M.E.D.

S 2015

SURGERY LECTURE 1

THYROID GLAND – most common endocrine gland; secretes Thyroid hormone

 Embryology:

o Remnant at the back of the tongue – FORAMEN CECUM

 This is where thyroid cartilage first appears. It descends passing through HYOID BONE and larynx 
THYROID CARTILAGE (final resting stage)

 Thyroid ANLAGE + Thyroglossal duct (connecting through the foramen cecum)

 Normally, as it grows, it is obliterated.

o Persistence    THYROGLOSSAL DUCT CYST

 1st of the MOST COMMON embryologic thyroid gland disorder

 Most common: Found in midline of neck or hyoid bone
 How to know if it’s thyroglossal duct cyst?
 It does NOT move upon swallowing
 PE: Let patient PROTRUDE HIS TONGUE – cyst goes up
 Removal is necessary due to prevent these complications:
1. Infection: URTI especially in children
2. Choking cessation common
 Before removal/ operation:
1. Do UTZ – not to determine diagnosis but to check if the patient
has thyroid gland in the neck, because the duct is part of its
development
 Surgery: CYSTRUNK OPERATION
– Removal of cyst + part of hyoid bone

o LINGUAL THYROID – If thyroid ANLAGE becomes your thyroid

 Confirmatory diagnostic tool: Radiosensitive iodine (TIA)

 Treatment in newborn:
1. TH suppression
2. PARTIAL THYROIDECTOMY – you leave small part of thyroglossal duct cyst

 Adult thyroid gland:

o Blood supply:
 Superior and inferior thyroid arteries (R and L)
 Superior, middle and inferior veins (R and L)

o Innervation:
 RECURRENT LARYNGEAL NERVE
 Closely related to posterior lobe of thyroid gland
 Implication:
1. At risk for nerve injury (Paralysis: affected vocal cord is paramedian)  vocal inlet becomes
small (Hoarseness of voice)
2. Airway obstruction
 Found normally in the tracheoespohageal groove at the base of the larynx
 Innervated: Intrinsic muscles of the thyroid gland
(EXCEPT: Cricopharyngeal muscle)
 DO NOT REMOVE thyroid gland unless you identify first recurrent laryngeal nerve
 M.E.D.S 2015

o Review: Functions of thyroid gland

o Thyroid hormone production from Iodine
 Iodine + TYROSINE = Monoiodine and diodine  T3 and T4
o Laboratory tests:
1. Serum TSH
a. Increased TSH, decreased T3 and T4
b. Decreased TSH, increased T3 and T4
2. Serum T3 and T4  hyper and hypothyroidism

o Physiology:
o Biofeedback mechanism: TRH  TSH  T4 and T3
o Diagnostic tests:
 Radioactive iodine scan
o 1-3-1 or 1-2-3
o Contrasts
o To determine if thyroid gland is hyper or hypo functioning
 WAR/HOT nodule – Increased uptake  HYPERFUNCTIONING
 “COLD” nodule – Decreased uptake  HYPOFUNCTIONING
 Ultrasound – for solid/cystic lesions of thyroid gland
 FNA biopsy

 Disorders:

1. HYPERTHYROIDISM
 Qualifications whether:
a. Thyroid gland is secreting excess TH
 Excess production:
i. GRAVES DISEASE
 Overproduction of TH (increased)
 Hyperthyroid state
 Etiology: AUTOIMMUNE
 TsAb: stimulates TSH which stimulates gland to produce T3 and T4
 Increased metabolism and adrenergic stimulation  GOITER
 Extrathyroidal manifestations:
i. EYE SIGN – classic HALLMARK of grave’s disease. It
dictate if you have grave’s disease or none
ii. OPHTHALMOPATHY – lid lag, spasm of upper eyelid +
periorbital edema
iii. PRE-TIBIAL EDEMA – accumulation of GAGs
(glycosaminoglycans) on skin above tibia brought by
chemical reaction
 Laboratory test:
1. Serum TSH
o Result:
 Decreased TSH
 Increased levels of T3, T4
2. Radioactive iodine scan

