Thyroid diseases
Embryology <ul><li>1 st  of the body’s endocrine glands to develop (28 th  day of gestation) </li></ul><ul><li>Originates ...
<ul><li>As the thyroid start to descent it is still connected to the tongue via thyroglossal duct </li></ul><ul><li>This t...
<ul><li>An ectopic thyroid gland  </li></ul><ul><li>Failure of thyroid to descend-> lingual thyroid </li></ul><ul><li>Inco...
<ul><li>If thyroglossal duct does not atrophy -> remnant can manifest clinically as thyroglossal cyst, midline mass track ...
<ul><li>Parafollicular ( C cells), special subset of cells within thyroid gland-> secrete calcitonin  </li></ul><ul><li>Ar...
Anatomy <ul><li>Under middle layer of deep cervical fascia, thyroid has an inner true capsule -> thin & adheres closely to...
<ul><li>Anterior  suspensory ligament extends from  superior-medial  aspect of each thyroid lobe to cricoid & thyroid cart...
<ul><li>Lateral surface of the gland is covered by sternothyroid m. </li></ul><ul><li>Sternohyoid & sternothyroid ms. are ...
Arterial spply <ul><li>Superior & inferior thyroid as. & occasionally thyroid ima a.  </li></ul><ul><li>Thyroid ima is a s...
<ul><li>Inferior thyroid a. -> arises from thyrocervical trunk </li></ul><ul><li>Closely associated with recurrent larynge...
<ul><li>Follicular cells   synthesize & secrete 2 major hormones (T3 & T4) ->collectively referred to as thyroid hormone <...
Investigations & Treatment
Blood tests <ul><li>Thyroid Function Test </li></ul><ul><li>   mesure serum TSH </li></ul><ul><li>   free T 4   &   free...
X- rays <ul><li>Plain radiograph  </li></ul><ul><li>chest & thoracic inlet  </li></ul><ul><li>… .to detect retrosternal th...
AP CXR with large retrosternal  Goitere  CT scan
Ultrasound <ul><li>Used to establish the size & shape of the gland . </li></ul><ul><li>May indicate if nodules are single ...
Radioisotpe scan <ul><li>Single or multiple nodules . </li></ul><ul><li>Over functioning (hot nodules) or non-functioning ...
How?? <ul><li>An injected or inhaled or ingested compound labelled with a suitable radionuclide is concentrated in the org...
FNA <ul><li>Should be performed in the investigation of all thyroid nodules. </li></ul><ul><li>Distinguish between a solid...
How?? <ul><li>A 21 G needle attached to a syringe ,flushed with saline. </li></ul><ul><li>is passed several times through ...
 
Thyroid Disorders
Hypothyroidism <ul><li>Usually due to autoimmune disorder (Hashimoto thyroiditis). </li></ul><ul><li>Investigations.. </li...
<ul><li>Treatment… </li></ul><ul><li>   thyroxine  </li></ul><ul><li>   to render the patient euthyroid  </li></ul><ul><...
Hyperthyroidism <ul><li>It may be caused by … </li></ul><ul><li>   Grave’s disease (autoimmune  thyrotoxicosis) </li></ul...
Graves’ Disease <ul><li>Investigations… </li></ul><ul><li>TSH   </li></ul><ul><li>free T4 &/or T3   </li></ul><ul><li>90...
<ul><li>Treatment… </li></ul><ul><li>Initial treatment.. </li></ul><ul><li>   thyroid uptake blocking drugs </li></ul><ul...
<ul><li>Defenitive treatment.. </li></ul><ul><li>   Radioactive iodine  </li></ul><ul><li>SE: long-term hypothyroidism </...
Multinodular goitre  <ul><li>Two types.. </li></ul><ul><li>non-toxic </li></ul><ul><li>toxic (plummer’s disease) </li></ul...
<ul><li>Treatment… </li></ul><ul><li>non-toxic goitre ….total thyoidoectomy </li></ul><ul><li>if there is …rterosternal ex...
Solitary toxic adenoma <ul><li>Investigations… </li></ul><ul><li>TSH   </li></ul><ul><li>99m TcO 4  thyroid isotope </li>...
Solitary toxic nodule <ul><li>Investigations… </li></ul><ul><li>exclude solitary toxic adenoma (TSH  ) </li></ul><ul><li>...
