt/notesSlides/notesSlide9.xml 9PK x2\1*ppt/notesSlides/_rels/notesSlide9.xml.rels PK x2\,)::ppt/slides/slide10.xml 10Management Overview 1Asymptomatic, euthyroid MNG — observation with regular follow-up 2Symptomatic or toxic MNG — definitive surgical treatment 3Suspicious nodule on FNAC — surgery is indicated 4Significant cosmetic concern is a valid surgical indicationProf. Zahid Mahmood | Management OverviewPK x2\Ѳ!ppt/slides/_rels/slide10.xml.rels PK x2\O ppt/notesSlides/notesSlide10.xml 10PK x2\T+ppt/notesSlides/_rels/notesSlide10.xml.rels PK x2\8::ppt/slides/slide11.xml 11Medical Management 1Antithyroid drugs — carbimazole controls toxic MNG 2Radioactive iodine — option in poor surgical candidates 3Beta-blockers — symptomatic control of thyrotoxicosis 4Levothyroxine suppression rarely shrinks established nodulesProf. Zahid Mahmood | Medical ManagementPK x2\;!ppt/slides/_rels/slide11.xml.rels PK x2\s6ӑ ppt/notesSlides/notesSlide11.xml 11PK x2\O+ppt/notesSlides/_rels/notesSlide11.xml.rels PK x2\+::ppt/slides/slide12.xml 12Surgical Management 1Total thyroidectomy — standard treatment for bilateral MNG 2Indications — pressure symptoms, toxicity, malignancy risk 3Hemithyroidectomy — considered for unilateral dominant nodule 4Sternotomy rarely required for retrosternal extensionProf. Zahid Mahmood | Surgical ManagementPK x2\c!ppt/slides/_rels/slide12.xml.rels PK x2\*)@ ppt/notesSlides/notesSlide12.xml 12PK x2\Fb+ppt/notesSlides/_rels/notesSlide12.xml.rels PK x2\܉::ppt/slides/slide13.xml 13Complications 1Recurrent laryngeal nerve injury — causes voice change 2Hypoparathyroidism — transient or permanent hypocalcemia 3Post-operative hemorrhage — risk of airway compression 4Hypothyroidism — requires lifelong levothyroxine replacementProf. Zahid Mahmood | ComplicationsPK x2\x!ppt/slides/_rels/slide13.xml.rels PK x2\Ї ppt/notesSlides/notesSlide13.xml 13PK x2\yv+ppt/notesSlides/_rels/notesSlide13.xml.rels PK x2\r::ppt/slides/slide14.xml 14Special Points / Mnemonics 1Pemberton's sign — facial congestion on raising arms 2Recall 'SAFE': Swallow test, Airway, FNAC, Endocrine status 3Graves' and Hashimoto's disease must be excluded clinically 4Malignancy risk is higher with a solitary dominant noduleProf. Zahid Mahmood | Special Points / MnemonicsPK x2\O!ppt/slides/_rels/slide14.xml.rels PK x2\0 ppt/notesSlides/notesSlide14.xml 14PK x2\?