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![Nerves relation to thyroid
🠶 Recurrent laryngeal nerve (RLN)
branch of the vagus (cranial nerve [CN] X)
that runs in the tracheoesophageal groove at the
posteromedial aspect of the thyroid
A. On the right: RLN recurs round the subclavian
artery and runs an oblique course, crossing the
inferior thyroid artery before entering the TE
groove.
B. On the left : RLN recurs round the ligmentum
arteriosum in the mediastinum and runs course
parallel to the TE groove.
RLN divides at variable locations into an anterior
branch and posterior branch.](https://image.slidesharecdn.com/thyroidgland6yearfinal2024-241117160250-f61f7c6f/85/thyroid-gland-6-year-final-2024-ppt-ddx-13-320.jpg)
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thyroid gland 6 year final 2024.ppt ddx
- 1. Thyroid Gland AMER YABURUMAILA,MD GENERAL SURGERY SPECIALIST FUCULTY OF MEDICINE -HEBRON UNIVERSITY AL-AHLI HOSPITAL-PALESTINE
- 2. Objectives ❖ Anatomy ❖ Embryology ❖Histology ❖ Metabolism ❖ Physiology ❖ Congenital Anomalies ❖ Hyperthyroidism ❖ Hypothyroidism ❖ Thyroiditis ❖ Thyroid Tumors ❖ Workup of Thyroid Masses
- 3. Embryology ❖The thyroid developsat the base of the tongue between the first and second pharyngeal pouches (foramen cecum) ❖The thyroid gland then descends ❖It remains connected to the floor of the mouth ❖ ❖ A pyramidal lobe (50–80%)
- 6. Anatomy ❖Normal thyroid glandweighs about 15-25 g in adults. ❖• Superior pole of the gland lies lateral to inferior constrictor muscle and posterior to sternothyroid muscle. ❖The inferior pole of thyroid gland extends up to the level of 5th or 6th tracheal rings.
- 7. Anatomy 🠶 The thyroidgland lies deep to the sternothyroid and sternohyoid muscles, 🠶 located anteriorlv in the neck at the level of the C5 - T1 vertebra 🠶 Consists of right and left lobes, anterolateral to the larynx and trachea 🠶 A relatively thin isthmus unites the lobes over the trachea , usually anterior to the second and third tracheal rings, the isthmus may be incomplete
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- 9. Thyroid capsules 🠶 TrueCapsule The thyroid gland is surrounded by a thin fibrous capsule, which sends septa deeply into the gland 🠶 False Capsule derived from the pre-trachial fascia. 🠶 Berry ligament : posteromedial condensation of pre-trachial fascia
- 10. Blood supply ⮚ Superiorthyroid artery The first branch of the external carotid artery, ⮚ Inferior thyroid artery: Rises from the thyrocervical trunk of the subclavian artery ⮚ Thyroidea ima artery: Rises from the aortic arch and connects to the thyroid isthmus inferiorly
- 11. Venous Drainage Superior thyroidveins: drain into the internal jugular vein Middle thyroid vein drains directly into the internal jugular vein Inferior thyroid veins: drain into innomminate vein
- 12. Lymphatic drainage 🠶 centralneck between the carotids and trachea (level 6) 🠶 long the course of the internal jugular vein (levels 2A, 2B, 3, 4) 🠶 in the posterior triangle (level 5)
- 13. Nerves relation tothyroid 🠶 Recurrent laryngeal nerve (RLN) branch of the vagus (cranial nerve [CN] X) that runs in the tracheoesophageal groove at the posteromedial aspect of the thyroid A. On the right: RLN recurs round the subclavian artery and runs an oblique course, crossing the inferior thyroid artery before entering the TE groove. B. On the left : RLN recurs round the ligmentum arteriosum in the mediastinum and runs course parallel to the TE groove. RLN divides at variable locations into an anterior branch and posterior branch.
