Thyroid Disease

Department of General surgery, the First Teaching Hospital

Teaching Objective And Requirement

1.Master the most common symptoms of thyroid tumor 2.Master the clinic sign of thyroid tumor 3.Understand the therapy of benign tumor and malignant tumor 4.Master clinical menifestation of hyperthyroidisim 5.Master the indication of thyroidectomy of hyperthyroidisim patients 6.Master clinical menifestation and indication of surgery of thyroid goiter

The Thyroid Gland: A General Introduction

The thyroid gland lies in front of the tracheal rings 2, 3 and 4. It consists of two lobes joined by an isthmus. The pyramidal lobe is present in about 40% of people. The gland lies deep to the strap muscles and for surgical access, these can be divided as high as possible so as to avoid the innervation entering from below from the ansa cervicalis.

 Anatomy of thyroid gland

The thyroid gland is surrounded by a fibrous capsule and external part of this gland is a sheet of pretracheal fascia. This causes the thyroid gland to be elevated on swallowing.

superior laryngeal nerve Carotid artery Parathyroid

Laryngeal recurrent nerve

Vagus nerve

Injury to the Recurrent Laryngeal Nerves

Near the inferior pole of the thyroid gland, the recurrent laryngeal nerves are intimately related to the inferior thyroid artery. These nerves may cross anterior or posterior to the artery or they may pass between its branches.

Injury to the External Laryngeal Nerve

This nerve is closely related to the superior thyroid, and care must be taken not to damage it when the superior thyroid artery is ligated and divided. Injury results in a voice becoming monotonous in character.

To avoid injury to the external laryngeal nerve, the superior thyroid artery is ligated and sectioned near the superior pole of the gland.

Injury to the Parathyroid

Hypocalcemia is the result of damage to the Parathyroid. Slight hypocalcemia will be cured after a period of calcium gluconate treatment , but the severe hypocalcemia may cause death because spasm of respiratory muscles.

Physiology:Thyroid Hormones
Thyroid gland is responsible for synthesizing,storing, and secretion of thyroid hormones:

thyroxine(T4).
Tri-iodothyronine(T3)

These hormones are essential for life and have many effects on body metabolism, growth, and development in foetal period and developing period.

Effects of Thyroid Hormones

Thyroid hormones have two major physiologic effects: (1)They increase protein synthesis in every tissue of body (2) T3 increases Oxygen T3 is believed to be the active thyroid hormone, although T4 itself may be biologically active.

Hypothalamic - Pituitary - Thyroid Axis

The thyroid gland is influenced by hormones produced by two other organs: 1.T3,T4 TRH TSH 2. T3,T4 T3,T4 TRH T3,T4

TSH

The three glands and the hormones they produce make up the "Hypothalamic - Pituitary - Thyroid axis."

Disease of the Thyroid

Thyroid Goitre

Thyroid Goitre
Thyroid goitre is an abnormal swelling of the thyroid gland. Patients who have a goitre can be euthyroid, hypothyroid, or hyperthyroid

Causes of goitre
Normal physiological change for example in puberty or during pregnancy

Iodine deficiency a dietary deficiency of iodine results in increased TSH activity to stimulate the gland to produce enough thyroxine, so the gland enlarges.

Causes of goitre
Graves' Disease a diffuse smooth vascular swelling of the thyroid gland associated with thyrotoxicosis and eye problems such as exopthalmos, lid lag, and ophthalmoplegia. Graves` disease is due to the presence of long-acting thyroid stimulating immunoglobulin(LATS).

Causes of goitre
Benign hyperplasia resulting in an adenomatous or multinodular. The gland may become acutely painful if haemorrhage occurs into a cyst. As the thyroid gland enlarges it may cause pressure symptoms such as dysphagia and stridor, especially if it is retrosternal

Causes of goitre
Thyroid malignancy

Thyroiditis

Graves' Disease Graves' disease (thyrotoxicosis ) is due to a unique antibody called "thyroid stimulating antibody" which stimulates the thyroid cells to grow larger and to produce excessive amounts of thyroid hormones. In this disease, the goitre is not due to TSH but to this unique antibody. Hashimoto's Thyroiditis In Hashimoto's thyroiditis , the goitre is caused by an accumulation of white blood cells and fluid (inflammation) in the thyroid gland. This leads to destruction of the thyroid cells and, eventually, thyroid failure (hypothyroidism). As the gland is destroyed, thyroid hormone production decreases; as a result, TSH increases, making the goitre even larger.

