DR MANPREET SINGH NANDA PROFESSOR ENT

1. Anatomy, physiology and clinical
examination

2.  Thyroid – throat (latin)
 Largest endocrine gland, 15-30 g in adults
 Butterfly/H shape
 Extent – middle of thyroid cartilage to 4th to
6th tracheal rings (C5,C6,C7,T1)
 Deep to cervical strap muscles covering
cricoid cartilage and upper tracheal rings
 2 lateral lobes (right and left) – conical in
shape (vertical limbs)
 Connected by isthmus (horizontal limb) –
connects lower part of 2 lobes, overlies 2nd
and 3rd tracheal rings

3.  Each lobe measures 5 cm length, 3 cm
breadth and 2 cm AP diameter
 Pyramidal lobe – 3rd lobe in 50% cases,
extends from isthmus near left lobe towards
the hyoid bone

5.  Capsule
 True capsule
 Surrounds the gland
 Formed by peripheral condensation of
connective tissue of the gland
 Deep to it lies dense capillary plexus
 Remove the gland along with true capsule
 False capsule
 Derived from pretracheal layer of deep cervical
fascia
 On inner surface of glands it forms a ligament on
each side – Posterior suspensory ligament of
Berry

6.  Berry ligament – attaches thyroid lobe to cricoid
cartilage and 1st and 2nd tracheal rings
 Leads to thyroid swelling moving up with
swallowing
 RLN passes deep, lateral or above the berry
ligament
 Branch of Inferior thyroid artery also passes deep
to this ligament. This can bleed during surgery
 So clamping of the artery can damage RLN
 Ligament also contains small amount of thyroid
tissue – if left behind during thyroid surgery
leads to incomplete removal

8.  Blood Supply
 Superior Thyroid artery
 Inferior Thyroid artery
 STA
 Upper 1/3rd of lobe and upper 1/3rd of isthmus
 1st ant br of ECA just below the greater horn of
hyoid bone
 Divides at upper pole into anterior and posterior
branches
 Ant branch anastomise with opp side ant branch
 Post branch anastomise with ascending branch of
ITA
 Related to external laryngeal nerve

9.  ITA
 Lower 2/3rd of each lobe and lower 2/3rd of isthmus
 Branch of thyrocervical trunk (br of subclavian
artery)
 Also supplies upper ½ of trachea
 Related to RLN behind the gland
 Divides into 4 or 5 branches
 One ascending br anastomise with post br of STA and
supplies parathyroid gland
 Thyroidea ima artery
 Lowest thyroid artery – 10%, at inferior border of
isthmus
 Arises from aortic arch/innominate artery/lower CCA

11.  Venous Drainage
 Sup thyroid vein
 At upper pole, accompanies STA
 Terminates into IJV/ common facial vein
 Middle thyroid vein
 Middle of lobe, no corresponding artery
 Terminates into IJV
 Inferior thyroid vein
 Lower border of isthmus, multiple
 Terminates into left or right brachiocephalic vein
 Kocher’s vein
 V rare, between middle thyroid vein and inferior
thyroid vein
 Drains into IJV

13.  Nerve supply
 Autonomic Nervous System
 Middle cervical ganglion (partially from superior and
inf cervical ganglion)
 Parasympathetic division from vagus nerve
 RLN
 Lies in Beahr’s RLN triangle or RLN triangle of lore
 Lat – carotid sheath, strap muscles
 Med – trachea, oesophagus
 Sup – lower pole of thyroid gland
 Rt RLN more prone for injury during thyroid surgery
as it lies more ant and lateral at inf pole of thyroid
gland

14.  Non recurrent laryngel n
 0.3-0.8%
 Rt side – mc
 Anomalous, dont hook around vessels
 SLN
 Related to STA and vein
 Divides into larger internal and smaller external
laryngeal nerve (cricothyroid muscle)
 Located in the sternothyrolaryngeal triangle or
triangle of joll
 Boundaries – sup –sternothyroid muscle, roof –
strap muscles, floor – cricothyroid muscle,
medially – cervical midline, laterally – upper pole
of thyroid gland and sup thyroid vessels

