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Surgery of the Thyroid Gland
The extirpation of the thyroid gland . . . typiﬁes, perhaps better than any operation, the supreme triumph of the surgeon’s art.... A feat which today can be accomplished by any competent operator without danger of mishap and which was conceived more than one thousand years ago.... There are operations today more delicate and perhaps more difﬁcult.... But is there any operative problem propounded so long ago and attacked by so many . . . which has yielded results as bountiful and so adequate? Dr. William S. Halsted, 1920 Modern thyroid surgery, as we know it today, began in the 1860s in Vienna with the school of Billroth (1). The mortality associated with thyroidectomy was high, recurrent laryngeal nerve injuries were common, and tetany was thought to be caused by “hysteria.” The parathyroid glands in humans were not discovered until 1880 by Sandstrom (2), and the fact that hypocalcemia was the deﬁnitive cause of tetany was not wholly accepted until several decades into the twentieth century. Kocher, a master thyroid surgeon who operated in the late nineteenth and early twentieth centuries in Bern, practiced meticulous surgical technique and greatly reduced the mortality and operative morbidity of thyroidectomy for goiter. He described “cachexia strumipriva “ in patients years after thyroidectomy (3) (Fig 1). Kocher recognized that this dreaded syndrome developed only in patients who had total thyroidectomy. As a result, he stopped performing total resection of the thyroid. We now know, of course, that cachexia strumipriva was surgical hypothyroidism. Kocher received the Nobel Prize for this very important contribution, which proved beyond a doubt the physiologic importance of the thyroid gland.
Figure 1. The dramatic case of Maria Richsel, the ﬁrst patient with postoperative myxedema to have come to Kocher’s attention. A. The child and her younger sister before the operation. B. Changes 9 years after the operation. The younger sister, now fully grown, contrasts vividly with the dwarfed and stunted patient. Also note Maria’s thickened face and ﬁngers, which are typical of myxedema. (From Kocher T: Uber Kropfextirpation und ihre Folgen. Arch Klin Chir 29:254, 1883.) By 1920, advances in thyroid surgery had reached the point that Halsted referred to this operation as a “feat which today can be accomplished by any competent operator without danger of mishap” (1). Unfortunately, decades later, complications still occur. In the best of hands, however, thyroid surgery can be performed today with a mortality that varies little from the risk of general anesthesia alone, as well as with low morbidity. To obtain such enviable results, however, surgeons must have a thorough understanding of the pathophysiology of thyroid disorders; be versed in the preop1
Chapter 21. Surgery of the Thyroid Gland erative and postoperative care of patients; have a clear knowledge of the anatomy of the neck region; and use an unhurried, careful, and meticulous operative technique.
The thyroid (which means “shield”) gland is composed of two lobes connected by an isthmus that lies on the trachea approximately at the level of the second tracheal ring (Fig. 2). The gland is enveloped by the deep cervical fascia and is attached ﬁrmly to the trachea by the ligament of Berry. Each lobe resides in a bed between the trachea and larynx medially and the carotid sheath and sternocleidomastoid muscles laterally. The strap muscles are anterior to the thyroid lobes, and the parathyroid glands and recurrent laryngeal nerves are associated within the posterior surface of each lobe. A pyramidal lobe is often present. This structure is a long, narrow projection of thyroid tissue extending upward from the isthmus and lying on the surface of the thyroid cartilage. It represents a vestige of the embryonic thyroglossal duct, and it often becomes palpable in cases of thyroiditis or Graves’ disease. The normal thyroid varies in size in different parts of the world, depending on the iodine content in the diet. In the United States it weighs approximately 15 grams.
Figure 2. The normal anatomy of the neck in the region of the thyroid gland. (From Halsted, W.S. The operative story of goiter. Johns Hopkins Hospital Rep 19:71, 1920.) 2
Chapter 21. Surgery of the Thyroid Gland
The thyroid has an abundant blood supply (Fig. 3). The arterial supply to each thyroid lobe is twofold. The superior thyroid arteries arise from the external carotid artery on each side and descend several centimeters in the neck to reach the upper poles of each thyroid lobe, where they branch. The inferior thyroid arteries, each of which arises from the thyrocervical trunk of the subclavian artery, cross beneath the carotid sheath and enter the lower or midpart of the thyroid lobe. The thyroidea ima is sometimes present; it arises from the arch of the aorta and enters the thyroid in the midline. A venous plexus forms under the thyroid capsule. Each lobe is drained by the superior thyroid vein at the upper pole, which ﬂows into the internal jugular vein; and by the middle thyroid vein at the middle part of the lobe, which enters either the internal jugular vein or the innominate vein. Arising from each lower pole is the inferior thyroid vein, which drains directly into the innominate vein.
Figure 3. Anatomy of the thyroid and parathyroid glands. A. Anterior view. B. Lateral view with the thyroid retracted anteriorly and medially to show the surgical landmarks (the head of the patient is to the left). (From Kaplan EL: Thyroid and parathyroid. In Schwartz SI (ed): Principles of Surgery, 5th ed., New York, McGraw-Hill, 1989, pp 1613-1685.)
The relationship of the thyroid gland to the recurrent laryngeal nerve and to the external branch of the superior laryngeal nerve is of major surgical signiﬁcance because damage to these nerves leads to disability in phonation or to difﬁculty breathing (4). Both nerves are branches of the vagus nerve. Recurrent Laryngeal Nerve The right recurrent laryngeal nerve arises from the vagus nerve, loops posteriorly around the subclavian artery, and ascends behind the right lobe of the thyroid (Figs. 3 and 4a). It enters the larynx behind the cricothyroid muscle and the inferior cornu of the thyroid cartilage and innervates all the intrinsic laryngeal muscles except the cricothyroid. The left recurrent laryngeal nerve comes from the left vagus nerve, loops posteriorly around the arch of the aorta, and ascends in the tracheoesophageal groove posterior to the left lobe of the thyroid, where it en3
Chapter 21. Surgery of the Thyroid Gland ters the larynx and innervates the musculature in a similar fashion as the right nerve. Several factors make the recurrent laryngeal nerve vulnerable to injury, especially in the hands of inexperienced surgeons (4,6). 1. The presence of a non-recurrent laryngeal nerve (Fig. 4b). Nonrecurrent nerves occur more on the right side (0.6%) than on the left (0.04%) (5). They are associated with vascular anomalies such as an aberrant takeoff of the right subclavian artery from the descending aorta (on the right) or a right-sided aortic arch (on the left). In these abnormal positions, each nerve is at greater risk of being divided. 2. Proximity of the recurrent nerve to the thyroid gland. The recurrent nerve is not always in the tracheoesophageal groove where it is expected to be. It can often be posterior or anterior to this position or may even be surrounded by thyroid parenchyma. Thus, the nerve is vulnerable to injury if it is not visualized and traced up to the larynx during thyroidectomy. 3. Relationship of the recurrent nerve to the inferior thyroid artery. The nerve often passes anterior, posterior, or through the branches of the inferior thyroid artery. Medial traction of the lobe often lifts the nerve anteriorly, thereby making it more vulnerable. Likewise, ligation of this artery, practiced by many surgeons, may be dangerous if the nerve is not identiﬁed ﬁrst. 4. Deformities from large thyroid nodules (6). In the presence of large nodules the laryngeal nerves may not be in their “correct” anatomic location but may be found even anterior to the thyroid (Fig. 5). Once more, there is no substitute for identiﬁcation of the nerve in a gentle and careful manner.
Chapter 21. Surgery of the Thyroid Gland
Figure 4a. A) Normal anatomy of the recurrent laryngeal nerve. Note that on the right side the recurrent laryngeal nerve hooks around behind the subclavian artery, while on the left side this nerve passes around behind the aortic arch before ascending in the neck.
In such a situation. the recurrent laryngeal nerve no longer "recurs" around this artery but proceeds from the vagus nerve in a more transverse direction to the larynx. (From Skandalakis et al. with permission.) 6 . B) When there is a vascular anomaly of the right subclavian artery.Chapter 21. the nerve is much more likely to be damaged during operation unless care is taken to visualize its course in the neck. Surgery of the Thyroid Gland Figure 4b.
In some patients the external branch of the superior laryngeal nerve lies on the anterior surface of the thyroid lobe. the external branch of the superior laryngeal nerve innervates the cricothyroid muscle. Udekwu AO (eds): Debates in Clinical Surgery. Rarely. In most cases. In 21% the nerve is intimately associated with the superior thyroid vessels. functional recovery may occur postoperatively. Year Book. In Simmons RL. Unfortunately. (From Thompson NW. which requires that the vessels be ligated with care to avoid injury to it (Figure 6). Such nerves are at risk during lobectomy unless the surgeon anticipates the unusual locations and is very careful.) External branch of the superior laryngeal nerve On each side. Recurrent laryngeal nerve displacements by cervical and substernal goiters. 1990. After careful dissection and preservation. Demers M: Exposure is not necessary to avoid the recurrent laryngeal nerve during thyroid operations.Chapter 21. this nerve lies close to the vascular pedicle of the superior poles of the thyroid lobe (7). Surgery of the Thyroid Gland Figure 5. making the possibility of damage during thyroidectomy even greater (8). In only 15% of patients is the superior laryngeal nerve sufﬁciently distant from the superior pole vessels to be protected from manipulation by the surgeon. the nerves are so stretched that spontaneous palsy results. many surgeons do not even attempt to identify this nerve before ligation of the upper pole vessels of the thyroid (9). 7 . Chicago.
Surgery of the Thyroid Gland Figure 6. and their usual anatomic position adjacent to the thyroid gland. They descend only slightly during embryologic development. Because of their small size. Usually four glands are present. The upper parathyroid glands arise embryologically from the fourth pharyngeal pouch (Figs. Proximity of the external branch of the superior laryngeal nerve to the superior thyroid vessels. This gland is usually found adjacent to the posterior surface of the middle part of the thyroid lobe. the major hormone that controls serum calcium homeostasis in humans. Surg Gynecol Obstet 127:1101. traumatized. these structures are at risk of being accidentally removed. 8).Chapter 21. and their position in adult life remains quite constant. or devascularized during thyroidectomy (10). (From Moosman DA. their delicate blood supply. PARATHYROID GLANDS The parathyroids are small glands that secrete parathyroid hormone. but they may be heavier if more fat is present. 7. two on each side. Each gland normally weighs 30 to 40 mg. 1968) (7). but three to six glands have been found. 8 . often just anterior to the recurrent laryngeal nerve as it enters the larynx. DeWeese MS: The external laryngeal nerve as related to thyroidectomy.
