ANATOMY OF THE THYROID GLAND

• THYROID MEANS ‘SHIELD

LIKE’
• ENDOCRINE GLAND
LOCATED IN THE LOWER
PART OF NECK AT THE
MIDLINE.
• IMP FOR 1- B.M.R. 2-
SOMATIC & PSYCHIC
GROWTH 3- CA++
METABOLISM.
• CONSISTS OF RT. & LT.
LOBES JOINED BY A
ISTHMUS..
• WHAT IS PYRAMIDAL
LOBE???
• WHAT IS LEVATOR
GLANDULAE
THYROIDAE???
LOCATION & CAPSULES
• VERTAEBRAE: C5 TO T1
• LOBE: MIDDLE OF THYROID
CARTILAGE TO 4TH OR 5TH
TRACHEAL RING.
• ISTHMUS: 2ND TO 4TH
TRACHEAL RING
• TRUE CAPSULE:
CONDENSATION OF
CONNECTIVE TISSUE OF
GLAND
• FALSE CAPSULE:
PRETRACHEAL FASCIA
• WHAT IS BERRY’S
LIGAMENT?
• AV. WT: 25gm LARGER IN
FEMALES.. INC DURING
MENARCHE, PREGNANCY &
MENOPAUSE.
RELATIONS OF THE THYROID GLAND
• LOBES:
• LATERAL: STRAP MUSCLES, ANT
BORDER OF SCM & SUP BELLY OF
OMOHYOID.
• MEDIAL: RULE OF TWO..
• TUBES: TRACHEA & OESOPHAGUS
• MUSCLES: INF CONSTRICTOR &
CRICOHYOID
• NERVES: RLN & ELN
• ANT BORDER: SUP THY ART
• POST BORDER: ANAS BETW ANT &
POST THY ART, PARATHYROID GLANDS.
• ISTHMUS:
• ANT: STRAP MUSCLES & ANT JUG VEIN
• POST: 2ND TO 4TH TRACHEAL RINGS
• UPPER BORDER: SUP THY ART BOTH
SIDES
• LOWER BORDER: INF THYROID VEINS
 IMPORTANCE OF THE RELATION
OF ISTHMUS IN TRACHEOSTOMY..
 IMPORTANCE OF THE RELATION
OF ISTHMUS IN TRACHEOSTOMY..
ARTERIAL SUPPLY OF THYROID GLAND
• FROM ECA: SUPERIOR
THYROID ARTERY.. 1ST ANT
BRANCH.. INTIMATE RELATION
TO EXT. LARYNGEAL N.. NEAR
THE THYROID GLAND THEY ARE
FARTHEST FROM EACH OTHER..
DIVIDES INTO ANT & POST
BRANCHES
• FROM SUBCLAVIAN:
INFERIOR THYROID ARTERY..
BRANCH OF THYROCERVICAL
TRUNK.. INTIMATE RELATION TO
RECURRENT LARYNGEAL N.
• FROM AORTA OR
BRACHIOCEPHALIC :
THYROIDEA IMA (3%).. WHY
IMPORTANT??
VENOUS DRAINAGE & LYMPHATICS OF
THYROID GLAND
• SUPERIOR THYROID VEIN -
-- I.J.V.
• MIDDLE THYROID VEIN ---
I.J.V.
• INFERIOR THYROID VEIN --
- BRACHIOCEPHALIC VEIN
• 4TH THYROID VEIN (VEIN OF
KOCHER) BETW MIDDLE &
INF & DRAINS INTO I.J.V.

• LYMPHATIC DRAINAGE:
• FROM PRELARYNGEAL &
PRETRACHEAL NODES TO THE
UPPER, MID & DEEP CERVICAL
NODES.
HISTOLOGY OF THYROID GLAND
• FOLLICULAR CELLS:
LINE THE FOLLICLES &
SECRETE T3 & T4. DURING
ACTIVE PHASE LINING IS
COLUMNAR & IN RESTING
PHASE CUBOIDAL.

