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THYROID AND PARATHYROIDS Not Lectured
REFERENCES
1. PPT (2015 Lecture)
2. 2016A Trans
3. 2015B Trans
4. Schwartz/Sabiston
CONGENITAL LESIONS
Unlike the abdomen and thoracic cavity, the neck is a relatively
superficial so its easier to diagnose thyroid disease, usually presenting
with an ANTERIOR NECK MASS Figure 2. Pyramidal Lobe
Normally, the thyroid gland should not be palpated
Embryologic life of the thyroid gland: it starts at the base of the tongue ECTOPIC THYROID
and goes down the neck where it lies during the adult life Failure of the thyroid to descend completely into the neck
Any problem with the descent of the thyroid gland to the neck will Results to thyroid tissue anywhere along the tract
cause congenital abnormalities
LINGUAL / SUBLINGUAL THYROID
THYROGLOSSAL DUCT ANOMALIES (Cyst, Sinus, Fistula) Mass or thyroid found at the base of the tongue
Thyroglossal duct (lifted from 2015B Trans) If you excise it, the patient will no longer have a thyroid
o The tract from the base of the tongue all the way to the neck Represents a failure of the median thyroid anlage to descend normally
o Supposed to disappear after the thyroid goes down and may be the only thyroid tissue present
Thyroglossal duct cysts are the most commonly encountered S/Sx:
CONGENITAL CERVICAL anomalies o Hypothyroid symptoms
Typically midline masses in childhood o Obstructive symptoms
80% below hyoid bone o Choking, dysphagia, airway obstruction
ELEVATES with tongue protrusion Treatment:
o Upon protrusion, the thyroid gland goes up through the patent If small in size, Exogenous thyroid hormone to suppress TSH
thyroglossal duct Radioactive iodine (RAI) ablation followed by hormone
During the embryologic life, the thyroid gland originates from the replacement
foramen cecum at the base of the tongue. From there, it will Surgical excision is rarely needed, but if required, should be
descend and will split into two forming the 2 lobes of the thyroid preceded by an evaluation of normal thyroid tissue in the neck to
gland. The thyroglossal duct is supposed to degenerate upon birth. avoid inadvertently rendering the patient hypothyroid (If big)
If it persists thyroglossal duct problems
Clinical Importance: distinguish thyroglossal duct from simple cyst
because they have different treatment
Cyst excise
Thyroglossal duct cyst Sistrunk Procedure
If the thyroglossal duct cyst is simply excised, it will recur
No external sinuses but may infect
Treatment: SISTRUNK Procedure removal of the mass and the entire
tract all the way to the base of the tongue, until the hyoid bone Figure 3. Lingual or Sublingual Thyroid
This procedure consists of en bloc cystectomy and excision of the
central hyoid bone to minimize recurrence
INITIAL WORK-UP
Initial diagnostic modality is thyroid function test
o TSH, FT4, FT3
If euthyroid
Figure 4. Hypothalamus Pituitary Thyroid Axis. The hypothalamus
o Ultrasound
releases TRH, stimulating the anterior pituitary gland to secrete TSH, which
o FNABC
stimulates the thyroid to produce thyroid hormones with iodine. Excess in
If hyperthyroid
thyroid hormones will produce a negative feedback mechanism which
o Thyroid scan
suppresses the production of TSH. Also, If TSH is increased, there is a
Hot / warm nodule: treat as toxic nodule
negative feedback to the hypothalamus which will decrease TRH secretion.