Frozen section examination during surgery can be helpful in their identiﬁcation. one becomes much more adept at recognizing these very important structures and in differentiating them from either lymph nodes or fat. C. Shifts in location of the thyroid. Cady B: Surgery of the Thyroid and Parathyroid Gland. the fact that they bleed freely when biopsy is performed. Approximates the adult location. Surgery of the Thyroid Gland Figure 7. 2nd ed. With experience. adapted from Norris EH: Parathyroid glands and lateral thyroid in man: Their morphogenesis. Note that what has been called the lateral thyroid is now commonly referred to as the ultimobranchial body. their small vascular pedicle. however. hence. 9 . Because they travel so far in embryologic life. and their darkening color of hematoma formation when they are traumatized. 1937.) The lower parathyroid glands arise from the third pharyngeal pouch. histogenesis. from just beneath the mandible to the anterior mediastinum (Fig. (From Sedgwick CE. topographic anatomy and prenatal growth. 8) (11). Contrib Embryol Carnegie Inst Wash 26:247-294.Chapter 21. Philadelphia. along with the thymus. Parathyroid glands can be recognized by their tan appearance. these glands are found on the lateral or posterior surface of the lower part of the thyroid gland or within several centimeters of the lower thyroid pole within the thymic tongue. as opposed to fatty tissue. 1980. A and B. Usually. they often descend with the thymus. parafollicular and parathyroid tissues.. they have a wide range of distribution in adults. WB Saunders. which contains both C cells and follicular elements.
The results of his studies. New York.. 5th ed. In Schwartz SI (ed): Principles of Surgery. it is nearly always in the anterior mediastinum. This fact probably accounts for the frequency with which the trachea is involved by thy10 .) LYMPHATICS A practical description of the lymphatic drainage of the thyroid gland for the thyroid surgeon has been proposed by Taylor (12). Copyright by McGraw-Hill. When this gland is in the chest. Used by permission of McGraw-Hill Book Company. are summarized in the following: Central Compartment of the Neck 1. the wall of which contains a rich network of lymphatics. Whereas the upper parathyroid occupies a relatively constant position in relation to the middle or upper third of the lateral thyroid lobe. (From Kaplan EL: Thyroid and parathyroid. Descent of the lower parathyroid. 1989. Inc. the lower parathyroid normally migrates in embryonic life and may end up anywhere along the course of the dotted line.Chapter 21. McGraw-Hill. Surgery of the Thyroid Gland Figure 8. pp 1613-1685. The most constant site to which dye goes when injected into the thyroid is the trachea. which are clinically very relevant to the lymphatic spread of thyroid carcinoma.
INDICATIONS FOR THYROIDECTOMY Thyroidectomy is usually performed for the following reasons: 1. a lymph vessel of considerable size. To treat benign and malignant thyroid tumors. the wound is likely to ﬁll with lymph. To alleviate pressure symptoms or respiratory difﬁculties associated with a benign or malignant process. 2. 6. A chain of lymph nodes lies in the groove between the trachea and the esophagus. 4. 3. Finally. Lateral Compartment of the Neck A constant group of nodes lies along the jugular vein on each side of the neck. To establish a deﬁnitive diagnosis of a mass within the thyroid gland. if palpable. 11 .Chapter 21. 5. and therefore in front of the larynx. To remove large substernal goiters. To remove an unsightly goiter (Figure 9). Lymph can always be shown to drain toward the mediastinum and to the nodes intimately associated with the thymus. These nodes have been called the Delphian nodes (named for the oracle of Delphi) because it has been said that. This involvement is sometimes the limiting factor in surgical excision. 5. they are diagnostic of carcinoma. the duct should always be sought and tied. especially when it is anaplastic. Surgery of the Thyroid Gland roid carcinoma. it should not be forgotten that the thoracic duct on the left side of the neck. and others with a hot nodule or toxic nodular goiter. 2. A wound that discharges lymph postoperatively should always raise suspicion of damage to the thoracic duct or a major tributary. The lymph glands found in the supraclavicular fossae may also be involved in more distant spread of malignant disease from the thyroid gland. those with Graves’ disease. especially when they cause respiratory difﬁculties. arches up out of the mediastinum and passes forward and laterally to drain into the left subclavian vein. Rarely. 4. this clinical sign is often misleading. usually just lateral to its junction with the internal jugular vein. are sometimes involved. 3. in such cases. A lateral lymph node dissection encompasses removal of these lateral lymph nodes. If the thoracic duct is damaged. the submental nodes are involved by metastatic thyroid cancer as well. especially when cytologic analysis after ﬁne needle aspiration (FNA) is either nondiagnostic or equivocal. However. As therapy for some individuals with thyrotoxicosis. One or more nodes lying above the isthmus. Central lymph node dissection clears out all these lymph nodes from one carotid artery to the other carotid artery and down into the superior mediastinum as far as possible.
Large goiters are prevalent in areas of iodine deﬁciency.Chapter 21. Surgery of the Thyroid Gland Figure 9a. 12 . Theodor Kocher (From Kocher (3)). A woman from Switzerland operated upon by Dr. A.
and for acne have long been discontinued. as demonstrated in this woman from a mountainous region of Vietnam. One hundred years later.Chapter 21. Therefore. Large goiters are prevalent in areas of iodine deﬁciency.15). LOW-DOSE EXTERNAL IRRADIATION OF THE HEAD AND NECK A history of low-dose external irradiation of the head or neck is probably the most important historical fact that can be obtained in a patient with a thyroid nodule because it indicates that cancer of the thyroid is more likely (in up to 35% of cases). Low-dose irradiation and its implications are discussed elsewhere. 1970. treatments of low-dose radiation for an “enlarged” thymus in infancy. SOLITARY THYROID NODULES Solitary thyroid nodules are present in 4% to 9% of patients by clinical examination and in 22% of patients by ultrasound in the United States. B. 13 . rather than operating on every patient with a thyroid nodule. most are benign (13). even if the gland is multinodular (14. for tonsils. Furthermore. Surgery of the Thyroid Gland Figure 9b. each surgeon must know the complications of thyroidectomy and either be able to perform a proper operation for thyroid cancer in a safe and effective manner or refer the patient to a center where it can be done. the physician or surgeon should select patients for surgery who are at high risk for thyroid cancer. Fortunately. large goiters still occur in many parts of the world.
These are called a possible follicular neoplasm or an indeterminate nodule. DIAGNOSIS OF THYROID NODULES Excellent review articles concerning the diagnosis of thyroid nodules have recently been published (20a. It is thought to be the result of exposure to iodine isotopes that were inhaled or that entered the food chain. including our own. These patients should also be observed carefully for the development of hypothyroidism. Thus. but currently most have been superseded by FNA of the mass with cytologic analysis (20c). more than 90% of nodules can be categorized histologically. more than 2000 rad. Rather. Most. This cancer may also be more aggressive than the usual papillary carcinoma. Falsepositive diagnoses are rare. HIGH-DOSE EXTERNAL IRRADIATION THERAPY High-dose external irradiation therapy. after operative removal of the nodule. RISK OF IONIZING RADIATION Sixty years after Hiroshima and 20 years after Chernobyl. Finally. it should be treated aggressively. particularly in patients with Hodgkin’s disease and other lymphomas who received upper mantle irradiation that included the thyroid gland. Children in the area of the Chernobyl nuclear accident have been shown to have at least a 30-fold increase in papillary thyroid cancer (18c). and less than 10% are non-diagnostic. non-palpable masses. has been found. the patient should be observed and not operated on unless tracheal compression or a substernal goiter is present. Twenty percent demonstrate sheets of follicular cells with little or no colloid. 20b). patients who had this therapy in childhood are still seen and are still at greater risk of cancer. a follicular carcinoma exhibits the same cytologic characteristics and cannot be differentiated by this technique. In the hands of a good thyroid cytologist. if an inadequate specimen is obtained. up to 90%. 18b).Chapter 21. does not confer safety from thyroid carcinoma. or unless the patient desires the benign mass to be removed. as was previously thought (16). Surgery of the Thyroid Gland However. usually papillary cancer. This test is usually reserved for diagnosis of a “hot” nodule. prove to be benign. there continues to be an increase in both benign and malignant nodules (18a. because their ﬁndings are compatible with a follicular neoplasm. can follicular carcinoma and adenoma be differentiated. FNA should be performed under ultrasound guidance. by emphasizing the importance of early cytologic examination of the needle aspirate (Fig. All patients who have malignant cytologic results should be operated on. If a thyroid mass appears. Both benign and malignant thyroid nodules are being recognized now that these persons survive for longer periods (17). The mechanism of radiationinduced thyroid cancer is thought to be caused by rearrangements in tyrosine kinase domains of the RET and TRK genes (19). FNA with cytologic assessment is the most powerful tool in our armamentarium for the diagnosis of a thyroid nodule (21). 11). because follicular cancers exhibit capsular and/or vascular invasion (20d). Approximately 65% to 70% are found to be compatible with a colloid nodule. however. that is. In summary. Five percent to 10% are malignant. an increased prevalence of thyroid carcinoma. Usually a dose of about 4000 to 5000 rad was given. Only by careful histologic examination. A number of diagnostic modalities have been used in the past. FNA with cytologic examination should be repeated. Far fewer isotope scans are currently being done because carcinomas represent only 5% to 10% of all cold nodules. When the diagnosis of colloid nodule is made cytologically. 10) has been replaced in most hospitals. the algorithm for the diagnosis of a thyroid nodule with isotope scintigraphy and ultrasonography as initial steps (Fig. With small. 14 . All patients with sheets of follicular cells with little or no colloid should also undergo surgery.
PREPARATION FOR SURGERY Most patients undergoing a thyroid operation are euthyroid and require no speciﬁc preoperative preparation related to their thyroid gland. Determination of the serum calcium level may be helpful. and endoscopic laryngoscopy should deﬁnitely be performed in those who are hoarse and in others who have had a prior thyroid or 15 . Figure 11. Surgery of the Thyroid Gland Figure 10.Chapter 21.