15.  Lymphatic drainage
 II,III,IV,V,VI,VII
 Upper part of lat lobe and sup border
isthmus – prelaryngeal ln, upper deep
cervical ln
 Lower part of lobe and lower isthmus –
pretracheal, paratracheal ln, lower deep
cervical ln

16.  Parathyroid glands
 On posterior aspect of each lobe
 Sup parathyroid
 Above inf thyroid artery
 Post to RLN
 Upper 1/3rd of lobe
 Close to cricoid cartilage
 Inf parathyroid
 Below inf thyroid artery
 Ant to RLN
 Near lower pole
 But can be located anywhere between hyoid bone to
sup mediastinum as they descend along with thymus
gland

18.  Development
 Midline thyoid diverticulum
 In floor of foregut and then migrate to adult
position
 Thyroglossal duct – connects thyroid diverticulum
to foregut (foramen caecum)
 If it persists lead to cyst or fistula
 Ectopic thyroid
 Lingual thyroid – if improper descent
 Ultimo branchial bodies
 Contribute 10% of thyroid
 Contribute to formation of parafollicular
calcitonin producing C cells

19.  Endocrine gland
 Cells 2 types
 Follicular cells
 Produce a glycoprotein called thyroglobulin
(Tg) – present as colloid in lumen of follicular
cells
 Role in formation of T3 and T4
 Parafollicular cells – C cells
 Secretes calcitonin – lowers calcium, role in
calcium metabolism

20.  Synthesis of thyroid hormones
 Hypothalamus – secretes TRH (Thyrotropin releasing
hormone), acts on pituitary
 Pituitary – releases TSH (Thyroid stimulating
hormone) or thyrotropin, acts on follicular cells of
thyroid gland
 Thyroid follicular cells – synthesis and release of T3,
T4 – inhibitory effect
 Action in follicular cells
 Enzyme Iodide peroxidase
 Uptaken iodide -> iodine
 Coupling of iodine and tyrosine -> iodotyrosine
 2 molecules of diiodotyrosine -> T4
 1 molecule of diiodotyrosine and 1 molecule of
monoiodotyrosine -> T3

21.  Secretion
 Enzyme Diiodotyrosine deiodinase
 Causes deiodination of MIT, DIT which
liberates iodine and recycled
 If enzyme absent – iodine lost in urine –
iodine deficiency
 T3
 Produced 20% in thyroid gland
 Remaining 80% in peripheral tissues due to
deiodination of T4
 3 times more potent than T4

22.  History taking
 AGE
 since birth – thyroglossal cyst
 Near puberty/pregnancy/teenage girls – simple
goitre, physiological goitre
 Young females – MNG, STN
 Malignancy - < 20 yrs, > 60 yrs
 Papillary ca, follicular ca, medullary ca – younger
age, anaplastic ca – older age
 Thyrotoxicosis – younger and middle age group
 SEX
 Females more common
 In males affected – more chances of turning
malignant

23.  OCCUPATION
 Stress – thyrotoxicosis
 RESIDENCE
 Endemic goitre – low iodine content areas – himalyas,
southern hills
 Areas of high calcium content- producing chalk or
limestone (calcium – goitrogenic)
 CHIEF COMPLAINTS
 Swelling
 Mc asymptomatic STN
 Onset/rate of growth
 Sudden increase in size with pain – haemorrhage
 Slow growth – simple/colloid/MNG/SNG, Papillary
ca/follicular ca
 Fast rapid growth – anaplastic ca/lymphoma

24.  Pain
 Inflammatory – painful
 Malignant – painless, later painful
 Hemoptysis – tracheal erosion
 Stridor/dyspnoea – tracheal pressure or
infiltration
 Dysphagia – oesophageal pressure or infiltration
 Hoarseness – RLN pressure or infiltration (mc –
anaplastic ca)
 Primary thyrotoxicosis – less enlargement, loss of
weight despite..... good appetite, cold climate
prefernce, intolerance to heat, excessive
sweating, irritability, tremors of hands and
tongue, loose stools, amenorrhoea

