Ms.

Amira Zino

Embryology
The thyroid gland arise from the foramen

caecum(floor of the pharynx ) at the base of the tongue & migrate in front of the foregut to lie anterior to trachea but remain attached to floor of mouth by thyroglossal duct which ultimately disappears , however its persistence result in : Thyroglossal sinus Thyroglossal cyst

Anatomical considerations:
The thyroid is the largest single endocrine

gland. It weighs 20-25 g but it varies with age, sex, & physiological condition. It is an only endocrine gland that does not store its hormone within the cell but in follicular cavities surrounded by the cells.

Anatomical considerations:
The thyroid gland is one of the necks viscera. Consists of right and left lobes connected by a

narrow isthmus. A very vascular organ,surrounded by a sheath derived from the pretracheal layer of deep fascia wich attaches the gland to the larynx and the trachea.

Anatomical considerations:
Each of the lobes is peared shape with an

apex being directed upward. Its base lies below at the level of the 4th or 5th tracheal ring. The isthmus extends across the midline in front of the 2nd, 3rd, &4th tracheal rings. Pyramidal lobe is often present & it projects upward from the isthmus & to the left.

Anatomical relathions:
Anterolaterally:
Sternothyroid, superior belly of the

omohyoid, ant. border of the sternocleidomastoid.

Posterolaterally:
Carotid sheath with the common carotid

artery, inetrnal jugular vein & vegus n..

Medially:
Larynx, trachea, pharynx & esophagus,,

also, cricothyroid muscle & its nerve supply, the ext. laryngial n. & recurrent

Topographic

Anatomy of Larynx and Trachea

Anatomical relathions:
Ant. To the isthmus: Sternothyroids m., sternohyoids m., ant. Jugular viens, facia & skin. Posr. To the isthmus:
The 2nd, 3rd, and 4th tracheal rings.

Blood supply:
The arteries to the thyroid gland

are:
Sup. Thyroid a. from the external

carotid a. Inf. Thyroid a. from thyrocervical trunk. Thyroidea ima. From the brachiocephalic a. or the arch of the aorta.

Blood supply:
The veins from the thyroid gland

are:
Sup. Thyroid vein, drains into internal

jugular v. Middle thyroid vein, drains into internal jugular vein. Inf. Thyroid vein, drains into left brachiocephalic vein.

Thyroid lymphatics drain into four groups of

nodes:
- Prelaryngeal lymph nodes. - Pretracheal lymph nodes. - Paratracheal lymph nodes. - Deep cervical lymph nodes.

Histological features
Thyroid is composed of follicles ( acini ) which

are spherical , lined by epithelium which secrete thyroid hormones which are stored in the colloid of the follicle. The cells are usually cuboidal but become columnar in response to pituitary (TSH) C-cells secreting calcitonin (of neural crest origin ) a Calcium lowering hormone.

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Physiology
T3 and T4 from thyroid

follicles. Tyrosine and iodine T3 is the active form. T4 is converted to T3 peripherally. Controlanterior pituitary T3 and T4 feedback mechanism and by TRH from the hypothalamus.

Hormones of the thyroid:

Thyroixine (levothyroxine) T4. Tryiodothyrodine T3. Calcitonin.

Regulation
Hypothalamic thyrotropin-releasing hormone

(TRH) stimulates the release of thyroidstimulating hormone (TSH or thyrotropin) from the anterior pituitary gland. TSH acts on extracellular receptors on the surface of thyroid follicle cells.

Factors affect on the hormones affect thyroid hormone A number of factors

release.
Three main factors stimulate secretion: 1.Long-term exposure to cold temperatures

acting on the anterior pituitary. 2.Estrogens acting on the anterior pituitary. 3.Epinephrine acting directly on the thyroid gland.

Transport of thyroid hormones

The thyroid hormones circulate bound to

plasma proteins produced in the liver, which protect the hormones from enzymic attack: - 70% are bound to thyroid-binding globulin (TBG). - 30% are bound to albumin. - Only 0.1% of T4 and 1% of T3 are carried unbound-this free (unbound) fraction is responsible for their hormonal activities.

The concentration of circulating T4 is much

higher than that of T3 (50: 1).

