Eldimson E.

Bermudo
Surgery Senior Clerk
 Review the anatomy and physiology of
thyroid gland
Discuss the epidiomology, risk factors,
pathogenesis, clinical manifestations and
management of Multinodular Goiter
-is anterior in the neck
below and lateral to the
thyroid cartilage

-consists of right and

left lobes connected by
a narrow isthmus

-a vascular organ
surrounded by a sheath
derived from the
pretracheal layer of
deep fascia.
-each lobe is pear-
shaped, with its apex
directed upward.

-its base lies below at the

level of the 4th or 5th
tracheal ring.

The isthmus extends

across the midline in front
of the 2nd , 3rd, 4th
tracheal rings.
-Pyrimidal lobe, often
present and projects
upward from the isthmus,
usually to the LEFT of the
MIDLINE.
 Superior Thyroid Artery
Inferior Thyroid Artery
Thyroidea ima

-these arteries anastomose profusely with

one another over the surface of the gland.
 The inferior thyroid artery crosses the recurrent laryngeal
nerve (RLN), necessitating identification of the RLN before the
arterial branches can be ligated.
 Three veins drain the thyroid gland:

-The superior thyroid vein primarily drains the

area supplied by the superior thyroid artery.
-The middle and inferior thyroid veins drain the
restof the thyroid gland.
 SUPERIOR THYROID VEIN INTERNAL
MIDDLE THYROID VEIN JUGULAR VEIN

INFERIOR L&R
THYROID VEIN BRACHIOCEPHALIC VEINS
 Lymphatic drainage of the thyroid gland
is to nodes beside the trachea
(paratracheal nodes) and to deep
cervical nodes inferior to the omohyoid
muscle along the internal jugular vein.
 The left RLN- arises from the vagus nerve where it crosses the
aortic arch, loops around the ligamentum arteriosum, and
ascends medially in the neck within the tracheoesophageal
groove

right RLN- arises from the vagus nerve at its crossing with the R
subclavian artery.
-along its course in the neck, the RLNs may branch, and pass
anterior, posterior, or interdigitate with branches of the inferior
thyroid artery
RLN
-innervate all the intrinsic muscles of the larynx, except the
cricothyroid muscles, which are innervated by the external
laryngeal nerves.

-Injury to one RLN leads to paralysis of the ipsilateral vocal cord,

which comes to lie in the paramedian or the abducted position

The paramedian position results in a normal but weak

voice
the abducted position leads to a hoarse voice and an
ineffective cough
 Bilateral RLN injury may lead to airway obstruction,
necessitating emergency tracheostomy, or loss of voice.

> If both cords come to lie in an abducted position, air movement

can occur, but the patient has an ineffective cough and is at
increased risk of repeated respiratory tract infections from
aspiration.
 SUPERIOR LARYNGEAL NERVES
-also arise from the vagus nerves
-travel along the internal carotid artery and divide into two
branches at the level of the hyoid bone:
>internal branch of the superior laryngeal nerve
-is sensory to the supraglottic larynx.
-Injury to this nerve is rare in thyroid surgery
-its occurrence may result in aspiration

>external branch of the superior laryngeal nerve

lies on the inferior pharyngeal constrictor muscle and
descends alongside the superior thyroid vessels before
innervating the cricothyroid muscle.
 Occurs up to 12% of adult population
More common in WOMEN than men
Increases prevalence with age
More common in Iodine-deficient regions
but also occurs in regions of iodine
sufficiency, reflecting multiple genetic,
autoimmune, and environmental influences
on the pathogenesis.
 Nodule size varies
PATHOLOGY:
Colloid-rich follicles lined by flattened , inactive
epithelium and areas of follicular hyperplasia
Fibrosis is often extensive, and areas of
hemorrhage or lymphocytic infiltration may be
seen
 Most patients are ASYMPTOMATIC and
EUTHYROID
If the goiter is large enough, can ultimately lead to
COMPRESSIVE SYMPTOMS which include:
Difficulty of swallowing
Respiratory distress (tracheal compression)
Plethora (venous congestion)
 SYMPTOMATIC MNGs are usually extraordinarily
large and or develop fibrotic areas causing
compression.
SUDDEN PAIN in an MNG is usually caused by
hemorrhage into a nodule but raises a possibility
of malignancy.
HOARSNESS- reflects laryngeal nerve involvement
- suggests MALIGNANCY
 On examination:
-multiple nodules of varying sizes can be appreciated
-PEMBERTON SIGN
characterized by facial suffusionwhen the patients arms
are elevated above the head
-goiter has increased pressre in the thoracic outlet
 TSH level should be measured to exclude subclinical hyper- or
hypothyroidism but thyroid function is usually normal.

Tracheal deviation is common, but compression must usually

exceed 70% of the tracheal diameter before there is
significant airway compromise.

CT or MRI can be used to evaluate the anatomy of the goiter

and the extent of substernal extension or tracheal narrowing.
 A barium swallow may reveal the extent of esophageal
compression.

Ultrasonography can be used to ntwhich nodules should be

biopsied based on sonographic features (see section above on
ultra sound) and size. For nodules with more suspicious imaging
character istics (e.g. hypoechogenicity microcalcifications
irregular margins) biopsy is recommended when 1 cm.
 Mostly, can be managed conservatively
T4 suppression is rarely effective for reducing goiter size and
introduces the risk of subclinical or overt thyrotoxicosis,
particularly if there is underlying autonomy or if it develops
during treatment.

Contrast agents and other iodine-containing substances should

be avoided beca use of the risk of inducing the Jod-Basedow
effect, characterized by enha nced thyroid hormone production
by autonomous nodules.
 RADIOIODINE
-used with increasing frequency in a reas where large
goiters are more prevalent because it can decrease
goiter size
-Dosage depends on the size of the goiter and
radioiodine uptake
-USUALLY 3.7MBq (0.1mCi)per gram of tissue
-Repeat treatment may be needed and effectiveness may
be increased by concurrent administration of TSH (0.1mg
IM)
 However, SURGERY remains HIGHLY EFFECTIVE