THYROID GLAND

BY:PALAK KHANNA
 EMBRYOLOGY
Thyroid originates from a medial anlage and two lateral anlagen, which fuse during development
Medial anlage gives rise to the major portion of each lateral lobe, isthmus and thyroglossal
duct with pyramidal lobe; it is a source of follicular cells
Lateral anlagen (ultimobranchial bodies) give rise to C cells, solid cell nests and portions of
the lateral thyroids
Thyroid development starts from the late 3rd to early 4th weeks of gestation, then the fetal
thyroid gland develops rapidly until the 4th month of intrauterine growth
SURGICAL ANATOMY
•The normal thyroid gland weighs 20–25 g.
•The functioning unit is the lobule supplied by
a single arteriole and consists of 24–40 follicles
lined with cuboidal epithelium.
•The follicle contains colloid in which
thyroglobulin is stored.
•The arterial supply is rich, and extensive
anastomoses occur between the main thyroid
arteries and branches of the tracheal and
oesophageal arteries .
•There is an extensive lymphatic network
within and around the gland.
PHYSIOLOGY
 THYROID IMAGING
The workhorse investigation in thyroid
disease for the surgeon is ultrasound.
This modality allows assessment of the gland
and the regional lymphatics.
Ultrasound has the advantages that it is not
associated with ionising radiation and is non-
invasive and cheap.
Visualisation of the central neck nodes, in
particular those behind the sternum, is
however limited.
For this reason, when metastatic disease is
detected cross-sectional imaging is required to
fully stage the disease.
Retrosternal extension, which can often be
predicted on plain chest x-ray, also requires
more advanced techniques to determine the
extent adequately prior to considering
management.
In the setting of an invasive primary thyroid
cancer, both CT and magnetic resonance
imaging (MRI) may have a role.
Isotope scanning
The uptake by the thyroid of a low dose of
either radiolabelled iodine (123I) or the
cheaper technetium (99mTc) will demonstrate
the distribution of activity in the whole gland.
Routine isotope scanning is unnecessary and
inappropriate for distinguishing benign from
malignant lesions
Fine-needle aspiration cytology
Fine-needle aspiration cytology (FNAC) is the
investigation of choice in discrete thyroid
swellings.
FNAC has excellent patient compliance, is
simple and quick to perform in the out-patient
department and is readily repeated.
Complications Of Thyroid Gland Enlargement
Tracheal obstruction may be due to gross lateral displacement or compression in a lateral or
anteroposterior plane by retrosternal extension of the goitre .
Acute respiratory obstruction may follow haemorrhage into a nodule impacted in the thoracic
inlet.
SECONDARY THYROTOXICOSIS
Transient episodes of mild hyperthyroidism are common, occurring in up to 30% of patients.
CARCINOMA
An increased incidence of cancer (usually follicular) has been reported from endemic areas.
Dominant or rapidly growing nodules in longstanding goitres should always be subjected to
aspiration cytology
There is a choice of surgical treatment in multinodular goitre:
total thyroidectomy with immediate and lifelong replacement of thyroxine or some form of
partial resection to conserve sufficient functioning thyroid tissue to subserve normal function
while reducing the risk of hypoparathyroidism that accompanies total thyroidectomy.
Subtotal thyroidectomy involves partial resection of each lobe removing the bulk of the gland,
leaving up to 8g of relatively normal tissue in each remnant.
total lobectomy on the more affected side is the appropriate management with either subtotal
resection (Dunhill procedure) or no intervention on the less affected side. In many cases, the
causative factors persist and recurrence is likely. Reoperation for recurrent nodular goitre is
more difficult and hazardous and, for this reason, an increasing number of thyroid surgeons
favour.
 total thyroidectomy in younger patients. However, when the first operation comprised
unilateral lobectomy alone for asymmetric goitre, reoperation and completion total
thyroidectomy is straightforward if required for progression of nodularity in the remaining lobe.
A discrete swelling in an otherwise
impalpable gland is termed isolated or solitary,
whereas the preferred term is dominant for a
similar swelling in a gland with clinical
evidence of generalised abnormality in the
form of a palpable contralateral lobe or
generalised mild nodularity.