<ul><li>Treatment… </li></ul>FNA benign Observe Repeat FNA After 6-12months suspicious surgery malignant surgery inadequat...
Mangement of thyroid malignancy <ul><li>Differentiated thyroid carcinoma… </li></ul><ul><li>which include… </li></ul><ul><...
<ul><li>Good prognosis </li></ul><ul><li>Female < 45yrs old </li></ul><ul><li>Male < 40 yrs old </li></ul><ul><li>Tumor < ...
<ul><li>Poor prognosis </li></ul><ul><li>Female > 45 yrs old </li></ul><ul><li>Male > 40 yrs old </li></ul><ul><li>Tumor >...
<ul><li>Undifferentiated thyroid carcinoma (anaplastic) </li></ul><ul><li>Treatment… </li></ul><ul><li>Surgery …limited ro...
Medullary thyroid carcinoma <ul><li>Treatment </li></ul><ul><li>Total thyroidectomy with central lymph node clearance </li...
Thyroid lymphoma <ul><li>Diagnosed by FNA or trucut biopsy </li></ul><ul><li>Should be staged with a bone marrow aspirate ...
Complication of thyroid surgery <ul><li>Damage to recurrent laryngeal nerve ….. leading to palsy & causing hoarseness. </l...
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عرض بوربوينت ل thyroid disease

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عرض بوربوينت ل thyroid disease

  1. 1. Thyroid diseases
  2. 2. Embryology <ul><li>1 st of the body’s endocrine glands to develop (28 th day of gestation) </li></ul><ul><li>Originates as a proliferation of endodermal epithelial cells </li></ul>
  3. 3. <ul><li>As the thyroid start to descent it is still connected to the tongue via thyroglossal duct </li></ul><ul><li>This tubular duct later solidifies & obliterates entirely (7-10 wk of gestation) </li></ul><ul><li>Some </li></ul><ul><li>While the gland descent it passes anterior to hyoid bone & then laryngeal cartilages, forming its mature shape & median isthmus </li></ul><ul><li>Completes its descent 7 th wk…immediately anterior to trachea </li></ul>
  4. 4. <ul><li>An ectopic thyroid gland </li></ul><ul><li>Failure of thyroid to descend-> lingual thyroid </li></ul><ul><li>Incomplete descent result in resting point of gland high in the neck or just below the hyoid bone </li></ul><ul><li>Imp. Differentiate between ectopic & thyroglossal cyst -> total thyroidectomy </li></ul><ul><li>Hyoid bone </li></ul><ul><li>Sistrunk procedure </li></ul>
  5. 5. <ul><li>If thyroglossal duct does not atrophy -> remnant can manifest clinically as thyroglossal cyst, midline mass track anywhere from the thyroid cartilage to base of tongue (rupture) </li></ul><ul><li>Pyramidal lobe of thyroid 50%. </li></ul><ul><li>Represents a persistence of inferior end of thyroglossal duct that has failed to obliterate </li></ul>
  6. 6. <ul><li>Parafollicular ( C cells), special subset of cells within thyroid gland-> secrete calcitonin </li></ul><ul><li>Arise from the ultimobranchial body, which is infiltrated by neural crest cells-> last structure derived from pharyngeal pouches </li></ul>
  7. 7. Anatomy <ul><li>Under middle layer of deep cervical fascia, thyroid has an inner true capsule -> thin & adheres closely to gland </li></ul><ul><li>Extension of the capsule ->lobes & lobules. Lobules are composed of follicles (structural units of gland) -> consist of a layer of simple epithelium enclosing a colloid- filled cavity, which contain iodothyroglobulin (precursor of thyroid hormone) </li></ul><ul><li>Epithelial cells: 1) principal (follicular) cells ->formation of colloid </li></ul><ul><li>2) parafollicular (C) cells ->cacitonin </li></ul>
  8. 8. <ul><li>Anterior suspensory ligament extends from superior-medial aspect of each thyroid lobe to cricoid & thyroid cartilage </li></ul><ul><li>Posteromedial aspect of gland is attached to side of cricoid cartilage, 1 st & 2 nd tracheal ring by posterior suspensory (Berry) ligament </li></ul><ul><li>This firm attachment to the laryngoskeleton is responsible for its movement during swallowing </li></ul>
