1

DISORDERS OF THYROID FUNCTION

HYPERTHYROIDISM

Hyperthyroidism is a condition in which there are increased levels of thyroid

hormones in the blood and one for which surgical correction is frequently
appropriate.
Causes of thyrotoxicosis
Common causes:
- diffuse toxic goiter (Grave’s disease)
- toxic multinodular goiter (Plummer’s disease
- toxic solitary nodule
- nodular goiter with hyperthyroidism due to exogenous iodine.
- exogenous thyroid hormone excess
- thyroiditis

Rare causes:
- metastatic thyroid carcinoma
- pituitary tumour secreting TSH

Grave’s disease (Basedow’s disease)

It is the most common cause of hyperthyroidism, it is an immunological
disorder in which thyroid stimulating antibodies of the Ig G type bind to the
TSH receptor and stimulate the thyroid cells to produce and secrete an excess of
thyroid hormones.
The thyroid gland hypertrophies producing diffuse enlargement.
Most of the symptoms and signs of thyrotoxicosis result from excess thyroid
hormones, stimulating metabolism, heat production and oxygen consumption.
It is especially common in young women between 20 and 40 years of age.
Ophthalmopathy has two major components:
1- non infiltrating ophthalmopathy resulting from sympathetic activity leading
to upper lid retraction, a stare and infrequent blinking.
2- infiltrating ophthalmopathy causing oedema of the orbital contents, lids and
periorbital tissues, cellular infiltration and deposition of mucopolysaccharide
material within the orbit.
Diplopia results from weakening and paralysis of the external ocular muscles.
The cornea is vulnerable to damage and ulceration may occur.
Investigations:
- measurement of free T4, T3, TSH will confirm the diagnosis.
- a radioactive iodine or technetium scan is not essential in patients with
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Grave’s disease although it is necessary in the assessment of toxic solitary and

multinodular goiter to determine the site of nodular overactivity.
- radioactive iodine uptake studies are particularly appropriate revealing an
increased uptake.
- chest X ray- position of trachea
- laryngoscopy- mobility of the vocal cords preoperatively
- ecg- cardiac activity.

Treatment
In Graves’s disease three treatment modalities can be used either alone or in
combination to restore the euthyroid state:
- antithyroid drugs
- radioactive iodine
- surgery

Antithyroid drugs
These drugs interfere with the thyroid hormones synthesis.
Medical treatment with antithyroid drugs has two principal roles:
- treatment of newly diagnosed patients with Grave’s disease in the hope
of inducing a permanent remission
- render the toxic patient euthyroid in preparation for surgery.

Beta-adrenergic blockers
Many of the manifestations of hyperthyroidism, particularly those relating to the
cardiovascular system, can be ameliorated by the administration of beta-
blockers such as metoprolol.
Beta-blockers are usually used in combination with one of antithyroid drugs in
patients who are severely toxic and in those patients being prepared for surgery.

Radioactive iodine
I 131 used to control thyrotoxicosis achieves its effect by destruction of
overactive thyroid tissue.
There would appear to be no adverse effects of I 131 treatment with respect to
leukemia, thyroid carcinoma, fetal damage or genetic mutation.
An ablative dose will render more than 60% of patients hypothyroid in one year.
Regular long-term surveillance is required and thyroxine replacement given as
necessary.

Surgery
Thyroidectomy in patients with Graves’s disease is safe and rapidly renders the
patient euthyroid. The principal indications for surgery are:
- relapse after an adequate course of antithyroid drugs
- severe thyrotoxicosis with a large goiter
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- difficulty in controlling toxicity with antithyroid drugs

The surgical procedure: bilateral subtotal thyroidectomy leaving a posterior
remnant of thyroid tissue on each side of the trachea or total thyroidectomy.

Toxic multinodular goitre

Antithyroid drugs are of no value as a long-term treatment because thyrotoxicity
is due to autonomy and will recur once any medication is discontinued.
I 131 can be used for small goitres but usually a subtotal thyroidectomy is most
appropriate after achievement of the euthyroid state or total thyroidectomy.