Most of our patients with Graves’ disease are treated initially with the antithyroid drugs propylthiouracil or methimazole (Tapazole) until they approach a euthyroid state. In most cases. Lugol’s solution or a saturated solution of potassium iodide is given up to 8 to 10 days. cardiovascular problems. prolonged anesthetic recovery. Young patients. and it is the best test of thyroid function. both the morbidity and the mortality of surgery are increased as a result of the effects of both the anesthesia and the operation. and then the dose is gradually increased. and an excellent anesthesiologist is mandatory for success. when severe myxedema is present. In general. and those with thyroid nodules or severe ophthalmopathy are commonly operated upon. In the early days of thyroid surgery. speech. Radioiodine therapy may lead to worsening ophthalmopathy. with proper preoperative preparation (23). small doses of thyroxine are initially given to patients who are severely hypothyroid. however.Chapter 21. intravenous thyroxine can be started preoperatively and continued thereafter. operations on the toxic gland were among the most dangerous surgical procedures because of the common occurrence of severe bleeding. iodine therapy alone has been used for preoperative preparation. Now. disorientation. The serum thyroid-stimulating hormone (TSH) level is high in all cases of hypothyroidism that are not caused by pituitary insufﬁciency. operations on the thyroid gland in Graves’ disease can be performed with about the same degree of safety as operations for other thyroid conditions. This medication is taken in milk or orange juice to make it more palatable. coma. Surgery of the Thyroid Gland parathyroid operation in order to detect the possibility of a recurrent laryngeal nerve injury. We use 16 . HYPERTHYROIDISM In the United States. a severe accentuation of the symptoms and signs of hyperthyroidism that can occur during or after surgery. those with very large goiters. If urgent surgery is necessary. gastrointestinal hypomotility. Sometimes thyroxine is added to this regimen to prevent hypothyroidism and to decrease the size of the gland. Such patients have a higher incidence of perioperative hypotension. fever. it is our practice to administer three drops two or three times daily. it should not be postponed simply for repletion of thyroid hormone. iodine is added to the regimen for 8 to 10 days before surgery. Then. as well as all the symptoms and signs of thyroid storm. HYPOTHYROIDISM Modest hypothyroidism is of little concern when treating a surgical patient. over 90% of all patients with Graves’ disease are treated with radioiodine therapy. and reﬂexes (22). Persons with Graves’ disease or other thyrotoxic states should be treated preoperatively to restore a euthyroid state and to prevent thyroid storm. pregnant women. Thyroid storm results in tachycardia or cardiac arrhythmias. it is preferable to defer elective surgery until a euthyroid state is achieved. The iodine decreases the vascularity and increases the ﬁrmness of the gland. most patients with thyrotoxicosis have Graves’ disease. as well as by slowness of affect. Severe hypothyroidism can be diagnosed clinically by myxedema. Although only several drops per day are needed to block the release of thyroxine from the toxic thyroid gland. They metabolize drugs slowly and are very sensitive to all medications. Endocrine consultation is imperative. In the United States. and even death. Circulating thyroxine and triiodothyronine values are low. Beta-adrenergic blockers such as propranolol (Inderal) have increased the safety of thyroidectomy for patients with Graves’ disease (23). and neuropsychiatric disturbances. In mild cases of Graves’ disease with thyrotoxicosis. although we do not recommend this approach routinely (22). severe hypothyroidism can be a signiﬁcant risk factor. Therefore. In the presence of severe hypothyroidism.
Chapter 21. In children and adolescents. and ameliorate the major signs of Graves’ disease by decreasing the patient’s pulse rate and eliminating the tremor. Leaving more leads to a higher rate of recurrence (25). one should leave smaller remnants because the incidence of recurrence of thyrotoxicosis appears to be greater in this group. Ablative Treatment of Graves’ Disease with Thyrotoxicosis Method Dose or extent of surgery Subtotal Excision of gland (leaving 2g remnant or less) Onset of response Immediate Remarks Complications Mortality < 1% Permanent hypothyroidism may occur Recurrent hyperthyroidism may occur Vocal cord paralysis: ~1% Hypoparathyroidism: ~1% Applicable in youger patients and pregnant women Prevents worsening ophthalmopathy of radioiodine Surgery Radioiodine 5-10 mCi Several weeks Permanent hyto months pothyroidism: 50-70%. Some surgeons recommend preoperative use of propranolol alone or with iodine (24). they believe. shorten the preparation time of patients with Graves’ disease for surgery and make the operation easier because the thyroid gland is smaller and less friable than it would otherwise be (24). although the peripheral manifestations of their disease have been blocked. Surgery of the Thyroid Gland them commonly with antithyroid drugs to block beta-adrenergic receptors. thyroidectomy as deﬁnitive treatment of Graves’ disease are listed in Table 1. Table 1. We have used propranolol therapy alone or with iodine without difﬁculty in some patients who are allergic to antithyroid medications. Remember that they are still in a thyrotoxic state immediately after surgery. In our patients we have never had a death from thyroidectomy in over 30 years. We do not favor these regimens for routine preparation because they do not appear to offer the same degree of safety as do preoperative programs that restore a euthyroid state before surgery. when operating 17 . multiple treatment somtehimes necessary. Surgical resection involves either subtotal thyroidectomy (Fig. 12) or lobectomy with contralateral subtotal lobectomy. Currently we leave about 2 g or less of thyroid tissue in the neck at the end of the operative procedure. These regimens. Finally. often with delayed onset. recurrence possible Avoid in children of pregnant women The advantages and disadvantages of radioiodine vs. In such patients it is essential to continue the propranolol for 1 to 2 weeks postoperatively. Instances of fever and tachycardia have been reported in persons with Graves’ disease who were taking only propranolol.
If a follicular neoplasm is diagnosed. enlarged lymph nodes of the central compartment are often sampled. or a benign Hurthle cell tumor from Hurthle cell carcinoma using frozen section is usually very difﬁcult. To aid in the diagnosis. with the understanding that a second operation may be necessary to complete the thyroidectomy if a carcinoma is ultimately diagnosed.Chapter 21. SURGICAL APPROACH TO THYROID NODULES Non-irradiated Patients Any single nodule suspected of being a carcinoma should be completely removed. Most patients with a benign neoplasm are treated with thyroxine replacement anyway. and a biopsy of the jugular nodes might be also performed. These diagnoses require careful assessment of capsular and vascular invasion. Surgery of the Thyroid Gland for severe ophthalmopathy. we try to perform near-total or total thyroidectomy. If the result is negative. Furthermore. If a colloid nodule is diagnosed. because the remaining small thyroid remnant can be ablated with radioiodine therapy. Figure 12. a second operation is eliminated if the lesion is later diagnosed as malignant. 12). which are often difﬁcult to evaluate on frozen section. The major beneﬁts of thyroidectomy appear to be the speed with which normalization is achieved and possibly a lower rate of hypothyroidism than is seen after radioiodine therapy. 18 . this means that a total lobectomy (or lobectomy with isthmectomy) is the initial operation of choice in most patients (see Fig. along with surrounding tissue. A frozen section should be obtained intraoperatively. two options are available: 1) stopping the operation after lobectomy. treatment is more controversial. the operation is terminated. Differentiating a follicular adenoma from a follicular carcinoma. even if only one lobe has been removed. or 2) performing a subtotal resection on the contralateral side.
even if a frozen section of the dominant nodule is benign. Treatment of minimal papillary carcinoma The term minimal papillary carcinoma refers to a small papillary cancer. Standard treatment of most papillary carcinomas Most papillary carcinomas are neither minimal nor occult. the lymph node-bearing tissue from the central and lateral triangles is removed. we use FNA with cytology to determine the need for operation. however. and spinal accessory nerve are spared and left in place. childhood. a near-total resection of the thyroid gland with biopsy of the jugular nodes is usually performed. whereas the carotid artery. they are also known occasionally to invade locally into the trachea or esophagus. which remove only the enlarged lymph nodes. that is not associated with lymph node metastases. with appropriate central and lateral neck dissection when nodes are involved (26a). Rather. if they are operated on for nodular disease. the known coincidence of benign and malignant nodules in the same gland. 12). less than 1 cm in diameter. Patients who have received high-dose radiation to their thyroid bed (e.. brachial plexus. At the conclusion of a modiﬁed radical neck dissection. those treated with upper mantle irradiation for Hodgkin’s disease) are also at greater risk for the development of thyroid carcinoma years later and should be monitored carefully (16). These tumors are known to be microscopically multicentric in up to 80% of patients. and the prevalence of papillary carcinoma in up to 35% of such patients (15). most of the thyroid tissue should be removed even if the dominant mass is thought to be benign. In patients with single nodules. and the patient is monitored at regular intervals. or adolescence. jugular vein. especially when the cancer is unicentric and 5 mm or smaller. should not be performed. when tumor is found in the lateral triangle. SURGICAL APPROACH TO THYROID CANCER Papillary Carcinoma The surgical treatment of papillary carcinoma is best divided into two groups based on the clinical characteristics and virulence of these lesions. The authors ﬁrmly believe that the best treatment of papillary cancer is near-total or total thyroidectomy (Fig. and to recur clinically in the other thyroid lobe in 7% to 18% of patients if treated only by thyroid lobectomy (26). In such instances. that demonstrates no local invasiveness through the thyroid capsule.g. these patients require therapy with thyroid hormone. The so-called cherry-picking operations. Many times sensory nerves 19 .Chapter 21. lobectomy is sufﬁcient and reoperations are unnecessary. Surgery of the Thyroid Gland Irradiated Patients In patients with multiple thyroid nodules who have been exposed to low-dose. a modiﬁed radical neck dissection should be performed (27) (Fig. phrenic nerve. This therapy is thought to be advantageous because small cancers can be present in the same gland and the remaining thyroid remnant of these patients can usually be ablated with radioiodine if a carcinoma is found on permanent section analysis. to metastasize commonly to lymph nodes and later to the lungs and other tissues. Once more. In any event. Thyroid hormone is given to suppress serum TSH levels. and that is often found in a young person as an occult lesion when thyroidectomy has been performed for another benign condition. external irradiation of the head and neck during infancy. The reasons for this include the frequency of bilaterality of the disease. sympathetic ganglia. 13).