ݤ+ppt/notesSlides/_rels/notesSlide14.xml.rels PK x2\k88ppt/slides/slide15.xml 15Clinical Scenario A 45-year-old woman presents with a 5-year history of painless anterior neck swelling and mild exertional dyspnea. Examination reveals a multinodular thyroid moving with deglutition, largest nodule 3 cm. TSH is low-normal; FNAC of the dominant nodule reports Bethesda category II.Q1What is the most appropriate definitive treatment?Q2Why is total thyroidectomy preferred over hemithyroidectomy here?Q3Which structures must be preserved during surgery?Q4What pre-operative counselling points are essential?Prof. Zahid Mahmood | Clinical ScenarioPK x2\*R!ppt/slides/_rels/slide15.xml.rels PK x2\Qz ppt/notesSlides/notesSlide15.xml 15PK x2\$Q+ppt/notesSlides/_rels/notesSlide15.xml.rels PK x2\pfg7g7ppt/slides/slide16.xml 16MCQs - 4 Single Best Answers 1. Best initial investigation in a euthyroid MNG?Ans: Serum TSH + thyroid ultrasound 2. Standard surgery for bilateral multinodular goiter?Ans: Total thyroidectomy 3. Earliest clinical sign of RLN injury?Ans: Hoarseness / voice change 4. Positive Pemberton's sign suggests which finding?Ans: Retrosternal extension with SVC compressionProf. Zahid Mahmood | MCQsPK x2\ !ppt/slides/_rels/slide16.xml.rels PK x2\  ppt/notesSlides/notesSlide16.xml 16PK x2\ y+ppt/notesSlides/_rels/notesSlide16.xml.rels PK x2\11ppt/slides/slide17.xml HIGH-YIELD SUMMARY1MNG results from chronic TSH-driven follicular hyperplasia and nodular degeneration2Toxic MNG is managed with antithyroid drugs before any surgery3Total thyroidectomy is the standard definitive treatment for bilateral disease4FNAC of the dominant nodule is mandatory to exclude malignancyProf. Zahid Mahmood | Multinodular Goiter | End of LecturePK x2\檋!ppt/slides/_rels/slide17.xml.rels PK x2\r. ppt/notesSlides/notesSlide17.xml 17PK x2\BI+ppt/notesSlides/_rels/notesSlide17.xml.rels PK x2\K !ppt/slideMasters/slideMaster1.xml PK x2\N),ppt/slideMasters/_rels/slideMaster1.xml.rels PK x2\6TT!ppt/notesMasters/notesMaster1.xml 7/23/19Click to edit Master text stylesSecond levelThird levelFourth levelFifth level‹#›PK x2\s **,ppt/notesMasters/_rels/notesMaster1.xml.rels PK x2\_rels/PK x2\ $docProps/PK x2\Kppt/PK x2\ mppt/_rels/PK x2\ ppt/charts/PK x2\ppt/charts/_rels/PK x2\ppt/embeddings/PK x2\ ppt/media/PK x2\Bppt/slideLayouts/PK x2\qppt/slideLayouts/_rels/PK x2\ppt/slideMasters/PK x2\ppt/slideMasters/_rels/PK x2\  ppt/slides/PK x2\3ppt/slides/_rels/PK x2\ bppt/theme/PK x2\ppt/notesMasters/PK x2\ppt/notesMasters/_rels/PK x2\ppt/notesSlides/PK x2\ppt/notesSlides/_rels/PK x2\V'$'$P[Content_Types].xmlPK x2\]] '_rels/.relsPK x2\A4.*docProps/app.xmlPK x2\F7y1docProps/core.xmlPK x2\c 4ppt/_rels/presentation.xml.relsPK x2\Oݨ Appt/theme/theme1.xmlPK x2\jbppt/presentation.xmlPK x2\Xqppt/presProps.xmlPK x2\rppt/tableStyles.xmlPK x2\D >00sppt/viewProps.xmlPK x2\H7t!Dwppt/slideLayouts/slideLayout1.xmlPK x2\ђ77,2zppt/slideLayouts/_rels/slideLayout1.xml.relsPK x2\Ul""{ppt/slides/slide1.xmlPK x2\3 ppt/slides/_rels/slide1.xml.relsPK x2\.ppt/notesSlides/notesSlide1.xmlPK x2\:A*ppt/notesSlides/_rels/notesSlide1.xml.relsPK x2\+::ppt/slides/slide2.xmlPK x2\2- ppt/slides/_rels/slide2.xml.relsPK