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KABWE CENTRAL HOSPITAL

KCH
“THYROID”
Wisdom’s Lecture Notes

Banda Wisdom Chilufya


MBChB
OUTLINE

• Anatomy
• Embryology
• Histology
• physiology
• Clinical features
• Thyroid cancers
• Investigations
• Management
• Complications
Thyroid Gland

• Location
– Anterior triangle of the neck
• Size
– 5X3X2
– 25gm
• Shape- H shape, 2 lateral lobes & Isthmus.
• Pyramidal lobe in few individuals

20-3
Lobes of the thyroid
gland

1. Pyramidal lobe
2. Right lobe
3. Isthmus
4. Left lobe

The most posterior


extension of the lateral
thyroid lobes is called the
Tubercle of Zuckerkandl
• Blood supply
Superior thyroid artery-branch of external carotid artery
 Inferior Thyroid artery-thyrocervical artery of subclacavian
artery
Thyroidea ima artery (only in about 5% of the population)
• Venous drainage
Superior thyroid vein
 middle thyroid vein
Inferior thyroid vein&
• Lymph drainage cx nodes
• Nerve: branches of the vagus neives
recurrent laryngeal-innervation to intrinsic muscles of the larynx
superior laryngeal nerve-innervates the cricothyroid muscles
• Clinical implications:
 Recurrent laryngeal neive injury will result into a horse voice and
breathing difficulties if bilateral damage due to damage to
abductor intrinsic muscles
 Superior laryngeal neive injury will results into inability to make
explosive sound
BORDERS

• Anteriorly:
Skin
Subcutaneous
Platysma
Strap muscles
 Thyrohyoid
 Omohyoid
Mnemonic:
 Sternohyoid
 sternothyroid TOSS
Pre-tracheal fascia
BORDERS

• Posterior aspect:
Trachea and esophagus

• Lateral Aspect:
Carotid sheath: Internal Jugular Vein, Vagus Neive and
the Internal Carotid Artery
• Mneumonic is JVC
EMBROLOGY

• Thyroid gland develops at about the 4th week,


• Arises from the floor of the mouth called foramen
caecum from the 2nd and 3rd tracheal rings also
called pharyngeal pouches and migrate via the
thyroglossal duct
• Functional by 10-12wk
• C cells originates from ultimobranchial bodies of the
fouth 4th pharyngeal pouch arising from the Neural
crest cells.
HISTOLOGY
 Thyroid Follicles
 Cuboidal epithelium-produces thyroid
hormones
- Intersitial Cells- C cells
- C cells produce calcitonin

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 16.32a
Thyroid Follicle

Thyroid
Colloid
C cells
PHYSIOLOGY

Thyroid gland has two secretory cells:


1. Follicular cells —secretes thyroid hormones
(Thyroxine (T4), Tri-iodothyronine (T3).

2. Parafollicular cells (‘C’ cells)—secretes calcitonin.


STEPS INVOLVED IN THYROID HORMONES SYNTHESIS

1. Iodide trapping; iodide is trapped into thyrocytes from


blood
2. Oxidation; Iodide is oxidized to iodine under the influence
of an enzyme peroxidase
3. Organification; iodine combines with tyrosine to form
monoiodotyrosin (MIT) and Diiodotyrosine (DIT)
4. Coupling: Two molecules of DIT forms Tetraiodotyrosin
with is T4, and MIT with DIT forms T3
5. Release via hydrolysis: hormones combines with globulin
to form colloid thyroglobulin and released as required by
hydrolysis
• T3 is an important physiological hormone and is
fast acting within few hours T4 is slow acting
hormone and takes 4-14 days to act

• Normal levels
• T3: 1.5- 3.5 nmol/l
• T4: 55-150 nmol/l
• TSH: 0.5-5 iu/ml
Functions in general

• Increases basal metabolic rate


• Affects protein synthesis
• Neural maturations
• Promote long bone growth
• Increase body’s response to catecholamine
HYPERTHYROIDISM FEATURES
Sympathetic overactivity
• tiredness,
• heat intolerance,
• sweating
Gastrointestinal system
• Weight loss in spite of increased appetite.
• Diarrhoea (due to increased activity at ganglionic level).
Cardiovascular system
• Palpitations.
• Shortness of breath at rest or on minimal exertion.
• Angina.
• Cardiac irregularity.
• Cardiac failure in the elderly (CCF).
Genitourinary system
• Oligo- or amenorrhoea.
• Occasional urinary frequency.
Integument
• Hair loss.
• Pruritus.
• Palmar erythema.
Psychiatry
• Irritability.
• Nervousness.
• Insomnia.
Neuromuscular system
• Undue fatigue and muscle weakness.
• Tremor.
Skeletal system
• Increase in linear growth in children.
HYPOTHYROIDISM FEATURES