- 14. Recurrent laryngeal nerve(RLN) D. Function: Anterior branch innervates the adductor muscles(thyroarytenoid, interarytenoid, and lateral cricoarytenoid), and posterior branch innervates the abductor muscles (posterior cricoarytenoid). E. Injury: Most commonly occurs where the nerve crosses the inferior thyroid artery or where it penetrates the cricothyroid membrane 1. Unilateral injury: results in vocal cord paralysis causing significant hoarseness as well as sensory loss resulting in dysphagia and aspiration 2. Bilateral injury: air way obstruction
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- 16. Nerves relation tothyroid Superior laryngeal nerve (SLN): 🠶 Intimately intertwined with the branches of the superior thyroid artery; 🠶 it branches into an internal and an external branch. A. Function: Internal branch of the SLN is sensory to the larynx,and the external branch is motor to the cricothyroid muscle. B. Injury: can be injured during mobilization of the upper pole, especially when the lobe is enlarged
- 17. Ansa Cervicalis (Createdby C1,2,3)
- 18. Relation of thethyroid gland
- 20. ❖ strap musclesof neck “Infrahyoid muscles” ❖ All supplied by Ansa Cervicalis except thyrohyoid (by thyrohyoid branch of the C1 via CNXII)
- 21. Histology of thyroidgland 🠶 Thyroid follicles = follicular cells and large pools of colloid 🠶 Follicular cells produce thyroid hormones and their cell surfaces possess thyroid-stimulating hormone (TSH)receptors 🠶 Thyroglobulin (Colloid) is an inactive storage for the T4 and T3hormones 🠶 Parafollicular cells (C cells) along the periphery of the thyroid follicles secrete calcitonin
- 22. Physiology ❖ Production ofhormones: ❖ Thyroid hormones (Follicular cells) ⮚ Triiodothyronine “T3” ⮚ Tetraiodothyronine “Thyroxine”“T4” ❖ Calcitonin (Parafollicular cells) ⮚ Stimulated by high serum calcium ⮚ Lowers the serum calcium by inhibiting osteoclasts
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- 25. Physiology ❖ The releaseof TH into circulation within 30 minutes of TSH stimulation ❖ 2-3 month supply stored in colloid ❖ In plasma: ⮚ T4 and T3 ⮚ Free T4 and T3 ⮚ Thyroxine binding globulin( 25% saturated) ⮚ If amount o thyroid-binding globulin (TBG) changes, only total T4 changes, not free T4
- 26. Physiology ❖ Cardiovascular system:HR, CO , blood flow, blood volume, widened pulse pressure ❖ Respiratory system: RR , tidal volume ❖ Gastrointestinal system: Increased motility ❖ Central nervous system: Temp. , Nervousness, anxiety ❖ Musculoskeletal system: Increased reactivity up to a point, fine motor tremor ❖ Sleep: Constant fatigue but decreased ability to sleep ❖ Nutrition: BMR increased , need of vitamins, decreased weight
- 27. Common Symptoms ❖Swelling “Goiter” ❖Heator cold- intolerance ❖Weight loss or gain ❖Increased or decreased appetite ❖Cardiovascular and/or respiratory symptoms ❖ Fatigue, weakness, apathy ❖Decreased libido, infertility ❖Menstrual abnormality
- 28. Investigation for thyroid 🠶Laboratory 🠶 Radiology (Neck us/neck ct /chest xray) 🠶 Isotope scan(radioactive iodine) 🠶 FNAC
- 29. Congenital Anomalies ❖ Thyroglossalcyst : (M.C.) ❖ Complete failure to develop ❖ Incomplete descent: Lingual or subhyoid position ⮚ May be the only functioning thyroid ❖ Excessive descent: Substernal thyroid more than 50% bellow the sternum
- 30. Thyroglossal cyst 🠶 Midlinecervical mass between the hyoid bone and the thyroid isthmus 🠶 May be all the thyroid tissue the patient has 🠶 Classically moves upward with protruded of the tongue and swallowing 🠶 Susceptible to infection 🠶 may be premalignant papillary ca 🠶 Tx: resection →(Sistrunk procedure) need to take midportion or all of hyoid bone along with the thyroglossal duct cyst
- 31. Lingual thyroid 🠶 Thyroidtissue that persists in foramen cecum at base of the tongue 🠶 Symptoms: dysphagia, dyspnea, dysphonia 🠶 Is the only thyroid tissue in 70% of patients who have it 🠶 2% malignancy risk 🠶 Tx: thyroxine suppression; abolish with 131I 🠶 Resection if worried about CA or if it does not shrink after medical therapy
- 32. Dyshormonogenesis 🠶 It isan autosomal recessive condition 🠶 is either deficiency of thyroid enzymes (either peroxidase or dehalogenase) or inability to concentrate or to bind or to retain iodine. 🠶 It may be familial and patient presents with large diffuse vascular goiter involving both lobes. 🠶 They respond very well to L-thyroxine and may not require surgery at any time. 🠶 Condition may be associated with congenital deafness which is being called as Pendred’s syndrome.