Toxic solitary nodule

This condition caused by a single autonomous thyroid can be treated by either a
unilateral thyroid lobectomy or I 131

Follow-up
Because of the risk of developing postoperative hypothyroidism patients who
have undergone any form of treatment for hyperthyroidism must be followed on
a long-term basis with regular clinical and biochemical assessment.

Preparation for surgery

Classically the patient comes to surgery in the euthyroid state, controlled by a
period of antithyroid drug therapy. Because the antithyroid drugs block the
synthesis of thyroxine but do not inhibit the release of the hormone from
existing colloid stores the time required for symptomatic improvement may
vary widely from two weeks to as long as three months.
There has been a lot of interest in carrying out the operation of thyroidectomy
for thyrotoxicosis in patients prepared for operation by beta-adrenergic
blockade with metoprolol. When the patient has become euthyroid, iodine
given as Lugol’s solution is administered for ten days before surgery for the
good reason to induce a firmity of the gland and reduce the hemorrhagic risk at
operation.
The operation is often made easier by avoidance of antithyroid drugs which are
to a degree goitrogenic. Beta-blockers may be reduced after surgery and
discontinued by 7 days after operation.

Postoperative complications

1. Postoperative bleeding
There is always a risk of postoperative bleeding after thyroid surgery.
It is rare but sometimes dramatic and fatal. The bleeding may occur in one of
two sites:
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- deep to the myofascial layer in relation to the thyroid remnant or vessels.

Evacuation must be done quickly but it will usually be possible to do this under
general anesthesia in the operating theatre.
- bleeding deep to the skin flaps is the more common and usually arises from
veins. Bleeding is slow but a substantial hematoma may develop and produce
pressure on the airway. Evacuation is mandatory. If hematoma is seen within
12 hours of operation it should probably be evacuated to prevent respiratory
embarrassment developing. Little is to be gained by observation.

2. Postoperative thyrotoxic crisis

Thyrotoxic crisis is a serious complication but it should not be seen where there
has been adequate preoperative preparation.
It occurs within the first 24 hours of thyroidectomy with the patient becoming
confused and hyperactive with a high temperature, profuse sweating and rapid
heart rate.
Treatment must be vigorous with beta-adrenergic blockade, intravenous
hydrocortisone and iodine.

3. Postoperative voice changes

Rarely are voice changes due to any damage to recurrent laryngeal nerves since
this occur in less than 1% of cases when thyroidectomy is carried out by
experienced thyroid surgeons.
Damage to the recurrent laryngeal nerve which may run between the bifurcation
of the inferior thyroid artery as it enters the gland.
Probably minor changes in the muscles around the cricoid and thyroid cartilages
are the most important and it is to some extent, inevitable that there will be
some changes with the mobilization of the gland.
Trauma to the external laryngeal nerve supplying the cricothyroid muscle can
lead to voice changes because of difficulty in achieving vocal cord tension if the
muscle is paralysed.
Damage to the internal laryngeal nerve is also serious and can occur where there
is difficulty in mobilizing the superior pole. This leads to desensitization of the
appropriate side of the larynx and spilling over, especially of liquids, during
swallowing.

4. Hypoparathyroidism
The commonly encountered hypocalcemia of the first few days after
thyroidectomy probably has little to do with hypoparathyroidism and is more
likely to be a consequence of the metabolic changes taking place with re-entry
of calcium into bone demineralized by hyperthyroidism (“hungry bones”).
The operation of thyroidectomy is designed to leave a large amount of thyroid
capsule and with it the parathyroids.
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However, parathyroids are very small and are not always easy to identify at
thyroidectomy. The incidence of hypoparathyroidism after surgery for
thyrotoxicosis should be less than 1%.

5. Hypothyroidism
All forms of treatment for thyrotoxicosis will produce a population of patients
prone to develop hypothyroidism, greatest after radioiodine therapy but seen
after all forms of treatment.

