EXAM #1, TRANS #4

Thyroid and Parathyroid Glands

SAMANTHA SORIANO-CASTAÑEDA, MD, FPSO-HNS
10/27/2017

OUTLINE ® Posterior group:

II. Parathyroid Glands § Also known as the Berry’s ligament
I. Thyroid Gland A. Anatomy of Parathyroid Glands
A. Anatomy of Thyroid Gland B. Embryology of Parathyroid Glands § Connects the thyroid to cricoid cartilage and continues to wrap
B. Embryology of Thyroid C. Physiology of Parathyroid Glands around 1st and 2nd tracheal rings
Gland D. Clinical Correlations
C. Physiology of Thyroid Quick Review
Gland Review Questions Clinical Correlation: Goiter
References

I. THYROID GLAND
• Location:
® Lies deep to the sternothyroid and sternohyoid muscles
® Anteriorly in the neck at the level of C5-T1 vertebrae
® Anterolateral to the trachea
® Can be found between cricoid cartilage and suprasternal notch

Figure 3. Normal Thyroid vs Goiter (Darling, 2015)

• Any enlargement of a part or the whole thyroid gland

• Endemic disease in our country
• Some goiters need to be removed through surgery while some will be
treated with drugs

Arteries

Figure 1. Thyroid Gland (Moore et al., 2015)

A. ANATOMY OF THYROID GLAND

Structural Characteristics
• Enveloped by the pretracheal layer of the deep cervical fascia
• Consists of 2 pear shaped lobes: the right and left lobes connected by a
thin isthmus that lies anterior to the 2nd and 3rd tracheal ring
® The apex of the lobes reaches the middle 3rd of the thyroid cartilage
and the base located between the 5th & 6th tracheal ring
® Weighs 15-25 grams
• Shape: anteriorly: convex; posteriorly: concave
• Boundaries:
® Medial: trachea and larynx
® Lateral: carotid sheath and SCM
§ Anterolateral: SCM
§ Inferolateral: carotid sheath
® Anterior: strap muscles
® Posterior: parathyroid gland, RLN, and esophagus

Figure 4. Blood Supply of the Thyroid and Parathyroid Glands (Moore et al., 2015)

• The thyroid gland is supplied mainly by 2 arteries and occasionally by 1

artery
® Superior Thyroid Artery
§ Main blood supply
§ Comes from the 1st branch of the external carotid artery
§ Path (2021 Trans)
1. Descend to the superior poles of the thyroid
2. Pierce the pretracheal layer of the deep cervical fascia
3. Divide into anterior and posterior branches
4. Supply mainly the anterosuperior aspect of the thyroid
® Inferior Thyroid Artery
§ From the largest branches of the thyrocervical trunk that
arises from subclavian artery
§ Path (2021 Trans)
1. Run superomedially posterior to the carotid sheaths toward
the posterior aspect of the thyroid
Figure 2. Thyroid gland and its relationships. (Moore et al., 2015) 2. Divide into branches
3. Pierce the pretracheal layer of the deep cervical fascia
• Suspensory Ligament 4. Supply the posteroinferior aspect, including the inferior poles
® Anterior group: of the thyroid
§ Extends from the superior-medial aspect of each thyroid lobe to ® Thyroid Ima Artery
the cricoid and thyroid cartilage § Prevalent in 10% of the population
Trans #4 Group #10: Anonas, Bangayan, Go, Liberato, Pineda, Talla 1 of 5