• PARAFOLLICULAR
CELLS (C CELLS): LIGHT
CELLS LIE IN BETWEEN
FOLLICLES. SECRETE
THYROCALCITONIN WHICH
PROMOTES DEPOSITION OF
CALCIUM IN SKELETAL &
OTHER TISSUES PRODUCING
HYPOCALCAEMIA.
DEVELOPMENT OF THYROID GLAND
FATE OF THE THYROGLOSSAL DUCT
• ECTOPIC THYROID
ESP-LINGUAL
THYROID

• PYRAMIDAL LOBE

• LEVATOR GLANDULAE
THYROIDAE

• THYROGLOSSAL CYST
PHYSIOLOGY OF THE THYROID GLAND
• IODINE– IODIDE (98%
TAKEN UP BY THYROID BY
IODIDE TRAPPING
MECHANISM)– MIN 20μg
OF IODINE REQD PER
DAY– IN THE GLAND
PEROXIDASE ENZYME
CONVERTS IT BACK TO
IODINE– BINDS WITH
TYROSINE TO FORM
TRIIODO AND
TETRAIODO TYROSINE.
• TRH (HYPOTHALAMUS)–
TSH (PITUTARY)–
THYROID GLAND
FUNCTIONS OF THE THYROID GLAND
IMPORTANCE OF HISTORY TAKING

• SYMPTOMS OF HYPO &

HYPERTHYROIDISM.
• PAIN- HAEMORRHAGE, THYROIDITIS AND
ADVANCED STAGE OF MALIGNANCY.
• PRESSURE EFFECTS-
DYSPNOEA(TRACHEA), HOARSNESS(RLN),
DYSPHAGIA(OESOPHAGUS)
GENERAL EXAMINATION- EYE SIGNS
• EXOPTHALMOS- PROTRUSION
OF THE EYEBALL
• APPARENT- DUE TO SPASM OF
UPPER EYELID DUE TO SYMP N
IRRITATION
• TRUE- E.P.S. RELEASED BY
PITUTARY
• SEVERE FORM DUE TO
INFILTRATIO OF RETROBULBAR
TISSUE WITH FLUID, FATTY
DEPOSITS AND ROUND CELLS.
ALSO CALLED ‘MALIGNANT
EXOPTHALMOS’
OTHER EYE SIGNS
• VON GRAFFE’S- LAGGING OF
UPPER EYELID WHEN PATIENT
LOOKS DOWN
• JOFFROY’S- ABSENSE OF
WRINKLING ON LOOKING UP.
• MOEBIUS’S- FAILURE OF
CONVERGENCE
• DALRYMPLE’S- UPPER SCLERA
SEEN DUE TO SPASM OF UPPER
EYELID.
• STELLWAG’S- ABSENSE OF
NORMAL BLINKING.
OTHER SIGNS ON GENERAL
EXAMINATION
• TACHYCARDIA-
SLEEPING PULSE
RATE IS IMP
• TREMOR OF HANDS
OR TONGUE
• MOIST SKIN OF PALM
• PRETIBIAL
MYXOEDEMA
INSPECTION OF THE THYROID
GLAND • WHY DOES IT MOVE WITH
DEGLUTITION?
• BERRY’S LIGAMENT
• ATTACHMENT TO TRACHEA
• LEVATOR GLANDULAE
THYROIDAE