25.  Secondary thyrotoxicosis
 In a long standing STN/MNG/colloid goitre
 Palpitation, dyspnoea on exertion, chest pain on
exertion, dysarrythmia
 Hypothyroidism
 Increase in weight despite.....poor appetite, fat
at back of neck and shoulders, intolerance to
cold weather, prefers warm climate, minimal
swelling, dull appearance, loss of hair, lethargy,
constipation, menstrual disturbances
 Pulmonary metastasis – chest pain, cough,
dyspnoea
 Bone metastasis – bone pain, pathological
fracture

26.  PAST HISTORY
 Any drug intake
 Radiotherapy – papillary ca
 HTN/DM/CAD
 PERSONAL HISTORY
 Diet
 Less iodine – follicular ca
 Excess iodine – papillary ca
 Brassica family veg like cabbage, brocali –
goitrogenic
 FAMILY HISTORY
 Medullary ca – runs in families

27.  EXAMINATION
 GENERAL PHYSICAL EXAMINATION
 Build and nutrition
 Thin and underweight – thyrotoxicosis
 Obese and overweight – hypothyroidism
 Anaemia, cachexia – malignancy
 FACIES
 Thyrotoxicosis – excitement, anxiety, tension,
agitated look....., nervousness
 Eye – protruding eye ball (exophthalmos), lid
retraction, widening of palpebral fissure, oedema of
eye lids (upper eye lid)
 Hypothyroidism – puffy face without expression, dull,
low intelligence

28.  PULSE RATE
 Rapid and irregular in thyrotoxicosis
(tachycardia)
 Slow in hypothyroidism (bradycardia)
 Sleeping pulse rate – 4 am to 5 am.........during
deep sleep
 TREMORS OF HAND – primary thyrotoxicosis
 Tremors of tongue
 Skin
 Moist and warm feet and hands – thyrotoxicosis
 Dry and cold skin - hypothyroidism

29.  LOCAL EXAMINATION
 INSPECTION
 Seen only if enlarged
 Pizzillo’s method – hands behind head and
patient asked to push his head against them
 Uniform enlargement – simple goitre, colloid
 Nodular
 Swallowing – swelling moves up (D/D – level
VI LN, thyroglossal cyst, sub hyoid bursa)
 Protrusion of tongue – no movement (diff
from thyroglossal cyst)

30.  PALPATION
 With neck slightly flexed
 From behind and front
 Lahey’s method
 Stand in front. Push the thyroid to the side being
examined and palpate
 Smooth – colloid goitre
 Hard – malignancy
 Bosselated – MNG
 Size of nodule > 1.5 cm – malignancy
 Mobility both horizontal and vertical directions –
fixed in malignancy

31.  Fixity to skin
 Consistency – hard in malignancy
 Extent
 Shape
 Position
 Lower border examination – for retrosternal
goitre
 Berry’s sign – absence of carotid pulsations if
carotid sheath involved
 Kocher’s test – press the lateral lobe – if leads to
stridor indicate tracheal pressing, infiltration

32.  Lymph node examination
 Level II,III,IV,V,VI
 Papillary ca – common, early ln metastasis
 Non tender, discrete, firm ln
 Position, size, site, number, consistency,
tenderness
 Measurements
 Circumference of neck over swelling – to find
out the change in size of swelling
 PERCUSSION – for retrosternal goitre..... Not
much role

33.  AUSCULTATION
 Guttman’s sign – thyroid bruit present –
systolic bruit over goitre, seen in primary
thyrotoxicosis
 Laryngoscopy
 Fixed vc- if RLN infiltrated.....
 Ankle examination – oedema – seen in
secondary thyrotoxicosis

34.  Thyroid Function Tests
 T3, T4, TSH
 T3, T4 -> Mostly bound to serum proteins, small
amount is unbound or free -> responsible for
metabolic activity
 Free T3, T4
 TSH – secreted from pituitary, depend on T3, T4
levels (negative feedback), also regulated by
thyrotropin releasing hormone (TRH) from
hypothalamus
 Normal values (euthyroid)
 Free T3 3.5-7-5 mmol/l, Free T4 10-30nmol/l,
TSH – 0.3-3.3 mU/l