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- 39. 🠶 is definedas having >50% goitre below the suprasternal notch. 🠶 Primary is rare—1%. Primary retrosternal goitre arises from ectopic thyroid tissue from mediastinum. It gets its blood supply from mediastinum itself, 🠶 Secondary is common. It is extension from the enlarged thyroid from the neck. Usually arises from the lower pole of a nodular goitre. Retrosternal Goitre
- 40. Clinical picture : 🠶 Dyspneaand stridor 🠶 Dysphagia. 🠶 Engorgement of neck veins 🠶 Lower border is not seen on inspection and not felt on palpation. 🠶 Pemberton’s sign is positive.
- 41. Treatment 🠶 Surgical removalof retrosternal thyroid is done through an incision in neck
- 42. Hyperthyroidism ❖ Definition: ⮚ Overactivethyroid, elevated level of TH (T4 and T3) with subsequent signs and symptoms of increased thyroid function
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- 44. Hyperthyroidism ❖ Symptoms: ⮚ CVS ⮚CNS ⮚ Weight and appetite ⮚ Sexual Dysfunction ❖ Sign: ⮚ Neck Swelling ⮚ Bruit ⮚ Exophthalmos ⮚ Pretibial myxedema
- 45. Signs of primarythyrotoxicosis 🠶 Eye manifestation of thyrotoxicosis Exophthalmos Led lag’s sign Led retraction Chemosis Staring look Moebius sign 🠶 Pretibial myoxedema 🠶 Thyroid Acropachy
- 46. Eye manifestation ofgraves disease
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- 49. Hyperthyroidism ❖ DDX: ⮚ Graves’disease (M.C.) ⮚ Toxic nodular goiter ⮚ Toxic thyroid adenoma ⮚ Subacute thyroiditis ⮚ Functional metastatic thyroid cancer ⮚ Struma ovarii ⮚ Jod bestow thyrotoxicosis (hyperthyroidism due to iodine supplement )
- 50. Investigation 🠶 Labs: primaryhyperthyroidism --------Low TSH—High T3 Free T4 secondery hyperthyroidism------High TSH---High T3 F T4 Neck us: according to the cause: diffuse enlargement or nodular cystic or solid radioactive iodine : hot nodule or diffuse uptake
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- 52. HYPERTHYROIDISM TREATMENT 🠶 Medicalmanagement ⮚ Methimazole 1st-line drug Not used in pregnancy • Inhibits peroxidases and prevents iodine–tyrosine coupling • Side effects: cretinism in newborns (crosses placenta), aplastic anemia, agranulocytosis (rare) ⮚ PTU (thioamides) not used 1st line anymore due to hepatotoxicity (especially in children) • Safe with pregnancy • Inhibits peroxidases and prevents iodine–tyrosine coupling • Side effects: aplastic anemia, agranulocytosis (rare)
- 53. Radioactive iodine (I131) Forpatients who are poor surgical risks or unresponsive to methimazole 131I should not be used in children or during pregnancy → can traverse placenta Surgical management Thyroidectomy HYPERTHYROIDISM TREATMENT
- 54. Surgical management Indication: 🠶 Coldnodules, toxic adenomas, Graves’ disease not responsive to medical therapy, 🠶 Pregnant patients not controlled with PTU, 🠶 multinodular goiters with compressive symptoms of suspicious nodule 🠶 toxic multinodular goiters ⮚ Best time to operate during pregnancy is 2nd trimester (↓ risk of teratogenic events and premature labor) ⮚ Subtotal thyroidectomy can leave patient euthyroid