 Treatment:
o Medical:
 Anti-thyroid drugs (E.g. PTU, Midimazole): It inhibits
coupling of iodine wuth TYROSINE
 Given up to 6 months-2 yrs
 Titration necessary (lower to higher doses up to maximal
decrease of s/sx
 Normally, Patient will respond
 Recurrence high: refractory to medical treatment
 M.E.D.S 2015

o Radioactive ablation – suppresses thyroid gland, 1-3-1 or 1-2-3

 Poor surgical patients
 Success rate higher
 Disadvantages:
 Risk for malignancy high
 Teratogenic
 Transmission to nursing mothers to newborn
o Surgical treatment:
 Removal of thyroid gland
 Best surgical treatment:
 SUB-TOTAL THYROIDECTOMY
 Leave 2cm/gland to prevent hypothyroidism
 Success rate: 80-90%
 Recurrence: 10-12%
ii. THYROIDITIS

b. Destroyed thyroid gland that releases TH

SURGERY LECTURE 2

 Hyperthyroid state patient:

o Before we subject patient to hypothyroidism, stabilize first. Make his in EUTHYROID state
 By giving PTU or Mitimazole
 Lugol’s solution for 10 days before surgery is 10 drops/10 days
 Reasons:
o To diminish iodine intake
o Increase vascularity of gland

o THYROID STORM/ THYROTOXICOSIS:

 Concomitant fever + CNS agitation/ dysfunction
 Triggering factors:
 Infection
 Trauma
 Surgery
 Over exaggerated TH
 Prevention: Put patient first to euthyroid
 Mortality rate: >50% (ICU decreases mortality)
 Management: Symptomatic treatment
 PTU
 Beta-blockers
 Oxygen
 Subtotal thyroidectom

 3 conditions of hyperthyroidism:

1. Grave’s disease
a. Lecture 1
2. Toxic multinodular goiter
a. Grave’s disease but with NO extrathyroidal manifestations (NO EYE signs)
b. Management still the same with 1
3. Toxic “Solitary” adenoma
a. Hyperfunctioning nodule
b. Management still the same with 1
 M.E.D.S 2015

2. HYPOTHYROIDISM

 Causes:
o Drugs
o Congenital
 Clinical manifestations: opposite to hyperthyroidism
o Fatigue, weakness, lethargy
o Bradycardia
o Pericardial effusion
 Laboratory tests:
o Increased TSH
o Decreased T3, T4
 Treatment:
o Oral Thyroxine 50-200ugday
 Initial dose: 100ug/day
 Titrate if patient is already euthyroid
 Maintenance therapy
 Most common disorder of thyroid: GOITER (enlargement of thyroid gland)
 Etiology:
 Hyper functioning
 Hypo functioning
 Iodine deficiency
 Malignancy
 Endemic goiter
 Asymptomatic
 If symptomatic, it is compressive type
 First structure obstructed: AIRWAY
o Initial manifestation: Choking sensation, dyspnea
 Management:
 Goiter < 2cm : TH replacement
o Rationae: To decrease TSH stimulation
 Goiter > 2cm : Surgery
o Rationale:
 Do not respond to TH replacement
 4 reasons:
1. Symptoms of choking sensation
2. Failure of medical treatment
3. Malignancy possible
4. Not cosmetically acceptable
 M.E.D.S 2015

SURGERY LECTURE 3

Thyroid nodule and malignancy

Most common:

1. SOLITARY THYROID NODULE

A. History: Compressive symptoms

a. Concomitant irradiation therapy
b. Malignant thyroid nodule – 40%
c. Hodgkin’s lymphoma (+)
d. Bone marrow disorders (+)
e. Sinus, gland enlargement (+)
B. PE:
a. Hoarseness of voice
b. Palpation – let patient swallow. If mass moves with swallowing, thyroid gland mass (+)

C. Laboratory test NOT needed

a. TSH, T3,T4 won’t help
b. Patient I in EUTHYROID
c. Check PR  tachycardia, thyrotoxicosis

D. Diagnostic:
a. FINE NEEDLE ASPIRATION – 1st armamentarium
 Diagnostic or therapeutic for cyst
 10cc syringe + 23G needle
 Insert it to thyroid nodule and aspirate
 Specimen color: yellow
 Sent for CYTOPATHOLOGY

a. 4 RESULTS to get:
1. Non-diagnostic  Repeat FNA
2. Benign:
a. COLLOID
 Partly solid/ mixed-solid
 If NO compressive symptoms:
i. Recommend to give TH to reduce TSH
stimulation  less stimulation on the nodule
 < 3cm
 If with compressive symptoms:
i. DO SURGERY
b. CYST
 After 3 aspirations, if cyst recurs DO SURGERY
 If > 4cm  DO SURGERY

