This is a clinical case presentation of Nodular Thyroid in a 40 year old woman. Detailed Anatomy, Physiology of Neck region including thyroid with their pahophysiology. Possible investigations and modalities of treatment have also been discussed in this presentation.

1. NECK LUMP
Prepared & Presented By –
Tasmia Akhtar
Imran Mahmud
Samiha Narzis
Abrar Galib Fahad

2. Presented by - Tasmia Akhtar
Anatomy

3. What Is Neck?
 The Neck is part of the body that connects the
head with the trunk
 The Neck joins the Head to the Trunk and Limbs,
Serving as a major conduit for structures passing
between them

4. Surface Anatomy
 Prominent landmarks
of the neck are –
 Thyroid Cartilage
 Cricoid Cartilage
 Trachea
 Sternocleidomastoid

5. Triangles of Neck

6. Anterior Triangle
 The anterior triangle is
situated at the front of the
neck. It is bounded:
 Superiorly – inferior border
of the mandible (jawbone).
 Laterally – anterior border of
the sternocleidomastoid.
 Medially – sagittal line down
the midline of the neck.
 Investing fascia covers the
roof of the triangle,
while visceral fascia covers
the floor.

7. Anterior Triangle
 Muscles: Suprahyoid and infrahyoid
muscles
 Organs: thyroid gland, parathyroid
glands, larynx, trachea,
esophagus, submandibular gland, caudal
part of the parotid gland
 Arteries: superior and inferior
thyroid, common carotid, external
carotid, internal carotid artery (and
sinus), facial, submental, lingual arteries
 Veins: anterior jugular veins, internal
jugular, common facial, lingual, superior
thyroid, middle thyroid veins, facial vein,
submental vein, lingual veins
Nerves: vagus nerve (CN X), hypoglossal
nerve (CN XII), part of sympathetic
trunk, mylohyoid nerve

8. Posterior Triangle
 Its boundaries are as
follows:
 Anterior – posterior
border of the
sternocleidomastoid.
 Posterior – anterior border
of the trapezius muscle.
 Inferior – middle 1/3 of
the clavicle.

9. Posterior Triangle
Vessels:
 3rd part of the subclavian
artery,
 thyrocervical trunk,
 external jugular vein,
Nerves:
 Accessory nerve (CN XI),
 the trunks of the brachial
plexus,
 fibers of the cervical plexus

10. Lymph Nodes of Neck

11. Thyroid
 Thyroid is highly
vascular endocrine
gland situated in front
and sides of the neck
 Location : Lower part
of the neck at the
level of C5-T1 vertebra

12. Thyroid
Parts of a Thyroid
Gland –
 Right Lobe
 Left Lobe
 Isthmus

13. Histology of Thyroid gland
 The thyroid gland consists
of two types of secretory
cells:
 follicular and parafollicular.
 The follicular cells secrete
two hormones: T3 amd T4
 The parafollicular cells or
C-cells secrete a hormone
called calcitonin.

14. Nerve Supply of Thyroid
 The thyroid gland is supplied by
both sympathetic and
parasympathetic nerve fibres:
 1. The parasympathetic supply is
derived from the vagus and
recurrent laryngeal nerves.
 2. The sympathetic supply is
derived from the superior,
middle, and inferior cervical
sympathetic ganglia.

15. Blood Supply of Thyroid

16. Thyroid Hormone Feedback

18. Presented By – Imran Mahmud
Pathophysiology of Neck Mass

19. What is a Neck Mass?
 Neck Mass is defined as any abnormal
enlargement, swelling or growth on neck.
 Clinically, Neck Masses can be divided into –
1. Those in the Midline
2. Those in the lateral aspect of neck

20. Midline Swellings of Neck

21. Lateral Swelling of Neck

22. Today’s Case

23. Salient Feature
 Mrs. Sabina Begum, a 40 years aged married
housewife, normotensive, non-diabetic hailing
from Moulavibazar presented with Midline neck
swelling for 3 years which is gradually increasing in
size. For the last few months she developed
increasing pain over the swelling. She has no
history of dysphagia, chest pain, hoarseness of
voice, tingling sensation of extremities. She gave
no history of taking drugs and there was no family
history of similar illness. She gave history of normal
menstruation and heat intolerance

