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Gross anatomy is mandatory for the surgeon

who is to operate on the thyroid gland


THYROID GLAND
ANATOMY
Two lobes connected by a narrow isthmus
Very vascular organ- 5% of the CO
Surrounded by a sheath derived from the
pretracheal layer of deep fascia
The sheath attaches the gland to the larynx
and the trachea
Each lobe is pear-shaped, isthmus is across
the midline in front of the 2nd,3rd,4th tracheal
rings
THYROID GLAND-
ANATOMY
Antero-laterally: sterno-thyroid,omo-hyoid,
sterno-hyoid, SCM.

Postero-laterally: carotid sheath

Medially: larynx, trachea, pharynx, esophagus


THYROID GLAND
BLOOD SUPPLY
Arterial supply: - STA from ECA,
- ITA from thyrocervical
from subclavian art.
- thyroidea ima art. from
the aortic arch.

Venous drainage: STV, MTV, ITV into IJV


THYROID GLAND
NERVES
The right recurrent laryngeal nerve- recurs
around the SCA, crossing the ITA, before
entering the tracheoesophageal groove.

The left recurrent laryngeal nerve-recurs


around the aortic arch-tracheoesophageal
groove-penetrates the cricothyroid
membrane.

Superior laryngeal nerve-intertwined with the


branches of the STA.
Right recurrent laryngeal
nerve
Passing around the SCA

Oblique direction toward the tracheo-


esophageal groove

Non-recurrent sometimes
Left Recurrent Laryngeal
Nerve
Always recurrent
Close related to tracheo-esophageal groove
Vertical direction
Behind the post. aspect of the left lobe
NORMAL THYROID FUNCTION
The follicular cells- T3, T4

T3, T4 bind with thyroglobulin, stored on the


gland until released onto the bloodstream

Release is under the control of TSH and TRH

A feed-back mechanism regulating T3, T4


release is related to the level of circulating T3,
T4.
HORMONAL ACTION
The thyroid hormones:

- increase the metabolic rate,


- increase the oxygen consumption,
- increase glycogenolysis,
- enhance the actions of catecholamines
HORMONAL ACTION
The result is:
Increase in the PR, CO and blood flow
Nervousness, irritability, muscular tremor,
muscle wasting
These effects can be blocked by the use of
beta-blockers
HORMONAL ACTION
The parafollicular or C-cells- produce
thyrocalcitonin
Thyrocalcitonin action:
- to lower serum calcium and phosphate
concentration,
- reduces bone resorption and the release of
calcium and phosphate into the
extracellular fluid,
- in the kidney accelerates calcium and
phosphate excretion:
CONGENITAL ANOMALIES
Agenesis of the thyroid gland- commonest
cause of cretinism
Incomplete descent of the thyroid gland-
lingual thyroid is the commonest form of
incomplete descent
Thyroglossal duct- persistence of a segment
of the duct with cystic formation
THYROID GLAND DISORDERS
CLINICAL EXAMINATION

Hypothyroidism
Symptoms: dry skin, cold intolerance, obesity,
constipation, deafness

Signs: slow movements, cold and rough skin,


periorbital puffiness, slow PR
THYROID GLAND
CLINICAL EXAMINATION
Hyperthyroidism
Symptoms: dyspnea on effort, palpitation,
tiredness, preferance for cold, sweating,
nervousness, weight loss, good appetite

Signs: palpable thyroid, exophtalmos, lid lag,


hyperkinesis, finger tremor, hot and moist
hands, rapid PR
THYROID GLAND DISORDERS
INVESTIGATIONS
TSH- raised in primary hypothyroidism and
after treatment of thyrotoxicosis by surgery or
radioiodine,
- reduced in hyperthyroidism
Free T3, T4- radioimmunoassays,
Radioiodine uptake,
Thyroid isotope scanning
Ultrasonography, CT, MRI
Fine needle aspiration cytology
Thyroid autoantibodies (ab.to thyroglobulin)
Ultrasonography

It is the most common and most


useful way to image the thyroid gland
and its pathology. 

The high sensitivity for nodules

Poor specificity for cancer  


Thyroid imaging
 Scintiscanning remains of primary importance in patients who
are hyperthyroid or for detection of iodine-avid tissue after
thyroidectomy for thyroid cancer,

 Sonography – largely used for the majority of patients who


require a graphic representation of the regional anatomy,
smaller expense, greater simplicity, and lack of need for
radioisotope administration.

 Computer tomography (CT) and magnetic resonance imaging


(MRI) are more costly than sonography, are not as efficient in
detecting small lesions, and are best used selectively when
sonography is inadequate to elucidate a clinical problem
Sonogram of the neck in the transverse
plane showing a normal right thyroid
lobe and isthmus
 L=small thyroid lobe in a
patient who is taking
suppressive amounts of L-
thyroxine, I=isthmus,
 T=tracheal ring ( dense
white arc is calcification,
distal to it is artefact),
 C=carotid artery ( note the
enhanced echoes deep to
the fluid-filled blood
vessel), J=jugular vein,
S=Sternocleidomastoid
muscle, m=strap muscle
Sonogram of the left lobe of the thyroid
gland in the transverse plane showing a
rounded lobe of a goiter.
 L=enlarged lobe,
 I= widened isthmus,
 T=trachea,
 C=carotid artery ( note the
enhanced echoes deep to
the fluid-filled blood
vessel), J=jugular vein,
S=Sternocleidomastoid
muscle, m=strap muscles,
 E=esophagus.
Sonograms showing
left lobe containing
a degenerated
thyroid nodule.
Note the thick wall
and irregularity.
N=nodule,
H=hemorrhagic
degenerated region.
 The left panel shows an
anterior scintiscan of a
euthyroid patient who
had a tense nodule in
the left thyroid lobe.
 The nodule is
"cold”nodule. The right
panel shows a sonogram
of the neck revealing
that the nodule is a
smooth-walled cystic
structure.
 C=cyst,
 L=thyroid lobe.
Thyroid scintigram
Autonomous adenoma in the
right lobe of the struma.
The test substance
accumulates almost
exclusively in the range of the
autonomous adenoma. The
other areas of the struma
show a considerable reduced
accumulation of activity.