- 55. Surgical management Preop Preparation: 🠶methimazole until euthyroid 🠶 β-blocker 🠶 Lugol’s solution for 14 days to decrease friability and vascularity (start only after euthyroid)
- 56. Thyroid Storm ❖ AKA“Thyrotoxicosis” ❖ Caused by exacerbating factors that precipitate extreme hyperthyroidism in a hyperthyroid patient ⮚ inadequately prepared patient ⮚ Infection ⮚ Labor ⮚ iodide administration ⮚ recent radioablation
- 57. Thyroid Storm ❖ Signsand Symptoms: ⮚ Fever, tachycardia, muscle stiffness or tremor, disorientation/altered mental status ⮚ 50% of patients develop CHF ❖ Mortality rate of 20-40% ❖ Treatment: ⮚ Best way is to AVOID it ⮚ Fluids, ⮚5 P : 1- PTU 2- β-blockers(propranlol), 3-corticosteroids(prednisolone), 4- Lugol’s solution (Potassium iodine), 5-Plasmapheresis
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- 59. Graves’ disease ❖ Autoimmunedisease caused by antibodies that activate the TSHR on the follicular cells ❖ Risk Factors: ⮚ Females ⮚ Age (20-25y) ⮚ Family history ⮚ Associated with Other autoimmune diseases ❖ Diagnosis: ⮚ Thyroid unction tests (high T4 and T3, Low TSH) ⮚ Radioactive iodide uptake test (RAIU) ⮚ Anti TSI Receptor
- 60. Graves’ disease ❖ Treatment: ⮚Medical ⮚ Radioablation ⮚ Surgery ❖ Choosing the treatment depend on the individual case (Age, severity, size, surgical risk, treatment side effects, comorbidities)
- 61. Graves’ disease ❖ Radioablation: ⮚Indicated for small or medium-sized goiters, if medical therapy has failed, or if other options are contraindicated ⮚ Euthyroid within 2 months ⮚ Most patients ultimately require TH replacement ⮚ Complications include exacerbation of thyroid storm initially ⮚ Contraindicated in pregnant patients, women of childbearing age and newborns
- 62. Graves’ disease ❖ Surgicaltreatment: ⮚ Total, Subtotal, Lobe removal ⮚ Indicated when radioablation is contraindicated or if medical management cannot be used ⮚ Patients should be euthyroid prior to excision ⮚ Advantage over radioablation is immediate cure ⮚ Complication: RLN injury, Hypoparathyroidism, persistent hyperthyroidism
- 63. Toxic nodular goiter ❖AKA “Plummer’s Disease” ❖ Etiology: ⮚ hyperplasia secondary to chronic low-grade TSH stimulation ⮚ Diagnosis: Labs, Biopsy radioactive iodine ❖ Treatment: Best is surgical because radioablation has high rate of failure
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- 65. Toxic thyroid adenoma 🠶It is benign functioning thyroid tumour 🠶 usually more than 3 cm in size. 🠶 It usually presents as functioning (toxic) solitary nodule of thyroid. 🠶 It is autonomous functioning tumour; not TSH responding. 🠶 Toxic adenoma secretes large quantity of thyroid hormone suppressing the function of the remaining normal thyroid tissue. 🠶 There are no eye signs and other features of Graves disease. 🠶 It commonly shows higher T 3 levels than T4 . 🠶 US neck, T3 , T4 , TSH and radioisotope scan (shows hot nodule)
- 66. Treatment of toxicadenoma 🠶 Initial control of toxicity with antithyroid drugs 🠶 then hemithyroidectomy is done. 🠶 Radioactive iodine therapy can be used which selectively concentrates and ablates the thyroid adenoma; later remaining normal thyroid starts functioning.
