Professional Documents
Culture Documents
Thyroid Surgery
Thyroid Surgery
Thyroid Surgery
Women under
treatment with
antithyroid drugs may
give birth to a
Adult hypothyroidism
• The term myxoedema should be reserved for severe thyroid failure
and not applied to the much commoner mild thyroid deficiency.
• The signs of thyroid deficiency are:
• bradycardia;
• cold extremities;
• dry skin and hair;
• periorbital puffiness;
• hoarse voice;
• bradykinesis —slow movements;
• delayed relaxation phase of ankle jerks
• The symptoms are:
• • tiredness;
• • mental lethargy;
• • cold intolerance;
• • weight gain;
• • constipation;
• • menstrual disturbance;
• • carpal tunnel syndrome.
• Comparison of the facial appearance with a
previous photo-graph may be helpful.
The signs
• The facial appearance) is typical, and
there isoften
1. supraclavicular puffiness,
2. a malar flush and a yellow tinge to the
skin.
• • tiredness;
• • emotional lability;
• •heat intolerance;
• • weight loss;
• • excessive appetite;
• •palpitations.
The signs of thyrotoxicosis are:
• tachycardia;
• hot, moist palms;
• exophthalmos;
•lid lag/retraction;
•agitation;
•thyroid goitre and bruit.
The ocular consequences
• proptosis, supraorbital and infraorbital
swelling, and conjunctival swelling and
edema, can be severe.
• The ophthalmopathy is thought to be due
to stimulation of the overexpressed TSH-R
in the retro-orbital tissues of Grave's
patients
WYNE CRITERIA
Dx
1.Thyroid Function test
• T3
• T4
• TSH
2.US
3.CT & MRI ?
Rx
1.Medical
a.betablockers
b. antithyroid
c.iodine
2. Radioisotope I131
3. Surgery; indicated
– obstructive goiter
– have a fear of radioactivit
– are noncompliant
– have had an adverse effect with antithyroid drugs
– pregnant patients or those with a suspicious nodule.
PO complications
• Haematoma
• RLN Paralysis i3% mostly temp for 3 monthes
• Hypothyroidism <0.5%
• HypoparathyroidismRates of postprocedure
hypocalcemia are about 5%, and it resolves in
80% of cases in about 12 months
• Thyrotoxic crisis (storm) is an acute
exacerbation of hyperthyroidism
• Superir LN palsy
• The external branch can run closely adherent to
the superior thyroid artery, and care must be
exercised during dissection in this area. Injury to
the branch causes voice changes, huskiness,
poor volume voice fatigue, and inability to sing at
higher ranges
• RLN Palsy
A wide spectrum of injuries to the voice or
swallowing mechanisms, or to both, can occur
because of the mixed fibers contained within the
nerve.Temporary or permanent voice change
can result and is extremely distressing to the
patient.
The hypermetabolic state
• of hyperthyroidism is clinically manifested as
sweating, weight loss, heat intolerance, and
thirst. Cardiovascular stress can be
demonstrated by high-output cardiac failure,
congestive heart failure with peripheral edema,
and arrhythmias such as ventricular tachycardia
or atrial fibrillation. Gastrointestinal signs may
include diarrhea and electrolyte wasting. The
menstrual cycle can be altered to the point of
amenorrhea. Psychiatric signs may include
altered sleep patterns, emotional mood swings,
fatigue, excitability, and agitation.
LECTURE 2
SOLITARY THYROID NODULE
WORKUP AND DIAGNOSIS OF A
SOLITARY THYROID NODULE
• Management and the ultimate decision to proceed to
surgical intervention after detection of a solitary nodule
depend on the findings of a cost-effective workup and
the prognosis .
• The majority of patients with a solitary thyroid nodule will
have a benign lesion; however, thyroid cancer is a
definite possibility in all patients. Deciding between
conservative management or surgical therapy relies on
careful analysis of the clinical findings, assessment of
images, and interventional diagnostic methods
Clinical Features
• The annual incidence is about 3.7 per 100 000 of the popu-lation
and the sex ratio is three females to one male. The mortality should
only be of the order of 2—3 per cent. The commonest
presentingsymptom is a thyroid swelling (Fig. 44.36) and a 5-year
history is far from uncommon indifferentiated growths. Enlarged
cervical lymph nodes may be the presentation of papillary
carcinoma. Recurrent laryngeal nerve paralysis may be a presenting
feature of locally advanced disease.
