Your SlideShare is downloading. ×
0
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Thyroid presentation
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Thyroid presentation

1,620

Published on

Here I present current benign thyroid management principles. This is the lecture I delivered at Ruhunu Clinical Society - Annual Academic Sessions - Symposium on Benign Thyroid Diseases.

Here I present current benign thyroid management principles. This is the lecture I delivered at Ruhunu Clinical Society - Annual Academic Sessions - Symposium on Benign Thyroid Diseases.

Published in: Health & Medicine
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,620
On Slideshare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
0
Comments
0
Likes
2
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Surgical Management of Benign Thyroid Disease Dr. MTD Lakshan MBBS (Col) MS (OTO) DOHNS FEB ORL-HNS FRCSEd ORL-HNS
  • 2. Facts 1. Palpable nodules – 5% women, 1% Men (High Resolution US 19 – 67%) 2. Risk of Cancer 5 -15% 3. Non-neoplastic diseases of the thyroid affect nearly 3/4 of a billion worldwide 4. Iodine deficiency common worldwide Iodine excess common in US (and in SL?) – contribution to thyroiditis – Jod-Basedow phenomena
  • 3. Management of Thyroid Enlargement 1. Clinical Evaluation – Malignant hints – Activity hints – Compression hints 2. FNAC 3. USS 4. TSH
  • 4. Surgical Principles 1. Pre-operative 2. Per-operative 3. Post-operative
  • 5. Clinical Evaluation ● History childhood head and neck irradiation ● Family history of thyroid carcinoma or thyroid cancer syndrome ● Rapid growth ● Hoarseness ● VC Palsy ● LN enlargement ● Fixation of nodule to the skin
  • 6. FNAC ● Sensitivity for malignancy 65 – 98% ● Specificity 76 – 100% ● Overall accuracy 69 – 97% ● Guided FNAC improves diagnostic yield
  • 7. Thy Thy 1 Non-Diagnostic for cytological diagnosis Thy1c Non-Diagnostic for cytological diagnosis Cystic Lesion Thy 2 Non - Neoplastic Thy 2c Non – Neoplastic Cystic Lesion Thy 3a Neoplasm Possible Atypia/Non-diagnostic Thy 3f Neoplasm Possible Suggesting follicular neoplasm Thy 4 Suspicious of malignancy Thy 5 Malignant
  • 8. Action Based on Thy Thy 1 Thy 2 Thy 3 Thy 4 Thy 5 1+c a +c a+f Repeat FNS Consider USS guidance Describe as cystic if no epithelial cells present Repeat FNA if no surgery planned Discuss at MDT Discuss at MDT Discuss at MDT Diagnostic Lobectomy usually recommended Diagnostic lobectomy +/on table frozen section to proceed to total thyroidectomy +/- central node clearance in high risk patients Radiotherapy/ch emotherapy or surgery where indicated Consider total thyroidectomy in larger lesions >4cm where incidence of malignancy is high Appropriate further investigations for staging when indicated Total thyroidectomy +-central node clearance in appropriate high risk patients
  • 9. USS ● Suspicious – – Hypervascularity – Irregular borders – Taller rather than wider nodule on transverse imaging – ● Micro calcifications, hypo-echoeic solid nodules Extra glandular invasion Other info – contralateral lobe – lymph nodes
  • 10. CT
  • 11. Radio Isotope Scanning
  • 12. Surgical Decision Making ● Nature of the goiter – Degenerative – Neoplastic – Physiological ● Function of the goiter ● Compression and Extension ● Cosmetic ● Patient comorbidities
  • 13. Indications ● Compressive symptoms esp. with sub-sternal goitre ● Concerned about the risk of malignancy – diagnostic lobectomy and isthmusectomy ● Controlling hyperthyroidism ● Cosmetic – 5cm Laryngoscope, 121:60–67, 2011 The Surgical Management of Goiter: Part I. Preoperative Evaluation Jennifer J. Shin, MD; Hermes C. Grillo, MD*; Doug Mathisen, MD; Mark R. Katlic, MD; David Zurakowski, PhD; Dipti Kamani, MD; Gregory W. Randolph, MD Laryngoscope, 121:60–67, 2011
  • 14. Preoperative planning ● Review of data – ● Clinical, imaging, pathology, TSH Informed consent – Bleeding, hypocalcaemia, recurrent laryngeal nerve damage, infection, cosmetic ● IDL – 2% pre-op IDL VC palsy + ● Lugol's iodine (KI)
  • 15. Surgical Options ● Lobectomy and isthmusectomy ● Total Thyroidectomy
  • 16. Steps ● Skin incision ● Flaps ● Lateral border and middle thyroid ● Upper pole ● Isthmus ● Lower pole ● Identification of RLN
  • 17. Basic Sciences - Anatomy
  • 18. Incision
  • 19. Flaps
  • 20. Straps
  • 21. Upper Pole
  • 22. Ex. Br. SLN
  • 23. RLN
  • 24. RLN ● Carotid Triangle – Carotid artery, Trachea and Thyroid gland – Lateral to medial – may devitalise parathyroids – Medial to Lateral ● Cricothyroid joint level consistent ● Branching 40% before reaching CTJ
  • 25. Branching of RLN
  • 26. Wound Closure
  • 27. Scar Management
  • 28. Complications ● RLN – 7%, permanent 3.6% ● Hypocalcaemia – 10-20%, permanent 1-5% ● Bleeding – Haematoma formation – 5% ● Scar Assessment of the Morbidity and Complications of Total Thyroidectomy Neil Bhattacharyya, MD;Marvin P. Fried, MD • Conclusions Postoperative hypocalcemia is the most common immediate surgical complication of total thyroidectomy. Other complications, including recurrent laryngeal nerve paralysis, can be expected at rates approximating 1%. JAMA Network | JAMA Otolaryngology–Head & Neck Surgery | Assessment of the Morbidity and Complications of Total Thyroidectomy
  • 29. Controversies ● Drain or not to drain ● Wound Closure ● Routine Calcium Supplementation ● DL examination of VC function at recovery ● Post op T3 or T4 ● Contrast in CT in imaging
  • 30. New Frontiers
  • 31. Endoscopic Thyroidectomy What is the Evidence for Endoscopic Thyroidectomy in the Management of Benign Thyroid Disease? E. Th. Slotema, F. Sebag, J. F. Henry World J Surg. 2008 July; 32(7): 1325–1332
  • 32. Intra-operative Nerve Monitoring
  • 33. New Frontiers • MicroPLIC • RhTSH • vMDT
  • 34. Personal Perspective
  • 35. DGH Thyroidectomy Audit – Period : 36 months from September 2009 to October 2013 – Number of Cases : 107 World Figures Our Audit RLN – 7%, permanent 3.6% 2% Hypocalcaemia – 10-20%, permanent 1-5% 4% Bleeding – Haematoma formation – 5% 2%
  • 36. MDT South Virtual Head and Neck Cancer Meeting
  • 37. William Halstead • Sterile Operating Room Concept • Invented Surgical Gloves • Introduced Radical Mastectomy • Performed first emergency blood transfusion • Intestinal Suturing
  • 38. William Halstead “The extirpation of the thyroid gland for goitre …… provide(s) perhaps more than other operations the supreme triumph of the surgeons art” William Halstead
  • 39. Thank You

×