Comparison of thyrotoxicosis and hypothyroidism

Feature

Thyrotoxicosis
Intolerance of heat, weight loss, increased appetite, tremor, palpitations, diarrhoea,sweating, anxiety,oligomenorrhoea Goitre, tachycardia, atrial fibrillation, warm and moist palms, tremor, Graves`disease(exophthalmos, lid lag, ophthalmoplegia) Graves`disease, secondary thyrotoxicosis in adenomatous goitre Increased T4 or T3, decreased TSH; Graves`disease presence of LATS Carbimazole or propylthiouracil, propranolol for increased heart rate, tremor, radioiodine, subtotal thyroidectomy

Hypothyroidism
Intolerance of cold, weight gain, lethargy, comstipation, dry skin and hair, hoarse voice Pallor, slow pulse, thickened dry skin and hair, periobital puffiness, loss of outer onethird of eye of eyebrows, peripheral oedema, slow recovery phase to ankle jerk Thyroiditis, post-thyroid surgery

Symptoms

Signs

Causes Diagnosis

decreased T4 ,increased TSH; Hashimoto`s thyroiditis inreases levels of antimitochordrial antibody or antithyroglobulin antibody Thyroxine replacement

Management

 Diagnosis of a thyroid nodule is aided by perfoming an ultrasound, which can differentiate cystic from solid lesions and nodules from diffuse thyroid enlargement .

A technetium-99m pertechnetate isotope scan can be used to differentiate hot and cold nodules. Inactive nodules(cold) corresponding to isolated nodules are indicators of a cyst or a tumour.

 If there is a solitary solid lesion it is investigated by fine-needle aspiration cytology(FNAC). If abnormal cells are obtained then the lesion must be removed to make a precise histological diagnosis in case it is a thyroid cancer. It can be difficult to differentiate benign from well-differentiated cancers by FNAC alone.

Thyroiditis

Diagnosis of Thyroiditis
Autoimmune Hashimoto`s thyroiditis The patient presents with a diffuse tender goitre. Diagnosis is made by detecting the presence of thyroid antibodies against thyroglobulin. The patient is initially euthyroid and then becomes hypothyroid as the gland becomes atrophic and fibrotic. 80% of the primarily Hypothyroidism is caused by Hashimoto`s thyroiditis.

 Treatment of Thyroiditis
1.thyroxine replacement therapy when the patient is hypothyroid. 2.If the pain is severe , the glucocorticosteroid therapy is necessary, if no relavation after therapy , operation must be taken . 3.When there is compression or suspect of canceration , operation is necessary.

Thyroid Carcinomas

THYROID CARCINOMAS
Thyroid carcinomas are more common in females than males and can occur in young adults. They occur as well-differentiated adenocarcinomas of papillry, follicular or medullary type. These have a relatively good prognosis. Anaplastic carcinomas occur in the elderly and have a very poor prognosis.

 Other tumours of the thyroid, include: Medullary carcinomavery rare tumour of the parafollicular or C cells of the thyroid that may arise within the syndrome of multiple endocrine neoplasia. Lymphoma of the thyroidrare , but may be associated with Hashimoto`s disease and is responsive to radiotherapy.

Features of main types of thyroid cancers Feature

Proportion of cases(%)
Age

Papillary
60
Children, young adults

Follicular
25
Middle age

Anaplastic
10
Elderly females

Location Growth rate

Spread

Often multifocal Slow

Lymphatic

Rarely multifocal Slow

Blood

Whole gland Rapid

Local infilteation causing pressure symptoms

Management Total thyroidencomy plus

lymph node dissection; TSH suppression by thyroxine

Thyroid lobectomy. Radioactive iodine

Usually inoperable; radiotherapy,che motherapy Very poor

Prognosis

good

Depends upon extent of vascular invasion

Treatment of Thyroid carcinoma

1.Operation:Recommended for papillry, follicular or medullary type. 2. Radioactive iodine thearopy: Indicated for papillry, follicular or medullary type. The Mets can absorb Radioactive iodine only after total thyroidectomy. 3. Endocrinal treatment : Aimed to suppress TSH and it`s stimulating affects on Thyroid, and reduce recurrence by Thyroxin therapy . 4. Radiotherapy is recommended for anaplastic carcinomas.

