medical and surgical approaches in the management of patients with thyroid, parathyroid, and adrenal diseases

1. THYROID,
PARATHYROID,
& ADRENAL GLANDS
REI KRISTOFFER C. UBINA
Junior Intern
St. Paul University Philippines

2. OBJECTIVES
• Review the embryology, histology, anatomy, and
physiology of the thyroid, parathyroid, and adrenal
glands
• Approach history and physical examination of patients
with thyroid, parathyroid, or adrenal pathology
• Discuss diagnostic investigations for thyroid, parathyroid,
and adrenal diseases
• Discuss the medical and surgical approaches in the
management of patients with thyroid, parathyroid, and
adrenal diseases

3. THETHYROID GLAND

4. THYROID EMBRYOLOGY
• 3rd week – arises as an
outpouching of the
primitive foregut
• 5th week – paired lateral
anlages fuse with the
median anlage
• 8th week – thyroid
follicles initially
apparent

5. THYROID EMBRYOLOGY
• Medial anlage – endoderm cells
• Lateral anlages – neuroectodermal in origin

6. THYROID EMBRYOLOGY
• Thyroglossal duct – epithelial-lined tube

7. THYROID EMBRYOLOGY
• Developmental Abnormalities
• Thyroglossal duct cyst and sinus
• Lingual thyroid
• Ectopic thyroid
• Pyramidal lobe

8. THYROID ANATOMY
• Brown
• Firm
• Located posterior to the
strap muscles
• Weighs approximately
20 g

9. THYROID ANATOMY

10. THYROID ANATOMY

11. BLOOD SUPPLY
• Superior thyroid arteries
• Inferior thyroid arteries
• Thyroidea ima

12. VENOUS DRAINAGE
• Superior thyroid vein
• Middle thyroid vein
• Inferior thyroid vein

13. INNERVATION
• Recurrent laryngeal
nerve

14. LYMPHATIC SYSTEM

15. THYROID HISTOLOGY
• Divided into lobules
that contain 20 to 40
follicles
• Spherical and average
30 µm in diameter

16. FOLLICLES
• Lined by cuboidal
epithelial cells
• Contains a central
store of colloid

17. PARAFOLLICULAR CELLS
• C cells
• Contain and secrete
calcitonin

18. THYROID PHYSIOLOGY
• Iodine metabolism
• Thyroid hormone synthesis, secretion, and
transport

19. THYROID PHYSIOLOGY

20. THYROID PHYSIOLOGY

21. CASE
• A 29-year old female was referred to a Head &
Neck clinic for the evaluation of a thyroid nodule.
Patient reports that this nodule was found
incidentally while she was getting ready for work
one morning.
• She went to her private medical doctor, who
ordered a thyroid ultrasound, which
demonstrated a 2-cm nodule in the right lobe of
the thyroid.

22. QUESTION
• After thorough history and physical examination,
what would you order first for this patient?
A.Thyroid function tests (TSH,T4)
B. CT neck
C. MRI neck
D. Radioactive Iodine uptake scan
E. Any of the above

23. QUESTION
• After thorough history and physical examination,
what would you order first for this patient?
A.Thyroid function tests (TSH,T4)
B. CT neck
C. MRI neck
D. Radioactive Iodine uptake scan
E. Any of the above

24. TESTS OFTHYROID FUNCTION
• SerumTSH (0.5-5 µU/mL)
• T4 (55-150 nmol/L)
• T3 (1.5-3.5 nmol/L)
• TRH
• Thyroid antibodies
• Serum thyroglobulin
• Serum calcitonin (0-4 pg/ml)

25. QUESTION
• What would you order first for this patient?
A.Thyroid function tests (TSH,T4)
It is important to first establish the patient’s
thyroid function.
At this point, you should also obtain Fine Needle
Aspiration (FNA) with ultrasound guidance, if
necessary, to obtain cells for cytopathology.