About 70% of discrete thyroid swellings are
clinically isolated and about 30% are dominant.
The true incidence of isolated swellings is
somewhat less than the clinical estimate.
Clinical classification is inevitably subjective
and overestimates the frequency of truly
isolated swellings.
When such a gland is exposed at operation
or examined by ultrasonography, CT or MRI,
clinically impalpable nodules are often
detected.
Selection of thyroid procedure
The choice of thyroid operation depends on:
● diagnosis (if known preoperatively); ● risk of thyroid failure;
● risk of RLN injury; ● risk of recurrence;
● Graves’ disease; ● multinodular goitre;
● differentiated thyroid cancer; ● risk of hypoparathyroidism.

HYPERTHYROIDISM
Thyrotoxicosis
The term thyrotoxicosis is retained because hyperthyroidism, i.e. symptoms due to a raised level
of circulating thyroid hormones, is not responsible for all manifestations of the disease.
Clinical types are:
● diffuse toxic goitre (Graves’ disease): Graves’ disease, a diffuse vascular goitre appearing at the
same time as hyperthyroidism, usually occurs in younger women and is frequently associated
with eye signs. The syndrome is that of primary thyrotoxicosis. 50% of patients have a family
history of autoimmune endocrine diseases.
● toxic nodular goitre: A simple nodular goitre is present for a long time before the
hyperthyroidism, usually in the middle-aged or elderly, and very infrequently is associated with
eye signs. The syndrome is that of secondary thyrotoxicosis.
● toxic nodule: A toxic nodule is a solitary overactive nodule, which may be part of a generalised
nodularity or a true toxic adenoma.
● hyperthyroidism due to rarer causes.
Principles of treatment of thyrotoxicosis
ANTITHYROID DRUGS
Those in common use are carbimazole and propylthiouracil.
● Advantages. No surgery and no use of radioactive materials.
● Disadvantages. Treatment is prolonged and the failure rate is at least 50%. The duration of
treatment may be tailored to the severity of the toxicity, with milder cases being treated for only
6 months and severe cases for 2 years before stopping therapy.
SURGERY
In diffuse toxic goitre and toxic nodular goitre with overactive internodular tissue, surgery cures
by reducing the mass of overactive tissue by reducing the thyroid below a critical mass.
● Advantages. The goitre is removed, the cure is rapid and the cure rate is high if surgery has
been adequate.
● Disadvantages. Recurrence of thyrotoxicosis occurs in at least 5% of cases when subtotal
thyroidectomy is carried out. There is a risk of permanent hypoparathyroidism and nerve injury.
Young women tend to have a poorer cosmetic result from the scar
RADIOIODINE
Radioiodine destroys thyroid cells and, as in thyroidectomy, reduces the mass of functioning
thyroid tissue to below a critical level.
● Advantages. No surgery and no prolonged drug therapy.
● Disadvantages. Isotope facilities must be available. The patient must be quarantined while
radiation levels are high and avoid pregnancy and close physical contact, particularly with
children. Eye signs may be aggravated.
CHOICE OF THERAPY
DIFFUSE TOXIC GOITRE
Most patients have an initial course of
antithyroid drugs with radioiodine for relapse.
TOXIC NODULAR GOITRE
Toxic nodular goitre is often large and
uncomfortable and enlarges still further with
SURGICAL TECHNIQUE OF
antithyroid drugs. A large goitre should be THYROIDECTOMY
treated surgically because it does not respond
as well or as rapidly to radioiodine or
antithyroid drugs as does a diffuse toxic goitre.
TOXIC NODULE
Surgery or radioiodine treatment is
appropriate. Resection is easy, certain and with
a low risk of morbidity. Radioiodine is a good
alternative for patients over the age of 45 years.
FAILURE OF PREVIOUS TREATMENT WITH
ANTITHYROID DRUGS OR RADIOIODINE
In this case, surgery or thyroid ablation with
123I is appropriate.