In a modiﬁed neck dissection the sternocleidomastoid muscle is not usually divided. it may be advisable to refer such patients to a major medical center where such expertise is available. After surgery. radioiodine scanning and treatment of metastases cannot be performed effectively.) Surgeons with limited experience should probably not perform total or near-total thyroidectomy unless capable of doing so with a low incidence of recurrent laryngeal nerve injuries and permanent hypoparathyroidism. (From Sedgwick CE. 20 . WB Saunders. If all or most of a lobe of normal thyroid remains. 28a). but only if the TSH level is very high and normal thyroid tissue has been removed or ablated. p 180. Otherwise. 131I is taken up by most metastatic papillary cancers. because these complications are serious. plexus. such dissections should be done only when enlarged nodes with tumor are found. reoperative completion thyroidectomy is done. Usually. and the jugular vein is not removed unless lymph nodes with tumor are adherent to it. Prophylactic neck dissection of the lateral triangle should not be performed for papillary cancer. and then the radioiodine is given. Cady B: In Surgery of the Thyroid and Parathyroid Glands. 1980. Figure 13. and spinal accessory nerve are preserved. Surgery of the Thyroid Gland can be retained as well.Chapter 21. radioiodine scanning and treatment are commonly used (28. Philadelphia.
controversy still exists over the proper treatment of papillary cancer in some patients. and size (MACIS adds completeness of excision). Microscopically. our studies (34. local recurrence and nodal metastases in the lobectomy group (14% and 19%. These indices did not differ between the surgical groups. perhaps because the cure rate is so good. distant metastases. Such patients also receive ablation or treatment with radioiodine as indicated (34). extent of local involvement. a threefold increase in tumor recurrence rates in the thyroid bed and lymph nodes was reported in the lobectomy group. and distant metastases occurred in 3%. AMES (30). Metastatic spread of tumor often occurs by hematogenous dissemination to the lungs. If the operation can be performed safely with low morbidity. females predominate.Chapter 21. FOLLICULAR CARCINOMA True follicular carcinomas are far less common than papillary cancer and are now rather uncommon.35) and those of Mazzaferri and Jhiang (36) have demonstrated a decrease in mortality and in tumor recurrence after near-total or total thyroidectomy followed by radioiodine ablation or therapy. or is bilateral thyroid resection more beneﬁcial? Low-risk papillary cancer Hay and associates studied 1685 low-risk patients treated at the Mayo Clinic between 1940 and 1991. Using the AGES (29). In addition. Surgery of the Thyroid Gland Controversies Because no randomized prospective study has ever been performed. A follicular cancer that demonstrates only microinvasion of the capsule has a very good prognosis (37). Twelve percent had unilateral lobectomy. Treatment of this low-risk group is most controversial. Cause-speciﬁc mortality at 30 years was 2%. this study recognizes patients’ anxiety about tumor recurrence. In general. respectively) were signiﬁcantly higher than the 2% and 6% rates seen after near-total or total thyroidectomy. and once more. 21 . whereas 88% had bilateral lobar resection. and their strong desire to face an operation only once and to be cured of their disease. and other peripheral tissues. Should a lobectomy be done. Tumor multicentricity and lymph node metastases are far less common than in papillary carcinoma. however. ipsilateral lobectomy is probably sufﬁcient. Although no differences in mortality were reported. while near-total thyroidectomy was performed in 60%. almost 80% of patients fall into a low-risk group. or MACIS (31) criteria. which evaluate risk by age. certainly in the high 90% range. it is agreed that bilateral thyroid resection improves survival (29) and reduces recurrence rates (33) when compared with unilateral resection. Patients with follicular carcinoma are usually older than those with papillary cancer. the diagnosis of follicular cancer is made when vascular and/or capsular invasion is present. High-risk papillary cancer For high-risk patients. This study is excellent. bones. this study supports the use of near-total or total thyroidectomy for patients with low-risk papillary cancer. Many clinicians now accept that patients with this disease can be separated into different risk groups according to a set of prognostic factors. the mean follow-up period was 18 years (32). 98% had complete tumor resection and 38% had initial nodal involvement. In this situation. Of the total. total thyroidectomy was done in 18%. Remember that the “follicular variant” of papillary cancer should be classiﬁed and treated as a papillary carcinoma.
Chapter 21. Figure 14.3% to 62% in different clinical series. During a mean follow-up period of 8. and 40 (74%) had lesions that were thought to be benign. and one was in the benign-appearing group. Near-total or total thyroidectomy should be performed not because of multicentricity but rather to facilitate later radioiodine treatment (36). 2) benign-appearing tumors later metastasize in up to 2. Finally. although the rationale for its performance differs. However.4 years. they should be treated with high-dose radioiodine therapy. the ideal operation is similar to that for papillary cancer. they are more difﬁcult to treat than the usual follicular neoplasms for several reasons (35): 1) the incidence of carcinoma varies from 5. Surgery of the Thyroid Gland However. which makes treatment of metastatic disease particularly difﬁcult. Although lymph node metastases in the lateral region of the neck are not commonly found. however. Remnants of normal thyroid in the neck are ablated by radioiodine. 7 of 54 (13%) of our patients who had a Hurthle cell tumor had Hurthle cell carci22 . and if peripheral metastases are detected (Fig. regardless of the operation. 10 had questionable diagnoses (“intermediate” lesions) because of partial penetration of their capsule by tumor. a modiﬁed radical neck dissection should be performed if large palpable metastatic nodes are present. and not to cause osteoporosis. About half the patients had a history of low-dose external irradiation. for most patients with follicular cancer that demonstrates gross capsular invasion or vascular invasion. many had separate papillary or follicular cancers in the same thyroid gland. Of 54 patients with Hurthle cell tumors whom we treated (38). three additional Hurthle cell tumors were recognized as malignant after metastases were discovered: Two were originally classiﬁed as intermediate lesions. all patients with papillary or follicular cancer should be treated for life with levothyroxine therapy in sufﬁcient doses to suppress the TSH level (36). 14). HURTHLE CELL TUMORS AND CANCER Hurthle cell tumors are thought to be variants of follicular neoplasms. 4 had grossly malignant lesions. Care should be taken to not cause cardiac or other problems from thyrotoxicosis. Thus.5% of patients. and 3) Hurthle cell cancers are far less likely to concentrate radioiodine than are the usual follicular carcinomas.
prolonged remissions are rarely achieved. C-cell hyperplasia. as part of the familial medullary thyroid cancer syndrome (FMTC). especially when widely metastatic tumor is present. neurotensin. This tumor or its precursor. Sometimes the isthmus must be divided to relieve tracheal compression. near-total or total thyroidectomy should be performed. Radioiodine treatment is almost always ineffective because tumor uptake is absent. or a tracheostomy might be beneﬁcial. but complications may be high (42). In addition to calcitonin. In a review of follicular cancers at The University of Chicago (39). and multi-drug regimens or combinations of chemotherapy with radiation therapy are being tried (43. Although some success has been observed with doxorubicin. has been by external radiation therapy. If it is operated on at that time. These substances may result in a carcinoid-like syndrome with diarrhea and Cushing’s syndrome. Nuclear DNA analysis may aid the surgeon in recognizing tumors that are potentially aggressive because such tumors usually demonstrate aneuploidy (40). anaplastic cancer is almost always advanced when the patient is ﬁrst evaluated. Most medullary cancer of the thyroid is sporadic (about 70% to 80%). or both. thus demonstrating the difﬁculty in treating metastatic disease which cannot be resected in the Hurthle cancer. surgical cure is unlikely no matter how aggressively it is pursued. and for patients whose tumors exhibit partial capsular invasion. Although remissions do occur. only the medullary cancer 23 . it may elaborate or secrete other peptides and amines such as carcinoembryonic antigen. rarely. with appropriate central and lateral neck dissections. The large cell type may be occasionally manifested as a solitary thyroid nodule early in its clinical course. and a high-molecular-weight adrenocorticotropic hormone-like peptide. occurs as a part of the multiple endocrine neoplasia type 2A (MEN2A) and type 2B (MEN2B) syndromes (45) (Table 2. The previously so-called small cell type is now known to be a lymphoma and is most often treated by a combination of external radiation and chemotherapy or chemotherapy alone. However. diagnosis by needle biopsy or by small open biopsy may be all that is appropriate. for patients with associated papillary or follicular carcinomas. calcitonin-producing tumor that contains amyloid or an amyloid-like substance. In particularly advanced cases.5% among patients described in the literature) (38). cures have rarely been achieved in advanced cases.Chapter 21. Total thyroid ablation is appropriate for frankly malignant Hurthle cell cancers. The tumor grows very rapidly and systemic symptoms are common. In such patients. whereas in Hurthle cell cancers it was 24%. Survival for most patients is measured in months. chemotherapy. Surgery of the Thyroid Gland noma. single. Hyperfractionated external radiation therapy that uses several treatments per day has some enthusiasts. and the other 6 are currently free of disease. Most treatment. 15). In FMTC. but it can also be transmitted in a familial pattern. However. for all Hurthle cell tumors in patients who received low-dose childhood irradiation.5% in our series and 1. for all large tumors. in non-Hurthle cell follicular cancers the mortality was 12%. wellencapsulated. increased genetic abnormalities have been shown in Hurthle cell carcinomas when compared with Hurthle cell adenomas (41). the overall mortality was 16%. serotonin. ANAPLASTIC CARCINOMA Anaplastic thyroid carcinoma remains one of the most virulent of all cancers in humans. or. benign-appearing Hurthle cell tumors that are small may be treated by lobectomy and careful follow-up because the chance that they will later exhibit malignant behavior is low (2. On the other hand. One of the 7 patients with Hurthle cell cancer died of widespread metastases after 35 years. Furthermore. however. twice that of papillary carcinomas.39). MEDULLARY THYROID CARCINOMA Medullary thyroid carcinoma is a C-cell. Fig. We believe that treatment of these lesions should be individualized (38.44).
multiple endocrine neoplasia 24 . this growth should be operated on ﬁrst because it has the greatest immediate risk to the patient. Genetic testing for ret mutations has largely replaced screening by calcitonin in family members (46a). Pheochromocytoma 3. so 50% of the offspring would be expected to have this disease. The MEN2 syndromes are transmitted as an autosomal-dominant trait. These defects are germ-line mutations and can therefore be found in blood samples. Surgery of the Thyroid Gland is inherited in a familiar pattern. Table 2. Mutations of the ret oncogene on chromosome 10 have been found to be the cause of the MEN2 syndromes (46. adrenal medullary hyperplasia) is present. Family members (including children) of a patient with medullary cancer of the thyroid should also be screened for medullary cancer of the thyroid. Diseases Included in the MEN2 Syndromes MEN2A 1.Chapter 21. Ganglioneuroma phenotype MEN. Hyperparathyroidsm MEN2B 1. However. All patients with medullary thyroid carcinoma should be screened for hyperparathyroidism and pheochromocytoma (47).46a). calcitonin measurement is still useful for screening patients with a thyroid mass when FNA analysis raises the possibility of medullary thyroid cancer. If a pheochromocytoma (or its precursor. Pheochromocytoma 3. Medullary carcinoma 2. Medullary carcinoma 2. Hyperparathyroidism – unlikely 4. especially if the tumor is bilateral or if C-cell hyperplasia is present.