Cold nodule: FNABC
THYROID FUNCTION TESTS
ULTRASOUND
MOST ACCURATE TESTS of thyroid function
Main advantage: determine consistency of mass
o SERUM TSH (Thyroid Stimulating Hormone)
o Simple cyst = thyroid cyst (purely fluid)
The most sensitive and specific test for determining thyroid
o Complex cyst = goiter (has both cystic and solid components)
function
o Solid nodule = tumor
Reflect the ability of the anterior pituitary to detect free T4
Noninvasive, no radiation exposure
levels
Monitoring nodule size (for non-operative tx)
There is an inverse relationship between free T4 levels and
the logarithm of TSH concentration small changes in in free Size & multicentricity: can detect masses even 1mm
T4 lead to a large shift in TSH levels Detects non-palpable masses
o FREE T4 & FREE T3 ASSAY (FT4 & FT3) Cervical lymphadenopathy
Measure the biologically active thyroid hormones which Guide fine-needle aspiration (FNA) biopsy
cause the clinical manifestations Evaluating substernal goiters (extent, tracheal compression)
FT4 is not performed as a routine screening tool in thyroid Characteristics associated w/ CA
disease. Use of this test is confined to cases of early o Hypoechogenicity
hyperthyroidism o Irregular margins
FT3 is most useful in confirming the diagnosis of early o Increased nodular flow (Doppler)
hyperthyroidism Hypervascular increased blood flow
o Invasion / regional lymphadenopathy
Table 1. Interpreting Thyroid Function Tests (Memorize)
SERUM TSH FT4 AND FT3 ASSAY DIAGNOSIS
High Low Hypothyroid
High Normal Subclinical Hypothyroid SOLID COMPLEX
Low High Hyperthyroid
Low Normal Subclinical Hyperthyroid
*If the patient can only avail one test, request for TSH
CYST
Others:
o Total T4 & T3
Both are measured by radioimmunoassay
Measure both the free and bound components of the
hormones
Figure 5. Ultrasound Results
T4 levels reflect the output from the thyroid gland
T3 levels in the non-stimulated thyroid gland are more
indicative of peripheral thyroid hormone metabolism; not
generally suitable for as a general screening test
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Surgery II 6.8
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Surgery II 6.8
THYROIDITIS
Inflammatory disorder of the thyroid gland
May cause initial hyperthyroidism, then progress over time to
hypothyroidism
Figure 11. Toxic Multi-Nodular Goiter
Thyroiditis usually is classified into acute, subacute, and chronic forms,
each associated with a distinct clinical presentation and histology
NON-TOXIC GOITER
Result from iodine deficiency and/or TSH stimulation, or idiopathic ACUTE (SUPPURATIVE) THYROIDITIS
Nowadays, its very hard to have iodine deficiency since a lot of food
Infectious cause
are fortified
The thyroid gland is inherently resistant to infection due to its extensive
Most of the time idiopathic
blood and lymphatic supply, high iodide content, and fibrous capsule.
May be diffuse, uninodular, multinodular Infectious agents can seed it via:
Familial goiters result from enzyme deficiencies necessary for thyroid o Hematogenous or lymphatic route
hormone synthesis o Direct spread from persistent pyriform sinus fistulae or
Endemic goiter refers to occurrence of a goiter in a significant thyroglossal duct cysts
proportion on individuals in a particular geographic region (*you should o Result of penetrating trauma to the thyroid gland
know - mountain area where no seafood) o Immunosuppression.
Diagnosis: Streptococcus and anaerobes account for about 70% of cases
o TSH, FT4, FT3 More common in children often preceded by an upper respiratory tract
o Ultrasound infection or otitis media
o FNAB Characterized by
If multinodular do FNAB on dominant nodule and/or any o Severe neck pain radiating to the jaws or ear, fever,
suspicious nodule on ultrasound o Chills
Treatment (Suppression vs. Surgery): o Odynophagia
o TSH suppression (conservative treatment) o Dysphonia
Give high dose exogenous thyroid hormone at levels that will Diagnosis
suppress TSH o Established by leukocytosis on blood tests and FNAB for Grams
o Thyroidectomy stain, culture, and cytology
o CT scans may help to delineate the extent of infection
Table 6. Indications for TSH suppression vs. Thyroidectomy o A persistent pyriform sinus fistula should always be suspected in
TSH SUPPRESSION THYROIDECTOMY children with recurrent acute thyroiditis
Patients from geographic areas o Barium swallow demonstrates the anomalous tract with 80%
Large goiters
with iodine deficiency sensitivity
Young patient with small nodule Compressive symptoms Treatment
Nodular goiter with no evidence o Parenteral antibiotics and drainage of abscesses
Suspicious nodules
of functional anatomy o Patients with pyriform sinus fistulae require complete resection of
Contraindication of TSH suppression the sinus tract, including the area of the thyroid where the tract
Post-menopausal terminates, to prevent recurrence.
Older than 60 y/o
Osteoporosis SUBACUTE THYROIDITIS
Cardiovascular disease Self-limiting
Failure of medical treatment o Remission in 2-4 months
Subtypes
o Granulomatous (De Quervains)
o Lymphocytic
o Postpartum
Can be painless or painful
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Surgery II 6.8
Table 7. Painful and Painless Subacute Thyroiditis Physical exam reveals a hard, woody thyroid gland with fixation to
PAINFUL PAINLESS surrounding tissues.
ONSET Gradual Diagnosis is confirmed by open thyroid biopsy, because the firm and
AGE 30-40 years old women 30-60 years old women fibrous nature of the gland renders FNAB inadequate.