35.  Thyrotoxicosis T3,T4 increased, TSH
decreased
 Hypothyroidism T3, T4 decreased, TSH
increased
 T3 toxicity T3 increased, T4 normal, TSH
decreased
 Developing hypothyroidism T3,T4 normal but
lower limits, TSH increased
 Thyroid auto antibodies – high in
autoimmune disorders, formed against
thyroid peroxidase, thyroglobulin (anti
thyroglobulin)

36.  FNAC/FNAB
 Fine needle aspiration cytology/biopsy
 Simple, quick, economical OPD procedure
 21 G needle and 5ml syringe
 Gold standard/ investigation of choice
 Accuracy 92-95%
 Results – malignant, benign, non neoplastic,
suspicious, insufficient
 USG guided FNAC – more accurate
 Complications – pain, haematoma, entry into
trachea, transient vc paralysis

37.  USG Neck
 To determine number, dimensions and
physical character of swelling
 Measures size of gland
 Detect small nodules 2-4 mm which cant be
palpated clinically
 Differentiate cystic from solid swellings
 Detect malignancy
 Detect cervical lymphadenopathy
 USG guided FNAC

38.  X Ray Neck, Chest and thoracic inlet
 Position and compression of trachea
 Tracheal deviation, displacement
 Retrosternal goitre
 Calcifications – help to determine type of ca
– stippled polymorph calcifications (papillary
ca), dense polymorph (medullary ca)

39.  CT/MRI/PET
 Detect regional metastasis, cervical
lymphadenopathy
 Detect local recurrence
 Detect invasion of larynx, pharynx, trachea,
oesophagus and invasion of thyroid cartilage
 Detect extent of disease and degree of
calcification
 Detect retrosternal goitre
 Detect pulmonary metastasis

40.  Thyroid scan/ Scintigraphy/ Isotope scan
 Technetium 99m, Thallium 201, Iodine 123,
Iodine 131
 To rule out area of overactivity in thyroid
gland
 To rule out malignancy, metastasis
 To differentiate between cold (non
functional) and hot (functional) nodule of > 5
mm, 80% cold, cold 10-20% chance of
malignancy, hot 1% chance of malignancy
 I 131 scan obtained at 24 hrs, Technetium
99m scan at half an hour................

41.  Serum calcium
 Normal – 8.5-10.5 mg/dl
 Screening test for medullary ca
 For post op thyroidectomy management
 Carcino embryonic antigen (CEA) –
screening test for medullary carcinoma
 Excision biopsy – lobectomy, excision of
isthmus
 Bone scan – bone metastasis
 IDL – vc paralysis
 Barium swallow – obstruction in oesophagus

42.  Echocardiography/ECG
 Blood investigations
 Blood Hb – anaemia
 ESR – malignancy, TB, lymphoma
 Blood sugar – hyperthyroidism
 Serum creatinine - hyperthyroidism

43.  Goitre – ..... Any generalised enlargement of
thyroid gland irresepective of its pathology
 NON TOXIC
 Simple goitre
 Physiological goitre (puberty, pregnancy,
lactation, menopause)
 Diffuse parenchymal goitre
 Colloid goitre
 Solitary nodular goitre
 Multinodular goitre
 Retrosternal goitre

44.  Endemic areas
 Younger age gp
 Etiology
 Iodine def
 Goitrogens
 Anti thyroid drugs
 Genetic
 Pregnancy
 Colloid goitre –whole gland enlarged, soft
and elastic, age 20-30 yrs

45.  Solitary nodular goitre
 Clinically palpable swelling when rest of the gland
not palpable
 Commonest site – at junction of isthmus and one
lateral lobe
 Middle aged females
 Due to hyperplasia of certain regions of thyroid
 C/F – dyspnoea, hoarseness of voice, secondary
thyrotoxicosis, dysphagia, stridor
 Cyst, benign (adenoma), malignant
 MNG
 Age gp 20-40 yrs, F:M 6:1
 Malignancy 8%
 Treatment – partial thyroidectomy