x2\ppt/notesSlides/notesSlide2.xmlPK x2\xշ*ppt/notesSlides/_rels/notesSlide2.xml.relsPK x2\ڱ&::ppt/slides/slide3.xmlPK x2\W/ ^ppt/slides/_rels/slide3.xml.relsPK x2\K |Őjppt/notesSlides/notesSlide3.xmlPK x2\9 Y*7&ppt/notesSlides/_rels/notesSlide3.xml.relsPK x2\0 ::J(ppt/slides/slide4.xmlPK x2\` cppt/slides/_rels/slide4.xml.relsPK x2\vseppt/notesSlides/notesSlide4.xmlPK x2\J *kppt/notesSlides/_rels/notesSlide4.xml.relsPK x2\W::mppt/slides/slide5.xmlPK x2\5 ppt/slides/_rels/slide5.xml.relsPK x2\W8ɪppt/notesSlides/notesSlide5.xmlPK x2\Qe*ppt/notesSlides/_rels/notesSlide5.xml.relsPK x2\`::ppt/slides/slide6.xmlPK x2\ج+ jppt/slides/_rels/slide6.xml.relsPK x2\zvppt/notesSlides/notesSlide6.xmlPK x2\=|*Cppt/notesSlides/_rels/notesSlide6.xml.relsPK x2\%J3::Vppt/slides/slide7.xmlPK x2\F 4ppt/slides/_rels/slide7.xml.relsPK x2\)l6ppt/notesSlides/notesSlide7.xmlPK x2\|g*<ppt/notesSlides/_rels/notesSlide7.xml.relsPK x2\"b::>ppt/slides/slide8.xmlPK x2\6 yppt/slides/_rels/slide8.xml.relsPK x2\iސ{ppt/notesSlides/notesSlide8.xmlPK x2\pO*ppt/notesSlides/_rels/notesSlide8.xml.relsPK x2\TÊ::ppt/slides/slide9.xmlPK x2\>$ dppt/slides/_rels/slide9.xml.relsPK x2\qpppt/notesSlides/notesSlide9.xmlPK x2\1*=ppt/notesSlides/_rels/notesSlide9.xml.relsPK x2\,)::Pppt/slides/slide10.xmlPK x2\Ѳ!!ppt/slides/_rels/slide10.xml.relsPK x2\O /ppt/notesSlides/notesSlide10.xmlPK x2\T+ ppt/notesSlides/_rels/notesSlide10.xml.relsPK x2\8::ppt/slides/slide11.xmlPK x2\;!Jppt/slides/_rels/slide11.xml.relsPK x2\s6ӑ Lppt/notesSlides/notesSlide11.xmlPK x2\O+Sppt/notesSlides/_rels/notesSlide11.xml.relsPK x2\+::Uppt/slides/slide12.xmlPK x2\c!ppt/slides/_rels/slide12.xml.relsPK x2\*)@ ppt/notesSlides/notesSlide12.xmlPK x2\Fb+|ppt/notesSlides/_rels/notesSlide12.xml.relsPK x2\܉::ppt/slides/slide13.xmlPK x2\x!Uppt/slides/_rels/slide13.xml.relsPK x2\Ї cppt/notesSlides/notesSlide13.xmlPK x2\yv+2ppt/notesSlides/_rels/notesSlide13.xml.relsPK x2\r::Gppt/slides/slide14.xmlPK x2\O!;ppt/slides/_rels/slide14.xml.relsPK x2\0 Ippt/notesSlides/notesSlide14.xmlPK x2\?ݤ+%ppt/notesSlides/_rels/notesSlide14.xml.relsPK x2\k88-'ppt/slides/slide15.xmlPK x2\*R!_ppt/slides/_rels/slide15.xml.relsPK x2\Qz appt/notesSlides/notesSlide15.xmlPK x2\$Q+hppt/notesSlides/_rels/notesSlide15.xml.relsPK x2\pfg7g7jppt/slides/slide16.xmlPK x2\ !xppt/slides/_rels/slide16.xml.relsPK x2\  ppt/notesSlides/notesSlide16.xmlPK x2\ y+Uppt/notesSlides/_rels/notesSlide16.xml.relsPK x2\11jppt/slides/slide17.xmlPK x2\檋!Nppt/slides/_rels/slide17.xml.relsPK x2\r. \ppt/notesSlides/notesSlide17.xmlPK x2\BI++ppt/notesSlides/_rels/notesSlide17.xml.relsPK x2\K !@ppt/slideMasters/slideMaster1.xmlPK x2\N), ppt/slideMasters/_rels/slideMaster1.xml.relsPK x2\6TT! ppt/notesMasters/notesMaster1.xmlPK x2\s **,(ppt/notesMasters/_rels/notesMaster1.xml.relsPKgg%*