Autoimmune; occurs in Surgery is the mainstay of the treatment
Upper respiratory tract
HISTORY postpartum period (<6
infection TREATMENT OF THYROIDITIS
weeks)
Gland is enlarged, Normal sized or minimally Medical Treatment
PE exquisitely tender, enlarged, slightly firm, non- Indications for surgery
and firm tender gland o Malignancy cannot be ruled out
Early stages: TSH o Significant signs of compression
decreased; Tg, T4, and T3 o Failure of medical treatment
levels are elevated due to Serial monitoring of thyroid function as indicated
DIAGNOSIS
the release of preformed
thyroid hormone from THYROID CYST
destroyed follicles Exact cause is unknown
Aspirin and steroids; Theories:
B-blockers and thyroid o Lack of iodine in the diet
Thyroidectomy if non
TREATMENT hormone replacement for o Autoimmune disorder that causes inflammation of the thyroid
responsive to medical
symptomatic (Hashimotos disease)
treatment
o Genetic defect
CHRONIC THYROIDITIS o Exposure to radiation in childhood
LYMPHOCYTIC (HASHIMOTOS) THYROIDITIS Treatment: needle aspiration +/- TSH suppression
Autoimmune
MOST COMMON INFLAMMATORY DISORDER OF THE THYROID and BENIGN TUMORS
the leading cause of hypothyroidism FOLLICULAR ADENOMA
Antibodies develop against thyroid antigens Hard to differentiate from follicular carcinoma
o Anti-thyroid peroxidase (anti-TPO) antibodies o Only histologic difference from follicular carcinoma is absence of
o Anti-thyroglobulin (anti-Tg) antibodies capsular & blood vessel invasion
o Must check for serum assays of anti-TPO and anti-TG antibodies o Do a preoperative biopsy
Others
o TSH receptor-blocking antibodies, Thyroid stimulating Ab, PLUMMER DISEASE (TOXIC ADENOMA)
Cytotoxic Ab Hyperthyroidism from a single hyperfunctioning nodule
Clinical Presentation Typically occurs in younger patients
o More common in women between ages of 30 and 50 Diagnostics: RAI scan; hot nodule
o Most common presentation is that of a minimally or moderately Treatment: Thyroidectomy after control of hyperthyroidism
enlarged firm granular gland discovered on routine physical
examination or the awareness of a painless anterior neck mass MALIGNANT TUMORS
o 20% of patients present with hypothyroidism Well-differentiated
o 5% presents with hyperthyroidism o Papillary
o Classically, presents with diffusely enlarged, firm gland, which also o Follicular
is lobulated. Medullary
Diagnostic Studies Anaplastic
o When suspected clinically, an elevated TSH and the presence of Others
thyroid autoantibodies usually confirm the diagnosis.
o FNAB is indicated in patients who present with a solitary nodule or Table 8. Frequency of Thyroid Carcinomas.
a rapidly enlarging goiter 90-95% of thyroid carcinomas are well differentiated cancers
Treatment PATHOLOGY FREQUENCY (%)
o Thyroid hormone replacement *Papillary 80
Follicular 10
RIEDELS THYROIDITIS Hurthle cell 3
Chronic inflammatory disease causing dense fibrosis of the gland Medullary 5
Fibrosis may extend beyond thyroid capsule to the neck
Anaplastic 1
May be mistaken for CA
Others 1
Causes intense fibrosis and presents as a hard mass on the neck, so this
is the one most operated on
The Etiology of this disorder is controversial, and it has been reported CLINICAL MANIFESTATIONS
to occur in patients with other autoimmune diseases. Initially asymptomatic
This association, coupled with the presence of lymphoid infiltration and Usually euthyroid
response to steroid therapy, suggests a primary autoimmune etiology. Progressive growth
Typically presents as a painless, hard anterior neck mass, which Invasion of structures
progresses over weeks to years to produce symptoms of compression, o Recurrent laryngeal nerve, esophagus, trachea,
including dysphagia, dyspnea, choking and hoarseness. Neck node enlargement
o Invasion of strap muscles, IJV, carotid
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Surgery II 6.8
Regional lymph nodes (N)include central, lateral cervical, and upper COMPLICATION OF THYROIDECTOMY
mediastinal nodes Bleeding - because it is a vascular area
Nx Regional lymph nodes cannot be assessed Recurrent Laryngeal nerve injury causes hoarseness. If both
N0 No regional lymph node metastasis recurrent laryngeal nerve injury the vocal cords will both close
N1 Regional lymph node metastasis necessitating tracheostomy
Metastases to level VI (pretracheal, paratracheal, and Superior Laryngeal nerve injury decrease volume of voice
N1a
prelaryngeal/Delphian lymph nodes) Hypocalcaemia inadvertent involvement of the parathyroids
Metastases to unilateral, bilateral, or contralateral cervical or Thyroid storm occurs if the patient was not euthyroid to begin with
N1b
superior mediastinal lymph nodes
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Surgery II 6.8
If serum Tg is still present after 6 months, we assume recurrence FNA can be diagnostic
If it is still positive, we work up the patient with a whole body can. The use of flow cytometry for monoclonality can confirm diagnosis
Areas with iodine will light up Neck, chest, abdominal CT or MRI to assess extrathyroidal spread.