46.  Cold nodules – 20% malignancy
 Cold nodules + semi solid/ solid – 50%
malignancy
 Nodule
 Filled with brown/green/black watery fluid
or jelly like material
 Cholesterol crystals
 Fibrous tissue
 Cystic, can undergo calcification

47.  Retrosternal goitre
 Congenital/acquired (mainly)
 Types
 Substernal – behind the sternum
 Intra thoracic – within thorax
 Plunging – intra thoracic but forced into neck by
raised intra thoracic pressure (on coughing)
 Dyspnoea on lying down on one side only
 Engorged veins over upper part of chest
 X Ray – soft tissue shadow in superior
mediatinum or calcification
 Deviation/compression of trachea
 I 131 scan

48.  Developmental anomaly
 1:10000
 Females
 Only thyroid tissue/additional thyroid tissue
 C/F
 Mass in base of tongue
 If large can cause airway obstruction, difficulty
in swallowing
 Diagnosis – USG, TFT
 D/D – Base of tongue lesions like lymphoma, scc,
lingual tonsil, minor salivary gland tumour,
thyroglossal cyst

49.  Treatment – surgical removal followed by
long term thyroid hormones
(suprahyoid/transpharyngeal)
 Radioactive iodine to ablate the thyroid

50.  Thyrotoxicosis
 Primary
 Secondary
 Hypothyroidism
 Neonates
 Adults
 Thyroiditis
 Acute bacterial
 Viral
 Auto immune
 Chronic bacterial (TB/Syphilis)

51.  PRIMARY THYROTOXICOSIS/GRAVE’S DISEASE
 Diffuse toxic goitre/ exophthalmic goitre
 F:M 5-10:1
 Etiology
 Genetic
 Enviromental
 Malignancy, pituitary tumour
 Thyroiditis
 C/F
 Hyperthyroidism
 Goitre
 Ophthalmopathy
 Dermatopathy

52.  Features of hyperthyroidism – nervousness,
irritability, hyperactivity, heat intolerance,
sweating, weight loss inspite of increased
appetite, diarrhoea, palpitations,
oligomenorrhoea, hot moist palm,
sleeplessness, preference for cold
 Tremors of fingers and tongue, tachycardia,
exophthalmos, lid retraction, periorbital
oedema
 Lab investigations – T3, T4 increased, TSH
decreased

53.  Treatment
 Medical – anti thyroid drugs – Carbimazole
over 18 months
 Relapse in 50% cases
 Surgery – Subtotal Thyroidectomy (after
euthyroid)
 Radioactive iodine

54.  SECONDARY THYROTOXICOSIS
 Plummer’s disease/ nodular toxic goitre
 Elderly women
 In patients with pre existing nodular goitre
 C/F
 Irregular pulse – rate and rythm
 Atrial fibrillations
 Precordial pain
 Exhaustion
 Heart failure
 Palpitation, dyspnoea on exerion, chest pain on
exertion, dysarrythmia
 Thyroid storm – exagerrated state of hyperthyroidism
which is life threatening

55.  Decreased phsiological function of thyroid gland (low
levels of thyroid hormone)
 ADULT HYPOTHYROIDISM/MYXOEDEMA
 Etiology
 Thyroid agenesis
 Iodine deficiency
 Autoimmune disease
 Pendred’s syndrome
 Total/subtotal thyroidectomy
 Radiotherapy to neck
 Radioactive iodine
 Antithyroid drugs like lithium, amiodarone, para
amino salicylic acid
 Goitrogens in diet

56.  C/F
 Fatigue, lethargy, weakness
 Intolerance to cold, preference for heat
 Dry hairy skin
 Coarse and sparse hair
 Rough hoarse voice
 Poor memory and lack of concentration
 Weight gain inspite of loss of appetite
 Hearing loss – SNHL
 Constipation
 Increase need for sleep
 Excessive menstruation
 Bradycardia
 Puffiness of face, hands and feet
 Bradykinesis – delayed ankle reflux