MALIGNANT DISEASE OF THE THYROID GLAND

Primary malignancies of the thyroid can be classified according to the element

from which they arise:

Tumours of thyroid follicular epithelium

1- papillary carcinoma
2- follicular carcinoma
3- anaplastic carcinoma

Tumours of parafollicular cells

1- medullary carcinoma

Tumour of lymphoid element

1- lymphoma

Papillary carcinoma
This is the commonest thyroid tumour which shows an increased incidence in
iodine-rich areas and usually affects children and young adults. Previous neck
irradiation particularly in the young may predispose to thyroid cancer.
Pathology
This tumour which has a propensity for lymphatic spread both within the
thyroid and to the paratracheal and cervical lymph nodes is usually a hard
whitish lesion infiltrating the thyroid gland and presents as a thyroid nodule.
The lesion is frequently multifocal, rarely encapsulated and blood-borne spread
is usually a late feature.
These tumours can be divided into three main types based on their size and
extent: - minimal- these are lesions 1 cm. or less in size, usually not clinically
obvious. They readily metastasise to regional lymph nodes.
- intrathyroidal- these lesions are larger than minimal tumours, have a
less favourable prognosis, are situated totally within the thyroid.
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- extrathyroidal- this a locally advanced condition extending through the

thyroid capsule often involving adjacent structures as the trachea, oesophagus
and recurrent laryngeal nerve.
Clinical presentation
The commonest presentation of papillary carcinoma is a thyroid nodule
frequently associated with enlarged cervical lymph nodes.
Involvement of the adjacent structures by a locally invasive tumour may cause
hoarseness of the voice due to recurrent laryngeal nerve palsy, airway
symptoms because of tracheal involvement and dysphagia as a result of
esophageal invasion.
Less than 1% of patients at the time of initial presentation will show features of
distant metastases.
Diagnosis is based on a combination of careful clinical assessment and fine
needle aspiration cytology.

Follicular carcinoma
This tumour, less common than papillary carcinoma, has a higher incidence in
iodine-deficient areas due to chronic TSH stimulation and can also be caused by
previous irradiation.

The disease has a female to male ratio of 3:1, affects an older age group (mean
age 50 years) than papillary carcinoma.
Pathology
Follicular carcinoma is invariably encapsulated, solitary, readily exhibiting
vascular invasion and spread via the bloodstream.
Follicular carcinoma is classified into two types according to histopathological
features: - minimally invasive- histology demonstrates only slight capsular or
vascular invasion
- frankly invasive- histology demonstrates venous extension
particularly into the middle thyroid and internal jugular veins.
Clinical features
Follicular thyroid cancer presents as a discrete solitary thyroid nodule
increasing in size. Although many tumours are firm a follicular carcinoma is
often soft because of hemorrhagy within the lesion.
Metastatic disease may already be present at the time of diagnosis with bone
and lung involvement.
Diagnosis
Unlike papillary thyroid carcinoma, follicular carcinoma cannot be diagnosed
precisely by FNAC. The cytology report will describe a follicular tumour,
usually showing a microfollicular pattern, the majority of such lesions being
entirely benign.
Only 20% of these will be subsequently identified as follicular carcinoma.
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Treatment of differentiated thyroid cancer

There is general agreement that thyroidectomy is the treatment of choice.
The treatment objectives are:
- eradicate primary tumour
- reduce the incidence of distant or local recurrence.
Total thyroidectomy has been advocated because of its ability to treat multifocal
tumour, decrease local and distal recurrence.
In the case of papillary carcinoma there is a high incidence of multifocality
which clearly would not be treated by a unilateral or even near total
thyroidectomy.
Retrospective studies of thyroidectomy for papillary tumours have demonstrated
a reduced local recurrence rate when total thyroidectomy was performed
compared with a subtotal resection.
Thyroidectomy must always include clearance of pretracheal and paratracheal
lymph nodes.

A unilateral lobectomy and isthmusectomy is adequate for minimal (less than 1

cm.) lesions.

Follicular tumours if minimal lesion then a unilateral lobectomy is all that is

required.
An invasive follicular tumour requires a total thyroidectomy.