Medullary cancer spreads to the lymph nodes of the neck and mediastinum. Surgery of the Thyroid Gland Figure 15a.Chapter 21. Figure 15b. and 25 .
computed tomography (CT) and magnetic resonance imaging (MRI) have localized some sites of tumor recurrence. and that of others. cures are expected. and the strap muscles are divided vertically in the midline and retracted laterally (Fig. Thus. early diagnosis and complete initial resection of tumor are very important. to prevent damage to this nerve (Fig. In other patients. The parathyroid glands are identiﬁed. With these prophylactic operations. Hence. an aggressive surgical approach is mandatory. free of distant metastatic lesions. The middle thyroid vein is ligated (Fig. because this cancer develops at a younger age than does MEN2A (49). the inferior thyroid artery should not be ligated laterally as a single trunk. and elsewhere. 6). The operation of choice for medullary cancer is total thyroidectomy coupled with aggressive resection of the central and mediastinal lymph nodes (46). total thyroidectomy should be considered at an earlier age. 16C). liver. 16B). does not take up radioiodine. 16E). Patients with MEN2B syndrome have very aggressive tumors and rarely survive to middle age. The inferior thyroid artery and recurrent laryngeal nerve are identiﬁed (Fig. Surgery of the Thyroid Gland later disseminates to the lungs. Cure is most likely in young children who are found by genetic screening to have a mutated ret oncogene. This nerve can be visualized over 90% of patients if it is carefully dissected in (51). The tumor is relatively radioresistant. The superior pole vessels are ligated adjacent to the thyroid lobe. A low collar incision is made and carried down through the subcutaneous tissue and platysma muscle (Fig. was 81% (50). If central lymph nodes or the lateral neck area contain tumor. The thyroid lobe is bluntly dissected free from its investing fascia and rotated medially. reoperative neck dissection under magniﬁcation to remove all the tiny lymph nodes.and 20-year survival rates were 63% and 44%. demonstrated that 25% to 35% of patients with elevated circulating calcitonin levels could be rendered eucalcitoninemic after extensive. children 5 years of age or younger who are found by genetic screening to have MEN2A have received prophylactic total thyroidectomy to prevent the development of medullary cancer. technetium-labeled sestamibi scanning. Their work. careful and extensive modiﬁed radical neck dissection is required. and care is taken to identify and preserve the external branch of the superior laryngeal nerve (Fig. and positron emission tomography combined with computerized tomography (PET-CT) have been successful in some patients. 16D). in recent years. respectively. often by age 2 years. Superior and inferior subplatysmal ﬂaps are developed. Long-term studies of medullary cancer from the Mayo Clinic group have shown that in patients without initial distant metastatic involvement and with complete resection of their medullary cancer. Recently. Patients with MEN2A syndrome have a better prognosis than do those with sporadic tumor (45). and is not responsive to thyroid hormone suppression. bone. 16). One hopes to operate on them when C-cell hyperplasia is present and before medullary cancer has started (46a). meticulous.Chapter 21. its branches should be ligated individually on the capsule of the lobe after they have supplied the parathyroid glands (Fig. Thus. OPERATIVE TECHNIQUE FOR THYROIDECTOMY Under general endotracheal anesthesia. and an attempt is made to leave each 26 . Lobectomy or total thyroidectomy The thyroid isthmus is usually divided early in the course of the operation. In children with MEN2B and with a mutated ret oncogene. rather. rather than cephalic to it. Treatment of pheochromocytoma and hyperparathyroidism is discussed elsewhere. 16F). the 20-year survival rate. the patient is placed in a supine position with the neck extended. The superior pole of the thyroid is dissected free. whereas octreotide or metaiodobenzylguanidine scanning have sometimes been helpful. Overall 10. Reoperations for metastatic tumor were rarely considered to be rewarding until the work of Tisell and Jansson (48). To preserve blood supply to the parathyroid glands.
Any parathyroid gland that appears to be devascularized can be minced and implanted into the sternocleidomastoid muscle after a frozen section biopsy conﬁrms that it is in fact a parathyroid gland. with care taken to avoid trauma to it. When closing. However. Proponents of this technique feel that visualization of the recurrent laryngeal nerve by its early dissection may lead to greater nerve damage.Chapter 21. the patient can almost always be safely discharged on the ﬁrst postoperative day. this allows drainage of blood superﬁcially and thus prevents a hematoma in the closed deep space. Sterile paper tapes (Steri-strips) are then applied and left in place for about a week. near-total or total thyroidectomy is performed. a small suction catheter is inserted through a small stab wound. 27 . the dermis is approximated by interrupted 4-0 sutures. Rather. Furthermore.53) and is used by the authors in some operations. but rather small bites of tissue are carefully divided along the thyroid capsule until the nerve is encountered near the ligament of Berry. Careful hemostasis and visualization of all important anatomic structures are mandatory for success. Care is taken to try to identify the recurrent laryngeal nerve along its course if a total lobectomy is to be done. the parathyroid glands and recurrent nerves should be identiﬁed and preserved. In this technique. a number of patients are hypothyroid with these small thyroid remnants and require thyroid hormone replacement. When it is needed. The nerve is gently unroofed from surrounding tissue. An alternative operation. The contralateral thyroid lobe is removed in a similar manner when total thyroidectomy is performed. we do not tightly approximate the strap muscles in the midline. Once more. where it is adjacent to the thyroid gland. However. we obtain better cosmesis by not approximating the platysmal muscle. Surgery of the Thyroid Gland with an adequate blood supply while moving the gland off the thyroid lobe. Others are kept longer if the need arises. the thyroid lobe can be removed from its tracheal attachments by dividing the ligament of Berry (Fig. The nerve is in greatest danger near the junction of the trachea with the larynx. however. A near-total thyroidectomy means that a small amount of thyroid tissue is left on the contralateral side to protect the parathyroid glands and recurrent nerve. Alternative technique of standard thyroidectomy An alternative technique of thyroidectomy is practiced by some excellent surgeons (6. several grams of thyroid tissue are usually left in place. is lobectomy on one side and subtotal lobectomy on the other side. Great care should be taken to not damage the recurrent laryngeal nerve when cutting across or suturing the thyroid lobe. Once the nerve and parathyroid glands have been identiﬁed and preserved. and the epithelial edges are approximated with a running subcuticular 5-0 absorbable suture. the authors feel that seeing the nerve and knowing its pathway is safer and facilitates the dissection in many instances. At the end of the operation. it is generally removed within 12 hours. We do not think that it is safe to discharge a patient on the day of surgery because of the risk of bleeding. After thyroidectomy. however. the dissection is begun on the thyroid lobe and the parathyroids are moved laterally as described previously. 16G). the recurrent laryngeal nerve is not dissected along its length. When the operation is done for severe ophthalmopathy. which is equally good. Subtotal thyroidectomy Bilateral subtotal lobectomy is the usual operation for Graves’ disease. The aim is to try to achieve a euthyroid state without a high recurrence of hyperthyroidism. even if a modiﬁed neck dissection is done for carcinoma. same-day discharge is being practiced at some centers (52).
B.B. The surgeon’s hand retracts the gland anteriorly and medially to expose the posterior surfaces of the thyroid gland. The neck is extended and a symmetrical. A. Surgery of the Thyroid Gland Figure 16abcd. Incision for thyroidectomy. (Courtesy of Alan P. D. In recent years the author has used a much smaller incision except when a large goiter is present. Clark) (54). Dackiw and Orlo H. The sternohyoid and sternothyroid muscles are retracted to expose the surface of the thyroid lobe. ligated and divided. gently curved incision is made 1 to 2 cm above the clavicle. The superior thyroid vessels are ligated close to the thyroid capsule of the superior pole to avoid inadvertent injury to the external branch of the superior laryngeal nerve. 28 . C. This nerve can be seen in many cases.Chapter 21. The middle thyroid vein is identiﬁed.
G.B. The ligament of Berry is then carefully ligated and divided while avoiding damage to the recurrent laryngeal nerve and the thyroid lobe is removed. 29 . F. leaving the delicate blood supply to the parathyroid glands intact. E.Chapter 21. With careful retraction of the lobe medially. The inferior thyroid artery is not ligated as a single trunk. Dackiw and Orlo H. Clark) (54). (Courtesy of Alan P. the inferior thyroid artery is placed under tension. This facilitates exposure of the recurrent laryngeal nerve and the parathyroid glands. Surgery of the Thyroid Gland Figure 16efg. but rather its tertiary branches are individually ligated.
2 mm embryo beginning to descend. are present in the sheets.Chapter 21. lateral view of the same structure. The lobes are thin sheets curing around the carotid arteries. A. 1. Thyroid primordium of a 6. Several lacunae. section through the same structure.5 mm embryo. which are not to be confused with follicles. The connection with the pharynx is broken. E. 1.5 mm embryo. Thyroid gland of a 13. section through the same structure showing a raised central portion.5 mm human embryo. parathyroid and thymus glands in man. 2. and the lobes are beginning to grow laterad. B. D. Thyroid primordium of an 11 mm embryo. (Lower). Thyroid primordium and pharyngeal epithelium of a 4. 1. 1933.) 30 . Contrib Embryol Carnegie Inst Wash 24:93-142. 2. Stages in the development of the thyroid gland. Surgery of the Thyroid Gland Figure 17. (From Weller GL: Development of the thyroid. C. 2. Thyroid primordium of an 8.