- 67. Hypothyroidism ❖ AKA: Myxedema ❖Definition: Underactive thyroid, low levels of T4 and T3 ❖ Signs and Symptoms: Differ depending on age ⮚ In ants/pediatrics: Characteristic Down’s-like faces, failure to thrive, mental retardation ⮚ Adolescents/adults: ❑ CVS ❑ CNS ❑ Weight and appetite ❑ Sexual Dysfunction
- 68. Hypothyroidism ❖ Less commoncomplaints: Yellow-tinged skin, hair loss, tongue enlargement ❖ Reduced Reflex Relaxation time is a pathognomonic ❖ DDX: ❖ Autoimmune thyroiditis ❖ Iatrogenic: thyroidectomy, radioablation, secondary to anti-thyroid medications ❖ Iodine deficiency
- 69. Hypothyroidism ❖ Diagnosis: byH&E and Labs ❖ low T4 and T3 ❖ Primary VS Secondary ❖ TRH challenge ❖ Thyroid autoantibodies positive in autoimmune thyroiditis ❖ Low hematocrit (Hct.) ❖ Treatment: PO Thyroxine
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- 71. Thyroiditis ❖ Inflammation ofthe thyroid gland ❖ May be infectious or autoimmune ❖ Could cause hyperthyroidism, hypothyroidism or no change.
- 72. Thyroiditis ❖ Types: ❖ Acute ❖Subacute “de Quervain’s Thyroiditis” ❖ Chronic “Hashimoto’s Thyroiditis” ❖ Riedel’s Fibrosing Thyroiditis
- 73. Acute Thyroiditis ❖ Infectiousinflammation of the thyroid ❖ Causes: Strep pyogenes, Staph aureus, Pneumococcus pneumoniae ❖ Risk actors: Female sex, goiter, thyroglossal duct ❖ Signs and symptoms: Unilateral neck pain and fever, euthyroid state, dysphagia ❖ Treatment: IV antibiotics and surgical drainage
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- 75. de Quervain’s Thyroiditis ❖Subacute granulomatous inflammation of the thyroid ❖ Etiology: Post–viral upper respiratory infection ❖ Risk actors: Female sex ❖ Signs and symptoms: Fatigue, depression, neck pain, ever, unilateral swelling of thyroid with overlying erythema, firm and tender thyroid, transient hyperthyroidism usually preceding hypothyroid phase
- 76. de Quervain’s Thyroiditis ❖Diagnosis: Made by history and exam ❖ Treatment: ❖Usually self -limited disease (within 6 weeks) ❖Manage pain with (NSAID) ❖Ten percent o patients with subacute thyroiditis become permanently hypothyroid, require Thyroxine
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- 78. Hashimoto’s Thyroiditis ❖ Etiology:Autoimmune ❖ Risk actors: Down’s syndrome, Turner syndrome, familial Alzheimer’s disease, history of radiation therapy as child ❖ Signs and symptoms: Painless enlargement of thyroid, neck tightness, presence of other autoimmune diseases ⮚ 20% of patients with Hashimoto’s thyroiditis will be hypothyroid at diagnosis. A euthyroid state is more common
- 79. Hashimoto’s Thyroiditis ❖ Diagnosis:Made by history, physical, and labs ❖ Labs: Circulating antibodies against microsomal thyroid cell, TH, T3,T4, or TSH receptor ❖ Pathology: Firm, symmetrical, enlargement; follicular and Hürthle cell hyperplasia; lymphocytic and plasma cell infiltrates ❖ Treatment: ⮚ Thyroid hormone (usually results in regression of goiter) ⮚ With failure of medical therapy, partial thyroidectomy is indicated
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- 84. Riedel’s Fibrosing Thyroiditis ❖Rare, fibrosis replaces both lobes and isthmus ❖ Risk actors: Associated with other fibrosing conditions, like retroperitoneal fibrosis, sclerosing cholangitis ❖ Signs and symptoms: Usually remain euthyroid; neck pain, possible airway compromise; firm, non-tender, enlarged thyroid ❖ Diagnosis: Open biopsy required to rule out carcinoma or lymphoma
- 85. Riedel’s Fibrosing Thyroiditis ❖Pathology: Dense, invasive fibrosis of both lobes and isthmus. May also involve adjacent structures ❖ Treatment: ❖ With airway compromise: Isthmectomy ❖ Without airway compromise: Medical treatment with steroids.