 POSTOPERATIVE COMPLICATIONS
Preoperative Haemorrhage :Haemorrhage is the most
preparation frequent life-threatening complication of
thyroidectomy. Around 1 in 50 patients will
Preparation is as an out-patient and only
develop a haematoma, and in almost all cases
rarely is admission to hospital necessary on
this will develop in the first 24 hours.
account of severe symptoms at presentation, 
Recurrent laryngeal nerve paralysis and voice
failure to control the hyperthyroidism or
change :Early routine postoperative laryngoscopy
non-compliance with medication.
reveals a much higher incidence of transient cord
Carbimazole 30–40mg per day is the drug
paralysis than is detectable by simple assessment
of choice for preparation.
of the integrity of the voice and cough.
When euthyroid (after 8–12 weeks), the
Thyroid insufficiency :Following total
dose may be reduced to 5mg 8-hourly or a
thyroidectomy, clearly thyroxine replacement will
‘block and replace’ regime used.
be required.
The last dose of carbimazole may be given
Parathyroid insufficiency :This is due to
on the evening before surgery.
removal of the parathyroid glands or infarction
Iodides are not used alone because, if the
through damage to the parathyroid end arteries;
patient needs preoperative treatment, a
often both factors occur together.
more effective drug should be given. Thyrotoxic crisis (storm) :This is an acute
An alternative method of preparation is to
exacerbation of hyperthyroidism.
abolish the clinical manifestations of the Wound infection: Cellulitis requiring
toxic state, using β-adrenergic blocking
prescription of antibiotics, often by the general
drugs. These act on the target organs and
practitioner, is more common than most
not on the gland itself.
surgeons appreciate.
POSTOPERATIVE CARE
Following surgery, the patient should be returned to the recovery room and
nursed overnight on the ward.
 Wound care should include vigilance for signs of a haematoma. Following
total thyroidectomy, calcium levels should be checked postoperatively.
Not all patients develop immediate hypocalcaemia and they should be
educated about the signs (parasthesia of the fingers and toes or round the
mouth).
Serial calcium monitoring should be recommended for those at highest risk.
Those patients who had a total thyroidectomy require thyroxine
replacement, which should start day 1 postoperatively.
On clinic review, in addition to checking the histology report, the wound
should be inspected and the larynx examined for vocal cord function.
Biochemical assessment of thyroid function and calcium, if required, should
be arranged.
 NEOPLASMS OF THE THYROID
Benign tumours
Follicular adenomas present as clinically solitary nodules and the distinction between a
follicular carcinoma and an adenoma can only be made by histological examination; in the
adenoma there is no invasion of the capsule or of pericapsular blood vessels. For this reason,
FNA, which provides cytologic detail but not tissue architecture, cannot differentiate between
benign and malignant follicular lesions. Diagnosis and treatment is therefore, by wide excision,
i.e. total lobectomy.
Malignant tumours
The vast majority of primary malignancies are carcinomas derived from the follicular cells. Such
tumors were thought of as differentiated (papillary, follicular and Hürthle cell) and
undifferentiated (anaplastic). However, now an intermediate class of ‘poorly differentiated
carcinoma’ is recognised, which is likely to represent a state of dedifferentiated, between classic
differentiated and undifferentiated diseases.
Surgical treatment for differentiated thyroid cancer
The aim of surgery is to rid the patient of macroscopic disease and minimise the chance
of recurrence and death.
An additional aim is to minimise surgical morbidity.
Achieving a balance between these aims is critical.
In addition, the surgeon must consider whether radioactive iodine is to be recommended.
In low-risk cases this is rarely indicated, whereas in high-risk patients it is used almost
universally.
In high-risk patients with nodal or distant metastases, total thyroidectomy will be
performed to eradicate disease in the thyroid and prepare the patient for radioactive
iodine.
Thyroxine
Following surgery, thyroid cells (both normal and malignant) can be suppressed using
high doses of thyroxine. This was once considered routine for all differentiated thyroid
cancers during follow-up. Again, risk stratification has modified our approach to these
patients.
Radioiodine
Thyroid tissue concentrates iodine. For this reason, 131I can be given in order to deliver
tumoricidal doses of radioactivity directly to thyroid tissue, both benign and malignant.