57.  Enlarged palpable thyroid gland
 Diagnosis
 Decrease T3, T4
 Increase TSH
 Thyroid antibodies
 Treatment
 Exogenous thyroid hormones – thyroxine
25,50,100 micro g. Start with lower dosage

58.  NEONATAL HYPOTHYROIDISM/CRETINISM
 1:5000
 Manifests after several weeks of intra uterine life
 Etiology
 Maternal or foetal deficiency of iodine due to inadequate
iodine in mother’s diet
 Anti thyroid drugs to mother
 Radio active iodine to mother
 Agenesis of thyroid in infant
 C/F
 Lethargy
 Stunted growth
 Mental retardation
 Hearing loss
 Myxoedema coma – severe hypothyroidism

59.  CHRONIC LYMPHOCYTIC THYROIDITIS
 MC – Women at menopause (50 yrs)
 Etiology
 Auto immune disease
 Genetic
 C/F
 Enlarged thyroid, soft, rubbery, firm on palpation
 Pain and tenderness
 Hypothyroidism
 Pressure symptoms on oesophagus
 Coughing
 Associated with other conditions like RA, myasthenia

60.  Diagnosis
 FNAC
 T3, T4 decreased, TSH increased
 High titre of antibodies – anti thyroglobulin,
anti thyro peroxidase, anti TSH receptor
 Treatment
 Thyroid supplements

61.  BACTERIAL THYROIDITIS
 Staphylococcus/streptococcus
 Swelling, pain during swallowing, redness
over skin, fever
 Antibiotics, anti inflammatory
 VIRAL THYROIDITIS
 Sub acute thyroiditis/ de quervain thyroiditis
 Endemic goitre areas
 Females
 Middle age (40 yrs)

62.  C/F
 Pain
 Low grade fever
 Thyroid swelling
 Sore throat
 Diagnosis
 ESR raised (>40)
 Increased T3, T4
 Low or normal TSH
 Treatment – oral prednisolone 1mg/kg body
weight tapered later over 4 weeks.....

63.  CLASSIFICATION
 BENIGN – ADENOMAS
 MALIGNANT
 PRIMARY
 ARISING FROM FOLLICULAR CELLS
 WELL DIFF – PAPILLARY CA (60-70%), FOLLICULAR CA
(10-20%)
 UNDIFF – ANAPLASTIC CA (5-10%)
 ARISING FROM PARAFOLLICULAR CELLS – MEDULLARY
CA (5%)
 ARISING FROM LYMPHOID CELLS – LYMPHOMA
 SECONDARY
 METASTASIS - DISTANT
 DIRECT SPREAD FROM LARYNX, POST CRICOID REGION

64.  Iodine deficiency – Follicular Ca due to dietary
deficiency
 Ionizing radiation – Papillary Ca
 Solitary thyroid nodule – 10-20%
 Familial/genetic – Medullary Ca
 Autoimmune disorders – Lymphoma
 Poor prognostic factors
 Age > 45 yrs
 Male gender
 LN, distant metastasis
 Size of tumour > 4 cm
 Poorly differentiated tumours

65.  MC benign thyroid neoplasms
 Types
 Follicular
 Microfollicular
 Hurthle cell
 C/F
 Present as solitary nodule or dominant
nodule in MNG in middle aged females
 Encapsulated, well demarcated tumour
 Rarely toxic
 Not a premalignant condition

66.  Etiology
 Exposure to ionizing radiation
 Can even occur in adequate iodine intake
 60-80%, MC
 Younger age gp 3rd and 4th decade
 Children
 M:F 1:3
 Well diff ca
 C/F
 Firm, non capsulated, hard, non tender slow
growing thyroid nodule/lump in neck for more
than one year involving both thyroid lobes