  9. 9. <ul><li>Lateral surface of the gland is covered by sternothyroid m. </li></ul><ul><li>Sternohyoid & sternothyroid ms. are joined in the midline by avascular fascia that must be incised to retract the muscles laterally to access the gland during thyroidectomy </li></ul><ul><li>Should…high in neck cus motor N. supply from ansa cervicalis enters these ms. inferiorly </li></ul>
  10. 10. Arterial spply <ul><li>Superior & inferior thyroid as. & occasionally thyroid ima a. </li></ul><ul><li>Thyroid ima is a single artery which enter the gland from inferior border of isthmus (imp. to consider in tracheostomy-> potential source of bleeding </li></ul><ul><li>Superior thyroid a. ->1 st anterior branch of external carotid a. </li></ul><ul><li>Superior to the superior pole the external branch of superior laryngeal N runs with superior thyroid a </li></ul><ul><li>High ligation of this artery places the nerve at risk of injury -> dysphonia </li></ul>
  11. 11. <ul><li>Inferior thyroid a. -> arises from thyrocervical trunk </li></ul><ul><li>Closely associated with recurrent laryngeal N, relationship is highly variable </li></ul>
  12. 12. <ul><li>Follicular cells synthesize & secrete 2 major hormones (T3 & T4) ->collectively referred to as thyroid hormone </li></ul><ul><li>Thyroid hormone affect all cells within the body except those in brain, spleen, testes & uterus </li></ul><ul><li>Regulated through a feedback loop </li></ul><ul><li>hypothalamus (TRH) </li></ul><ul><li>↓ </li></ul><ul><li>Anterior part of pituitary (TSH) </li></ul><ul><li>↓ </li></ul><ul><li>Thyroid gland (T3 & T4) </li></ul><ul><li>90% T4 & 10% T3..in body tissues T4 ->T3 greatest metabolic effect </li></ul>
  13. 13. Investigations & Treatment
  14. 14. Blood tests <ul><li>Thyroid Function Test </li></ul><ul><li> mesure serum TSH </li></ul><ul><li> free T 4 & free T 3 </li></ul><ul><li>Thyroid Autoantibody estimation . </li></ul><ul><li> Antithyroid Ab  thyroid microsomal Ab (TMAb)  95% of patients with Hashimoto.D </li></ul><ul><li> Thyroglobulin Ab (TGAb)  60% of patients with Hashimoto.D </li></ul><ul><li> Ab against thyroid TSH receptors (TRAbs)  seen in patients with Graves . D </li></ul><ul><li>Serum thyrogloublin …used in follow up of metastatic thyroid carcinoma after tyhyroidectomy </li></ul>
  15. 15. X- rays <ul><li>Plain radiograph </li></ul><ul><li>chest & thoracic inlet </li></ul><ul><li>… .to detect retrosternal thyroid extension ,thyroid calcification ,bony or mediastinal LN & lung metastases </li></ul><ul><li>CT scan… </li></ul><ul><li>… For detecting regional &distant metasasis from thyroid cancr </li></ul><ul><li>MRI </li></ul><ul><li>… .diagnosis of cervical LN metastasis </li></ul>
  16. 16. AP CXR with large retrosternal Goitere CT scan
  17. 17. Ultrasound <ul><li>Used to establish the size & shape of the gland . </li></ul><ul><li>May indicate if nodules are single or multiple. </li></ul><ul><li>It will distinguish between cystic & solid lesions. (intrathyroid lesion) </li></ul>
  18. 18. Radioisotpe scan <ul><li>Single or multiple nodules . </li></ul><ul><li>Over functioning (hot nodules) or non-functioning (cold nodules) </li></ul><ul><li>20% of cold nodules are malignant </li></ul><ul><li>Hot nodules ….rarely malignant </li></ul>Hot n Cold n
  19. 19. How?? <ul><li>An injected or inhaled or ingested compound labelled with a suitable radionuclide is concentrated in the organ under review . </li></ul><ul><li>The emitted radiation is detected by the gamma camera. </li></ul><ul><li>Examples of radionuclides… Technetium 99m ( 99m Tc) </li></ul><ul><li>iodine 131 ( 131 I) </li></ul><ul><li>Krypton ( 81m Kr) </li></ul><ul><li>Gallium 67 ( 67 Ga) </li></ul>
