Transcript - for easy reading!

Welcome to this presentation on the neck, part two.

During this presentation, we're going to cover three subject areas. We're going to
begin by looking at the thyroid gland. Secondly, we'll visit the stellate ganglion,
and then lastly, we'll visit the thoracic outlet. And as we move through each of
these three topical areas, we'll discuss clinical correlations.

So here we begin with the thyroid, and what I want you to understand here at the
beginning is some really basic anatomy. First, the thyroid is made up of lobes.
Here we see the right lobe, next we have the left lobe, and lastly, both lobes are
connected by an isthmus. This particular slide shows a very important clinical
relationship or anatomic relationship, and this is the relationship of the thyroid
gland to the recurrent laryngeal nerves. Each laryngeal nerve - here is the right
recurrent laryngeal nerve. It's lined within the tracheoesophageal groove, and we
see that groove between the trachea and the esophagus, which lies posteriorly. We
also see the same relationship, however it's unlabeled, on the opposite side. So,
here's your left recurrent laryngeal nerve, and again, it travels in the
tracheoesophageal groove on that particular slide. Clinically, these are important
during a thyroidectomy. The surgeon has to carefully identify these nerves and
preserve them so they are not injured during the removal of the thyroid gland.
We'll also demonstrate another clinical correlation or the recurrence when we talk
about thyroid goiter.

Here are some important aspects about the recurrent laryngeal nerves. Both
recurrent laryngeal nerves are branches of the vagus nerve and they will supply all
the intrinsic laryngeal muscles with the exception of the cricothyroid. They are
called recurrent, as they come off the vagus nerve and then travel back upwards to
either side of the trachea and ultimately to their destination of the larynx. The
left and right recurrent laryngeal nerves do have some anatomic relationship
differences. The left recurrent laryngeal nerve loops around the aortic arch in the
vicinity of the ligamentum arteriosum, whereas the right recurrent laryngeal nerve
loops more superiorly on the right side, and loops under the right subclavian
artery. Here is an important clinical correlation. Here we're looking at goiter.
And this particular individual has a very enlarged thyroid gland, very large mass
that's very visible. In this particular individual there are multiple enlarged
nodules. So this particular form of Goiter is multinodular. Some of the symptoms
that are associated with a goiter are as follows: One is coughing and this has a
mass effect on the respiratory passageways and the larynx. A second symptom is
hoarseness. Very large goiters can involve the recurrent laryngeal nerves and if
they become involved, then they're unable to effectively activate the muscles of
the larynx and can then create the hoarseness. Another symptom that can be
associated with goiter is a difficulty swallowing, dysphagia, and this would be due
to a mass effect. So the mass is compressing the structures that convey the bolus
of food. And then lastly, again, due to a mass effect, you can have compression of
your respiratory passageways in the area, the trachea, and making that a problem
for some patients.

A very common procedure to demonstrate whether or not nodules are functional

nodules or non-functional nodules, is to utilize the Technetium 99m Pertechnetate
Scan. And we see here in the image are the results of such a scan. Hot nodules are
gonna show up in this kind of coloration that we see here, this is due to the
presence of functional thyroid nodules and they're taking up the technetium 99, so
these areas light up when you have a hot nodule region. A cold nodule is not a
functional nodule, so these types of nodules will not pick up the technetium. And
this area here represents a cold nodule in this scan. So here we are demonstrating,
more specifically, some of the aspects of a cold nodule. And again, it's this area
here - non-functional. These are usually benign. And then lastly, the odds of
being malignant are going to be greater than the hot nodules.

Here we're looking at the thyroid gland with respect to a clinical procedure, it's
removal, a thyroidectomy. Some of the indications for a thyroidectomy are what we
just went through, for example, a goiter, cancer of the thyroid gland would also be
another indication for it's a removal, and then lastly, persistent hyperthyroidism.
Some complications associated with a thyroidectomy include bleeding from the
vasculature, either arterial bleeding or venous bleeding. Infection is always a
concern in any surgical procedure. As we discussed not too long ago, hoarseness of
the voice can occur if there's surgical injury to one of the recurrent laryngeal
nerves. So again, it's very important to isolate them and protect them during a
thyroidectomy. The last complication to highlight, for your information, is that
some patients can have hypoparathyroidism. This is due to not being able to
adequately identify the parathyroid glands before the removal of the thyroid, and
as a result, the parathyroids are also removed, and then you do not have enough
functional parathyroid tissue remaining for them to carry out their function.

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