Clinical Anatomy of the

Neck B
Thyroid
Salivary
Lymph nodes
THYROID DISEASE—BENIGN

thyroid goitre,
hypothyroidism
hyperthyroidism
 Goiter

Associated with pendred syndrome and sensory neural deafness

 Thyroid gland: Anatomy
It consists of right and left lobes connected by a narrow isthmus.
It is surrounded by a sheath derived from the pretracheal layer of deep fascia. The sheath
attaches the gland larynx and trachea.
Each lobe is pear shaped, its base lies below at the level of the fourth or fifth tracheal ring , its
apex directed upward as far as the oblique line on the lamina of the thyroid cartilage.
The isthmus extends across the midline in front of the 2,3,and 4th tracheal ring .
A pyramidal lobe is often present , and it project upward from isthmus usually to the left of the
midline.
Blood supply
1- superior thyroid artery branch of external carotid artery .
2- inferior thyroid artery branch of thyrocervical trunk .
3- thyroid ima artery if present branch of brachiocephalic artery or arch of aorta ,it ascend in
front of the trachea to the isthmus.
Venous drainge to
1- superior and middle thyroid veins which drains into internal jugular vein and the inferior
thyroid veins which drain into the left brachiocephalic vein
Lymph drainage
1- mainly to deep cervical lymph nodes
2- a few to the paratracheal nodes
Nerve supply
Superior , middle and inferior cervical sympathetic ganglia.
 parathroid glands
Parathyroid glands are ovoid bodies measuring about 6 mm long in their great diameter.-
- they are 4 in number and are closely related to the posterior border of the thyroid gland, lying -
within its fascial capsule.
the two superior parathyroid glands are the more constant in position and lie at the level of -
the middle of the posterior border of the thyroid gland.
The two inferior glands usually lie close to the inferior poles of the thyroid glands. They may lie -
within the fascial sheath , embedded in the thyroid substance , or outside the fascial sheath.
Sometimes , they are found some distance caudal to the thyroid gland even in the superior
mediastinum in the thorax ‫متغيرة املوقع صعبه التمييز‬
Blood supply-
From superior and inferior thyroid artery-
Venous drainage to the superior , middle and inferior thyroid veins-
Lymph drainage-
Deep cervical and paratracheal lymph nodes-
Nerve supply-
Superior or middle cervical sympathetic ganglia. -
 Classification of goitre
goitre ‫ نسميه‬Thyroid gland ‫اي توسع بال‬

• Simple (non toxic) Diffuse, nodular, multinodular, and recurrent •

nodular.
Mean increase in thyroid hormones
• Toxic Diffuse, nodular, multinodular, and recurrent nodular. •
• Inflammatory Hashimoto’s, De Quervain’s, Reidel’s thyroiditis. •
• Neoplastic Benign and malignant. •
• Rare goitres TB, amyloid, syphilis, HIV and lithium •
Thyroid Physiology
Hypothalamus-Pituitary-Thyroid Axis

Thyrotropin releasing hormone

Thyroid stimulating hormone

T3 , T4
Thyroid hormone synthesis, metabolism
and action
 Iodine enters thyroid gland and is used for T3 and T4
production

 Hormones are released from the thyroid and vast

majority are protein bound (TBG) and deposited in
peripheral cells Thyroxine binding globulin

 T4 has 4 iodine atoms, removal of one produces T3

 Total= Bound to TBG Thyroxine binding globulin

 Free= Unbound
 T3 & T4
 Facilitate normal growth and
development
 Increase metabolism
 Increase catecholamine effects

TSH

 Most useful marker of thyroid hormone

function
 Released in a pulsatile diurnal rhythm-
highest at night
 Hypothyroidism
Insufficient thyroid hormone •

1.Primary: thyroid gland failure

2.Secondary: pituitary gland failure
3.Tertiary: hypothalamus failure •
 Hypothyroidism Causes

 Primary hypothyroidism
Present in sea fishes  Iodine deficiency- most common cause worldwide
 Congenital
 Autoimmune mediated
Hashimoto’s thyroiditis- B lymphocytes invade thyroid
 Iatrogenic- post-thyroidectomy or radio-iodine
treatment
 Drug-induced – Anti-thyroid, lithium, amiodarone antiarrhythmic medication
 Severe infection
 Trauma to thyroid/pituitary/hypothalamus
 Pituitary tumour
 Hyperthyroidism Causes
 Hyperthyroidism (thyrotoxicosis) is excess thyroid
hormone

 1.Autoimmune
 Graves Disease (76%)
 F>M, age 20-40
 IgG auto antibodies bind TSH receptors T3 & T4
 Leads to gland hyper function
The problem in thyroid gland lesion that causes abnormal excessive secretion of T3 and T4
 2. Toxic adenoma and toxic multinodular goitre
 3. Viral Thyroiditis (de Quervain’s)
 Fever and ESR- self limiting Firm sensation and pain
Erythrocyte sedimentation rate
 4.Exogenous Iodine
 5.Neonatal thyrotoxicosis
 6.Drugs- Amiodarone
 7.TSH secreting pituitary adenoma (rare)
Investigating Thyroid Disease

 TSH- first thing you assess

 Normal range 0.5-5 U/ml
 Supressed= Hyperthyroid
 Elevated= Hypothyroid

 If TSH abnormal request Free T4

 Elevated= Hyperthyroid
 Suppressed= Hypothyroid
 Thyroid ‫ عالي بس من يروح يحفز ال‬TSH ‫هنا ال‬
‫ حتى تفرز هورموناتها مجاي تتحفز يعني ما‬gland
‫تستجيب فاملشكله بيها ومن مجاي تفرز وما تستجيب‬
Pituitary ‫ لل‬negative feedback ‫راح يصير‬
‫ لذلك يكون عالي هنا‬TSH ‫ حتى تزيد افراز ال‬gland
Investigations – TFTs
‫هنا العكس جاي يصير‬