Most thyroid lymphomas are B cell in origin
WHOLE BODY IODINE-131 SCAN Use of the CHOP regimen (cyclophosphamide,
In cases where there is still positive serum thyroglobulin (Tg) 6-12 hydroxydaunomycin [doxorubicin], vincristine, and prednisolone)
months after total thyroidectomy for a high risk well-differentiated has been associated with excellent survival.
carcinoma, one must suspect recurrence since Tg is produced only by Metastatic cancer
the thyroid o Kidney, breast, lung, and melanoma
When this happens, work up the patient and what is usually done is FNAB usually provides definitive diagnosis.
Whole Body Iodine-131 Scan. It works in a similar principle to RAI scan, Resection of the thyroid, usually lobectomy, may be helpful in
but it is applied for the whole body. The distant metastatic lesions will many patients, depending on the status of their primary tumor
imbibe iodine and will light up
Treatment for metastatic sites: Radioactive Iodine Tablets PARATHYROID GLANDS
CALCIUM HOMEOSTASIS
HURTHLE CELL CARCINOMA Parathyroid hormone (PTH): increases serum calcium
Subtype of follicular CA Vitamin D: increases serum calcium by stimulating the absorption of
More often multifocal and bilateral (30 %), usually do not take up RAI calcium and phosphate from the gut.
(5 %), more likely to metastasize, associated with higher mortality rate o The first hydroxylation at carbon 25 occurs in the liver
(20% at 10 years). o The second hydroxylation at carbon 1 occurs in the kidney in
It DOES NOT respond to RAI. response to increased PTH levels.
Treatment: lobectomy and isthmusectomy o 1,25(OH)2D3 increases calcium and phosphate resorption from the
gastrointestinal tract and stimulates bone resorption, which raises
MEDULLARY CARCINOMA calcium levels
More aggressive than papillary/follicular carcinoma Calcitonin: decreases serum calcium
Arise from parafollicular or C cells of the thyroid
o C cells secrete calcitonin Table 10. Actions of Major Calcium-Regulating Hormones
o 25% occur within the spectrum of several inherited syndromes BONE KIDNEY INTESTINE
(germline mutations in the RET ) proto-oncogene Stimulates resorption of
Stimulates
Familial medullary thyroid cancer, MEN2A & B PARA- calcium and conversion of
resorption of No direct
Diagnosis THYROID 25(OH)D3; inhibits
calcium and effects
o Raised serum calcitonin levels this finding clinches the diagnosis HORMONE resorption of phosphate
phosphate
o FNA cytology confirms the diagnosis and bicarbonate
o Once diagnosed, all new patients with MTC should be screened for Stimulates
Stimulates
RET point mutations, pheochromocytoma, & hyperparathyroidism Inhibits resorption of calcium and
VITAMIN D transport of
Treatment calcium phosphate
calcium
o Minimum is total thyroidectomy + central neck dissection absorption
Inhibits
ANAPLASTIC CARCINOMA resorption of Inhibits resorption of No direct
CALCITONIN
Most aggressive of all calcium and calcium and phosphate effects
Rapidly enlarging phosphate
o Doctors experience: A patient with anaplastic carcinoma was
admitted once, but whose surgery was delayed for 1 month
because of financial constraints. The tumor was observed to be
growing bigger and bigger every day before their very eyes
Treatment:
o Tracheostomy + Radiotherapy (RT provides only 30% success rate)
Most of the time, because of the immense size of the mass,
thyroidectomy/resection may not be possible. Thus,
tracheostomy is done to address the obstruction of airways.
o Total thyroidectomy / Chemotherapy / Radiotherapy
Done if the tumor is still resectable
o Palliative treatment Figure 16. Calcium homeostasis and parathyroid hormone (PTH).
1,25(OH)2D3, 1,25-dihydroxycholecalciferol.