67.  Types
 Minimal/micro/occult ca - < 1.5 cm, common,
incidental finding on USG
 Intra thyroid ca – within thyroid but > 1.5 cm
 Extra thyroid ca – outside thyroid capsule
 Spread
 Locally to strap muscles, trachea, oesophagus,
RLN
 LN – high incidence level III – VI 40-50%
 Less incidence of distant metastasis (mainly
pulmonary)
 Prognosis – 10 yr survival rate > 90% for
intrathyroid and 60% for extra thyroid

68.  Pathology
 “ orphan annie eyed “ large nuclei
 Laminated calcified “ psammoma bodies” (40-
50%)
 Treatment
 Minimal invasive/ age < 45 yrs – lobectomy/
isthmusectomy with 1 cm margin
 Age > 45 yrs – total thyroidectomy
 Nodal metastasis – selective neck dissection
 Post op radio iodine ablation of residual thyroid
tissue
 Thyroxine supplements to suppress TSH
 Post op RT if doubtful clearance or extensive LN

69.  Etiology
 Low iodine intake
 Middle age 5th – 6th decade
 M:F 1:3
 10-20%
 Well diff ca
 C/F
 New solitary thyroid nodule
 Malignant changes in thyroid swelling of
many years duration
 Capsular invasion

70.  Types
 Minimally invasive
 Widely invasive with distant metastasis
mainly to bone and lungs
 Diagnosis – lobectomy ( to diff from follicular
adenoma)

71.  ONCOCYTIC CARCINOMA
 Sub type of follicular ca
 Age gp – older 6th decade
 M:F 1:2
 Mainly benign
 If malignant – highly aggressive
 More incidence of LN and distant metastasis
 Reduced 10 yr survival rate
 Dont take up radioactive iodine
 Technetium scan for follow up

72.  UNDIFFERENTIATED CA
 Etiology
 Long standing goitre
 < 5%
 M:F 2:3
 Older age gp 60-80 yrs
 h/o pre existing MNG
 h/o previous treated well diff ca
 C/F
 Painful rapid growing, hard, irregular mass fixed
to surrounding structures associated with
referred otalgia, hoarseness of voice, cervical
lymphadenopathy, dysphagia and dyspnoea

73.  Spread
 Local spread to larynx, pharynx, oesophagus,
trachea and neck
 High incidence of LN and distant metastasis
 Poor prognosis – death within few months or 1 yr
 Treatment
 Palliative
 Tracheostomy with division of isthmus if stridor
 RT and CT – limited role only for regression of
tumour but recurrence common

74.  Arise from calcitonin producing parafollicular
cells
 5%
 Located in upper and middle part of gland
 Types
 Familial/hereditary/multifocal
 Less common 20-25%
 Younger age gp
 Females
 Associated with MEN (multiple endocrine
neoplasia) syndrome
 Diarrhoea – 30%, pain, dyspnoea, dysphagia and
hoarseness

75.  MEN II A (sipple’s syndrome)
 Autosomal dominant inheritance associated with
phaeochromocytoma, hyperparathyroidism and
hirschprung disease
 MEN II B
 Rare condition associated with
phaeochromocytoma, hyperparathyroidism,
marafanoid habitus and mucosal neuroma
involving tongue and lips
 Sporadic
 MC 75-80%
 4th decade
 Both sexes equally involved

76.  Tumour markers
 S Calcitonin
 CEA
 RET Protooncogene
 Pathology
 Solid, well circumscribed, non capsulated
 Consists of eosinophil cells
 Spread
 LN metastasis – 50-75%, more in sporadic
 Distant metastasis – lungs, liver, bones, adrenal
glands
 Prognosis – 10 yr survival rate 80%

77.  Treatment
 Total thyroidectomy
 Level VI LN clearance even in N0 neck
 If LN metastasis – II – VI LN clearance
 If inoperable – RT
 Radio active iodine – not much role except
for recurrence.....

