Thyroid diseases

Embryology
1st of the bodys endocrine glands to develop (28th day of gestation) Originates as a proliferation of endodermal epithelial cells

 As the thyroid start to descent it is still connected to the tongue via thyroglossal duct This tubular duct later solidifies & obliterates entirely (7-10 wk of gestation) Some While the gland descent it passes anterior to hyoid bone & then laryngeal cartilages, forming its mature shape & median isthmus Completes its descent 7th wkimmediately anterior to trachea

 An ectopic thyroid gland Failure of thyroid to descend lingual thyroid Incomplete descent result in resting point of gland high in the neck or just below the hyoid bone Imp. Differentiate between ectopic & thyroglossal cyst total thyroidectomy Hyoid bone Sistrunk procedure

 If thyroglossal duct does not atrophy remnant can manifest clinically as thyroglossal cyst, midline mass track anywhere from the thyroid cartilage to base of tongue (rupture) Pyramidal lobe of thyroid 50%. Represents a persistence of inferior end of thyroglossal duct that has failed to obliterate

 Parafollicular ( C cells), special subset of cells within thyroid gland secrete calcitonin Arise from the ultimobranchial body, which is infiltrated by neural crest cells last structure derived from pharyngeal pouches

Anatomy
Under middle layer of deep cervical fascia, thyroid has an inner true capsule thin & adheres closely to gland Extension of the capsule lobes & lobules. Lobules are composed of follicles (structural units of gland) consist of a layer of simple epithelium enclosing a colloid- filled cavity, which contain iodothyroglobulin (precursor of thyroid hormone) Epithelial cells: 1) principal (follicular) cells formation of colloid 2) parafollicular (C) cells cacitonin

 Anterior suspensory ligament extends from superior-medial aspect of each thyroid lobe to cricoid & thyroid cartilage Posteromedial aspect of gland is attached to side of cricoid cartilage, 1st & 2nd tracheal ring by posterior suspensory (Berry) ligament This firm attachment to the laryngoskeleton is responsible for its movement during swallowing

 Lateral surface of the gland is covered by sternothyroid m. Sternohyoid & sternothyroid ms. are joined in the midline by avascular fascia that must be incised to retract the muscles laterally to access the gland during thyroidectomy Shouldhigh in neck cus motor N. supply from ansa cervicalis enters these ms. inferiorly

Arterial spply
Superior & inferior thyroid as. & occasionally thyroid ima a. Thyroid ima is a single artery which enter the gland from inferior border of isthmus (imp. to consider in tracheostomy potential source of bleeding Superior thyroid a. 1st anterior branch of external carotid a. Superior to the superior pole the external branch of superior laryngeal N runs with superior thyroid a High ligation of this artery places the nerve at risk of injury

dysphonia

 Inferior thyroid a. arises from thyrocervical trunk Closely associated with recurrent laryngeal N, relationship is highly variable

 Follicular cells synthesize & secrete 2 major hormones (T3 & T4) collectively referred to as thyroid hormone Thyroid hormone affect all cells within the body except those in brain, spleen, testes & uterus Regulated through a feedback loop hypothalamus (TRH) Anterior part of pituitary (TSH) Thyroid gland (T3 & T4) 90% T4 & 10% T3..in body tissues T4 T3 greatest metabolic effect

Investigations & Treatment

Blood tests
Thyroid Function Test
mesure serum TSH free T4 & free T3

Thyroid Autoantibody estimation .

Antithyroid Abthyroid microsomal Ab (TMAb) 95% of patients with Hashimoto.D Thyroglobulin Ab (TGAb) 60% of patients with Hashimoto.D Ab against thyroid TSH receptors (TRAbs) seen in patients with Graves . D

Serum thyrogloublin used in follow up of metastatic thyroid carcinoma after tyhyroidectomy

X- rays
Plain radiograph chest & thoracic inlet
.to detect retrosternal thyroid extension ,thyroid calcification ,bony or mediastinal LN & lung metastases

CT scan
For detecting regional &distant metasasis from thyroid cancr

MRI
.diagnosis of cervical LN metastasis

CT scan AP CXR with large retrosternal Goitere

Ultrasound
Used to establish the size & shape of the gland . May indicate if nodules are single or multiple. It will distinguish between cystic & solid lesions. (intrathyroid lesion)

Radioisotpe scan
Single or multiple nodules . Over functioning (hot nodules) or non-functioning (cold nodules) 20% of cold nodules are malignant Hot nodules .rarely malignant

Hot n

Cold n

How??
An injected or inhaled or ingested compound labelled with a suitable radionuclide is concentrated in the organ under review . The emitted radiation is detected by the gamma camera. Examples of radionuclides Technetium 99m (99mTc) iodine 131(131I) Krypton (81mKr) Gallium67 (67Ga)

FNA
Should be performed in the investigation of all thyroid nodules. Distinguish between a solid lesion & a cyst If the lesion is solid.cells are sent for cytological examination If the lesion is a cyst .then the fluid can be removed

How??
A 21 G needle attached to a syringe ,flushed with saline. is passed several times through the nodule while suction is maintained on the syringe.