• WHEN DOES IT NOT MOVE

WITH DEGLUTITION?
• THYROIDITIS
• MALIGNANCY
• RETROSTERNAL EXTENSION
PALPATION & AUSCULTATION OF
THE THYROID GLAND
• FROM BEHIND
• LAHEY’S METHOD IS
PREFFERED FOR
PALPATING A NODULE.
• KOCHER’S TEST TO FIND
OUT PRESSURE ON
TRACHEA
• AUSCULTAION MAY
EXHIBIT A BRUIT DUE TO
INCREASED VASCULARITY
IN THYROTOXICOSIS.
ASSESSMENT OF THYROID FN
• SERUM T3(0.6-1.8ng/ml), T4(4.5-11mcg/dl) &
TSH(0.3-5mI.U/ml)
• RADIO ACTIVE IODINE UPTAKE (R.A.I.U.)- I-
132 IS USED AS SHORTER HALF LIFE– SHOULD
NOT BE DONE IN CHILDREN OR DURING
PREGNANCY.
• TSH STIMULATION TEST- PRIMARY &
SECONDARY HYPOTHYROIDISM.
• MEASUREMENT OF L.A.T.S. FOR GRAVES DZ &
ANTI THYROGLOBIN AND ANTI MICROSOMAL
ANTIBODIES FOR THYROIDITIS
U.S.G. AND THYROID SCAN
• I-131 & Tc-99 to
distinguish betw
functioning (hot) and
non functioning (cold)
nodules.
• Indicated in:-
• Solitory nodule
• Suspected retrostenal
goitre
• Ectopic thyroid tissue
• Toxic nodular goitre
F.N.A.B.C.
• Investigation of choice in solitory
nodules.
• Nowadays done USG guided

• Useful to:
• Differentiate benign nodules from
malignant ones
• To know the type of malignancy.
• Diagnose thyroiditis which can mimic
malignancy.

• Pitfalls:-
• Cant differentiate betw follicular
adenoma and malignancy
• Not very useful in cyst.
 WHAT IS GOITRE &
HOW DO YOU CLASSIFY IT?
• ENLARGEMENT OF THE THYROID GLAND
IRRESPECTIVE OF IT’S CAUSE IS CALLED
‘GOITRE’
• CLASSIFICATION:-
• SIMPLE- 1-DIFFUSE 2-NODULAR 3-
COLLOID
• TOXIC- DIFFUSE OR NODULAR
(SOLITORY OR MULTI)
• NEOPLASTIC- A- BENIGN B-
MALIGNANGT
• THYROIDITIS:- A- ACUTE SUPPURATIVE
THYROIDITIS B- AUTOIMMUNE OR
HASHIMOTO’S C- SUBACUTE OR DE
QUERVAIN’S D- RIEDEL’S
SIMPLE GOITRE
• FAMILIAL- ENZYME DEFICIENCY
• ENDEMIC- HILLY
REGIONS(IODINE DEFN)
• GOITROGENS- CABBAGE,
CAULIFLOWER, TURNIPS AND
CALCIUM.
• PHYSIOLOGICAL
• IDIOPATHIC OR SPORADIC

• SPECIAL GOITRES:-
• JODBASEDOW DISEASE:-
EXCESSIVE IODINE CONSUMPTION
WITH THYROTOXICOSIS
• PENRED’S SYNDROME:- A DEAF
PATIENT WITH GOITRE SINCE
BIRTH.
THYROTOXICOSIS
• GRAVE’S DISEASE:- DUE TO
L.A.T.S.
• YOUNG FEMALE F:M=6:1
• SECONDARY THYROTOXICOSIS
IS MORE COMMON IN OLDER PTS
WITH MULTINODULAR GOITRE
• TACHYCARDIA, PALPITATION,
ATRIAL FIBRILLATION, HIGH
SYSTOLIC AND LOW DIATOLIC BP,
LASTLY C.C.F.
• JODBASEDOW DZ
• EARLY STAGE OF DEQUERVAIN’S
THYROIDITIS
• THYROTOXICOSIS FACTITIA
• NEONATAL THYROTOXICOSIS
INVESTIGATIONS

• THYROID FUNCTION TESTS INCLUDING

FREE T3
• RADIO IODINE STUDY FOR TOXIC
NODULE
• THYROID AUTO ANTIBODIES.
 TREATMENT- ANTITHYROID DRUGS
• PROPYLTHIOURACIL & CARBIMAZOLE:-
CARBIMAZOLE IS 10 TIMES MORE EFFECTIVE. ACTS
BY PREVENTING ORGANIC BINDING OF IODINE AND
COUPLING OF IODOTYROSINES.
• MAY BE STARTED IN THE DOSE OF 10mg 3 TABS
ONCE DAILY OR 1/8hrs AND THEN ADJUSED
ACCORDING TO T.F.T.
• SERIOUS SIDE EFFECTS:- AGRANULOCYTOSIS
AND APLASTIC ANAEMIA.
• ADV:- BELOW 45 yrs, PREGNANCY, CHILDREN.
• DISADV:- PROLONGED TREATMENT, NO
GUARANTEE OF CURE, FAILURE RATE>50%, GOITRE
MAY INCREASE IN SIZE.
TREATMENT- SURGERY
• PREPARATION:-
• PT SHOULD BE MADE EUTHYROID
FOR 2mnths.
• KI OR LUGOL’S IODINE GIVEN TO
DECREASE SIZE AND VASCULARITY-
10 DAYS PRIOR
• BETA BLOCKER LIKE PROPRANOLOL

