Thyroid presentation

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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

Thyroid presentation

  1. 1. Surgical Management of Benign Thyroid Disease Dr. MTD Lakshan MBBS (Col) MS (OTO) DOHNS FEB ORL-HNS FRCSEd ORL-HNS
  2. 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. 3. Management of Thyroid Enlargement 1. Clinical Evaluation – Malignant hints – Activity hints – Compression hints 2. FNAC 3. USS 4. TSH
  4. 4. Surgical Principles 1. Pre-operative 2. Per-operative 3. Post-operative
  5. 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. 6. FNAC ● Sensitivity for malignancy 65 – 98% ● Specificity 76 – 100% ● Overall accuracy 69 – 97% ● Guided FNAC improves diagnostic yield
  7. 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. 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. 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. 10. CT
  11. 11. Radio Isotope Scanning
  12. 12. Surgical Decision Making ● Nature of the goiter – Degenerative – Neoplastic – Physiological ● Function of the goiter ● Compression and Extension ● Cosmetic ● Patient comorbidities
  13. 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. 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. 15. Surgical Options ● Lobectomy and isthmusectomy ● Total Thyroidectomy
  16. 16. Steps ● Skin incision ● Flaps ● Lateral border and middle thyroid ● Upper pole ● Isthmus ● Lower pole ● Identification of RLN
  17. 17. Basic Sciences - Anatomy
  18. 18. Incision
  19. 19. Flaps
  20. 20. Straps
  21. 21. Upper Pole
  22. 22. Ex. Br. SLN
  23. 23. RLN
  24. 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. 25. Branching of RLN
  26. 26. Wound Closure
  27. 27. Scar Management
  28. 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. 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. 30. New Frontiers
  31. 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. 32. Intra-operative Nerve Monitoring
  33. 33. New Frontiers • MicroPLIC • RhTSH • vMDT
  34. 34. Personal Perspective
  35. 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. 36. MDT South Virtual Head and Neck Cancer Meeting
  37. 37. William Halstead • Sterile Operating Room Concept • Invented Surgical Gloves • Introduced Radical Mastectomy • Performed first emergency blood transfusion • Intestinal Suturing
  38. 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. 39. Thank You

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