Lymph node dissection is not routinely performed for follicular tumours. A

decision to proceed to a total thyroidectomy can often be made at the time of
surgery on the basis of the macroscopic appearance of the lesion and especially
when the tumour size is in excess of 4 cm.

Postoperative treatment
Thyroxine
Any patient who has undergone total thyroidectomy will require replacement
treatment with thyroxine.
Thyroglobulin measurement
It is a sensitive indicator of residual or recurrent differentiated thyroid cancer
when a total thyroidectomy has been performed and the patient is on full
replacement thyroxine dosage.
This measurement is now performed routinely and has markedly reduced the
need for routine serial radioactive iodine scanning.
Radioactive iodine
Radioactive iodine is a most useful means of detecting metastatic disease when
total thyroidectomy has been performed for differentiated cancer.
Postoperatively, patients are initially placed on T3 and sent home to wait an I
131
scan six weeks later.
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T3 is discontinued two weeks before the scan to allow a rise in TSH level
before administering 2-5mCi of I 131.
If there are no metastases and the total thyroidectomy has been successfully
performed the uptake at 24h. should be less than 1%.
When there is significant uptake in the thyroid bed this can be ablated with
radioiodine and many metastatic disease subsequently treated with a therapeutic
dose of 150-200mCi I 131.
The maximum cumulative dose of I 131 should be no greater than 800-1000mCi.

Anaplastic carcinoma
This highly aggressive tumour usually affects the elderly with a peak incidence
between 60 and 70 years of age.
The tumour has a higher incidence in areas of endemic goitre. The tumour
rapidly infiltrates local structures and metastases via the bloodstream and
lymphatics.
The frequent finding of foci of papillary or follicular carcinoma in anaplastic
tumours suggests that this disease originates in an unrecognised or untreated
differentiated tumour.
The clinical findings are typically those of an elderly female often with a long
history of goiter that suddenly starts to grow rapidly with hoarseness,
dysphonia, dysphagia and a compromised airway.
Confirmation of clinical diagnosis may be obtained by FNAC, the aspirate
showing bizzare giant cells, multinucleated cells.
Resection of the thyroid is rarely possible because of the local extent of
disease.
Incision biopsy for diagnostic purposes should be avoided for fear of infiltrating
an uncontrollable local spread of the disease.
If surgery is possible it should relieve an obstructed airway by excision of the
of the isthmus.
Radiotherapy and doxorubicin are the main modalities of treatment but
invariably the tumour rapidly progresses usually leading to death of the patient
within six months.