- +
TSH
- +
TSH
TSH TSH

- +
-
+
T3, T4 T3, T4
T3, T4 T3, T4
Hyperthyroidism due to
secondary hyperpituitarism
Hypothyroidism Hyperthyroidism Hypopituitarism TSH secreting
Secondary hypothyroidism tumour
↑TSH; ↓T4,T3 ↓TSH; ↑T4,T3 ↓TSH; ↓T4,T3 ↑TSH; ↑T4,T3
 Investigations – Other tests

 Bloods
 Thyroid auto-antibodies
 Anti thyroid peroxidase antibodies
 TSH receptor antibodies – Graves’ disease
 USS Thyroid- can detect nodules >3mm
 FNAC
 Isotope scan
 CXR- retrosternal expansion or tracheal
compression
 Investigating Thyroid cancers
 Serum calcitonin & CEA (CarcinoEmbryonic Antigen ) in Medullary
cancer
 Radioactive iodine scan
 Ultrasound
 FNA
 CT scan- detects metastases
 MRI and PET scans- distant metastases
 Treatment

Medical and /or surgical

The indications for surgery are:
• Suspected malignancy.
• Cosmetic reasons.
• Tracheal or oesophageal compression.
• Thyrotoxicosis.
 Types of surgery

The following operations can be performed on the thyroid gland:

• Lumpectomy.
• Hemithyroidectomy (total lobectomy).
• Subtotal thyroidectomy.
• Near-total or total thyroidectomy.
 Management

There are a number of treatment modalities for thyroid malignancy


Surgery.
Radio-active iodine.
External beam radiotherapy.
Hormonal manipulation.
Chemotherapy
 *** e.g. :Treatment: Total thyroidectomy & wide LN clearance
 RAI ablation for papillary & follicular
Salivary glands
 Salivary glands
Salivary glands:
are composed of 4 major
glands, in addition to minor
glands.

Major: Minor:
•2 parotid glands. •Multiple minor
•2 submandibular glands
glands
•2 Sublingual glands .
Important structure that run through the parotid
gland:

Branch of facial nerve.

Terminal branch of external carotid artery that
divided into maxillary & superficial temporal artery.
The retromandibular vein ( post. Facial ).posterior facial vein
Intraparotid lymph node.
 1.THE PAROTID DUCT:

• Stensen’s duct is 5 cm long.

•open opposite the second upper

molar tooth
It’s paired of gland that lie below the mandible on either side. •
Has 2 lobes, superficial & deep. •
Warthon’s duct, drained submandibular gland that opens into anterior •
floor of mouth.
Anatomical relationship:
Lingual nerve.
Hypoglossal nerve.
Anterior facial vein.
Facial artery.
Marginal mandibular branch of facial nerve.
When do surgery in submandibular gland should be careful about marginal
mandibular branch of facial ner ve if it damage it causes the lips to drop
• Lie on the superior surface of the mylohyoid
muscle and are separated from the oral cavity
by a thin layer of mucosa.

• The ducts of the sublingual glands drained

by 8-20 excretory ducts called
the ducts of Rivinus .
 About 450 lie under the mucosa
 They are distirbuted in the mucosa of the lips, cheeks, palate, floor
of mouth & retromolar area
 Also appear in oropharyanx, larynx & trachea
 SALIVA - Functions
Epithelial lubrication
PROTECTION For tooth: Rinsing

ALIMENTARY Food approval: taste, texture

Mastication
Digestion
MATERIALS
Swallowing Water
OTHER Vocalization Mucins (glycoproteins)
Antibodies IgAs

Radiotherapy in thyroid gland tumour treatment side effect is

Lysozyme
Dry mouth because radiotherapy causes damage to salivary glands
Called Xerostomia Amylase
 Salivary Gland Diseases
1.Functional disorders •
Sialorrhea (Increase in saliva flow) Normally occurs in children
Xerostomia (Decrease in saliva flow)
2.Obstructive disorders •
stone (Sialolith) Most commonly in submandibular gland because the duct lies
above the gland so the secretion occurs against the gravity.
Mucocel (ranula) Then sublingual then parotid gland

3.Infectious disorders •
Acute Sialadenitis – Infectious( viral / Mumps, or Bacteria/ staphylococcal •
Chronic Sialadenitis: tuberculosis •
4.Neoplastic disorders •
. Benign. Pleomorphic adenoma, Warthin’s tumour
Malignant. Adenoid cystic carcinoma, adenocarcinoma
 Neoplastic disorders of salivary glands:
Role of eight
* 80% of all salivary tumours are in the parotid, 80% of parotid
tumours are benign and 80% of the benign tumours that arise in the
parotid are pleomorphic adenoma.

One in three tumours arising in the submandibular gland are

malignant

Half
*one in two tumours that arise in the minor salivary glands are
malignant
It’s either:
•Extravasation cyst result from
trauma to overlying mucosa.

•Mucous retention cyst in the floor

of the mouth due to obstruction.

•RANULA extravasation cyst that

arises from sublingual gland.
• It is rare form of mucus retention cyst arise from
both sublingual & submandibular.

• The mucus collects around the gland &penetrates

the mylohyoid diaphragm to enter the neck.

Pt. presents with

Dumbbell shaped
swelling , soft,
fluctuant & painless
Tumors of minor & sublingual salivary gland are extremely rare.

80% are malignant.

Most common site: upper lip, palate & retromolar region.