Two different approaches have been taken to minimally invasive thyroidectomies. Perhaps most concerning to many American surgeons with these approaches is that if bleeding problems are encountered in the course of the thyroid dissection. The surgeon then creates a tunnel up to the neck where the thyroidectomy is performed with endoscopic instruments utilizing the endoscope for visualization. Several authors in the United States have reported good results in small series with this video-assisted ap31 . The scope is utilized to visualize the tissue along the lateral aspect of the thyroid gland and especially for the superior pole vessels. One technique. Although some authors utilizing such approaches have described removing large thyroid glands.0 cm incision is made in a conventional location in the neck and after the strap muscles are retracted from the thyroid gland. largely popularized in areas of the Far East such as Japan.5-2. utilizes a smaller incision than usual. most reports suggest signiﬁcantly longer operative times. involves making incisions away from the neck in hidden areas such as in the axillae. Surgery of the Thyroid Gland Figure 17abcde. The alternative technique. developed by Dr. China. In general. Paolo Miccoli and more widely utilized in Europe and to a less extent in the United States. a separate neck incision may need to be made to solve the problem. the parathyroid glands and recurrent nerve are visualized and then the thyroid lobe is delivered through the neck incision and the remainder of the operation is performed in the conventional manner through the small cervical incision. MINIMALLY INVASIVE OPTIONS FOR THYROIDECTOMY Over recent years. or in the areola of the breast. a 5 mm 30 degree endoscope is introduced into the incision. but it is placed in the conventional location in the neck (58.59). a 1. chest. Approaches such as these are done in a gasless manner and can completely avoid any incisions on the neck itself (55-57).Chapter 21. the development of ultrasonic shears for hemostasis and small size endoscopes has allowed surgeons to perform thyroidectomies through much smaller incisions than using traditional techniques. and Korea. Usually after the superior and lateral aspects of the thyroid gland have been dissected free.
Five major complications are associated with thyroid surgery: 1) thyroid storm.3% to 1. and they can be deliberate or accidental. or handling of the nerve. 4) recurrent laryngeal nerve injury. POSTOPERATIVE COMPLICATIONS Many authors have reported large series of thyroidectomies with no deaths. minimally invasive video-assisted thyroidectomy is offered in few specialized centers for selected patients with small thyroid nodules (usually less than 3 cm) and without evidence of thyroiditis. At this time in the United States. Except in the hands of surgeons very experienced in the technique. mortality does not differ greatly from that from anesthesia alone. Occasionally. A signiﬁcant beneﬁt of this approach is that the incision is in the usual location so that if any bleeding results in difﬁculty with visualization during the procedure. Loss of function can be caused by transaction.61). A small suction drain placed in the wound is not usually adequate for decompression. ligation. especially if any respiratory compromise is present. The urgency of treating this condition as soon as it is recognized cannot be overemphasized if respiratory compromise is present. Pressure should be applied with a sterile sponge and the patient returned to the operating room. Clinical manifestations and management of thyroid storm are discussed elsewhere in this text. but it occurs less commonly in patients with toxic adenoma or toxic multinodular goiter. Most authors have found this approach to be similar to conventional thyroidectomy in operative time. Sometimes the nerve is purposely sacriﬁced if it runs into an aggressive thyroid cancer. Tumor invasion can also involve the nerve. Later. Treatment consists of immediately opening the wound and evacuating the clot. 3) wound infection. it is seen most often in Graves’ disease. Injury to the Recurrent Laryngeal Nerve Injuries to the recurrent laryngeal nerve occur in 1% to 2% of thyroid operations when performed by experienced neck surgeons. Wound Hemorrhage Wound hemorrhage with hematoma is an uncommon complication reported in 0.Chapter 21. Swelling of the neck and bulging of the wound can be quickly followed by respiratory impairment. even at the bedside. 2) wound hemorrhage. it is a well-recognized and potentially lethal complication (52). However. clamping. and 5) hypoparathyroidism. Nerve injuries can be unilateral or bilateral and temporary or permanent. the incision can be enlarged and a conventional thyroidectomy can readily be completed. They occur more commonly when thyroidectomy is done for malignant disease. Surgery of the Thyroid Gland proach (60. Thyroid Storm Thyroid storm reﬂects an exacerbation of a thyrotoxic state. although the small neck incision does limit the size of the thyroid gland that could be resected utilizing this technique. the bleeding vessel can be ligated in a careful and more leisurely manner under optimal sterile conditions with good lighting in the operating room. especially if bleeding occurs from an arterial vessel. vocal cord impairment occurs as a result of pressure from the balloon of an endotracheal 32 . In other reports. A small hematoma deep to the strap muscles can compress the trachea and cause respiratory distress. traction. it should not be utilized for the treatment of most thyroid cancers.0% of patients in most large series. and at a higher prevalence when thyroidectomy is done by a less experienced surgeon. Wound Hemorrhage Wound hemorrhage is an emergency situation.
9% for subtotal thyroidectomy. it certainly returns within 9 to 12 months if it is to return at all. Usually. Postoperative hypoparathyroidism is rarely the result of inadvertent removal of all of the parathyroid glands but is more commonly caused by disruption of their delicate blood supply. Other excellent neck surgeons have reported a lower incidence of permanent hypoparathyroidism (68). permanent injuries to the recurrent laryngeal nerve are best avoided by identifying and carefully tracing the path of the recurrent nerve. all have in common some means of detecting vocal cord movement when the recurrent laryngeal nerve is stimulated. this has not been shown to be the case. Accidental transaction occurs most often at the level of the upper two tracheal rings. In recent years many surgeons have sought to try to further diminish the low incidence of recurrent laryngeal nerve (RLN) injury by use of nerve monitoring devices during surgery. 6) if the nerve is not visualized (9). many believe that the transected nerve should be reapproximated by microsurgical techniques.998 nerves at risk in thyroidectomy (66). Many small series have been reported in the literature assessing the potential beneﬁts of monitoring to decrease the incidence of nerve injury (63-65). vocal cord function returns within several months. Surgeons may choose to use the technology. tracheostomy is required. nerve monitoring technology in thyroid surgery should not take the place of meticulous dissection. Among the problems of nerve monitoring technology are that the devices can malfunction so that the surgeon cannot depend on the device to always identify the nerve (67). it is not surprising that no study has shown a statistically signiﬁcant decrease in RLN injury when using a nerve monitor. Although some authors have suggested that RLN monitors may be most helpful in difﬁcult reoperative cases when signiﬁcant scar tissue is encountered. The largest series in the literature by Dralle reported on a multi-institutional German study of 29. Hypoparathyroidism Postoperative hypoparathyroidism can be temporary or permanent. If recognized. Bilateral recurrent laryngeal nerve damage is much more serious. Most often. In unilateral recurrent nerve injuries. In the authors’ experience. If no function returns by that time. Surgery of the Thyroid Gland tube as the recurrent nerve enters the larynx. although this is controversial. where the nerve closely approximates the thyroid lobe in the area of Berry’s ligament. Given the low incidence of RLN injury. The choice is insertion of a piece of Silastic to move the paralyzed cord to the midline. no statistically signiﬁcant decrease in rates of RLN injury could be showed with nerve monitoring. Proponents of nerve monitoring suggest that the technology might be helpful even if a statistically signiﬁcant decrease in the rate of RLN cannot be shown. This injury causes an inability to forcefully project one’s voice or to sing high notes because of loss of function of the cricothyroid muscle. Injury to the external branch of the superior laryngeal nerve may occur when the upper pole vessels are divided (Fig. a ﬁne tuner of the vocal cord. At this time. the voice can be improved by operative means. The incidence of permanent hypoparathyroidism has been reported to be as high as 20% when total thyroidectomy and radical neck dissection are performed. this procedure is called a laryngoplasty. Shortness of breath and aspiration of liquids sometimes occur. and as low as 0. but the data do not support the suggestion that nerve monitors allow thyroid surgery to be performed in a safer fashion than that by a good surgeon utilizing careful technique. Often. This injury results in impairment of function of the ipsilateral cricothyroid muscle. Although several devices have been utilized. because both vocal cords may assume a medial or paramedian position and cause airway obstruction and difﬁculty with respiratory toilet. Devascularization can 33 . this disability improves during the ﬁrst few months after surgery. A number of procedures to later reinnervate the laryngeal muscles have been attempted with only limited success (62).Chapter 21. the voice becomes husky because the vocal cords do not approximate one another. Even with this large of a study.