3. Suspicious for malignancy

a. Management: RADIOACTIVE IODINE SCAN
 Hot – Iodine 1-3-1 or surgery
 Cold – Do surgery

4. Malignant
a. Management: THYROIDECTOMY

b. If with DIFFUSE thyroid mass – NO FNA NEEDED

c. Principle: If FNA (+), remove area of involved thyroid lobe
 M.E.D.S 2015

2. THYROID CANCER

A. Well-differentiated type:
a. Painless nodule
b. Hard
c. Euthyroid
d. Types: High risk
1. PAPILLARY Low risk

a. “AMES” SCALE
A – Age
M – Metastases/ grade
E – Extra thyroidal lesions
S – Size
b. LOW RISK: < 40 years old, M (-), E (-), < 2-3cm size
c. Multi centric – 80-85%
d. Metastases to cervical nodes HIGH
e. Characteristics:
1. Painless
2. Distant metastases RARE
3. Most common: Cervical node metastasis
4. Cytologic FNA finding : Orphan Annie nuclei

f. 3 types:

1. Minimimal/ Occult
- <1cm or < 1.5cm
- Incidental
- Posteriorly located
- Diagnosis: Frozen section
- Management:
o R LOBE THRYOIDECTOMY and ISTHMECTOMY– If
Occult Ca in Right lobe, remove involved lobe +
Isthmus
o Chances of multi centricity is VERY LOW
2. Intra thyroidal Management:
3. Extra thyroidal - TOTAL THYROIDECTOMY – Remove ALL
including cervical nodes
- NEAR-TOTAL THYROIDECTOMY
- TOTAL THYROIDECTOMY with NECK
DISSECTION: Cervical node
Involvement (+)
- TOTAL THYROIDECTOMY in sufficed:
Cervical node involvement (-)
 M.E.D.S 2015

SURGERY LECTURE 4

2. FOLLICULAR
a. Same characteristics
b. Cervical lymph adenopathy RARE
c. Most common: Distant metastases
d. Capsular/ vascular invasion, more aggressive
e. Diagnosis:
1. FNA NOT needed
2. Tissue diagnosis: HISTOPATHOLOGIC

3. HURTLE CELL TUMORS

a. Same as follicular

APPROACH TO PATIENT FOLLOWING SURGERY

1. Give TH
 Reasons to give:
a. Prevent hypothyroidism
b. Decreased TSH  to prevent recurrence and so as not to stimulate the remaining portions of the gland

2. Thyroglobulin should be < 2mg after < 3mos

 If it goes beyond 2mg,  consider RECURRENCE
 Which is more specific? THYROGLOBULIN is more specific

3. Radioactive iodine scan

 Follow up: 3 months (-)  6 months (-)  1-2 years after

B. Poorly-differentiated type:
1. MEDULLARY – MEN
a. Management: TOTAL THYROIDECTOMY
2. ANAPLASTIC
 Characteristics:
a. Very hard, “woody” mass
b. Obstructive symptom
c. Very worst prognosis
d. Treatment:
1. Alleviate compressive symptoms
2. Surgery: TRACHEOSTOMY
3. Chemotherapy failed
 M.E.D.S 2015

SURGERY LECTURE 5

PARATHYROID GLANDS

 Beside thyroid gland

 4 parathyroid glands
 Function: PTH secretion for Ca2+ metabolism
 Disorders NOT common
 Most common disorder:

1. HYPERPARATHYROIDISM

a. Types:
i. PRIMARY
 Parathyroid gland malfunction
 Most common cause: ADENOMA/ TUMOR – 80%
ii. SECONDARY
 Other disorders co-exist

2+
Chronic renal failure (E.g. Decreased serum Ca )
iii. TERTIARY
 Rare
 Most common cause: AUTONOMOUS
 Hyperfunctioning of PTH gland
 NO TUMORS FOUND!