There are two reasons: 1. The thyroid secretes more T4 than T3. 2.T4 has a longer half-life (7 days vs. 1 day).

The major manifestations of

thyroid disease are :

Hyperthyroidism. Hypothyroidism. Goitre.

Hyperthyroidism
Hyperthyroidism is a condition characterized

by increased levels of thyroid hormones in the blood. The term thyrotoxicoisis is retained because hyperthyroidism i.e. symptoms due to a raised level of circulating thyroid hormones, is not responsible for all manifestations of the disease.

Thyrotoxicosis:
Clinical types are: Diffuse toxic goitre (Graves disease). 1ry

thyrotoxicosis. Toxic nodular goitre. 2ry thyrotoxicosis. Toxic nodule. Hyperthyroidism due to rare causes: exogenous thyroid hormone excessive, thyroiditis, metastatic thyroid ca., pituitary tumor secreting TSH, etc.

Diffuse toxic goitre (Graves disease):

Affect young females. Associated with eye signs. The whole of the functioning thyroid tissue

is involved. The hypertrophy &hyperplasia are due abnormal thyroid-stimulating antibodies (TsAb) of IgG immunoglobulins.

Toxic nodular goitre (2ry thyrotoxicosis):

A simple nodular goitre is present for a

long time before hyperthyroidism. Affects middle-age or elderly. Very infrequently associated with eye signs. In many cases the nodules are inactive, and it is the internodular thyroid tissue that is overactive.

Toxic nodule:
This is a solitary overactive nodule, which

may be part of a generalized nodularity or a true toxic adenoma. It is autonomous & its hypertrophy & hyperplasia are not due to thyroidstimulating antibodies (TsAb). Because of TSH is suppressed by high levels of circulating thyroid hormones, the normal thyroid tissue surrounding the nodule is suppressed & inactive.

Thyrotoxicosis

Clinical features of thyrotoxicosis: Metabolic effects:

Hotness and intolerant to heat. Skin, especially of the palms, is sweaty and warm. Loss of weight despite the good appetite.

Sympathetic effects:
Palpitation and tachycardia (even during sleep) Fine finger tremors. Lid retraction, lid lag and exophthalmos ( more in

primary) Anxiety and nervousness

Other features:
Finger clubbing, proximal myopathy and menstrual

disturbances

Thyrotoxicosis
Diagnosis: Clinical features and raised serumT3 and/or T4 levels (low TSH). Treatment: Antithyroid drugs (Carbimazole). - blockers (Propranolol) Radioactive iodine is an alternative and Subtotal thyroidectomy is indicated in certain, specially young, patients.

Hypothyroidism
Condition characterized by complete or partial

thyroid failure & hence absent or low thyroid hormone production. Cretinism (fetal or infantile hypothyroidism): Can be sporadic or endemic which is due to maternal & fetal iodine deficiency. Immediate diagnosis & treatment with thyroxine within a few days of birth are essential if physical & mental development are to be normal. Female under treatment with antithyroid drugs may give birth to a hypothyroid infant.

Adult hypothyroidism:
The term myxoedema is applied for severe thyroid

failure .Common causes of hypothyroidism: Autoimmune thyroiditis, iatrogenic (after thyroidectomy , after radioiodine treatment or drug induced i.e. antithyroid drugs), 2ry to pituitary or hypothalamic diseases. Clinical features of hypothyroidism include: Bradycardia, cold extremities dry skin &hair, hoarse voice, tiredness, cold intolerance wt. gain, constipation & menstrual disturbance.

In hypothyroidism the thyroid function test

show low T4& T3 levels with high TSH. Treatment: oral thyroxine 0.1- 0.2 mg as single daily dose.

Goitre:
Diffenition:
Enlargement of the thyroid gland.

classifications of goitre:
Simple goitre: Toxic goitre: Neoplastic goitre: Inflammotory: others

Classification
1. Simple goiter (euthyroid):

Diffuse hyperblastic : physiological, puberty, pregnancy. Multinodular. Solitarynodular. Diffuse toxic (graves disease). Multinodular toxic. Solitarynodular toxic .

1. Toxic goiter (hyperthyroidism):

Classification
3. Neoplastic goiter:

Benign ( adenomas ). Malignant ( primary or secondary ). Autoimmune chronic lymphocitic thyroiditis, Hashimotos diseases. Grandulomatous. Fibrosing.