Medullary carcinoma
This is a tumour which arises from the C-cells, derived from neural ectoderm,
and accounts for approximately 8% of malignant thyroid tumours.
This is a solid non-follicular carcinoma that arises from the parafollicular C-
cells which secretes calcitonin, a peptide capable of lowering the blood calcium
and amenable to measurement by radioimmunoassay.
Pathology
Medullary carcinoma is a solid tumour located in the upper two thirds of the
thyroid and is usually both multicentric and bilateral.
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The tumour grows locally but readily spreads by lymphatics to regional nodes
and via the bloodstream to distant sites such as liver, lungs, bones.
This tumour produces and secretes calcitonin, a most valuable histochemical
marker for medullary carcinoma. Carcinoembryonic antigen (CEA) is another
tumour marker.
Clinical features
The disease tipically presents as a mass in the neck often with enlarged cervical
and mediastinal lymph nodes.
Involvement of adjacent organs and the recurrent laryngeal nerve may cause
respiratory or swallowing difficulties and voice changes.
Sporadic disease has a peak incidence at 40-50 years of age whereas inherited
familial disease is usually seen at a younger age.
Diarrhea is often a prominent clinical feature but the ability of this tumour to
secrete a range of hormones and peptides including calcitonin, prostaglandins,
5-hydroxytryptamine and ACTH can give rise to a range of clinical syndromes
which may include Cushing’s syndrome.
Diagnosis
Clinical assessment and the taking of a careful family history are fundamental to
establishing a precise diagnosis and confirmation is obtained by FNAC and
measurement of serum calcitonin.
Because of the close association of phaeochromocytoma and MC in the MEN
familial forms measurement of urinary VMA and metanephrines should be
carried out in all patients with MC before progressing to any invasive measures
such as surgery.
Treatment
Total thyroidectomy is the appropriate procedure to adequately treat
multicentric and bilateral disease.
The central and paratracheal lymph nodes are cleared from the level of the
thyroid cartilage to the upper mediastinum.
The lateral nodes in the carotid sheath are sampled and if involved with tumour
a modified radical node dissection is performed preserving the internal jugular
vein, sternomastoid muscle and spinal accessory nerve.
Even when the primary tumour is extensive the recurrent laryngeal nerve can
usually be preserved. Because of the multifocal nature of hereditary tumours a
bilateral lymph node clearance is advised.
Prognosis
The presence or absence of distant metastases and lymph node positivity are
major factors in determining the ultimate prognosis.
When lymph node metastases are present this survival rate is reduced to 45% at
10-years suevival.
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Follow-up
After surgery regular clinical and biochemical follow-up is carried out with
measurement of the two tumour markers calcitonin and carcinoembryonic
antigen (CEA).
When raised levels of these agents persist after thyroidectomy or develop at a
later stage this may signify persistent and recurrent disease.
Ultrasonography, CT, MRI and scanning with other isotopes such as
dimercaptosuccinic acid (DMSA) and meta-iodobenzyl guanidine (MIBG) can
be utilised to detect this disease.
For recurrence, external irradiation can occasionally produce some benefit but
chemotherapy with doxorubicin is both toxic and disappointing.
The TNM stages of thyroid cancer
“TNM” stands for Tumour, Node, Metastasis.

There are 4 main T stages for thyroid cancer

T1 - the tumour is entirely inside the thyroid and is less than 2cm across in any
direction

T2 - The tumour is entirely inside the thyroid and is more than 2cm but no
more than 4cm across in any direction
T3 - The tumour is entirely inside the thyroid and is more than 4cm across in
any direction
T4a - The cancer has grown outside the covering of the thyroid gland into the
surrounding tissues.
T4b - The cancer has grown outside the thyroid gland into the area surrounding
the bones of the spine, or one of the main blood vessels nearby.

N0- no lymph nodes contain cancer cells

N1 is divided into 2 groups

N1a - there are lymph nodes containing cancer cells on one side of the neck
only (on the same side as the cancer)
N1b - there are lymph nodes containing cancer cells anywhere else (usually the
other side of the neck or in the chest)

M0- no metastases

M1- present distant metastases

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Papillary and follicular thyroid cancer

The number stages for papillary and follicular thyroid cancer are the same.
There are 4 number stages. These cancers are staged differently depending on
age of the patient. These types of thyroid cancer tend to respond well to
treatment, particularly in young patients.

Under 45years of age:

Stage 1 - cancer is only inside the thyroid, or the thyroid and the lymph glands
Stage 2 - cancer has spread presenting metastases

Over 45:

Stage 1 - cancer is only inside the thyroid and is less than 2cm across
Stage 2 - cancer is any size, but is only inside the thyroid
Stage 3 - cancer has grown beyond the thyroid capsule, or there are cancer
cells in the lymph nodes
Stage 4 - cancer has spread to other parts of the body, such as lungs or bones
Medullary thyroid cancer
There are 4 number stages for medullary thyroid cancer. These are:

Stage 1 - cancer is less than 2cm across

Stage 2 - cancer is between 2cm and 4cm across
Stage 3 - There is spread to cervical lymph nodes
Stage 4 - The cancer cells have spread to another part of the body

Staging for anaplastic thyroid cancer

There is no number staging system for anaplastic thyroid cancer. This is
because there is a high risk of the cancer spreading.

Whether the cancer is only in the neck and so may be able to be completely
removed

Whether the patient is fit enough to have treatments such as surgery or

radiotherapy
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THYROIDITIS

The thyroid gland may be subject to inflammatory change in a variety of

conditions, the process being either focal or diffuse and often associated with
thyroid dysfunction.