  20. 20. FNA <ul><li>Should be performed in the investigation of all thyroid nodules. </li></ul><ul><li>Distinguish between a solid lesion & a cyst </li></ul><ul><li>If the lesion is solid….cells are sent for cytological examination </li></ul><ul><li>If the lesion is a cyst ….then the fluid can be removed </li></ul>
  21. 21. How?? <ul><li>A 21 G needle attached to a syringe ,flushed with saline. </li></ul><ul><li>is passed several times through the nodule while suction is maintained on the syringe. </li></ul><ul><li>The aspirated cells are then smeared onto slide & wet &/or dry fixed. </li></ul><ul><li>Results of cytology show benign cells, suspicious cells , malignant cells or the specimen is inadequate & consists of red cells only. </li></ul>
  22. 23. Thyroid Disorders
  23. 24. Hypothyroidism <ul><li>Usually due to autoimmune disorder (Hashimoto thyroiditis). </li></ul><ul><li>Investigations.. </li></ul><ul><li> TSH </li></ul><ul><li> free T4 &/or T3 </li></ul><ul><li>Ab : TPO (thyroid peroxidase enzyme) </li></ul><ul><li>antithyroglobulin </li></ul>
  24. 25. <ul><li>Treatment… </li></ul><ul><li> thyroxine </li></ul><ul><li> to render the patient euthyroid </li></ul><ul><li> normal dose 75-150 ug </li></ul><ul><li> TSH cheacked every 12-18 months </li></ul><ul><li> liothyronine(T3) is an alternative </li></ul><ul><li> elderly patient with ischemic heart disease </li></ul><ul><li> starting at 25ug &  dose every fortnight </li></ul><ul><li>(to avoid tachyarrhythmias & cardiac failure) </li></ul>
  25. 26. Hyperthyroidism <ul><li>It may be caused by … </li></ul><ul><li> Grave’s disease (autoimmune thyrotoxicosis) </li></ul><ul><li> Toxic multinodular goiter </li></ul><ul><li> solitary toxic adenoma </li></ul>
  26. 27. Graves’ Disease <ul><li>Investigations… </li></ul><ul><li>TSH  </li></ul><ul><li>free T4 &/or T3  </li></ul><ul><li>90% of patients will have arised TRAb </li></ul><ul><li>70% of patients will have arised TPO </li></ul>
  27. 28. <ul><li>Treatment… </li></ul><ul><li>Initial treatment.. </li></ul><ul><li> thyroid uptake blocking drugs </li></ul><ul><li>eg…carbimazole & propylthyouracil </li></ul><ul><li>SE…neutropenia (sore throat) </li></ul><ul><li>profuse diarrhea </li></ul><ul><li>hepatocellular failure </li></ul><ul><li> B-blockers (propanolol) </li></ul><ul><li>if the patient is symptomatic with sweating ,termor or tachycardia </li></ul><ul><li>Note.. Control of thyrotoxicosis usually takes 6 weeks. </li></ul><ul><li>But maintenance is required for 18 months </li></ul>
  28. 29. <ul><li>Defenitive treatment.. </li></ul><ul><li> Radioactive iodine </li></ul><ul><li>SE: long-term hypothyroidism </li></ul><ul><li>if inappropriate (young children at home)  surgery </li></ul><ul><li> Sugery </li></ul><ul><li>previously…subtotal thyroidectomy </li></ul><ul><li>but…10% recurrent thyrotoxicosis </li></ul><ul><li>70% hypothyroidism in long term </li></ul><ul><li>current surgical tratment of choice….. </li></ul><ul><li>total thyroidectomy & long term thyroxine postoperatively </li></ul>
  29. 30. Multinodular goitre <ul><li>Two types.. </li></ul><ul><li>non-toxic </li></ul><ul><li>toxic (plummer’s disease) </li></ul><ul><li>Investigations… </li></ul><ul><li>TSH  (if toxic MNG) </li></ul><ul><li>FNA…of the dominant nodule if present </li></ul><ul><li>Ultrasound…may confirm multiple nodules </li></ul><ul><li>X-ray of thoracic inlet & CT… </li></ul><ul><li>extent of retrosternal extension & the degree of tracheal deviation & compression . </li></ul>