4. Inflammatory goiter.

Classification
5. Infective : Acute ; bacteria thyroiditis.
Chronic ; TB.

6. Other : amyloid.

?Questions to be asked in pt with goitre

Is the goitre diffuse or nodular? If nodular, is the gland multinodular? If multinodular is there a dominant nodule

suggesting malignancy? Is there retrosternal extension of the goitre? Is there enlargement of regional lymph node? Are there any other features suggestive of malignancy?

Is the pt. euthyroid, thyrotoxic or

myxoedematous? Is there evidence of thyroiditis?

Simple Goiter:
Simple diffuse;

develop due to stimulation of thyroid gland by TSH, the most important factor is iodine deficiency. The goiter is soft and symmetrical. Simple multinodular; usually multiple, forming a multinodular goiter. Most occur in females due to present of estrogen receptors in normal thyroid tissue and in nodular goiter. Very large goiter may cause mediastinal compression with stridor, dysphagia &obstruction of the sup. vena cava.

Clinical features of simple goiter

Discomfort Dysphagia Engorgement of neck viens Horse voice

Toxic Goiter;
Diffuse;
Graves disease. Diffuse vascular goiter appears in younger women associated with eye signs. Nodular; Goiter present for long time before hyperthyroidism.

Clinical features of toxic goiter;

Wt loss despite normal or increased

appetite. Diarrhea and steatorrhea. Vomiting. Palpitation. Heat intolerance. Nervousness,irritability,emotional lability. Tremor. Muscle weakness, proximal myopathy,

Solitary nodule:
Truly solitary nodules may be caused by,

adenoma, carcinoma, or occasionally thyroiditis. Female : male ratio is 4:1. Commonly in 30-40ys old pt. About 10% of solitary n. in middle-age are malignant, this figure exceeds 50% in old age group pt. Enquiries should be made into the rate of enlargement of the swelling & about

Swallowing, pain & symptoms of

thyrotoxicosis or myxoedema.

Neoplasmic Goiter;
Benign;
Follicular adenoma. Malignant;
Primary :

Follicular epithelium. Papillary Anaplastic Parafolicular: medullary. Lymphoid: lymphoma.

Neoplasmic Goiter;
Secondary;

Metastatic. Local lesion.

Clinical Features;
Lymph nodes enlargement. Paralysis of the recurrent laryngeal nerve.

Thyroid tumor
1\ Benign tumors:

Follicular adenomas are benign tumor commonly occur in young adult . but may affect any age group , clinically appear as solitary discrete mass usually up to 4 cm in diameter .

2\ malignant tumors: Women are affected more than men in a ratio

of 2: 1 . Peak incidence between the age of 40 _ 60 y. Thyroid cancer had tow important clinical associations : 1st large amount of radiation particularly to the head and neck that lead to thyroid cancer . 2nd prolonged TSH stimulation of the thyroid may eventually lead to a malignant

Classification of thyroid neoplasm & their relative incidence :

Type

Incidence % Papillary carcinoma 61 Follicular carcinoma 18 Anaplastic carcinoma 15 Medullary carcinoma 6 Malignant lymphoma

:Histological classification
1\ Differentiated: Follicular Papillary medulary 2\Undifferentiated: Anaplastic

Clinical feature of the thyroid neoplasm:

1. Neck swelling. 2. Hoarsens of voice due to laryngeal nerve 3. 4. 5. 6. 7.

paralysis. Enlarged cervical lymph nodes in papillary carcinoma. Swallowing difficulties. Occult carcinoma ( small papillary tumors may be impalpable ) Pain referred to ear in infiltrating growth. Malignant lesions are often firm, irregular or fixed, but some papillary lesions are cystic. Follicular lesions may be soft as a result of haemorrhage.

Papillary carcinoma:
Commonest type 60%. Lymphatic spread. A disease of young adult & children. Increase incidence in iodine rich

areas. Previous neck irradiation is a risk factor. Seldom encapsulated, & may have fibrous & calcified areas (psammomas bodies).