Subacute thyroiditis
This condition, often called granulomatous or de Quervain’s thyroiditis is
probably of viral origin.
It is characterised by painful swelling of one or both thyroid lobes with
associated malaise and fever.
Frequently there is a preceding history of sore throat or viral infection a week or
two before the onset of thyroid symptoms.
Approximately one third of patients are asymptomatic apart from enlargement
of the thyroid gland but 15% have a more acute illness with symptoms and signs
of hyperthyroidism.
Thyroid hormone levels are raised but in contrast to Grave’s disease there is low
uptake of radioactive iodine on scintigraphy. The ESR is raised.
The disease process of subacute thyroiditis is usually self-limiting with
resolution of local symptoms and thyroid dysfunction.
A few patients, however, pass through a mild hypothyroid phase.
Local symptoms can be controlled with aspirin but if severe and prolonged a
course of steroids can be helpful.
The transient hyperthyroidism does not require treatment with antithyroid drugs.

Autoimmune thyroiditis
This condition was described by Hashimoto and occurs as a diffuse process
throughout the thyroid gland which usually enlarges to several times normal
size.
Although clasically the gland enlargement is diffuse there may be nodularity
and lobulation making distinction from simple multinodular goitre or even
malignant disease difficult.
Histologically there is infiltration of the thyroid by lymphocytes and plasma
cells, frequently secondary lymphoid nodules and adjacent stromal fibrosis.
The condition is due to an immunological disorder characterised by thyroid
antibodies in the serum.
A positive family history of other autoimmune disease such as pernicious
anaemia, gastritis, thyrotoxicosis is frequently obtained.
As a result of destructive changes within the infiltrated thyroid, hypothyroidism
usually ensues and when present requires treatment with thyroxine.
This medication supresses TSH and leads to shrinkage of the thyroid gland with
relief of any symptoms.
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Surgery is not usually required since pressure symptoms and involvement of

adjacent structures occurs rarely.
Occasionally a satisfactory reduction in the size of the goiter can be achieved by
the administration of steroids.
When the thyroid, involved with autoimmune disease, is seen to rapidly enlarge
or develop a firm asymmetrical nodular area, exclusion of lymphoma by FNAC
is required.

Riedel’s thyroiditis
This condition, sometimes called invasive fibrous thyroiditis is characterised by
a dense fibrous inflammatory infiltrate throughout the thyroid, sometimes
extending through the capsule to involve adjacent structures.
The condition is rare but is important because the clinical picture mimics
thyroid malignancy.
Needle biopsy is likely to be required to free a compromised airway.
Steroid medication has been tried without much success and recently there have
been reports of benefit from tamoxifen.

Acute suppurative thyroiditis

The thyroid can be infected by a variety of bacterial or fungal agents producing
clinical features of an acute painfully inflamed gland.
Confirmation of diagnosis and bacteriology is obtained by needle aspiration and
appropriate antibiotics administered.

DISORDERS OF THE PARATHYROID GLANDS

The parathyroid glands are important to surgeons for two reasons.

First, because surgeons treat patients with symptomatic hyperparathyroidism
they must know the cause and management of various hyperparathyroid
conditions and second during operations in the neck, it is imperative that the
intergrity of the parathyroids be preserved to avoid permanent
hypoparathyroidism.
There is no satisfactory replacement for endogenously produced parathyroid
hormone and the patient with hypoparathyroidism is doomed to a lifelong
process of episodic, symptomatic hypocalcemia despite calcium and vit. D
therapy.
Anatomy
The superior parathyroid glands usually lie at the junction of the upper and
middle third of the thyroid gland on its posteromedial surface and in the
tracheooesophageal groove.
The inferior parathyroid glands lie close to the inferior poles of the thyroid
gland.
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Sometimes they are found some distance caudal to the thyroid gland in
association with the inferior thyroid veins.