• SUBTOTAL THYROIDECTOMY- 4-
5gms TISSUE IS KEPT ON BOTH
SIDES.

• POST OP- INDIRECT

LARYNGOSCOPY, SERUM CALCIUM
AFTER 6 WKS, THYROID FUNCTION
TESTS AT 6mnths AND THEN AT
YEARLY INTERVALS.
 TREATMENT- RADIOACTIVE IODINE
• DESTROYS THYROID CELLS
• RESULT IN 8-12wks TIME. 20% MAY REQ A
REPEAT DOSE.
• ADV:- SHORTEST AND CHEAPEST(Rs 4000)
(ANTITHROID DRUGS- 500/month, SURGERY
20-25 THOUSAND)
• DISADV:- PERMANENT HYPOTHYROIDISM,
NOT VERY SATISFACTORY IN NODULAR
GOITRE, LATE HYPOTHYROID IN APPROX 70%
pts.
COMPLICATIONS OF SURGERY
• IMMEDIATE:-
• HAEMORRHAGE
• INFECTION
• R.L.N. PARALYSIS
• PARATHYROID
INSUFFICIENCY OR
TETANY
• THYROID CRISIS
• LATE:-
• THYROID
INSUFFICIENCY
• RECURRENT
THYROTOXICOSIS
• PROGRESSIVE
EXOPTHALMOS
• HYPERTROPHIC SCAR OR
KELOID
HYPOTHYROIDISM
TREATMENT
• L-THYROXINE (ELTROXIN,
THYRONORM)- USUALLY
STARTED WITH A DOSE OF
1mcg/kg BODY WEIGHT.
TITRATED AFTER MEASURING
EVERY 3 MONTHS. TESTS TO BE
REPEATED EARLIER IN CASE OF
SYMPTOMS OR DURING
PREGNANCY & LACTATION.
• THYROID EXTRACT & L-
TRIIODOTHYROXINE MAY ALSO
BE GIVEN.
PATIENTS OF THYROID DISORDERS
 THYROIDITIS
• ACUTE:- ACUTE INFECTIVE
THYROIDITIS