May present as (occult ca.) with no palpable

abnormality of thyroid gland but with LN. met. Have excellent prognosis. Treatment is total thyroidectomy with clearance of the involved nodes & with thyroxine replacement to suppress TSH.

Follicular carcinoma:
Incidence is about 20%. Spread is mainly by blood. Affect older age group (mean age

50). Increase incidence in iodine deficient areas. May be caused by previous irradiation. Is usually solitary encapsulatd lesion. Diagnosis of malignancy is based on capsular penetration by tumor &

FNAC has no place in diagnosis of the tumor. Multifocality is rarely seen. Prognosis is mainly dependent on the

presence of extrathyroidal spread. Treatment for tumor confined to one lobe is total lobectomy. A frankly invasive lesion requires total thyroidectomy, radioactive iodine for met. & thyroxine to suppress TSH.

Medullary carcinoma:
Accounts for about 5%. Arises from parafollicular C cells. Peak incidence is 50-60ys. In most cases the disease is sporadic but

in about 20% is familiar & consist of MEN type IIA & type IIB syndromes. Tumor synthesis & secrete calcitonin which can be used as tumor marker. Treatment is total thyroidectomy .

& regional lymph node clearance. Prognosis is slightly worse than follicular ca. Other family members of the affected pt. should be screened.

Anaplastic carcinoma:
Account for about 5% of thyroid ca. Affect the elderly, with peak incidence 60-

70ys. Undifferentiated & highly aggressive. Higher incidence in areas of endemic goiter. Local met. And spread through blood & lymphatics. Radiotherapy & doxorubicin chemo. are the main modalities of treatment. Surgery is mainly to relief airway obstruction & to debulk tumor.

Inflammotory goiter: Autoimmune thyroiditis, it is Clinical Features:

associated with increase titer of thyroid antibodies.

May be asymptomatic or so sudden painful, mild hypothyroidism may present initially.

Thyroiditis:
Autoimmune (Hashimotos) thyroiditis: Commonest form of thyroiditis. Familial. High levels of thyroid antibodies against thyroglobulin or thyroid cell microsomes. Affect young females. Diffuse thyroid enlargement, which is tender initially & there may be signs of hyperthyroidism in some pt. but gradually hypothyroidism develop, with destruction of thyroid tissue & increasing atrophy & fibrosis. Treatment is by thyroid replacement therapy.

Subacute (de Quervains) thyroiditis: Uncommon condition. Thyroid gland undergo diffuse painful enlargement. Cause ? Viral. Onset is acute, thyroid enlargement may be

associated with fever, general malaise & wt loss. ESR is high in the early stages of disease. The condition last weeks or months & may recur. Treatment consists of simple analgesia but sometimes steroids are required for symptoms relief.

Riedels (struma ) thyroiditis: Very rare condition, gives rise to a very hard irregular swelling of the thyroid gland with progressive fibrosis. Resembles tumor & may give rise to pressure symptoms. Resection may be necessary if signs of compression develops.

Management:
1. History taking :

-determine the status of the goitre . 2. Clinical examination : -local. -general. -systemic.

History
The thyroid gland can cause two groups of

sumptoms and signs:

1- those connected with swelling in the neck 2- those related to the endocrine activity of

the gland

Neck symptoms
A lump in the neck: The majority grow slowly and painlessly. In a few pts , a lump will appear suddenly and

may be painfull This may caused by; Haemorrhage into a necrotic nodule. A fast-growing carcinoma. Thyroiditis.

Discomfort during swallowing: Large swellings may give tugging sensation. Dyspnoea: Deviation or compression of the trachea by a

mass in the thyroid may cause difficulty in breathing The whistling sound of air rushing through a narrowed trachea is called Stridor.

Pain:
Is not common feature. Acute or subacute thyroiditis can present with

a painfull gland. Hashimotos disease often causes an uncomfortable ache in the neck. Anaplastic carcinoma can cause local pain and pain referred to the ear if it infiltrates surrounding structures.

Hoarseness: A change in the quality of the voice of a pt. It is probably caused by a paralysis of one of

the recurrent laryngeal nerves, which means that the lump is likely to be malignant and infiltrate the nerve.

Endocrine dysfunction
Symptoms and signs of thyrotoxicosis

1.Nervous system:
Nervousness, irritability, insomnia and nervous instability, and examination may reveal a tremor of the hands, and occasionally thyrotoxic psychosis may be apparent.