§ An unpaired, single artery that usually arises from the
brachiocephalic trunk but may also arise from the subclavian or
common carotid arteries or the aorta
§ Path (2021 trans)
1. Ascends on the anterior surface of and supplies small
branches to the trachea
2. Continues to and supplies the isthmus of the thyroid
Venous Drainage
Figure 5. Venous drainage of the Thyroid Gland
• There are 3 pairs of veins which provide venous drainage to the thyroid
gland
® Superior thyroid vein
§ Drains the superior poles of the glands to the internal jugular vein
§ Runs with the superior thyroid artery
® Middle thyroid vein
§ Drain the middle part of the lobes
§ Follow the internal jugular vein either laterally or directly
® Inferior thyroid vein
§ Drain the inferior of the lobes
§ Veins run different paths, depending on the sides
- The right vein passes anterior to the innominate artery to the
right brachiocephalic vein or anterior to the trachea to the left
brachiocephalic vein
- The left vein drains to the left brachiocephalic vein
§ Occasionally, both inferior veins form a common trunk called the
thyroid ima vein, which empties into the left brachiocephalic vein
Which of the following is true about the blood supply of the thyroid gland?
a. It is supplied by the superior and inferior thyroid arteries
b. It is drained by the superior and inferior thyroid veins
c. The inferior thyroid artery is a branch of the external carotid artery
d. The inferior thyroid vein drains into the internal jugular vein
Nice to Know:
Tracheotomy
“A tracheotomy or a tracheostomy is an opening surgically created through
the neck into the trachea (windpipe) to allow direct access to the breathing
tube and is commonly done in an operating room under general anesthesia.
A tube is usually placed through this opening to provide an airway and to
remove secretions from the lungs.” (Molnar, n.d)
The presence of the thyroidea ima artery can cause bleeding in this
type of procedure especially when a transverse cut is made, rather
than a longitudinal cut.
Innervations
• Innervated by branches from the autonomic nervous system
• Parasympathetic fibers come from the vagus nerves (found in the
carotid sheath)
• Sympathetic fibers are distributed from the superior, middle, and inferior
ganglia of the sympathetic trunk
• Mainly supplied by 2 nerves
Head and Neck 05.04: THYROID AND PARATHYROID GLANDS
® Recurrent laryngeal nerve
§ Lies medial or deep to the middle thyroid vein and also lies at the
tracheoesophageal groove
§ Branch of the vagus nerve
- Vagus nerve seen in carotid sheath, posterior to carotid artery
- These nerves allow for sensory and motor functions
o Supplies motor innervation to intrinsic muscles of larynx
o Also sensory from the level of vocal cords downwards
§ 2 pathways for each side
- Right: Vagus branch ® goes around subclavian on the right
® goes up behind the carotid at the tracheoesophageal
groove ® inserts into the area of cricothyroid membrane
- Left: Loops around the arch of the aorta
§ Importance of pathways
- Paralysis on the RLN on the left as seen in cases of
Pulmonary TB
- Lymph nodes enlarges ® left RLN impinged because of the
RLN loops around the arch of the aorta
§ If cut, manifestations include a coarse voice and aspiration
Which of the following is true about the recurrent laryngeal nerve (RLN)?
a. It is a branch of the vagus nerve
b. It is purely a motor nerve
c. It passes anterior to the subclavian artery
d. It innervates the cricothyroid muscle
® Superior laryngeal nerve
§ Also a branch of the vagus nerve with 2 branches
- Internal laryngeal nerve
o Pierces the thyrohyoid membrane which provides sensory
innervation to vocal cords upwards
- External laryngeal nerve
o Supplies motor innervation to cricothyroid muscle
o Tenses vocal cords and is responsible for high pitch
o If injured, low pitched voice will be observed
Lymphatic Drainage
Figure 6. Lymphatic Drainage of Thyroid and Parathyroid Glands. (Moore et al., 2015)
• Lymph drainage of thyroid gland flows multidirectional
• It passes to paratracheal nodes, pre-tracheal lymph nodes and
prelaryngeal (delphian) nodes
® Middle to upper pole of lobe, superior portion of the isthmus
§ Drains into superior deep cervical nodes and delphian nodes
® Lower lobe and isthmus
§ Drains into pretracheal, paratracheal, and inferior deep cervical
nodes
• Deep cervical lymph nodes are found in levels II, III, and IV
B. EMBRYOLOGY OF THYROID GLAND
• First endocrine gland to develop in the embryo (4th week of
development)
• Originates from two main structures:
® Primitive pharynx - gives rise to the median thyroid
® Neural crest - gives rise to the lateral thyroid
• Events
2 of 5