J. OTHER RARE CANCERS
Sarcoma HYPERPARATHYROIDISM
Lymphoma There is excess PTH, thus there is hypercalcemia
The diagnosis is considered in patients with a goiter, especially one Primary (PHPT)
that has apparently grown significantly in a short period. o From abnormal parathyroid glands, usually due to a tumor
Other initial symptoms include hoarseness, dysphagia, and fever. Secondary
There is also an increased association between lymphoma and o A compensatory response to hypocalcemic states
Hashimoto's thyroiditis. Chronic renal failure
Ultrasound may demonstrate a classic pseudocystic pattern. Gastrointestinal malabsorption of calcium
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Surgery II 6.8
Tertiary HYPOPARATHYROIDISM
o Chronically stimulated glands become autonomous, resulting in Causes
persistence or recurrence of hypercalcemia after successful renal o Di Georges syndrome - congenitally absent parathyroid
transplantation o Neonatal hypoparathyroidism - from hyperparathyroid mother
o Even though serum calcium is elevated, PTH is still being o THYROID SURGERY: leading to injury to the parathyroid, most
continuously secreted. common cause, 95% of cases (total thyroidectomy)
Temporary hypoparathyroidism occurs in 90% of all
PRIMARY HYPERTHYROIDISM (PHPT) thyroidectomy cases. In the course of thyroid gland
Arises from increased PTH production from abnormal parathyroid dissection, edema of the parathyroids is unavoidable thus it
glands and results from a disturbance of normal feedback control temporarily becomes dysfunctional and cannot produce PTH.
exerted by serum calcium. Permanent hypoparathyroidism remaining 5-10%. Means
PHPT is characterized by increased parathyroid cell proliferation and the surgeon has inadvertently removed the parathyroids.
PTH secretion that is independent of calcium levels Signs and Symptoms
Causes o Hypocalcemia causing increased neuromuscular excitability
o Parathyroid hyperplasia (20%) o Circumoral and fingertip numbness and tingling
o Adenoma (80% single if single adenoma) o Mental symptoms: anxiety, confusion, and depression
o Carcinoma (1%) o (+) CHVOSTEK SIGN: Contraction of facial muscles elicited by
o Low dose ionizing radiation tapping on the facial nerve anterior to the ear
Latency: 30 to 40 years o (+) TROUSSEAU SIGN: Carpopedal spasm, which is elicited by
Higher PTH levels and a higher incidence of concomitant occluding blood flow to the forearm with a blood pressure cuff for
thyroid neoplasms than those who did not have exposure 23 min
o Family history o Tetany
MEN1, MEN2A, isolated familial HPT, and familial HPT with o These signs and symptoms must be monitored in a patient who
jaw-tumor syndrome has undergone thyroidectomy.
PHPT is the most common primary presentation of MEN1 Diagnosis
(80%) o Decreased serum ionized calcium levels
Signs and Symptoms Treatment
o Due to increased serum calcium o Calcium tablets or IV infusion
o Classic pentad of symptoms o Vitamin D supplements
Kidney stones (80%), painful bones(15 to 20%), abdominal
groans, psychic moans & fatigue
o Minimally symptomatic
Weakness, fatigue, polydipsia, polyuria, nocturia, bone & I can't think of a single reason why I should be a surgeon, but I can think of a
joint pain, constipation, decreased appetite, nausea, thousand reasons why I should quit. They make it hard on purpose. There
heartburn, pruritus, depression, & memory loss are lives in our hands. There comes a moment when it's more than just a
o Asymptomatic game, and you either take that step forward or turn around and walk away. I
Diagnosis could quit but here's the thing, I love the playing field. Dr. Meredith Grey
o High serum calcium (Greys Anatomy)
First done if suspicion of PHPT is raised because of signs and
symptoms. If serum calcium is high, do serum PTH.
o High serum PTH assay
A high serum PTH suggests the pathology is indeed primarily
located in the parathyroids. Thus perform a parathyroid scan.
o Parathyroid scan
Presence of abnormal growth confirms the diagnosis, thus, do
parathyroidectomy.
o Radiology
Bone involvement
Pathognomonic signs seen best on hand X-ray: Subperiosteal
resorption (most apparent on the radial aspect of the middle
phalanx of the second and third fingers), bone cysts, and
tufting of the distal phalanges LAST TRANS FOR SURGERY!!! The L-team now signing off :)) See you clerkship!
Treatment: Parathyroidectomy God bless for the upcoming exams!! :D
o Subtotal
If dealing with an adenoma, usually, just one needs to be
removed, since not all parathyroids will be enlarged. Editors note: Good luck to everyone!! Last push for third year!!
If dealing with hyperplasia, the problem is that all 4 glands DOnt quIT!!
will be enlarged. You cant remove all four. Thus, do a three-
and-one-half parathyroidectomy, leaving of one
parathyroid in place.
o Total parathyroidectomy with autotransplantation or transfer of
a gland to a neck or forearm muscle Edited by: Kyle Ompoc
Alternative to 3 parathyroidectomy.
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