Cardiovascular system: Palpitation, breathlessness on exertion,

swelling of the ankle and chest pain Metabolic and alimentary system: Increase in appetite but loss of weight, change of bowel habit (usually diarrhoea), proximal muscle myopathies may occur with wasting and weakness, preference for cold weather, excessive sweating, change in menstruation usually diarrhoea.

Symptoms and signs of myxoedema Increase in weight, slow thought speech and

action, intolerance of cold weather, loss of hair, muscle fatigue, dry skin, and constipation.

Aim of the history is to state whether it is

simple or toxic goitre +/- evidence of malignancy (pressure symptoms) You must ask about: The swelling: Onset - duration - pain - change in size. Functional state: Symptoms of hyper and hypothyroidism.

Pressure related symptoms: Stridor, choking, dysphagia. Change of voice Family history

Examination
Your examination begins with the first observation. a.Overall appearance of the pt: noisy, agitated, nervous

b. Examination of the hand: hot or cold, dry or sweaty, tachycardia or bradycardia, .thyroid acropachy

c. Examination of the thyroid: Inspection: - Confirm the swelling to be arising from the

thyroid ( site and moves with swallowing ) - Prominent neck veins - puckering of the skin

Palpation: - Palpate from behind the seated pt.

- Always start your palpation by asking

yourself: Is the trachea central or displaced to one side or the other? - Comment on the swelling: Site, size, consistency, solitary, multinodular, or diffuse.

Can you define the lower limit?

(retrosternal extension).

- Lymph nodes along the jugular chain or in

the posterior triangle. - Palpate the thrill if present (thyrotoxicosis). Percussion: For retrosternal extension. Auscultation: a systolic bruit may be heared in Graves disease

Special signs: Lid lag Lid retraction Stare Thyroid associated ophthalmopathy

( TAO),ophthalmoplegia Proptosis and exophthalmous Coarse, brittle hair Ankle jerk Dry, thickened cold skin

Investigations
Thyroid ultrasound (solid or cyst). Thyroid Function Test (TFT). Thoracic inlet X-ray. Chest CT-scan. FNAC: in case of solitary nodule or when there

is possibility of malignancy.

radioiodine study. Thyroid antibodies. Serum cholesterol = is usually raised in

myxoedema and may be normal or a little low in thyrotoxicosis. ECG: - low electrical activity with small complex in myxoedema - atrial fibrilation in hyperthyroidism.

Serum free T4 . Serum free T3 . T.S.H .

2. A thyroid scintigram or isotope scan

This test measures the rate of

function of the gland. It is done by intravenous injection of dose of a radioactive substance which is taken up by thyroid gland. The isotope emits gamma rays which are detected by a gamma camera.

Active nodules show up as hot with

increased activity whereas cold nodules are inactive. Most thyroid nodules are cold. And normal one shows neutral picture .

3.thyroid ultrasound :
This is a painless test which uses the principle

of echoes to assess internal tissues and especially whether tissues are solid or fluid (cystic). help to determine the size of the thyroid gland and location of abnormalities.

4-thyroid antibodies :
It indicate an autoimmune pathology such as

Hashimotos thyroiditis or Graves disease .

*To obtain the diagnosis of suspicious lesions 5. Fine needle aspiration :

This is an extremely valuable test for

differentiating the type of goiter . A small sample of cells or fluid is removed from the thyroid gland by passing a needle through the nodule or cyst in the gland. The aspirate is then taken for cytology and histology . 6. C.T scan .

Treatment:
It depends on the type .

1. Surgical treatment :

Thyroidectomy

a surgical procedure in which all or part

of the thyroid gland is removed. Indications : 1. If it cause pressure symptoms. 2. Suspicion of malignancy .

1. Cosmetic reasons . 2. Thyrotoicosis which is not responding to

medical treatment . 3. Retrosternal extension .