b. Increased Ca2+ in the blood – HYPERCALCEMIA

i. Side effects: End-organ disorders
 5 symptoms of end-organ malfunctioning:
1. KIDNEY
a. Stones
b. Impairs urine concentration ability
c. Polyuria
2. BONE
a. Bone resorption  fragile
b. Radiologic finding: OSTEITIS FIBROSA CYSTICA
In radius and phalanx  fractures
3. GIT
a. Stimulates GASTRIN hormones  hyperacidity
b. BPUD
c. Pancreatitis
d. Calcium stones obstructing pancreatic duct
4. CNS
a. Neuropathy
5. MUSCULOSKELETAL
a. Muscle fatigue
c. Diagnosis:
2+
i. Serum Ca
ii. PTH assay

d. Treatment:
i. Surgery – PARATHYROIDECTOMY
 Which among the 4 glands?
1. Use localization tests: SESTAMIBI SCAN
 What are you going to look for? RECURRENT LARYNGEAL NERVE in close proximity
to parathyroid gland
 Color of the parathyroid gland: GOLDEN BROWN
 Color of the thyroid gland: REDDISH BROWN
 M.E.D.S 2015

e. Complications:
i. Bleeding
ii. Laryngeal nerve injury
iii. Hypocalcemia
- After 24-48 hour – complaints of CHVOSTEK’S and TROUSSEAUS’ signs
iv. Transient hypocalcemia

SURGERY LECTURE 6

2. SECONDARY HYPERPARATHYROIDISM
a. Most common: Chronic renal failure  loss of renal tissue
 1,25 hydroxycholecalciferol – synthesized
 Increased Ca2+ levels in the kidney
 Over exaggerated
b. Treatment:
i. Synthetic Ca2+,
ii. Seldom we operate, but conditions indicated:
 BONE PAIN associated with increased calcium >11mg/dl (Normal value: 8-10mg/dl)
 OSTEODYSTROPHIES – bone abnormalities
 CALCIPHYLAXIS
1. Rare
2. Limb-threatening syndrome
3. Manifestations:
a. Obstructive-type
b. Gangrene, ulcers
c. Sepsis
iii. Renal transplantation
 Complication: AUTONOMOUS HYPERPARATHYROIDISM ( Tertiary)
 Management: PARATHYROIDECTOMY (Localize it
first)
 M.E.D.S 2015

SURGERY LECTURE 7

ADRENAL GLAND

 Hormonal, metabolic
 Most common disorders:
A. COHN’S SYNDROME
B. CUSHING’S SYNDROME
C. PHEOCHROMOCYTOMA
D. INCIDENTALOMA

COHN’S SYNDROME – ADH hormone stimulated by Renin AT

- PRIMARY hyperaldosteronism – autonomous, constant secretion of ADH, ADRENAL TUMOR

Clinical manifestations:
Hypernatremic, hypokalemic
Hypertension refractory to medical treatment (if resistant to treatment, suspect hyperaldosteronism)

1. Confirmatory diagnosis: Biochemical test

1. PLASMA aldosterone level (E.g. 30:1 or 35:1 ratio  hyperaldoteronism)
2. Renin level

2. Localization which adrenal gland:

 Used tool: CT scan
o If one side/ unilateral, do surgery (outright adrenalectomy lap or open)
o If bilateral, do another scan  reconfirm with invasive tehinique using
 Selective venous catheterization to check aldosterone level
 Scintigraphy: Np59 scan to localize which side of adrenal gland
 Same sensitivity as venous catherization
 Np59 scan result is unilateral, management is SURGICAL
 Np59 says result shows bilateral, management is MEDICAL
o You cannot do adrenalectomy in bilateral
o Spironolactone – potassium-sparing diuretics
 To remove high sodium content in the body
- SECONDARY hyperaldosteronism –
Na+ goes in, K+ goes out

PHEOCHROMOCYTOMA

- Disorder of adrenal MEDULLA that secretes catecholamines

o Sympathetic effects on heart
o CLINICAL TRIAD:
 Headache
 Palpitations
 Diaphoresis
o Most clinical sign: HYPERTENSION
o Confirmatory: Biochemical tests
 Plasma METANEPHRINES
- Rare, younger age group 30-40 years old
- Rules of 10% tumor:
 10% bilateral
 10% malignant
 10% pediatrics
 10% familial
- MEN: Medullary thyroid, parathyroid, pheochromocytoma
- Treatment: SURGERY
o Prior, place patient in a NORMOTENSIVE state by giving alpha/beta blockers