24. Salient Feature – cont.
 On examination,
 General examination – Thyroid gland was
enlarged. The swelling was slightly tender and
temperature was normal, 8x6 cm in size, surface is
nodular, firm in consistency, regular margin, fixed
with underlying structure and overlying skin, get
below the swelling is possible, berry’s sign is
positive . Kocher's sign, exophthalmos, lid lag and
lid retraction negative
 Systemic Examination – All systems are intact

25. Salient Feature – cont.
 Provisional diagnosis is – Nodular Goitre

26. What is Goitre
 Goitre maybe defined
as enlargement of
thyroid caused by
compensatory
hyperplasia and
hypertrophy of the
folliculer epithelium in
response to thyroid
hormone deficiency

27. Classification

28. Etiology
 Geographic areas such
as North Bengal
 Excessive ingestion of
goitrogens such as
cabbage and
cauliflower.
Endemic Goitre Sporadic Goitre

29. Pathogenesis
Iodine Lack or Goitrogens
Deficient Thyroid Hormone Production
Excessive TSH stimulation
Cystic hyperplasia
Diffuse Goitre

30. Pathogenesis
Repeated Hyperplasia and Involution
Fibrosis of involuted area and growth of hyperplastic
area
Nodular Goitre

32. Presented By – Samiha Narzis
Investigation and Diagnosis

33. Clinical Features of Goitre
 Patient is either euthyroid, hypothyroid or
hyperthyroid.
 Palpable nodule, smooth or hard
 Painless, moves freely on deglutition
 Hardness and irregularity

34. Evaluation of a Goitre
 1. History
 2. Physical Examination
 3. Thyroid Function Test
 4. Ultrasound of Thyroid
 5. Thyroid Scan
 6. Fine Needle Aspiration Cytology
 7. CT/MRI

35. Thyroid Function Test
 In the euthyroid state, T3, T4 and TSH levels will all be within the normal
range.
 Florid thyroid failure results in depressed T3 and T4 levels, with gross
elevation of TSH.
 Incipient or developing thyroid failure is characterised by low normal values of
T3 and T4 and elevation of TSH.
 In toxic states, the TSH level is suppressed and undetectable

36. Ultrasound of Thyroid
 Ultrasound is now central in the assessment of
these patients
 Advantages :
a) Small nodules which cannot be palpated or nodules in obese neck.
b) Accurate size of nodule(s) and their location.
c) It can guide Fine Needle Aspiration
d) Associated cervical lymph nodes.
e) Vascularity of thyroid gland or nodules.

37. Ultrasound of Thyroid
Abnormal Nodule in Thyroid Normal Thyroid

38. Isotope Scanning
 The uptake of radiolabelled Iodine(123I) and
Technitium (99Tc) demonstrate distribution of
activity in the gland.
 Routine isotope scanning is unnecessary and
inappropriate because, majority (80%) of ‘cold’
swellings are benign and some (5%) functioning or
‘warm’ swellings will be malignant.
 Its principal value is in the toxic patient with
nodule or nodularity of the thyroid.

39. Fine Needle Aspiration Cytology
 Fine-needle aspiration cytology (FNAC) is the
investigation of choice in discrete thyroid swellings.
 FNAC has excellent patient compliance, is simple
and quick to perform in the out-patient
department and is readily repeated.

40. Fine Needle Aspiration Cytology

41. Autoantibody Titre
 The autoantibody status may determine whether a
swelling is a manifestation of chronic lymphocytic
thyroiditis.
 The presence of circulating antibodies increases
the risk of thyroid failure after lobectomy.

42. SOLITARY NODULES WITH HIGH RISK
FOR MALIGNANCY
 • Age < 20 and > 45 years
 • Male gender
 • History of previous radiation to neck
 • Family history of thyroid cancer
 • Rapid growth
 • Pain
 • Compressive or invasive features such as stridor, dyspnoea and
dysphagia
 • Fixed and hard lesion
 • Size of nodule > 4 cm
 • Recurrent or rapidly filling cyst after aspiration
 • Nodules that occur in Graves’ or Hashimoto thyroiditis

43. Preoperative Work-up
 1. Detailed history.
 2. Physical examination.
 3. Thyroid profile. TSH, T4 and T3.
 4. Indirect laryngoscopy. For vocal cord paralysis or a
 compensated vocal cord function.
 5. FNAC. To know the histology.
 6. TPO antibodies. When indicated for Graves’ disease.
 7. Level of calcitonin. When medullary carcinoma is
 suspected.
 8. Serum calcium level. As a baseline.
 9. Ultrasound thyroid/neck. For size and number of thyroid
 nodules and status of lymph nodes in the neck.