  30. 31. <ul><li>Treatment… </li></ul><ul><li>non-toxic goitre ….total thyoidoectomy </li></ul><ul><li>if there is …rterosternal extension </li></ul><ul><li>tracheal compression </li></ul><ul><li>cosmetically unacceptable </li></ul><ul><li>toxic MNG.. </li></ul><ul><li>initially…carbimazole </li></ul><ul><li>then ….total thyroidectomy </li></ul><ul><li>or radioiodine </li></ul>
  31. 32. Solitary toxic adenoma <ul><li>Investigations… </li></ul><ul><li>TSH  </li></ul><ul><li>99m TcO 4 thyroid isotope </li></ul><ul><li> solitary hot nodule </li></ul><ul><li>Treatment.. </li></ul><ul><li>initially…carbimazole </li></ul><ul><li>then……thyroid lobectomy or radioactive iodine </li></ul>
  32. 33. Solitary toxic nodule <ul><li>Investigations… </li></ul><ul><li>exclude solitary toxic adenoma (TSH  ) </li></ul><ul><li>FNA…..to exclude malignancy </li></ul><ul><li>other investigations (not routinely required for the majority of STNs) </li></ul><ul><li>ultrasound …discriminate between solid & cysts </li></ul><ul><li>99m TcO 4 thyroid isotope scan….function of nodule </li></ul>
  33. 34. <ul><li>Treatment… </li></ul>FNA benign Observe Repeat FNA After 6-12months suspicious surgery malignant surgery inadequate Repeat FNA Thyroid lobectomy
  34. 35. Mangement of thyroid malignancy <ul><li>Differentiated thyroid carcinoma… </li></ul><ul><li>which include… </li></ul><ul><li>papillary thyroid carcinoma </li></ul><ul><li>follicular thyroid carcinoma </li></ul><ul><li>Treatment….according to the Grading system </li></ul><ul><li>Good prognosis </li></ul><ul><li>Poor prognosis </li></ul>
  35. 36. <ul><li>Good prognosis </li></ul><ul><li>Female < 45yrs old </li></ul><ul><li>Male < 40 yrs old </li></ul><ul><li>Tumor < 5cm </li></ul><ul><li>Minimally invasive follicular carcinoma </li></ul><ul><li>Treatment </li></ul><ul><li>Thyroid lobectomy with subsequent TSH suppression </li></ul>
  36. 37. <ul><li>Poor prognosis </li></ul><ul><li>Female > 45 yrs old </li></ul><ul><li>Male > 40 yrs old </li></ul><ul><li>Tumor >5 cm </li></ul><ul><li>Any patient with distant metastsis </li></ul><ul><li>Extrathyroidal invasion </li></ul><ul><li>Treatment </li></ul><ul><li>Total thyroidectomy </li></ul><ul><li>subsequent radioiodine ( 131 I) </li></ul><ul><li>& TSH suppression with thyroxine </li></ul>
  37. 38. <ul><li>Undifferentiated thyroid carcinoma (anaplastic) </li></ul><ul><li>Treatment… </li></ul><ul><li>Surgery …limited role …… (releive airway obstruction) </li></ul><ul><li>External beam radiotherapy &/or chemotherapy (mostly palliative) </li></ul><ul><li>the vast majority of patients die within 12 months </li></ul>
  38. 39. Medullary thyroid carcinoma <ul><li>Treatment </li></ul><ul><li>Total thyroidectomy with central lymph node clearance </li></ul><ul><li>Postoperatively …thyroxine replacement (but not TSH suppression) </li></ul><ul><li>Postoperative calcitonin measurement is auseful tumor cell marker (follow up) </li></ul>
  39. 40. Thyroid lymphoma <ul><li>Diagnosed by FNA or trucut biopsy </li></ul><ul><li>Should be staged with a bone marrow aspirate & CT scan of chest & abdomen </li></ul><ul><li>Treatment </li></ul><ul><li>If confined to the thyroid alone… </li></ul><ul><li> thyroid lobectomy </li></ul><ul><li> with subsequent adjuvant radiotherapy & chemotherapy </li></ul><ul><li>Otherwise ….chemoradiation alone </li></ul>
  40. 41. Complication of thyroid surgery <ul><li>Damage to recurrent laryngeal nerve ….. leading to palsy & causing hoarseness. </li></ul><ul><li>Damage to external branch of superior laryngeal nerve … leading to palsy & hoarseness </li></ul><ul><li>Hypocalcaemia …caused by damage to parathyroids </li></ul><ul><li>Haemorrhage…causing laryngeal oedema & respiratory compromise. </li></ul>

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