78.  Etiology
 Uncommon
 In case of Hashimoto’s autoimmune thyroiditis
(80%)
 Age gp 60-80 yrs
 M:F 1:4
 C/F
 Rapidly enlarging non tender mass associated
with dysphagia, dyspnoea and hoarseness
 More chances of extra thyroidal spread and
distant metastasis
 Non Hodgkin B Cell Lymphoma

79.  Treatment
 Localised – surgery
 RT – main treatment
 CT + RT – advanced
 Doxorubicin + Cisplatin for chemotherapy

80.  2-4%
 Due to metastasis from
 Kidney
 Breasts
 Lungs
 Head and Neck
 Malignant melanoma

81.  I 131
 For radio active ablation of residual thyroid
tissue after surgery
 Complications
 Radiation toxicity
 Withdrawl of thyroxine for 6 weeks
 Thyroxine supplements
 T4
 To suppress TSH post surgery
 Complications
 Cardiac arrythmias
 Decrease bone density

82.  External beam radiotherapy
 Unresectable tumours
 Recurrence
 Lymphoma
 Chemotherapy
 Inoperable advanced tumours
 If I 131 ablation not possible
 lymphoma

83.  Papillary carcinoma/medullary carcinoma
 N0 – level VI clearance
 Follicular carcinoma
 N0 – no role
 If neck nodes positive
 Selective neck dissection or MRND – sparing
level I, IJV, SCM, and XI CN
 Clearance of level II – VI LN

84.  Indications
 Carcinoma
 Compressive symptoms on trachea, oesophagus, RLN
 Cosmetic
 Types
 Lobectomy/hemithyroidectomy
 Indication – benign tumour, intrathyroid ca
 Complete resection of one thyroid lobe and isthmus
 Sub total thyroidectomy
 Indication – MNG
 B/L resection of more than half of thyroid lobe on
each side (leaving 3 g on each side) and isthmus

85.  Near total thyroidectomy
 Indication - malignancy
 Complete removal of one lobe, isthmus and more
than 90% of other lobe leaving only 1 g behind to
protect parathyroid and RLN
 Total thyroidectomy
 Indication – malignancy
 Complete removal of both side lobe and isthmus
 Isthmusectomy
 Indication
 Small tumour invoving only isthmus
 Diagnostic biopsy
 Complete removal of isthmus

86.  Completion thyroidectomy
 Indication – if HP report of lobectomy turns
out to be malignant with capsular/vascular
invasion
 Conversion of lesser surgery into near total,
sub total or total thyroidectomy

87.  Anaesthesia – GA with endotracheal intubation
 Position – supine with extension of head and
neck by placing sandbag under shoulder and
head ring under head
 Incision – horizontal 2 finger breadth above
clavicle from one ant border of SCM to other ant
border
 Can be extended post sup to
 Hockey stick incision – for U/L ND
 Modified apron flap – for B/L ND
 Sub platysmal flap elevation – till level of hyoid
bone above and suprasternal notch below

88.  Division of strap muscles – midline vertical incision
dividing sternohyoid and sternothyroid muscles which
are then retracted or resected
 At lower pole
 Identification and ligation of middle thyroid vein
 Identification of parathyroid – if uninvolved preserved
 Identification of RLN in tracheo oesophageal groove
 Identification of ITA – ligated
 Identification of berry ligament – divided
 At upper pole
 Identification of SLN
 Identification and ligation of STA and superior
thyroid vein

89.  Isthmus
 Separation of isthmus from trachea
 Division of isthmus
 Cut surface of isthmus ligated
 Similar procedure on other side
 Required dissection of LN
 Specimen delivered
 Irrigation of wound with saline
 Closure of wound by approximation ofstrap
muscles and platysma with sutures

90.  COMPLICATIONS
 Haematoma and haemorrhage
 RLN injury
 SLN injury
 Chylous fistula
 Pneumothorax
 Wound infection
 Airway obstruction – may need tracheostomy
 Hypoparathyroidism
 Hypothyroidism
 Fluid electrolyte imbalance
 Hypocalcemia
 Anaesthesia complications
 Scar

91.  Hypocalcemia
 Due to removal of parathyroid glands......
 Seen 1-4 days post operatively
 Serum calcium < 8 mg/dl
 C/F –
 Numbness and tingling of lips, hands and feet
 Treatment
 Calcium and vitamin D supplements orally or
IV