Hyperthyroidism

Graves' Hyperthyroidism (Thyrotoxicosis)

Graves Disease (primary hyperthyroidism) Graves' disease, by far the most common cause of hyperthyroidism, affects perhaps one in every 100 people. The disease is an inherited disorder, although not every member of the afflicted families will suffer this condition. It is more common in females than in males. Thyroid Stimulating Antibody Graves' disease is an autoimmune disorder. It is caused by an abnormal protein, called thyroid stimulating antibody. This antibody stimulates the thyroid gland to produce large amounts of thyroid hormone in an uncontrolled manner. In normal people, the production of thyroid stimulating antibody is prevented by a surveillance system. This system consists of certain blood cells called suppressor and helper lymphocytes and Killer (K) cells, as well as other constituents. The suppressor lymphocytes suppress unwanted lymphocytes. Measurement of the thyroid stimulating antibody present in the blood of most patients with Graves' disease is not usually necessary, in order to establish the diagnosis.

Graves' Hyperthyroidism (Thyrotoxicosis)

Clinical Features The symptoms and signs of Graves' hyperthyroidism are due to the effects of excess amounts of thyroid hormone on body function and metabolism. Common symptoms include: weight loss, nervousness, irritability, intolerance to hot weather, excessive sweating, shakiness, and muscle weakness. Other signs include : a rapid pulse, loss of body fat and muscle bulk, thyroid enlargement (goitre), fine tremors of the fingers and hot, moist, velvety skin.

 Many of the symptoms of Graves' disease are directly related to its cause: organ-specific autoimmunity. For example, the goiter that is typical of Graves' disease is caused by swelling of the thyroid due to inflammation and lymphocyte infiltration. Lymphocytes within the thyroid contribute to further autoimmune responses, and the thyroid cells themselves interact with the immune system to exacerbate the symptoms of hyperthyroidism. These thyrocytes express proteins they normally would not

About 50% of patients also have significant eye signs (Ophthalmopathy). The eyes, which bulge from their sockets are red and watery and the lids are swollen. Quite often the eyes do not move normally because the swollen eye muscles are unable to work precisely. The remaining 50% of patients with Graves' hyperthyroidism may have slightly bulging eyes because of spasm of the muscle of the lids, giving them a staring appearance.

Thyroid hormones have a wide variety of effects on the body and the symptoms and signs reflect these. In simple terms, all the metabolic processes are "speeded up"; for example 1.the pulse rate is rapid (over 100) 2. bowel function is increased (diarrhea). 3.The nervous system is also stimulated so that the patient becomes irritable and nervous. 4.Despite increased appetite, the patient usually loses weight because food intake cannot keep up with the increased breakdown of body proteins. The end result is a thin, hot, nervous patient with "poppy" eyes and a goitre - a classical clinical situation quickly recognized by any medical practitioner who has previously seen such a patient.

Graves' Hyperthyroidism (Thyrotoxicosis)

Treatment Since the end result of this problem is an overstimulation of thyroid function, treatment of the symptoms is quite easy 1. surgically remove part of the thyroid gland (thyroidectomy). 2. destroy the thyroid cells with radioactive iodine. 3. block thyroid hormone production with antithyroid drugs.

Graves' Hyperthyroidism (Thyrotoxicosis)

Indication of Surgical treatment (Thyroidectomy) Surgical treatment is indicated for 1) younger patients with Graves' disease whose disease has recurred after courses of antithyroid drug and who refuse 131I therapy; 2) in patients who cannot tolerate other drugs because of hypersensitivity or other problems; 3) in patients with very large goiters; 4) in some younger patients with toxic adenoma and multinodular goiter, 5) for patients with ophthalmopathy; 6) for patients with malignant thyroid nodule; 7) in older patients with giant nodular;

 After treatment with radioactive iodine or thyroidectomy, it is hoped that enough of the thyroid gland remains to function normally. There is a strong tendency for the remaining thyroid gland to become underactive (hypothyroidism) - perhaps 80% of all patients with Graves' disease will eventually require lifelong thyroid hormone replacement therapy. This is not considered a problem as long as the hypothyroidism is recognized and treated. It is much more of a problem for patients to have a recurrence of hyperthyroidism.