• Anaplastic growths are usually hard, irregular and infiltrating. A
differentiated carcinoma may be suspiciously firm and irregular, but
is often indistinguishable from a benign swelling. Smallpapillary
tumours may be impalpable (occult carcinoma) — even when
lymphatic metastases are present (so-called lateral aberrant
thyroid). Pain, often referred to the ear, is frequent in infiltrating
growths.
Diagnosis of thyroid neoplasms
• 2ndaries
Surgical treatment
Anatomy
• The parathyroid glands, four in number, are small, oval in shape,
commonly about 0.5 cm in size, soft, mobile, yellowish brown in
colour and arranged in pairs — most often closely applied to the
thyroid gland, either within or closely applied to its capsule. The
upper pair is more constant in position than the lower: 80 per cent
are found on the posterolateral aspect of the thyroid, immediately
above the termination of the inferior thyroid artery, close to the
cricothyroid articulation. Most of the remaining 20 per cent are
posterolateral to the upper pole of the thyroid lobe. The lower pair is
more variable in position: 40 per cent are found at the lower pole of
the thyroid and 40 per cent are within the thymic tongue (Fig. 45.1).
The remaining 20 per cent are variable in site, most often some
distance lateral to the thyroid, and less often in the mediastinal
thymus a few centimeters below the sternal notch or, very
occasionally, ectopicallv situated near the carotid sheath,
sometimes as high as the carotid bifurcation.
Physiology
• The chief cells of the parathyroids produce parathormone, the hormone being
released directly into the bloodstream. The circulating level of parathormone can be
measured by radioimmuno-assay, which is sufficiently reliable to distinguish between
high and low levels. Facilities for obtaining the estimation are widely available.
• Parathormone:
• •stimulates osteoclastic activity, thereby increasing bone resorption by mobilizing
calcium and phosphate;
• •increases the reabsorption of calcium by the renal tubules, thus reducing the urinary
excretion of calcium;
• •augments the absorption of calcium from the gut;
• •reduces the renal tubular reabsorption of phosphate, thus promoting phosphaturia.
• Parathyroid hormone is an 84 amino acid peptide which has a short half-life before
degradation into amino-terminal and carboxy-terminal fragments, with the amino-
terminal fragment having biological activity. The amino-terminal fragment retains
biological activity with a half-life of minutes and the carboxy-terminal fragment a half-
life of hours. Available assays measure either the intact hormone, the amino- or
carboxy-terminal or ‘mid-portion’ fragments.
• Calcitonin(Copp) is secreted by the parafollicular cells of the thyroid (thyrocalcitonin).
It lowers the serum calcium and affects calcium storage in bones; quite the opposite
action of parathormone.
Parathyroid hormone-related protein
(PTH-rP)
• is a hypercalcaemic factor with similar
bioactivity to that of parathyroid hormone.
Since its isolation from cancer cell lines
and carcinoma of the breast, strong
evidence has emerged that it is an
important hormonal mediator of cancer-
associated hypercalcaemia in patients
with solid tumours. Plasma PTH-rP 1—86
concentrations may be measured by a
two-site immunoradiometric assay.
Hypoparathyroidism
• The first symptoms are tingling and numbness in the face, fingers
and toes. In extreme cases, cramps in the hands and feet are very
painful; the extended fingers are flexed at their
metacarpophalangeal joints, with the thumb strongly adducted (Fig.
45.3); the toes are plantar-flexed and the ankle joints extended —
the so-called carpopedal spasm. Spasm of the muscles of
respiration results in not only pain and stridor, but also dread of
suffocation. In infancy, the symptoms of tetany may be mistaken for
epilepsy, although there is no loss of consciousness.
• Latent tetany may be demonstrated by the following.
• • Chvostek’s sign. Tapping over the branches of the facial nerve at
the angle of the jaw will produce twitching at the corner of the
mouth, the ala of the nose and the eyelids.
• • Trousseau’s sign. A sphygmomanometer cuff applied to the arm
and inflated above the systolic blood pressure for not more than 2
minutes will produce carpal spasm.
Treatment