44. Preoperative Work-up
 10. Thyroid scan. If indicated, e.g. for autonomous
nodule.
 11. CT chest. For retrosternal goitre.
 12. Investigations for surgical fitness:
 • Haemogram.
 • Urine; routine and microscopic.
 • Blood sugar (F).
 • Blood urea/creatinine.
 • X-ray chest.
 • ECG.
 • Cardiac echo (if required).

45. Presented By – Abrar Galib Fahad
Treatment and Management

46. Treatment
 Observation
 Levithyroxine suppression therapy
 I131 Therapy
 Surgical Resection

47. Treatment
 In the early stages hyperplastic goitre may regress
if Thyroxine is given in a dose of 0.15-0.2 mg daily
for a few month.
 Although the nodular stage is irreversible, more
than half of benign nodules will regress in size over
years.
 Operation maybe indicated on cosmetic ground,
for pressure symptoms or in response to patient
anxiety.

48. Observation
 Asymptomatic euthyroid patients
 Small to moderate sized goitre
 No risk for malignancy
 Should be Periodically examined with
Ultrasonogram.
 Concern for malignancy - FNAC

49. Thyroid Surgery
 Indications for Thyroid Surgery:
1. Carcinoma thyroid.
2. Suspicion of cancer, e.g. thyroid neoplasm on
FNAC and thyroid nodule with risk factors.
3. Compressive symptoms, e.g. pressure on trachea
or oesophagus or veins causing dyspnoea or
dysphagia.
4. Cosmetic. A large nodule or a multinodular goitre.

50. Types of Thyroid Surgery
 Hemithyroidectomy or thyroid lobectomy
 Subtotal thyroidectomy
 Near total thyroidectomy
 Total thyroidectomy
 Isthmusectomy
 Completion thyroidectomy

51.  When the entire gland is involved Total
Thyroidectomy is better.
 Subtotal Thyroidectomy is done depending on the
amount of gland involved.
 Re-operation for recurrent nodular goitre is more
difficult and hazardous and for this reason total
thyroidectomy is preferred in younger patients.

52.  Total Thyroidectomy and Total Lobectomy have
additional advantage of being therapeutic for
incidental carcinoma.
 There is some evidence that radioactive iodine
may reduce size of recurrent nodular goitre after
previous subtotal resection and in some instances
its safer alternative than re-operation.

53. Selection of thyroid procedure
The choice of thyroid operation depends on:
 diagnosis (if known preoperatively);
 risk of thyroid failure;
 risk of RLN injury;
 risk of recurrence;
 Graves’ disease;
 multinodular goitre;
 differentiated thyroid cancer;
 risk of hypoparathyroidism.

54. Complications
 1. Haematoma
 2. Airway obstruction. Tracheotomy may be
required. Compression by haematoma,
tracheomalacia and laryngeal oedema or
myxoedematous cords also cause obstruction to
airway.
 3. Injury to recurrent laryngeal nerve.
 4. Injury to superior laryngeal nerve.
 5. Wound infection.

55. Complications
 6. Hypocalcaemia. Removal or devascularization of
parathyroid glands causes numbness and tingling of lips,
hands and feet. In such cases calcium level may be less
than 8.0 mg/dL. Critical period is 24-96 h after operation.
Always check for serum calcium levels postoperatively and
compare with the preoperative baseline value. It may
require calcium and vitamin Dsupplementation by oral or
i.v. route depending on the severity of hypocalcaemia.
 7. Pneumothorax. Due to injury to pleura in the lower
neck.
 8. Hypothyroidism. It is usually seen 4-6 weeks after
operation. This would require long-term thyroid replacement.

56. Prevention
 Use of Iodized salt
 At Puberty: 0.1mg or 0.2mg of
thyroxine
 Reduction of use of goitrogens