The anatomical structures likely to be injuried

in thyroidectomy: The Recurrent laryngeal nerve. The Superior laryngeal nerve. The Parathyroid glands. The cervical sympathetic chain (rarely), which gives Horners syndrome

Types of surgery
Open surgery Laproscopic surgery

Types of surgery
Partial lobectomy thyroid surgery: A portion of

one lobe of the thyroid is removed Lobectomy thyroid surgery: An entire lobe of the thyroid is removed Lobectomy with isthmusectomy thyroid surgery: One lobe, along with the isthmus, is removed. Subtotal thyroidectomy: Most of the thyroid is removed, but a functioning section remains (typically used for the treatment of Graves disease) Total Thyroidectomy: Both lobes and the isthmus are removed

The Surgical Procedure

In the surgery, the surgeon will cut a 3- to 5-inch incision across the base of your neck in front. The skin and muscle are pulled back to expose the thyroid gland. The incision is usually made so that it falls in the fold of the skin in your neck, making it less noticeable. Blood supply to the gland is "tied off," and the parathyroid glands are identified (so that they can be protected). The surgeon then separates the trachea from the . thyroid, and removes all or part of the gland

Management of patients who are undergoing thyroid surgery

Render patient euthyroid & treat other

toxicity effects such as AF & heart failure Investigations Indirect laryngoscopy to assess vocal cds Baseline plasma calcium concentration WBC in patients receiving antithyroid dr.

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Information & consenting the patient Continue antithyroid medication up to day of

surgery At operation be careful about structures at risk mentioned earlier Complications Bleeding 2)hypocalcaemia: clinically present with

104

Paraethesia around mouth & fingers later

muscle spasm & then tetany (signs = Trousseus& Chvostek ) , condition is managed with IV calcium gluconate. 3) Nerve injury: RLN injury refer to ENT surgeon ,invasive treatment withheld for 9 months (it may recover) if not surgical lateral fixation 4) thyrotoxic storm (crisis):rendering patients euthyroid have abolished this prob.
105

Mortality of condition is 10% Clinical features Restlessness confusion , tachycardia &

hyperpyrexia + hypotension Prevention :render all patients euthyroid Treatment IV fluids , steroids , propranolol , antithyroid drugs ,potasium iodide & anti-pyrexic agents.

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Complications of thyroid surgery:

General complications: 1.Wound infection. 2.Stitch abscesses. 3.Hypertrophic or keloid scar formation. 4.Respiratory infections. 5.Deep vein thrombosis. 6.Pulmonary embolism. 7.Cardiac events . 8.TIAs due to overenthusiastic retraction of the common carotid artery.

Specific complications: 1-Bleeding & airway obstruction. 2-Nerve damage: Transverse cutaneous nerve of neck

(C2-C3). External branch of superior laryngeal nerve. Recurrent laryngeal nerve. Cervical sympathetic plexus. 3-Hypothyroidism.

Airway Complications and Management after Thyroidectomy

Intubation related complications
Tracheal tear laryngeal edema laryngeal nerve apraxia long term intubation: tracheomalacia, scarring,

granuloma

Airway Complications and Management after Thyroidectomy

Incidence of respiratory complications at extubation and in the recovery room is greater than at intubation
Hematoma (0.79% -1.2%) airway obstruction Laryngeal edema (0.19%) airway obstruction Hypoparathyroidism, temp.: 0.9-8.3%, perm.:

<1.7% stridor, hypocalcemia Dysphagia (1.4%) Infection (0.3%) Tracheomalacia

Thyroid storm (thyroid crisis)

A sudden and dangerous increase

in all of the symptoms of hyperthyroidism due to excessive amounts of circulating TH. Symptoms include fever, rapid heart rate, high blood pressure, dehydration, nervousness, and tremors. Precipitating factors include stressful situations, excessive

QUESTIONS

. When progressive enlargement of a multinodular goiter causes symptomatic tracheal compression, the preferred management in otherwise good-risk patients is: A. Iodine treatment. B. Thyroid hormone treatment. C. Surgical resection of the abnormal thyroid. D. Radioactive iodine treatment.

2. The most precise diagnostic screening procedure for differentiating benign thyroid nodules from malignant ones is : A. Thyroid ultrasonography. B. Thyroid scintiscan. C. Fine-needle-aspiration biopsy (FNAB). D. Thyroid hormone suppression.

What is your diagnosis ? How can you prepare these pt for surgery ? 6 h after the operation she developed upper airway obstruction what is your immediate action ?