26. PATIENT HISTORY
• Family history of thyroid disease or thyroid cancer?
• Familial syndromes (MEN)
• Personal history of radiation to head/neck
• Increased risk of thyroid cancer
• Hoarseness, SOB, difficulty swallowing
• Compressive symptoms of thyroid goiter

27. CASE
• Patient reports that her voice seems to have
become slightly more “husky” lately. She recalls
only occasional discomfort with sensation that
something is “pushing” in.
• Denies shortness of breath
• Denies family history of thyroid cancer
• Denies personal history of radiation therapy or
thyroid or any other type of cancer

28. PHYSICAL EXAMINATION
What components of the physical examination are
critical for this patient?

29. PHYSICAL EXAMINATION
What components of the physical examination are
critical for this patient?
• Full head and neck exam to look for any
“lumps or bumps”
• Palpate for lymphadenopathy
• Palpate thyroid for nodularity, firmness, or
hard masses
• Fiberoptic or direct laryngoscopy to evaluate
vocal cord function

30. CASE
• On physical examination, you palpate a grossly
enlarged thyroid gland with a 2-cm dominant
nodule on the right thyroid lobe.
• You discover the following findings on fiberoptic
exam:
Upon inspiration:
symmetric bilateral
vocal fold abduction
Vocal folds
(true cords)
False vocal folds
Base of tongue/lingual tonsil
trachea
Epiglottis
Opening of esophagus
View on laryngoscopy
anterior

31. QUESTION
• Patient is sent for labs as well as FNA. Patient
returns to the clinic the following week with FNA
report reading “follicular cells, cannot rule out
follicular neoplasm”. Is surgery indicated for this
patient at this time?
• Yes
• No

32. QUESTION
• Patient is sent for labs as well as FNA. Patient
returns to the clinic the following week with FNA
report reading “follicular cells, cannot rule out
follicular neoplasm”. Is surgery indicated for this
patient at this time?
• Yes
• No

33. EXPLANATION
• Surgery is indicated. Follicular cells on FNA can be a
benign finding or may indicate follicular carcinoma.

34. DIAGNOSTIC INVESTIGATION

35. ETIOLOGIES OFTHYROID NODULES
• Benign
• Benign thyroid cysts (degenerated nodules)
• Colloid nodules
• Multinodular goiter

36. ETIOLOGIES OFTHYROID NODULES
• Malignant
• Papillary carcinoma
• Follicular carcinoma
• Hurthle cell tumor
• MedullaryThyroid Carcinoma
• Anaplastic Carcinoma
• Lymphoma of thyroid

37. MALIGNANTTHYROID DISEASES

38. TESTS
• CBC, Chemistry
• Thyroid function (TSH, freeT4)
• Parathyroid hormone (PTH)
• Coagulation studies (INR, PTT)
• FNA of nodule (+/- Ultrasound guidance)
• CT Neck for surgical planning, if appropriate

39. THYROID IMAGING
• Radionuclide Imaging
• Iodine 123 (123I)
• Iodine 131 (131I)
• TechnetiumTc 99m
pertechnetate
(99mTc)

40. THYROID IMAGING
• Ultrasound
• Computed tomography
• Magnetic resonance
imaging
CT scan demonstrating large right thyroid
mass causing tracheal deviation to left

41. BENIGNTHYROID DISORDERS
• Hyperthyroidism
• Hypothyroidism
• Goiter

42. HYPERTHYROIDISM

43. HYPOTHYROIDISM

44. GOITER

45. TREATMENT
Medical Management
• Involve endocrinology early to assist in
management
• Thyroid hormone replacement
(Levothyroxine) for hypothyroidism
• Thyroid suppression for hyperthyroidism
• I-131 for medical thyroid ablation
• Observation for benign nodules

46. TREATMENT
Surgery
• Failure of medical management
• Malignancy or concern for malignant
potential
• Symptom management

47. INDICATIONS FORTHYROIDECTOMY
• Hyperthyroidism (Grave’s) not
responsive to medical therapy with
ophthalmic symptoms
• Malignancy (confirmed or high
suspicion based on history and/or
FNA)
• Goiter with compressive symptoms
• Large thyroid nodule (>2cm) that is
unable to be adequately sampled by
FNA (sampling error due to large area
of nodule and risk of combination of
benign and malignant cells)

48. THYROID SURGERY

49. THYROID SURGERY

50. THYROID SURGERY

51. THYROID SURGERY

52. THYROID SURGERY

53. THYROID SURGERY

54. THYROID SURGERY

55. TREATMENT
Post-surgical therapy
• I-131 : Radioactive iodine ablation may be
indicated postoperatively for any residual
malignancy
• Thyroid hormone replacement after total
thyroidectomy
• Calcium replacement
• Surgery to thyroid/parathyroid bed