® 4th week of gestation: Thyroid diverticulum arises from the foramen Which of the following is true about the embryology of the thyroid gland?
cecum between the tuberculum impar and copula a. It arises from the foramen caecum and ends its descent at the 5th
® Gland descends through a midline anterior path infront of the week of gestation
pharyngeal gut, hyoid bone, and laryngeal cartilages b. Epithelial remnants of the thyroid tract can lead to ectopic thyroid
® Gland remains connected to the foramen cecum through the tissue.
thyroglossal duct c. Removal of a lingual thyroid does not cause hypothyroidism.
® 5th week: Thyroglossal duct starts to break down d. The pyramidal lobe is due to failure of degeneration of the
® 7th week: Thyroid gland reaches its final position in front of the thyroid tract.
trachea
C. PHYSIOLOGY OF THYROID GLAND
• Thyroid is largest endocrine gland in the body
• Ductless
• Produces two hormones: Thyroid hormones and Calcitonin

Production of Thyroid Hormones

• Main function of thyroid hormones: Maintain proper level of
metabolism in body’s cells
• Two types of thyroid hormones:
® Thyroxine (T4) – produced by the coupling of two DIT
(diiodothyronine) molecules
® Trioiodothyronine (T3) - produced by the coupling of one DIT and one
MIT (monoiodothyronine) molecule; 3 times as potent as T4
• Biologically active form of thyroid hormones in bloodstream are Free T4
and T3.

1. Iodide (I-) from the diet goes to the bloodstream and enters the follicular
cell of the thyroid via Sodium-Iodide Symporter (NIS) on the basal
membrane of the thyroid epithelium (Iodide Trapping)
2. Iodide is quickly transported out of the apical membrane via pendrin
(chloride-iodide antiporter).
3. Amino acids are processed into thyroglobulin inside the follicular cells
and transported out of the apical membrane.
4. Iodide is oxidized to iodine and incorporated into tyrosine molecules to
form MIT and DIT molecules which are then bound to thyroglobulin to
form a complex. Two DIT molecules couple to form Thyroxine (T4), while
one DIT and one MIT molecule couple to form Trioiodothyronine (T3).
These reactions are catalyzed by thyroid peroxidase (TPO). This is the
storage form of the thyroid hormones.
5. To secrete T4 and T3, the complex goes into the follicular cell through
the receptor megalin on the apical membrane. The complex is then
endocytosed and thyroglobulin is degraded by lysosomes, releasing T4
and T3 into the bloodstream.
Figure 7. Development of the Thyroid Gland (Moore et al., 2016) 6. Most thyroid hormones are still bound in the bloodstream. 70% of thyroid
hormones are bound by thyroid-binding globulins (TBG), transthyretin,
Clinical Correlations and albumin. When these are bound, the hormones are inactive. (Free =
• Lingual Thyroid Active)
® Undescended thyroid tissue that remains at the base of the tongue 7. T4 can sometimes be converted to T3 via the action of deiodinase.
® Only thyroid tissue found in the body
§ Not removed unless it blocks the airway or causes dysphagia
§ Patient is given thyroid hormones upon ablation
• Thyroglossal Duct Cyst
® Occurs when the thyroglossal duct does not atrophy and leaves
epithelial remnants
® Forms a swelling in the anterior part of the neck that moves with
tongue protrusion
® Excised using the Sistrunk procedure

Figure 8. Manifestation of (A) Lingual Thyroid and (B) Thyroglossal Duct Cyst.

• Pyramidal Lobe
® Long, narrow projection of thyroid tissue extending upward from the
isthmus and lying on the surface of the thyroid cartilage
® Results from failure of thyroglossal tract degeneration
® Usually non-palpable
• Levator Glandulae Thyroideae
® Rare developmental anomaly Figure 9. Production of Thyroid Hormones
® Muscular tissue connecting the isthmus to the hyoid
Stimulation of Production of Thyroid Hormones
1. Certain stimuli will induce the production of Thyrotropin-releasing
Hormone (TRH) by the hypothalamus.