The aspirated cells are then smeared onto slide & wet &/or dry fixed.
Results of cytology show benign cells, suspicious cells , malignant cells or the specimen is inadequate & consists of red cells only.

Thyroid Disorders

Hypothyroidism
Usually due to autoimmune disorder (Hashimoto thyroiditis).

Investigations..
TSH free T4 &/or T3 Ab : TPO (thyroid peroxidase enzyme)
antithyroglobulin

 Treatment thyroxine
to render the patient euthyroid normal dose 75-150 ug TSH cheacked every 12-18 months liothyronine(T3) is an alternative

elderly patient with ischemic heart disease

starting at 25ug & dose every fortnight (to avoid tachyarrhythmias & cardiac failure)

Hyperthyroidism
It may be caused by Graves disease (autoimmune
thyrotoxicosis)

Toxic multinodular goiter

solitary toxic adenoma

Graves Disease
Investigations
TSH free T4 &/or T3 90% of patients will have arised TRAb 70% of patients will have arised TPO

 Treatment
Initial treatment.. thyroid uptake blocking drugs
egcarbimazole & propylthyouracil SEneutropenia (sore throat) profuse diarrhea hepatocellular failure

B-blockers (propanolol)
if the patient is symptomatic with sweating ,termor or tachycardia Note.. Control of thyrotoxicosis usually takes 6 weeks. But maintenance is required for 18 months

 Defenitive treatment.. Radioactive iodine

SE: long-term hypothyroidism if inappropriate (young children at home) surgery

Sugery
previouslysubtotal thyroidectomy but10% recurrent thyrotoxicosis 70% hypothyroidism in long term current surgical tratment of choice.. total thyroidectomy & long term thyroxine postoperatively

Multinodular goitre
Two types.. non-toxic toxic (plummers disease)

Investigations
TSH (if toxic MNG)
FNAof the dominant nodule if present Ultrasoundmay confirm multiple nodules X-ray of thoracic inlet & CT extent of retrosternal extension & the degree of tracheal deviation & compression .

 Treatment
non-toxic goitre .total thyoidoectomy if there is rterosternal extension tracheal compression cosmetically unacceptable toxic MNG.. initiallycarbimazole then .total thyroidectomy or radioiodine

Solitary toxic adenoma

Investigations
TSH 99mTcO4 thyroid isotope solitary hot nodule

Treatment..
initiallycarbimazole thenthyroid lobectomy or radioactive iodine

Solitary toxic nodule

Investigations
exclude solitary toxic adenoma (TSH) FNA..to exclude malignancy
other investigations (not routinely required for the majority of STNs) ultrasound discriminate between solid & cysts 99mTcO4 thyroid isotope scan.function of nodule

 Treatment
FNA

benign

suspicious

malignant

inadequate

Observe Repeat FNA After 6-12months

surgery
Thyroid lobectomy

surgery

Repeat FNA

Mangement of thyroid malignancy

Differentiated thyroid carcinoma
which include
papillary thyroid carcinoma follicular thyroid carcinoma

Treatment.according to the Grading system

Good prognosis Poor prognosis

 Good prognosis
Female < 45yrs old Male < 40 yrs old Tumor < 5cm Minimally invasive follicular carcinoma

Treatment Thyroid lobectomy with subsequent TSH suppression

 Poor prognosis
Female > 45 yrs old Male > 40 yrs old Tumor >5 cm Any patient with distant metastsis Extrathyroidal invasion Treatment Total thyroidectomy subsequent radioiodine (131I) & TSH suppression with thyroxine

 Undifferentiated thyroid carcinoma (anaplastic)

Treatment Surgery limited role obstruction)

(releive airway

External beam radiotherapy &/or chemotherapy (mostly palliative) the vast majority of patients die within 12 months

Medullary thyroid carcinoma

Treatment
Total thyroidectomy with central lymph node clearance Postoperatively thyroxine replacement (but not TSH suppression) Postoperative calcitonin measurement is auseful tumor cell marker (follow up)

Thyroid lymphoma
Diagnosed by FNA or trucut biopsy Should be staged with a bone marrow aspirate & CT scan of chest & abdomen Treatment If confined to the thyroid alone thyroid lobectomy with subsequent adjuvant radiotherapy & chemotherapy Otherwise .chemoradiation alone

Complication of thyroid surgery

Damage to recurrent laryngeal nerve .. leading to palsy & causing hoarseness. Damage to external branch of superior laryngeal nerve leading to palsy & hoarseness Hypocalcaemia caused by damage to parathyroids Haemorrhagecausing laryngeal oedema & respiratory compromise.