• Cold intolerance,
• decreased sweating.
• Hoarseness.
• Weight increase,
• constipation.
• Slow cerebration,
• tiredness.
• Muscle pains.
THYROID CANCER-TYPES

1. Papillary carcinoma: 80% (Popular Papillary)


2. Follicular carcinoma: 10%
3. Medullary carcinoma: 5%
4. Hürthle cell carcinoma: 4%
5. Anaplastic/undifferentiated carcinoma: 1% to 2%
1. Papillary carcinoma: 80% (Popular
Papillary)

• Most common thyroid cancer (Think: Papillary


Popular) 80% of all thyroid cancers
• 30–40 years
• Female male; 2:1
• Histological feature: Psammoma bodies
• Most spread via lymphatics
• Good uptake I^131
• 10-year survival rate is 95%
• Pulmonary metastases is the common distance metastasis
In summary
Papillary cancer:
• Popular (most common)
• Psammoma bodies
• Palpable lymph nodes (spreads most commonly by
lymphatics, seen in 33% of patients)
• Positive 131I uptake
• Positive prognosis
• Postoperative 131I scan to diagnose/treat
metastases
• Pulmonary metastases
2. Follicular cancer:

• Rubbery, encapsulated
• Male/female ration 1:3
• Hematogenous spread, more aggressive than
papillary adenocarcinoma
• Good uptake I^131
• 10-year survival rate is 85%
• FNA can’t make a diagnosis
• Bone metastasis is the common distance spread
Follicular cancer:

• Far-away metastasis (spreads hematogenously)


• Female (3 to 1 ratio)
• FNA . . . NOT (FNA CANNOT diagnose cancer)
• Favorable prognosis
3. MEDULLARY CARCINOMA

• 5%
• Female male; 1.5:1
• Associated with MEN type II;
• Histologically -Amyloid (aMyloid Medullary)
• Secretes Calcitonin (tumor marker)
• Lymphatic and hematogenous distant metastasis
• Poor uptake I^131
4. HÜRTHLE CELL THYROID CANCER

• Thyroid cancer of the Hürthle cells variant of


follicular cell
• 5%
• Lymphatic hematogenous
• No uptake
• 10-year survival rate 80%
5. ANAPLASTIC CARCINOMA

• Undifferentiated carcinoma
• 2%
• Women >men
• Histologically Giant cells, spindle cells
• Very poor uptake I^131
• Very aggressive
• Poor prognosis because most patients are at stage
IV at presentation (3% alive at 5 years)
INVESTIGATIONS

Diagnostic

• Lab: TSH, T3,T4


• U/S—solid or cystic nodule
• Fine Needle Aspirate (FNA) for cytology
• 123I scintiscan—hot or cold nodule
SURGICAL MANAGEMENT: THYROIDECTOMY

Indications;
• Thyroid malignancies
• Symptomatic thyroid mass
• Patient with refractory medically graves disease or
hyperthyroidism
Contraindication;
• Uncontrolled hyperthyroidism
• Pregnancy
• Cretinism
PATIENT MUST BE EUTHYROID BEFORE THYROIDECTOMY
TYPES OF THYROIDECTOMY

1. Hemi-thyroidectomy-lobectomy
• Remove the lobe and the isthmus
2. Subtotal thyroidectomy
• Leave 4g on either side of the glands
3. Near total thyroidectomy
• Remove all and leave 4g on either side
4. Total thyroidectomy
• Remove both lobes and the isthmus
Complications of thyroidectomy

• Hemorrhage
• Obstruction-tracheomalacia,
• Injury to the nerves
• Hypothyroidism
• Wound infection
• Hypoparathyroidism
• Thyroid storm
COMPLICATIONS-THYROID STORM

• Thyroid storm occurs in patient with primary thyrotoxicosis


who are improperly prepared for surgery
• During surgery thyroxine is released into circulation
FEATURES;
• Hyperpyrexia
• Severe sweating
• Gross dehydration
• Hypovolemic shock
• tachycardia
MANAGEMENT

• ICU admission
• O2
• Rehydration by rapid IVF fluid
• Cold tepid sponging
• Propranolol
• Hydrocortisone
• Carbimazole or propyl thiouracil
• In pite of above intervention mortality is high
Pearls of Wisdom

‘Measure your impact on


humanity not in likes, but in the
lives you touch, not in
popularity, but in the people
you save’
Tim Cook