Head and Neck 05.04: THYROID AND PARATHYROID GLANDS 3 of 5



2. TRH will stimulate the anterior pituitary gland to produce Thyroid- § 2 inferior parathyroid glands
stimulating hormone (TSH). ® Intimately related to thyroid gland
3. TSH will stimulate the production and release of T3 and T4, which will act ® Weight: 30-70 mg
on the target organs. ® Height: 3-5 mm
4. Production of T3 and T4 inhibit the production of TSH by the anterior ® Tan in color
pituitary gland, stopping the stimulation for more thyroid hormone ® Same blood supply as the thyroid gland
production (Negative Feedback) ® Innervated by the cervical sympathetic ganglia (vasomotor)
® It produces parathyroid hormone (PTH)
§ PTH controls extracellular calcium and phosphate concentrations

B. EMBRYOLOGY OF PARATHYROID GLANDS

• Superior parathyroid
® 4th pharyngeal/brachial pouch
® More constant location (relatively stationary)
• Inferior parathyroid
® 3rd pharyngeal pouch
® Along with thymus
® Migratory

C. PHYSIOLOGY OF PARATHYROID GLAND

• PTG is responsible for the production of parathyroid hormone (PTH)
® For calcium metabolism and regulation
® Acts directly on bone and kidney, and indirectly on intestine
® PTG initially detects low calcium levels through its membrane
containing protein called calcium-sensing receptor
® Once it detects low levels of calcium, kidneys:
Figure 10. Pathway of Stimulation of Thyroid Hormone Production
§ Increase Ca2+ reabsorption from urine while decreasing
phosphate reabsorption
Clinical Correlations
§ Activates 1-hydroxylase which converts vitamin D3 into its active
• Goitrogens - Naturally-occurring substances that can interfere with
form 1,25-dihydroxycholecalciferol
function of the thyroid gland; block thyroid peroxidase activity
® Bone resorption is promoted through osteoclast activation to release
® Inactivated by cooking
calcium into blood
® Do not eat excessive amounts
® Leads to increased calcium and phosphate absorption in the
§ soybean-related foods (Isoflavones)
intestines
§ cruciferous vegetables e.g. broccoli, cauliflower, cabbage,
® Net effect of PTH= increase in serum calcium ions
mustard and turnips (Isothiocyanates)
§ peaches, strawberries and millet ® Feedback regulation of PTH:
§ Negative feedback due to increased serum calcium levels
• Hyperthyroidism
- PTG decreases PTH production
® Excessive amounts of thyroid hormone
® Weak negative feedback by 1,25-dihydroxycholecalciferol
® Important symptoms: Uncontrollable weight loss, exophthalmia
(bulging of eyes), Nervousness, Goiter ® Decrease in PTH would result to:
§ ↑ renal excretion of calcium
• Hypothyroidism
§ ↓ absorption of calcium on intestines
® Deficiency of thyroid hormone
§ ↓ release of calcium from bone
® Important symptoms: Uncontrollable weight gain, weakness and § ↓ serum calcium
fatigue
Important: If in case the parathyroid glands are accidentally removed
II. PARATHYROID GLANDS during surgery (due to its small size), it would cause the inability to
A. ANATOMY OF PARATHYROID GLAND produce parathyroid hormones which leads to a decreased calcium levels
in the body or hypocalcemia.

D. CLINICAL CORRELATIONS
Signs and Symptoms of Hypocalcemia
• Early: perioral numbness, numbness of fingertips, paresthesia, muscle
cramps, mild mental status changes
• Late: mental status changes, seizure, tetany, hypotension, acute heart
failure

Figure 12. Hyperextension of limb (Castañeda, 2017)

Figure 11. Parathyroid Gland (Moore et al., 2016) Clinical Tests for Hypocalcemia
• Trousseau’s sign
• Location: ® Ischemia-induced pain
® Found on the posterior portion of the thyroid gland ® Inflation of a blood pressure cuff resulting in carpopedal spasm
• Characteristics (hyperextension of fingers)
® Four in number ® Not advisable to perform to avoid pain and discomfort on patient
§ 2 superior parathyroid glands
Head and Neck 05.04: THYROID AND PARATHYROID GLANDS 4 of 5