Parathyroid hormone (PTH)

PTH is a major regulator of calcium metabolism. It acts in conjunction with
calcitonin and activated vitamin D3 to regulate the plasma concentration of the
ionized form of calcium.
As serum calcium falls, the secretion of PTH increases.
As serum calcium rises, the secretion of PTH decreases.
PTH exerts its biologic effect on bone, intestine and kidney:
- increases the mobilization of calcium and phosphate from bone.
- acts synergistically with D3 to increase the absorbtion of calcium and
phosphorus from the gut.
- promotes the active reabsorbtion of calcium in the distal nephron.
- inhibits phosphate reabsorbtion in the proximal tubule.
Increased PTH secretion has the following clinical effects on bone, intestine and
kidney:
- hypercalcemia
- hypocalciuria initially due to increased calcium reabsorbtion, then in a chronic
state hypercalciuria
-hypophosphatemia
-hyperphosphaturia

Laboratory tests
Serum PTH levels can be measured by radioimmunoassay.

Hyperparathyroidism
Primary hyperparathyroidism
Incidence. It may occur sporadically but may occur as:
- part of a multiple endocrine adenomatosis syndrome
- familial hyperparathyroidism
- ectopic tumour

Etiology and pathology

- 90% of primary HPT cases are due to a solitary adenoma of one of the four
glands.
- about 10% are due to four-gland hyperplasia
- parathyroid carcinoma accounts for 1% of primary hyperparathyroidism cases.
Clinical presentation
Most patients with primary HPT are asymptomatic.
When patients are symptomatic, the symptoms are:
-renal lithiasis
-osteitis fibrosa cystica
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-psychiatric manifestations
-peptic ulcer disease, usually associated with hypergastrinemia that results from
hypercalcemia
- cholelithiasis or pancreatitis may occur.
- non-specific symptoms: weakness, easy fatigability, constipation, arthralgia.

Diagnosis
Lab. tests
An elevated serum calcium level is the cornerstone of diagnosis.
While primary HPT is a relatively common cause of hypercalcemia, other
causes must be excluded, such as metastatic bone disease, myeloma, sarcoidosis
the use of thiazide diuretics, thyrotoxicosis and Addison’s disease.
A serum PT hormone level is high, disproportionately.
In patients with metastatic bone disease, ythypercalcemia occurs without a
disproportionate elevation of PH.
In patients with secondary HPT, the serum PTH level is high and the serum
calcium is low.
In patients with hypoparathyroidism the serum calcium and serum PTH are both
low.
The serum phosphorus level is decreased, hyperphosphaturia.

Radiographic studies
X-ray of the skull may show a “ ground-glass” appearance in the outer 2/3 of
the skull.
Skull X-rays are also obtained to search for enlargement of the sella turcica due
to pituitary tumour.
X-rays of the proximal ends of the long bones may demonstrate bony
reabsorbtion.
Indications for surgery
Once the diagnosis of primary hyperparathyroidism is confirmed biochemically
patients should be selected for operation.
1. All symptomatic patients with biochemically proven HPT should be
considered for surgery.
2. Operation is also advised for an asymptomatic patient whose serum calcium
levels exceed 11 mg/dl, especially if the patient has a decrease in bone density,
hypercalciuria or a decrease in renal function due to other diseases such as
hypertension or diabetes mellitus.
Methods of preoperative localization
- ultrasonography
- scanning of the neck after administering Thallium 201
- thyrocervical angiography by Seldinger technique
- CT and MRI
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Surgical treatment
Solitary adenoma- removal of adenoma
Four-gland hyperplasia- two options:
- subtotal parathyroidectomy- 5% recurrence rate after it
- total parathyroidectomy with autotransplantation of minced parathyroid
tissue into a well vascularized accessible forearm muscle.

THYMUS

The thymus gland has right and left lobes closely bound together which may
overlap each other to some extent. It lies anteriorly in the superior mediastinum
and extends both superiorly into the neck in front of the left brachiocephalic
vein and also inferiorly into the anterior mediastinum where its lower poles are
closely related to the pericardium.

After puberty the thymus undergoes fatty degeneration to a varying extent.