Patients with symptomatic hypocalcemia are treated in the hospital with 1 g (10 mL) of 10% calcium gluconate infused intravenously over several minutes. along with calcium carbonate. It divides into an isthmus and two lobes. and by treating the parathyroids with great care. Calcitriol (0. The thyroid is embryologically an offshoot of the primitive alimentary tract. it is important to brieﬂy review normal development of this gland. Serum calcium levels must be monitored carefully after discharge. referred to as the median lobe or median thyroid component. circulating PTH is normal and all therapy could be stopped. Surgery of the Thyroid Gland be minimized during thyroid lobectomy by dissecting close to the thyroid capsule. both the serum calcium and phosphorus values are low. It is joined by a pair of lateral thyroid lobes originating from the fourth and ﬁfth branchial pouches (Fig. the serum PTH level should be analyzed periodically to determine whether permanent hypoparathyroidism is truly present.8 mg/dL or above. follows the descent of the heart and great vessels and moves caudally into the neck from this origin.5 to 8 mg/dL.25-dihydroxyvitamin D (Calcitriol) because it is the active metabolite of vitamin D and has a more rapid action. starting with about 30 mL/hour. The parathyroid hormone is low or absent in hypoparathyroidism. It is manifested by circumoral numbness. then this priming dose of vitamin D is reduced. and intense anxiety occurring soon after surgery. usually as calcium carbonate (1250 mg to 2500 mg four times per day). whereas in hypoparathyroidism. Management of more persistent severe hypocalcemia requires the addition of a vitamin D preparation to facilitate the absorption of oral calcium. and carpopedal spasm can occur. With this treatment regimen most patients become asymptomatic and their calcium and PTH levels become normal. should be started. 16F). perhaps caused by “bone hunger. Oral calcium. tingling of the ﬁngers and toes. If a parathyroid gland is recognized to be nonviable during surgery. 7). it can be autotransplanted after identiﬁcation by frozen section. 34 . Remember that in bone hunger. and then 5 g of this calcium solution placed in each 500 mL intravenous bottle to run continuously.0 mcg) with oral calcium carbonate therapy is given four times daily for the ﬁrst several days. The main body of the thyroid.” that later resolved completely. We measure the serum calcium level every 12 hours while the patient is in the hospital.e. from which it later becomes separated (69-72) (Figs.Chapter 21. because the authors and others have seen cases of postoperative tetany. The usual maintenance dose for most patients with permanent hypoparathyroidism is Calcitriol 0. 7 and 17). Chvostek’s sign appears early..5 µg daily. although some patients require larger doses. During the third to fourth week in utero. Postoperative hypoparathyroidism results in hypocalcemia.25 to 0. We prefer the use of 1. and the patient is sent home and told to take oral calcium pills. hyperphosphatemia. a median anlage of epithelium arises from the pharyngeal ﬂoor in the region of the foramen cecum of the tongue (i. 500 mg Ca2+ several times daily. Most patients are able to leave the hospital on the morning after surgery if they are asymptomatic and their serum calcium level is 7. and a low parathyroid hormone (PTH) level. Oral calcium pills are used liberally. Symptoms develop in most patients when the serum calcium level is less than 7. The intravenous therapy is tapered and stopped as soon as possible. In such cases. by carefully ligating the branches of the inferior thyroid artery on the thyroid capsule distal to their supply of the parathyroid glands (rather than ligating the inferior thyroid artery as a single trunk) (Fig. This condition is referred to as transient hypocalcemia or transient hypoparathyroidism. and the dosage of the medications is adjusted promptly to prevent hypercalcemia as well as hypocalcemia. DEVELOPMENTAL ABNORMALITIES OF THE THYROID To understand the different thyroid anomalies. the serum calcium value is low but the phosphorus level is elevated. Finally. The gland is minced into 1 mm to 2 mm cubes and placed into pockets in the sternocleidomastoid muscle. at the junction of the anterior two-thirds and the posterior third of the tongue). and by 7 weeks it forms a “shield” over the front of the trachea and thyroid cartilage.5 mcg to 1.
Usually the pyramidal lobe is small. if looked on as such. which has been reported to be present in as many as 80% of patients in whom the gland was surgically exposed. Both benign and malignant nodules have been reported in this condition (74). infrahyoid. fail to develop. ECTOPIC THYROID Lingual Thyroid A lingual thyroid is relatively rare and is estimated to occur in 1 in 3000 cases of thyroid disease. Most intrathoracic goiters. Often. Other variations involving the median thyroid anlage represent an arrest in the usual descent of part or all of the thyroid-forming material along the normal pathway. and even within the interventricular septum of the heart. Finally. or intratracheal location. is associated with cretinism. Williams and associates have described cystic structures in the neck near the upper parathyroid glands in cases in which thyroid tissue was totally lingual in location (72a). From this structure both thyroglossal duct cysts and the pyramidal lobe of the thyroid develop. C cells (parafollicular cells) enter the thyroid lobes. in Graves’ disease or in lymphocytic thyroiditis. Surgery of the Thyroid Gland From these lateral thyroid components. however. As the gland moves downward. it represents the most common location for functioning ectopic thyroid tissue. however. Each of these abnormalities is discussed in greater depth. Ectopic thyroid development can result in a lingual thyroid or in thyroid tissue in a suprahyoid. The pyramidal lobe generally lies in the midline but can arise from either lobe. C cells contain and secrete calcitonin and are the cells that give rise to medullary carcinoma of the thyroid gland. These cysts contained both cells staining for calcitonin and others staining for thyroglobulin. it is often enlarged and is commonly clinically palpable. The anlage also may differentiate in locations other than the isthmus and lateral lobes. Persistence of the thyroglossal duct as a sinus tract or as a cyst (called a thyroglossal duct cyst) is the most common of the clinically important anomalies of thyroid development. The resultant athyrosis. The most common developmental abnormality. The mature thyroid gland may take on many different conﬁgurations depending on the embryologic development of the thyroid and its descent (Fig. Lingual thyroid tissue is associated with an absence of the 35 . the entire gland or part of it may descend more caudally. Origin from the left lobe is more common than is origin from the right lobe (72b). this results in thyroid tissue located in the superior mediastinum behind the sternum. on rare occasions. adjacent to the aortic arch or between the aorta and pulmonary trunk. they believe. Females are affected three times as often as males. THYROID HEMIAGENESIS More than 100 cases have been reported in which only one lobe of the thyroid is present (73). within the upper portion of the pericardium. but rather are extensions of pathologic elements of a normally situated gland into the anterior or posterior mediastinum. it leaves behind a trace of epithelial cells known as the thyroglossal tract. are not true anomalies. This study. now commonly called the ultimobranchial bodies. the thyroid lobe that is present is enlarged. or absence of the thyroid gland. offers evidence that the ultimobranchial body contributes both C cells and follicular cells to the thyroid gland of humans. and both hyperthyroidism and hypothyroidism have been reported at times.Chapter 21. THYROID ABNORMALITIES The median thyroid anlage may. 18 upper). The left lobe is absent in 80% of these patients. is the pyramidal lobe. However.
Indications for extirpation include failure of suppressive therapy to reduce the size. hemorrhage. Only rarely is surgical excision necessary. dysphonia. Hypothyroidism is often present and may cause the mass to enlarge and become symptomatic. or a sensation of choking (75). In women. He attributed this distribution to hormonal disturbances. and it is deﬁnitively established by radioisotope scanning (Fig. in his review of 140 cases of symptomatic lingual thyroids in females. dyspnea. which are more apparent in female subjects during puberty and may be precipitated by pregnancy. and it has apparently been successful. Surgery of the Thyroid Gland normal cervical thyroid in 70% of cases. 10% at menopause. A lingual thyroid was reported in two brothers. which suggests that this condition may be inherited (79). Buckman. 36 . 18a). It occurs much more commonly in women than in men. The incidence of malignancy in lingual thyroid glands is low (77). 55% between the ages of 18 and 40 years. reported that 30% occurred in puberty. 18 b).Chapter 21. Autotransplantation of thyroid tissue has been tried on rare occasions when no other thyroid tissue is present. The diagnosis of a lingual thyroid should be suspected when a mass is detected in the region of the foramen cecum of the tongue. and 5% in old age (76). The usual treatment of this condition is thyroid hormone therapy to suppress the lingual thyroid and reduce its size. and suspicion of malignancy (78). but hyperthyroidism is very unusual. The mass may enlarge and cause dysphagia. The diagnosis is usually made by the discovery of an incidental mass on the back of the tongue in an asymptomatic patient (Fig. ulceration. symptomatic lingual thyroid glands develop during puberty or early adulthood in most cases.
Surgery of the Thyroid Gland Figure 18a.Chapter 21. Figure 18b. 37 .
all thyroid tissue may be ablated. This procedure is necessary because the thyroglossal duct is intimately associated with the central part of the hyoid bone (Fig. 20). Almost all carcinomas have been papillary. rare cases of Hurthle cell and anaplastic cancer have also been reported. Finally. These cysts are the most common anomaly in thyroid development seen in clinical practice. Suprahyoid and Infrahyoid Thyroid In these cases. where it is no longer manifested as a mass. This operative procedure permits later radioiodine therapy as well. childhood. If any doubt exists. An enlarging mass commonly occurs during infancy. Furthermore. and their prognosis is excellent. thyroid tissue is present in a midline position above or below the hyoid bone. They commonly become repeatedly infected and may rupture spontaneously. the thyroglossal duct becomes obliterated early in embryonic life. Recurrent cysts are very common if this operative procedure is not followed. become apparent only after age 30 years (82). Such lesions occur equally in males and females. about 5% of all carcinomas arising from a thyroglossal duct cyst are squamous. before removing what appears to be thyroglossal duct cyst. and each half translocated laterally. 19). this mass is mistaken for a thyroglossal duct cyst because it is usually located in the same anatomic position (84). To prevent total thyroid ablation. Normally. Hypothyroidism with elevation of thyrotropin (TSH) secretion is commonly present because of the absence of a normal thyroid gland in most instances. They are seen at birth in about 25% of cases. because carcinoma arising from these developmental abnormalities. about one-third.4%) also contained papillary cancer (81). Our practice and that of many others is to perform near-total or total thyroidectomy with appropriate nodal resection when a thyroglossal duct carcinoma is found and resected.Chapter 21. and the rest. a sinus tract or ﬁstula persists. Often. although rare. most appear in early childhood. Cysts usually appear in the midline or just off the midline between the isthmus of the thyroid and the hyoid bone. When this complication occurs. At least 115 cases of thyroid carcinoma have been reported to originate from the thyroglossal duct (81). the normal thyroid gland should be explored and palpated. at the time of surgery the thyroid gland should be inspected for evidence of other tumor nodules. many recommend that a thyroid scan or ultrasound examination be performed in all cases of thyroglossal duct cyst before its removal to be certain that a normal thyroid gland is present. If it is removed. In one series of 35 patients with papillary carcinoma arising in a thyroglossal duct cyst. three families have been reported in which a total of 11 members had a thyroglossal duct cyst (83). Finally. if ectopic thyroid tissue rather than a thyroglossal duct cyst is encountered at surgery. has been reported. it may be better to remove the ectopic tissue rather than transplant it. its blood supply should be preserved. the thyroid gland of 4 patients (11. in such cases an association is noted with low-dose external irradiation of the head and neck in infancy or childhood. Often. Surgery of the Thyroid Gland Thyroglossal Duct Cysts Both cysts and ﬁstulas can develop along the course of the thyroglossal duct (80) (Fig. If a carcinoma is recognized. and the lateral lymph nodes should be sampled. the ectopic gland divided vertically. but occasionally it persists as a cyst. a prudent surgeon should be certain that no solid areas are present. If normal thyroid tissue is demonstrated to be present elsewhere. a consequence that has deﬁnite physiologic as well as possible medicolegal implications. 38 . deep to the strap muscles. Removal of a thyroglossal cyst or ﬁstula requires excision of the central part of the hyoid bone and dissection of the thyroglossal tract to the base of the tongue (the Sistrunk procedure) if recurrence is to be minimized. or later life. In addition to papillary cancer.
Chapter 21. 39 . Surgery of the Thyroid Gland Figure 19.