Antithyroid Drugs Antithyroid drugs (Propylthiouracil and Methimazole) are almost mandatory in children and adults under the age of 20-25. It may also be used at any age so as to bring about remissions, or prior to ablation therapy. There are two main drawbacks with this type of treatment: 1. patients must take tablets for many months or years; once treatment is stopped, there is only about a 50% chance that the disease will not flare up again. 2. In addition a very small percentage suffer side effects which very rarely can be severe. Eventually, most patients require treatment with either radioactive iodine or thyroidectomy. Another tablet that can be given to treat the symptoms of hyperthyroidism is Propranolol. This drug blocks the effects of excess thyroid hormones on the heart, blood vessels, and nervous system, but has no direct effect on the thyroid gland.

Graves' Hyperthyroidism (Thyrotoxicosis)

 Preoperatively the patient should be rendered euthyroid

(if for Graves` disease), by prescribing carbimazole and propranolol to control symptoms. If the patient is thyrotoxic Lugol`s iodine may be prescribed for 10 days to decreases the vascularity of the gland. Before operation the vocal cords should ber inspected by direct laryngoscopy to ensure that they are functioning satisfactorily.

Complications of thyroid operations

Immediate haematoma may occur in the first few hours after operation. It can cause laryngeal oedema, stridor, and dyspnoea. The wound should be openend immediately, and the patient returned to theatre to control any haemorrhage.

 Recurrent laryngeal nerve injury manifests as a hoarse voice or a bovine cough if one nerve is damaged, If there is bilateral damage the patient is unable to speak and any exertion causes airway obstruction. Neurapraxia usually recovers, but if there is unilateral and permanent nerve damage the cord can be injected with polytetrafluoroethylene. If both nerves are damaged an emergency tracheostomy is required.

 Superior laryngeal nerve (external branch) injury produces voice changes such as loss of pitch, but it usually recovers. Hypoparathyroidismthis may be temporary or permanent. signs of hypocalcaemia will be paraethesia, carpopedal spasm

 Hpothyroidism :Give thyroid hormon orally

Thyroid crisisrarely seen if the patient is euthyroid preoperatively. It may, be precipitated by other illnesses such as pneumonia if the patient is thyrotoxic. Symptoms are pyrexia, agitation, confusion, and tachycardia, and medication is given to control the symptoms

Thyroid storm
Is characterized by the abrupt onset of more florid symptoms of
hyperthyroidism, with some exacerbated symptoms and atypical signs. Included are fever; marked weakness and extreme restlessness with wide emotional swings; confusion, psychosis, or even coma; and hepatomegaly with mild jaundice. The patient may present with cardiovascular collapse and shock. Thyroid storm, which is rare in children, results from untreated or inadequately treated hyperthyroidism and may be precipitated by infection, trauma, a surgical procedure, embolism, diabetic acidosis, or toxemia of pregnancy or labor.

Thyroid storm is a life-threatening emergency requiring prompt and specific treatment

TREATMENT OF THYROID STORM

Indicantions for a thyroid operation

The common reasons for surgical intervention include: Subtotal thyroidectomy for control of Graves` disease. Relief of pressure symptoms from an enlarged multinodular goitre. Lobectomy or total thyroidectomy for malignant tumour.

Question
1.The indications for Surgical removal of a nodular goiter are following choice except: a. symptom of pressure b. substernal extension c. cosmetic deformity d. suspicion of cancer e. thyroititis

Question
2.which of the following choise are not the complications of surgical treatment of thyroidectomy a. Trouble of respiration and suffocation b. Injury of recurrent laryngeal nerve c. Injury of superior laryngeal nerve d. Thyroid storm e. Acidosis

Question
3.The course of papillary carcinoma of the thyroid is

best described by which of the following statements? a .Metastases are rare;local growth is rapid;erosion into the trachea and large blood vessels is frequent b.Local invasion and metastases almost never occur,which makes the term carcinoma misleading c.Bony metastases are frequent and produce an osteolytic pattern particularly in vertebrae d.Metastases frequently occur to cervical lymph nodes;distant metastases and local invasion are rare e.Rapid,widespread metastatic involvement of the liver,lungs,and bone marrow results in a 5-year survival rate of approximately 10%

True or false
About thyroid cancers A)They usually occur in elderly people B)60% of cases are papillary cancer C)Follicular cancer usually presents with pressure symptoms D)Lymphoma is related to Hashimoto`s disease E)It can be diagnosed accurately by fine needle aspiration and cytology