• Stimuli will stimulate production of TRH which in turn will stimulate

production of TSH, which will stimulate production of T3 and T4.
• Production of T3 and T4 will produce a negative feedback on anterior
pituitary gland.
• Parathyroid is typically 4 in number and found on the posterior portion of
the thyroid gland
• Parathyroid gland produces parathyroid hormones for calcium
metabolism and regulation.
• Parathyroid hormone (PTH) directly acts on bone and kidney, and
indirectly on intestine/gut.
• Negative feedback regulates the parathyroid hormones due to increased
level of serum calcium levels.
• Decrease in PTH would increase renal excretion of calcium, decreased
absorption of calcium in intestines, decreased release of calcium from
bone and decreased serum calcium.
• Hypocalcemia occurs when there is a decreased level of serum calcium
levels in the body.
Figure 13. Trousseau’s Sign (Castañeda, 2017) • Most obvious symptom for a patient with hypocalcemia is the
hyperextension of the fingers on the limbs.
• Chvostek’s sign • Clinical tests for hypocalcemia include Trousseau's sign and Chvostek's
® Facial nerve irritability or spasms elicited by tapping the facial nerve sign.
branches
§ Tap on marginal mandibular (facial nerve) resulting to a twitch in REVIEW QUESTIONS
lower lip (depressor) 1. Medial boundary of the thyroid?
§ Tap on buccal nerve resulting to a “smile” a. Trachea
b. Larynx
c. AOTA
d. NOTA

2. The thyroid gland is supplied by which arteries?

a. Superior thyroid artery, Inferior thyroid artery, thyroid ima artery
b. Lateral thyroid artery, Medial thyroid artery, thyroid ima artery
c. Anterior thyroid artery, Posterior thyroid artery, thyroid ima artery
d. Carotid artery, thyrocervical artery, thyroid ima artery

3. This condition results from the failure of thyroid tissue to descend down
the neck and thus, remains at the base of the tongue.
a. Levator glandulae thyroideae
b. Pyramidal lobe
c. Thyroglossal duct cyst
d. Lingual thyroid

4. The parathyroid gland has the following in common with the thyroid
Figure 14. Chvostek’s sign, tapped on the buccal nerve causing a “smile” gland, making the two intimately related:
(Castañeda, 2017) a. Blood supply
b. Lymphatic drainage
A 55 y.o female is noticed numbness of her fingertips with cramping after a c. Innervation
total thyroidectomy. Which of the following is true about this patient? d. Both A and B
a. The patient has a parathyroid adenoma.
b. Tapping a branch of the trigeminal nerve to elicit facial twitching is a 5. What receptor is used to transport iodide out of the apical membrane of
clinical test. the follicular cell?
c. The patient has elevated parathyroid hormones. a. Megalin
d. None of the above b. NIS
c. Pendrin
QUICK REVIEW d. Ryanodine receptors
• Thyroid consists of right and left lobes connected by isthmus
Answers: 1C, 2A, 3D, 4D, 5C
• Boundaries of Thyroid: Medial (trachea and larynx), Lateral (carotid
sheath and SCM), Anterior (strap muscles), Posterior (parathyroid gland,
RLN and esophagus) REFERENCES
• The thyroid gland is supplied by 2, sometimes 3 main arteries (1) Dr. Sam Castaneda. October 27, 2017. Thyroid and Parathyroid Glands.
® Superior thyroid, from the 1st branch of the external carotid artery [Lecture slides].
® Inferior thyroid, from the thyrocervical trunk (2) Berne, Robert M., Koeppen, Bruce M.Stanton, Bruce, A. (Eds.) (2008).
® Thyroid ima, a rare artery, from the brachiocephalic trunk Berne & Levy physiology. Philadelphia: Mosby/Elsevier
• There are 3 veins that drain the thyroid glands (3) Moore, K.L., Dalley, A.F. and Agure, A.M.R. (2014). Clinically oriented
anatomy (7th ed.)
® Superior thyroid vein, drains superior parts
® Middle thyroid vein, drains middle parts
® Inferior thyroid vein, drains inferior parts and runs different paths
depending on the side it runs through
• Thyroid Gland Embryology
® Thyroid diverticulum arises from foramen cecum → formation of
thyroglossal duct upon descension of gland → degeneration of
thyroglossal duct → gland reaches final position at the neck
® Clinical correlations
§ Lingual thyroid
§ Thyroglossal duct cyst
§ Pyramidal lobe
§ Levator glandulae thyroideae
• Thyroid produces thyroid hormones (T3 and T4) and calcitonin
• Iodide is taken up by thyroid follicular cells and converted into MIT and
DIT which are coupled to form T3 and T4, which are bound to
thyroglobulin.
Head and Neck 05.04: THYROID AND PARATHYROID GLANDS 5 of 5