56. THE PARATHYROID GLAND

57. PARATHYROID EMBRYOLOGY
• Superior parathyroid
glands – derived from
the fourth branchial
pouch
• Inferior parathyroid
glands – arise from the
third branchial pouches

58. PARATHYROID EMBRYOLOGY

59. PARATHYROIDANATOMY
• Four parathyroid glands
• Gray
• Semitransparent in newborns
• Golden yellow to light brown in adults
• Ovoid
• 7 mm
• 40-50 mg each

60. PARATHYROID PHYSIOLOGY
• Chief cells –
produce PTH
• Oxyphil cells
• Water-clear cells

61. PARATHYROID PHYSIOLOGY
• Calcium homeostasis

62. PARATHYROID
PHYSIOLOGY
• Parathormone
• Calcitonin
• Vitamin D

63. PARATHYROID DISORDERS
• Hyperparathyroidism
• Hypoparathyroidism
• Parathyroid carcinoma
• Parathyromatosis

64. DIAGNOSTIC INVESTIGATION

65. PARATHYROID SURGERY

66. PARATHYROID SURGERY

67. PARATHYROID SURGERY

68. Care of Patients with
Adrenal Gland Problems

73. Adrenal Cortex: Steroid Hormone
Production

74. Adrenal Gland Hypofunction
• Adrenocortical steroids may decrease as a result of
inadequate secretion of ACTH
• Dysfunction of the hypothalamic-pituitary control
mechanism
• Direct dysfunction of adrenal tissue

75. Effect of Insufficiency of
Adrenocortical Steroids
• Loss of aldosterone and cortical action
• Decreased gluconeogenesis
• Depletion of liver and muscle glycogen
• Hypoglycemia
• Reduced urea nitrogen excretion
• Anorexia and weight loss
• Potassium, sodium, and water imbalances

76. Addison’s Disease
• Primary
• Secondary:
• Sudden cessation of long-term high-dose glucocorticoid therapy

77. Acute Adrenal
Insufficiency/Addisonian Crisis
• Life-threatening event in which the need for cortisol and
aldosterone is greater than the available supply
• Usually occurs in a response to a stressful event

78. Patient-Centered Collaborative
Care
• Assessment
• Clinical manifestations

79. Assessment
• Psychosocial assessment
• Laboratory tests
• Imaging assessment

80. Adrenal Gland Hyperfunction
• Hypersecretion by the adrenal cortex results in Cushing’s
syndrome/disease, hypercortisolism, or excessive
androgen production

81. Pheochromocytoma
• Hyperstimulation of the adrenal medulla caused by a
tumor
• Excessive secretion of catecholamines

82. Hypercortisolism (Cushing’s
Disease)
• Etiology
• Incidence/prevalence
• Patient-centered collaborative care
• Assessment:
• Clinical manifestations—skin changes, cardiac changes,
musculoskeletal changes, glucose metabolism, immune changes

83. Hypercortisolism
Cushing’s Disease
• Psychosocial assessment
• Laboratory tests—blood, salivary and urine cortisol levels
• Imaging assessment

84. Hypercortisolism: Nonsurgical
Management
• Patient safety
• Drug therapy
• Nutrition therapy
• Monitoring

85. Hypercortisolism: Surgical
Management
• Hypophysectomy
• Adrenalectomy

86. Hyperaldosteronism
• Increased secretion of aldosterone results in
mineralocorticoid excess.
• Primary hyperaldosteronism (Conn's syndrome) is a result
of excessive secretion of aldosterone from one or both
adrenal glands.

87. Patient-Centered Collaborative
Care
• Assessment
• Most common issues—hypokalemia and elevated blood
pressure

88. Interventions
• Adrenalectomy
• Drug therapy
• Glucocorticoid replacement
• When surgery cannot be performed—spironolactone
therapy

89. Pheochromocytoma
• Catecholamine-producing tumors that arise in the
adrenal medulla
• Tumors produce, store, and release epinephrine and
norepinephrine

90. Patient-Centered Collaborative
Care
• Assessment
• Interventions:
• Surgery is main treatment.
• After surgery, assess blood pressure.