• CHRONIC:-
• HASHIMOTO’S DISEASE OR
AUTOIMMUNE
• SUBACUTE OR DE QUERVAIN’S DISEASE
• RIEDEL’S THYROIDITIS
 HASHIMOTO’S THYROIDITIS
• MOST COMMON
• ALSO CALLED CHRONIC LYMPHOCYTIC THYROIDITIS
• AUTOIMMUNE DISEASE
• FAMILIAL- AUTOIMMUNE GASTRITIS & PERNICIOUS ANAEMIA
ASSOCIATED.
• FEMALES AROUND THE AGE OF 50 MOST COMMONLY
AFFECTED.
• GOITRE WITH PAIN & TENDERNESS.
• MILD HYPERTHYROIDISM FOLLOWED BY HYPOTHYROIDISM.
• FIRM TO RUBBERY IN CONSISTENCY USUALLY
MULTINODULAR
• OTHER AUTOIMMUNE DISORDERS ASSOCIATED.
• DIAGNOSTIC INV:- T.F.T., ANIBODY TITRES, NEEDLE
BIOPSY CONFIRMATORY.
• Rx- SUPPRESSIVE THERAPY WITH ELTROXIN
• INDICATIONS OF SURGERY:- 1- PRESSURE SYMPTOMS 2-
COSMETIC 3- SUSPECTED MALIGNANCY (PAPILLARY)
 SUBACUTE OR
DE QUERVAIN’S THYROIDITIS
• GRANULOMATOUS THYROIDITIS
• VIRAL ORIGIN- UYSUALLY FOLLOWING URTI.
• AGE:- ANY AGE MOST COMMON IN 5TH DECADE.
• SWOLLEN PAINFUL THYROID FOLLOWED BY
CONSTITUTIONAL SYMPTOMS.
• FOUR STAGES:- ACUTELY ENLARGED, TENDER AND
HYPERTHYROID– EUTHYROID– HYPOTHYROID–
REMISSION.. LASTS ABOUT 6 MONTHS.
• INV:- NEEDLE BIOPSY
• Rx- CORTICOSTEROIDS (PREDNISOLONE 1mg/kg
BODY WT) GRADUALLY TAPPERED.
• SURGERY:- CONTRAINDICATED.
 RIEDEL’S THYROIDITIS
• MIMICS MALIGNANCY
• INFILTRATES SURROUNDING TISSUES
• WOMEN IN THE 5TH DECADE MOST
COMMONLY AFFECTED.
• FIRM TO HARD SWELLING WITH ILL DEFINED
MARGINS. USUALLY IMMOBILE. PRESENCE OF
PRESSURE SYMPTOMS.
• INV:- T.F.T.- HYPOTHYROIDISM
• TREATMENT:- THYROXIN AS REPLACEMENT
• SURGERY:- TO RELIEVE PRESSURE
SYMPTOMS. USUALLY ISTHMUSECTOMY.
TUMORS OF THE THYROID GLAND
• BENIGN- MAINLY ADENOMAS. FOLLICULAR
ADENOMA.
• WOMEN IN THE MIDDLE AGE MOST
COMMONLY AFFECTED.
• VERY DIFFICULT TO DISTINGUISH FROM
MALIGNANT TUMORS BY ANY TESTS. ONLY
CAN BE KNOWN BY CAPSULAR OR
ANGIOINVASION.
• HURTHLE CELL ADENOMA IS A VARIETY OF
FOLLICULAR ADENOMA.
APPROACH TO A PATIENT WITH
SOLITORY NODULE OF THYROID
• MOST COMMON
PRESENTATION IN GOITRE
• A CHALLENGE AS IT CAN
BE ONE OF THE
FOLLOWING:-
• A BENIGN NON
FUNCTIONING OR NORMAL
FN NODULE OR CYST.
• A TOXIC NODULE
• A MALIGNANT NODULE.
MALIGNANT NEOPLASMS
• FOLLICULAR CELL ORIGIN
• DIFFERENTIATED
• PAPILLARY (60%)
• FOLLICULAR (15%)
• MIXED
• UNDIFFERENTIATED
• ANAPLASTIC (13%)

• PARAFOLLICULAR
• MEDULLARY CARCINOMA(6%)

• NON THYROID
• MALIGNANT LYMPHOMA
• SARCOMA
• METASTATIC CARCINOMA
PAPILLARY CARCINOMA
• MOST COMMON
• MULTICENTRICITY
• DEPOSITS OF CALCIUM CALLED PSAMMOMA BODIES
• LYMPH NODE METASTASIS EARLY
• DEPENDANT ON TSH STIMULATION
• LATERAL ABERRANT THYROD.
• AGE < 40 GOOD PROGNOSIS.
• PULMONARY METASTASES
• NEAR TOTAL THYROIDECTOMY WITH REMOVAL OF
NODES WITH SUPPRESSIVE DOSE OF THYROID
HORMONE.
FOLLICULAR CARCINOMA
• CAPSULAR INVASION AND VASCULAR
INVASION
• HAEMATOGENOUS SPREAD TO BONE, LUNG
AND LIVER COMMON
• HURTHLE CELL CA- A VARIETY OF FOLLICULAR
WITH LOCAL METASTASIS MORE
• OSTEOLYTIC BONY METS
• GOOD RESPONSE TO RADIO IODINE.(I-131)
• THYROGLOBULIN INDICATOR OF METS.
MEDULLARY CARCINOMA

• PARAFOLLICULAR ‘C’ CELLS