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- 88. ⚫4% of allcancers ⚫More in female Types ⚫Differentiated thyroid carcinoma (DTC) ⚫ 90-95% ⚫ Arises from follicular cells ⚫ Good prognosis ⚫Medullary (6%) ⚫Anaplastic (1%) carcinomas Thyroid cancer
- 89. DTC ⚫ PTC (70-80%) ⚫FTC ⚫ Hurthle cell carcinoma
- 91. ⚫Excellent prognosis ⚫10 ysurvival >95% ⚫Female 30-40y ⚫Prior radiation ⚫FNA – inclusion body, Psammoma bodies , Orphan ann eyes ⚫Cervical LN mets (>50%) ⚫Distant met (lung & bone) ⚫Multicentric ⚫Thyroglobulin use as a tumor marker Papillary thyroid carcinoma
- 92. Unfavorable prognostic factors ⚫Male ⚫ Age >40y ⚫ Size >4 cm ⚫ Poorly differentiated histology ⚫ Capsular invasion ⚫ Extrathyroidal extension ⚫ Regional or distant metastasis
- 94. Treatment ⚫Surgery +/- cervicalLN dissection ⚫RAI ablation ⚫TSH suppression
- 95. ⚫F:M (3:1) ⚫40-60y ⚫Iodine deficiencyarea ⚫FNA is insufficient in diagnosis capsular/vascular invasion ⚫LN mets <10% ⚫Distant mets 10% (lung & bone) ⚫10y survival ⚫<40Y (95%) ⚫40-60y (80%) Follicular thyroid carcinoma
- 97. MTC ⚫ C- cells ⚫80% sporadic ⚫ 20% familial (MEN - RET mutation) ⚫ Distant mets (lung & liver) ⚫ Work-up – calcitonin, Ca, CEA, RET ⚫ FNA: amyloid cells ⚫R/O pheochromocytoma before surgery ⚫Rx: Total thyroidectomy + central LN dissection +/- lateral neck dissection
- 98. Anaplastic carcinoma ⚫ Mostaggressive ⚫ Mortality 100% ⚫ P53 mutation (15%) ⚫ Distant mets (90%) ⚫ FNA : spindle cells
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- 103. MEN SYNDROME ❖ MENII A “Sipple’s Syndrome” ⮚ Medullary Thyroid cancer (100%) ❑ 20% of MTC is due to MEN II ⮚ Parathyroid hyperplasia (50%) ⮚ Pheochromocytoma (33%) ❖ MEN II B: ⮚ Mucosal Neuroma (100%) ⮚ Medullary Thyroid Caner (85%) ⮚ Pheochromocytoma (50%) ⮚ Marfanoid Habitus
- 104. Thyroid Cancer ❖ Workupof a mass: ⮚ Solitary nodule (15% malignant) ⮚ Multiple nodules (5% malignant) ⮚ 90-95% are well differentiated ❖ Start with U/S and Lab tests, if not diagnostic, FNA is used: ⮚ Benign(65%): follow on U/S and labs ⮚ Malignant(15%): Surgery ⮚ Suspicious
- 105. Thyroid Cancer ⮚ Suspicious/Non-diagnostic(15%):obtain 123 I Scan ❑ 85% cold nodule with 10-25% chance of malignancy ❑ 5% hot nodule with 1% chance of malignancy ❑ Surgery if: serial T4 levels fail to regress or future biopsies are worrisome
- 107. ⚫ Hypocalcemia ⚫ Nerveinjury ⚫ Wound hematoma Post-thyroidectomy complications
- 109. Nerve injury ⚫ Recurrentlaryngeal nerve ⚫ Hoarseness ⚫ Bilateral injury may cause airway obstruction ⚫ External branch of Superior laryngeal nerve ⚫ Vocal changes/fatigue ⚫ Poor volume and projection ⚫ Disability to produce high pitches ⚫ Internal branch of Superior laryngeal nerve ⚫ Sensory and motor deficits of the larynx ⚫ Significant risk for aspiration
- 110. Wound hematoma ⚫ Life-threatening ⚫Expanding firm swelling at wound bed ⚫ Immediate opening bedside ⚫ Securing the airway
- 112.