If these tissue elements are near the thyroid. not in lymph nodes. Most agree that the overwhelming number of cases of what in the past was called “lateral aberrant thyroid” actually represented well-differentiated.86). it is important to be certain that each of these lesions does not represent a well-differentiated metastasis that has totally replaced a lymph node and in which the primary thyroid carcinoma is small or even microscopic and was not recognized. it is possible that they represent developmental abnormalities. metastatic thyroid cancer within cervical lymph nodes or replacing them rather than an embryonic rest. probably followed by radioiodine therapy. In such cases. we favor near-total or total thyroidectomy with a modiﬁed radical neck dissection on the side of the lymph node. True lateral aberrant thyroid tissue or embryonic rests of thyroid tissue in the lymph nodes of the lateral neck region are very rare. and entirely normal histologically. However. before accepting this explanation. The authors of these studies suggest that they may develop ectopically because of failure of fusion of the lateral thyroid component with the median thyroid. Surgery of the Thyroid Gland Figure 20. Lateral Aberrant Thyroid Small amounts of histologically normal thyroid tissue are occasionally found separate from the thyroid.Chapter 21. Substernal Goiters Developmental abnormalities may lead to the ﬁnding of thyroid tissue in the medi40 . Several lateral thyroid masses have been reported that are said to be benign adenomas in lateral ectopic sites (85.
41 . once part of a thyroid goiter has passed into the superior mediastinum. Although the goiters of Graves’ disease are rarely intrathoracic.1% to 21% of patients in whom thyroidectomies were performed. however. Many substernal goiters are found on routine chest radiography in patients who are completely asymptomatic. however. less commonly. Thus. however. rarely. in most instances. However. Only rarely does an intrathoracic goiter receive its blood supply from mediastinal vessels. it can increase its size only by descending further into the chest. Substernal goiters should be operated on initially through a cervical incision. however. This large variability is undoubtedly caused partly by a difference in classiﬁcation among the authors. More recent series report an incidence of 2% or less (87). CT or MRI may be more helpful.Chapter 21. no thyroid enlargement in the cervical area is present. In either instance the diagnosis is suggested if a goiter can be palpated in the neck and if it appears to continue below the sternum. Superior vena caval obstruction can occasionally occur with edema and cyanosis of the face (88) and venous engorgement of the arms and face is present (Fig. most substernal goiters undoubtedly originate in the neck and then “fall” or are “swallowed” into the mediastinum and are not embryologically determined at all. but it may also be caused by the incidence of endemic goiter. Most individuals with substernal goiters are euthyroid or hypothyroid. because the blood supply to the substernal thyroid almost always originates in the neck and can be readily controlled in this area. we generally agree with the recommendation made by Lahey and Swinton more than 70 years ago that goiters that are deﬁnitely intrathoracic should usually be removed if the patient is a good operative risk (89). and instead of being in continuity. Because of the coneshaped anatomy of the upper thoracic outlet. and perhaps a more difﬁcult or hazardous operative procedure. single or multiple “hot” nodules may occur within an intrathoracic goiter and result in hyperthyroidism as part of a toxic nodular goiter. Rarely. such a ﬁnding favors a developmental cause. Surgery of the Thyroid Gland astinum or. in the posterior mediastinum. The diagnosis of an intrathoracic thyroid mass can be made with certainty by the use of a thyroid isotope scan. a greater degree of symptoms. the intrathoracic component may be attached to the cervical thyroid only by a narrow bridge of thyroid or ﬁbrous tissue. 21). Regarding therapy. even within the tracheal or esophageal wall. Thus. good hemostasis can be obtained by control of the superior and inferior thyroid arteries in the neck. hyperthyroidism occurs as well. Intrathoracic goiters are usually found in the anterior mediastinum and. Intrathoracic goiters have been reported to occur in 0. delay in surgical management may lead to increased size of the lesion. Other patients may have dyspnea or dysphagia from tracheal or esophageal compression or displacement.
Piecemeal morcellation of the thyroid gland should not be practiced. Any ﬂuid-ﬁlled cysts may be aspirated to reduce the size of the mass and permit its egress through the thoracic outlet. Furthermore. With the use of this method. the recurrent laryngeal nerves must be preserved and treated with care. and this technique violates all principles of cancer surgery. While gentle traction is exerted from above. The affected thyroid lobe is then carefully dissected along its capsule by blunt dissection into the superior mediastinum. which might result in hypoparathyroidism. As in all thyroid surgery.Chapter 21. The authors like to divide the isthmus and the upper pole vessels early in the dissection. This procedure affords direct control of any mediastinal vessels and permits resection of the thyroid gland to be carried out safely. curved clamps (Fig. however. because this occasionally has led to severe bleeding. Surgery of the Thyroid Gland Figure 21. the great majority of substernal thyroid glands can be removed transcervically. a partial or complete sternotomy should be performed. If the thyroid gland cannot be easily extracted from the mediastinum. and the inferior thyroid artery’s branches should be ligated close to the thyroid capsule to prevent ischemia of the parathyroid glands. 42 . the mass is elevated by the surgeon’s ﬁngers or blunt. The parathyroid glands should be identiﬁed and preserved. 22). several substernal goiters have been found to contain carcinoma. Often these maneuvers sufﬁce to permit extraction of a mass from the mediastinum and into the neck area.
the mass can be elevated into the neck wound and resected. glucagon. often with peritoneal or pleural effusion that may be bloody. chromogranin. because they contain functionally signiﬁcant thyroid tissue or thyroid tissue occupying more than 50% of the volume of the tumor. Many more such tumors contain small amounts of thyroid tissue. Some strumae ovarii are associated with carcinoid-appearing tissue. Occasionally a sternotomy is necessary. Occasionally. Philadelphia. Some are associated with carcinoid syndromes. (From Sedgwick CE. In such cases. Most of these lesions synthesize and 43 . insulin. a substernal goiter does not pass out through the superior thoracic outlet because of its size. Then. serotonin. occur in female subjects of all age groups. 2nd ed. Cady B: Surgery of the Thyroid and Parathyroid Glands.. These strumal-carcinoid tumors secrete or contain thyroid hormones as well as somatostatin.Chapter 21. with gentle upward traction on the capsule. gastrin. Dermoid cysts or teratomas. Struma ovarii is sometimes manifested as an abdominal mass lesion.) Struma Ovarii Ectopic development of thyroid tissue far from the neck area can also lead to difﬁculties in rare instances. About 3% can be classiﬁed as an ovarian struma. which are uncommon ovarian germ cell tumors. WB Saunders. Surgery of the Thyroid Gland Figure 22. it may be necessary to evacuate some of the colloid material from within the goiter. or calcitonin (90). Finger dissection of a substernal goiter. 1980. Note that the index ﬁnger is inserted into the mediastinum outside the thyroid capsule and is swept around until the gland is freed from the pleura and other tissue in the mediastinum. despite traction.
and the iris of the eye (101). Finally. Chicago. the adrenal (99). Udekwu AO (eds): Debates in Clinical Surgery. Many of these lesions may be contributing to autoimmune hyperthyroidism in response to a common stimulator such as thyroid-stimulating immunoglobulins. References 1 . Patricia Schaddelee for her assistance in the preparation of this chapter. Kocher T: Uber Kropfextirpation und ihre Folgen. 1883. Head Neck 14:380-383. Metastatic disease occurs in about 5% of these malignant tumors. Usually these lesions are resectable. 5. 1990. 7. 1988 6. ectopic thyroid tissue has been reported rarely in the submandibular (96) an parotid (97) salivary glands. 4. Johns Hopkins Hosp Rep 19:71. but external radiation therapy and/or 131I ablation has been advised after resection of the malignant tumors to avoid the tendency for late recurrence or metastatic disease. Thompson NW: The history of hyperparathyroidism. Thus. Udekwu AO (eds): Debates in Clinical surgery. Kaplan EL. and about 5% manifest evidence of carcinoma (94). Moosman DA. operative resection of an ovarian tumor is indicated. 1920 2. a suppressed TSH value. Denizot A et al: The non-recurrent inferior laryngeal nerve: Review of 33 cases including 2 on the left side.Chapter 21. Halsted WS: The operative story of goiter.92). Ferraz AR. Schark C: Routine exposure of the recurrent laryngeal nerve is important during thyroidectomy. 1992. pp 191206. et al: Surgical anatomy of the external branch of the superior laryngeal nerve. In other instances. Audriffe J. in the duodenum (98). perhaps one-fourth to one-third of ovarian strumae are associated with thyrotoxicosis (91. 1990. Arch Klin Chirurgie 29:254. Vol. Cernea CR. and TSH suppression should be given as for thyroid cancer originating in the usual location. pp. Thompson NW. 3. transient postoperative hypothyroidism and “thyroid storm” have occasionally been reported. Chicago. despite growth of the mass. DeWeese JS: The external laryngeal nerve as related to thyroidectomy. and uptake of radioiodine in a mass in the pelvis are the obvious prerequisites for making the diagnosis (93). Surgery of the Thyroid Gland iodinate thyroglobulin poorly. In Simmons RL. An elevated free thyroxine index. symptoms and ﬁndings of thyrotoxicosis are present in patients who have low uptake of radioiodine in their thyroid glands. It is best treated with 131I therapy. the gallbladder (100). 207219. 1. After surgery. Often. However. 1990. Henry JF. Vol. Usually. Year Book. Nishio S. and the diagnosis has typically been made after operative removal. Acknowledgements: The authors wish to thank Mrs. which has sometimes been fatal. 1. 44 . Year Book. Struma Cordis Functioning apparently normal intracardiac thyroid tissue has been reported a few times and has been visualized by radioiodine imaging (95). Acta Chir Scand 156:5-21. Of course. 1968 8. the struma alone is clearly responsible for the thyrotoxicity. Surgery 104:977-984. In Simmons RL. in ovarian struma. Demers M: Exposure is not necessary to avoid the recurrent laryngeal nerve during thyroid operations. Kadowaki MH. thyrotoxicosis does not develop. great care must be exercised to be certain that these are not metastases from a well differentiated thyroid cancer. a “high index of suspicion” is most important. The clinical ﬁnding is usually a right ventricular mass. Surg Gynecol Obstet 127:1011. Benign thyroid adenomas in strumae are common. and thus.
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