Thyroid scintigram of a patient with
Basedow hyperthyroidism
The struma weighs 62
g and shows a highly
increased uptake of
6.79% of the injected
activity of TC99m.
The distribution of the
activity within the
struma is regular.
Lumps are not
recognizable
Parathyroid adenoma
 99Tcm pertechnetate
scintigram shows uptake by
thyroid tissue only.
 99Tcm sestamibi with uptake
in both thyroid and
parathyroid tissue.
 The subtraction image
locates the parathyroid
adenoma behind the lower
pole of the right lobe of the
thyroid gland.
AM, 46-year-old woman, 2007 multinodular goitre
and myasthenia gravis
Thyroid profile (TSH-0.1 µUI/ml, fT4-1.2ng/dl),
Thyroid total volume of 65.9 ml. (Prof. dr. C. Vulpoi)

Compressive goiter Retrosternal goiter


Total thyroidectomy for MNG-2007,
Myasthenia gravis aggravated

Normal Chest Normal thymus


Thymic scintigraphy
Hypercaptation of 99mTc-tf. consistent with a
thymoma
Antero- inferior mediastinal mass
Thymectomy, 6 months following TT, june
2008

Paramedian low
Well-encapsulated mass
retrosternal mass
Discussions
In this case the thyroid lesion was more evident, and thus first
treated while MG was erroneously considered secondary to
hyperthyroidism and consequently likely to remit following total
thyroidectomy.

On thymic scintigraphy, the hyperfixation in lower anterior


mediastinum raised the suspicion of thymoma,

Pathology report of the surgical specimen (mixt thymoma -


Muller-Hermelink classification or AB type - WHO classification,
with capsular microscopic invasion, Masaoka II stage).
GOITER
ENLARGEMENT OF THE THYROID
GLAND
Simple goiter- diffuse hyperplastic goiter,
- nodular goiter
Toxic goiter- diffuse (Grave’s disease),
- toxic multinodular goiter, -
toxic solitary nodule
Neoplastic goiter- benign,
- malignant
Thyroiditis- subacute (de Quervain’s),
- autoimmune(Hashimoto’s), -
invasive fibrous thyroiditis (Riedel’s) - acute
suppurative
SIMPLE GOITER
Result of TSH stimulation, secondary, to
inadequate levels of T3, T4.
TSH stimulation causes diffuse hyperplasia of
the thyroid
Iodine deficiency is a key factor in simple
endemic goitre
All types of goitre occur more often in women
Simple goiter
Prevention- addition of iodine to table salt

Treatment- prenodular stage- thyroxine,


- nodular stage with pressure
effects- thyroidectomy
THYROID NODULES
CLINICAL ASSESSMENT
Most thyroid nodules are asymptomatic
Acute painful swelling in the thyroid suggests
hemorrhage into a nodule
Rapid growth of an existing nodule- malignancy
A solitary nodule in a male- risk of cancer
In the elderly, a rapid growing firm painful nodule-
anaplastic cancer
Neck irradiation increases the risk of cancer
THYROID NODULES
CLINICAL ASSESSMENT
Most patients with a solitary thyroid nodule are
euthyroid
A nodule in a hyperthyroid patient is unlikely to be
malignant
A hard fixed nodule is likely to be malignant but not
uncommon for papillary cancer to be cystic and
follicular cancer to be soft as result of hemorrhage
A very hard nodule- calcified colloid nodule
Lymphadenopathy- common finding in papillary and
medullar carcinoma
Reccurent laryngeal nerve palsy on the side of a
palpable nodule- malignant infiltration
THYROID NODULES
INVESTIGATIONS

Measurement of T3, T4, TSH


CXR- tracheal deviation or retrosternal
extension
Isotope scanning- cold or hot nodule
Ultrasonography- the structure
Fine needle aspiration cytology
SOLITARY THYROID NODULE
MANAGEMENT
 Hyperthyroid- FNAC & isotope scan
 Greater than 3 cm.- surgery
 Less than 3 cm.- iodine therapy

 Euthyroid- FNAC
 Benign-no pressure sy.-observe, repeat FNAC in 6 months
 Benign- with pressure sy.- surgery
 Thyoiditis- T4 treatment
 Suspicious- surgery
 Malinant- surgery
 Inadequate FNAC- repeat
 Cystic benign- observe,review in 6 weeks
 Cystic malignant- surgery
MULTINODULAR GOITRE
MANAGEMENT
Hyperthyroid- iodine scan
Large- ATD & surgery
Small- iodine therapy
Euthyroid
No dominant nodule-observe
Dominant nodule-FNAC
 Benign, no sy-observe
 Malignant- surgery
 Suspicious- surgery
 Inadequate- repeat FNAC
 Retrosternal- surgery
 Cosmetic- surgery