Blood supply comes from the internal thoracic arteries and the venous drainage
is into the left brachiocephalic vein.
The function of the thymus gland has been the subject of an enormous amount
of research over the last 20 years and has still not been completely clarified.
Some aspects of its function are of considerable relevance to surgeons.
The thymus, plays a vital role, particularly in childhood in determining the
immunological competence of the individual. The thymic cells influence other
lymphocytes, the B-cells to produce immunoglobulins in response to antigenic
stimulation. The lymphocytes are from the bone marrow initially and develop
into the two distinct populations, T-cells and B-cells.
T-cells develop their identity in the neonatal period after passing through a
thymic phase. The T-cells then migrate to colonize the T-cell area of the lymph
nodes and spleen.
T-cells have been identified: helper and suppressor, which influence the B-cell
accordingly. The normal ratio of helper and suppressor T-cells is 2:1, this ratio
is reversed in the immunocompromised patient

Myasthenia gravis
Myasthenia gravis is an acquired autoimmune disorder which involves
autoimmune blockage of postsynaptic nicotinic cholinergic receptors. The
disease is related to the production of an antibody which blocks the effect of
acetylcholine at the motor end-plate. The neuromuscular transmission is
compromised the clinical result being muscular weakness and fatigability.
The sourse of these autoantibodies is the abnormal thymus in the majority of
cases.
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The pathological appearance of the thymic gland in the majority of myasthenics

shows some degree of hyperplasia of the lymphoid elements but 10-20% of
myasthenics are reported to have thymomas.
Affected patients experience weakness which worsens by exertion and improves
by rest.
Occular muscle involvement induces ptosis and diplopia, facial muscle
involvement induces loss of facial expression and jaw drop. Bulbar muscle
involvement induces nasal speech, choking on foods, dysphagia.
Abnormal fatigability of the limb muscles causes difficulty in combing hair,
lifting objects, climbing stairs, walking and running.

Diagnosis is based on the characteristic history of progressive weakness of the

voluntary muscles, on physical examination which shows no neurological
abnormality but impaired muscles strength and specific investigations.
Anticholinesterase tests with edrophoniu or neostigmine which shows
improvement of the muscle strength after injection.
Electromyography- supramaximal stimulation of a motor nerve results in a 10%
decrement of the amplitude of the evoked muscle action potential. In
mysthenics the decrement is more than 10%.
Assessment of the serum levels of autoantibodies to Acetyl choline receptors.
CT of the thorax may show enlarged thymic gland or a thymic tumour located
in anterior-superior mediastinum.

Thymectomy is an effective treatment for this disease in most patients.

Thymoma without myasthenia

The majority of such patients are asymptomatic.
When symptoms occur they are often non-specific: chest pain, cough and
occasionally breathlessness.
Chest X-rays, lateral and antero-posterior views may depict an opacity
retrosternally but CT scan represents the mainstay of diagnostic investigations.
Thymic scintigraphy with 99mTc-tetrophosmin can show increased uptake at
the site of thymoma.
Any suspicion of a thymoma should be surgically excised.
The contraindication of surgical treatment is clear-cut evidence of tumor
invasion into the great vessels.
Radiochemotherapy is useful in inoperable patients or in postoperative
recurrence of a thymoma.
 18

Study questions

1. A 35 years-old lady, underweight in spite of her good appetite went to her

G.P. being concerned of sleeplessness, anxious state and palpitation. On
physical examination her G.P. revealed a BP of 15/8 cm Hg, PR 90/min. and
palpated a slightly enlarged painless thyroid gland. He prescribed sleeping
tablets and tranquilizers (anti-anxiety agents). Did he manage well this patient?

2. What treatment should be done in the toxic solitary nodule ?

3. A 42 years-old lady complains of 2 weeks history of voice change and

dysphagia along with a rapid growing painless neck lump. She is from Ukraine
and it passed 10 years from Cernobil nuclear blast. How would you manage this
patient?
4. How could you know that a total thyroidectomy for papillary carcinoma
has been performed in the past by another surgeon if the patient cannot
remember or lost her medical discharge form and now she came with a lateral
neck lump?