234 HIGH-YIELD FACTS IN
Men i i B
WARD TIP
Persistence o the thyroid-pharynx
connection may occur via a sinus or
cyst, called a thyroglossal duct cyst.
These cysts present as midline neck
masses that move with swallowing
and are usually seen in children or
adolescents. They should be surgically
excised because o the risk o in ection.
EXAMTIP
Lymphatics ultimately drain to
internal jugular nodes. Intraglandular
lymphatics connect both lobes,
explaining the relatively high requency
o multi ocal tumors in the thyroid.
THE ENDOCRINE SYSTEM
■ Mucosal neuroma may be earliest sign present (100%)—hypertrophied
lips, thickened eyelids.
■ Medullary thyroid carcinoma (85%).
■ Pheochromocytoma (50%).
■ Mar anoid habitus—skeletal abnormalities o spine (e.g., kyphosis), pectus
excavatum.
T at t
■ Per orm subtotal or total parathyroidectomy with autotransplantation or
parathyroid hyperplasia (MEN I and MEN IIA).
■ Per orm total thyroidectomy with bilateral prophylactic central lymph
node dissection or medullary thyroid cancer (MEN II).
Thyroid
Gen er a l
The thyroid gland is responsible or the metabolic activity o the body.
Dys unction o the thyroid can result in hyper or hypo states o hormone pro-
duction. Several di erent types o cancer can also orm in the thyroid gland.
These conditions may ultimately require surgical correction.
Devel o pMen t
■ The thyroid develops at the base o the tongue between the rst pair o
pharyngeal pouches, in an area called the oramen cecum.
■ The thyroid gland then descends down the midline to its nal location
overlying the thyroid cartilage, and develops into a bilobed organ with an
isthmus between the two lobes.
■ It remains connected to the f oor o the pharynx via the thyroglossal duct,
which subsequently obliterates around the second month o gestation.
However, the thyroglossal duct may ail to obliterate and orm a thyroglos-
sal cyst or stula instead. These are most commonly seen in children and
should be surgically excised.
■ A pyramidal lobe can be seen in 50–80% o the population and repre-
sents a remnant o the distal thyroglossal tract. The pyramidal lobe extends
superiorly rom the median isthmus.
a n a t o My
See Figure 15-1.
G ss A at
■ Two lobes, isthmus, pyramidal lobe (pyramidal lobe present in 50–80%).
■ Suspended rom larynx, attached to trachea (cricoid cartilage and tracheal
rings).
■ Weighs 20–25 g in adults.
■ Relationships:
■ Anterior: Strap muscles (sternohyoid, sternothyroid, thyrohyoid, omo-
hyoid).
■ Posterior: Trachea.
■ Posterolateral: Common carotid arteries, internal jugular veins, vagus nerves.
■ Parathyroid glands on posterior sur ace o thyroid, and may be within
capsule.
 THE ENDOCRINE SYSTEM HIGH-YIELD FACTS IN 235

Superior Thyroid A. and V.

Phrenic N. Thyroid Gland:

CN X Lateral Lobe
Isthmus
Vertebral A.
Middle Thyroid V.
Inferior
Thyroid A. Inferior Thyroid V.
Transverse Left Recurrent Laryngeal N.
Cervical A.
Thoracic Duct
Supra-
Scapular A. Trachea

Thyrocervical
Trunk CN X
Subclavian A. and V. Hyoid Bone
Longus Colli M.

A
Pharynx
CN X

CN X

Thyroid
Parathryroid Gland
Gland

Inferior Thyroid A.

Right Recurrent
Thyrocervical Laryngeal N.
Trunk

Esophagus
and Trachea
Left Recurrent
Laryngeal N.

Fi GU r e 1 5 - 1 . T a at . (Reproduced, with permission, rom Morton DA, Foreman KB, Albertine KH. The Big Picture: Gross Anatomy. New York, NY: McGraw-Hill
Education; 2011. Figure 26-3AB.)

va s Cu l a t u r e

See Figure 15-2.

236 HIGH-YIELD FACTS IN
EXAMTIP
The RLN innervates all the intrinsic
muscles o the larynx, except the
cricothyroid (supplied by the superior
laryngeal nerve), and provides sensory
innervation to the mucous membranes
below the vocal cord. It can be
damaged during a thyroid operation, so
the surgeon must know its course well.
Damage produces ipsilateral vocal cord
paralysis and results in hoarseness or
sometimes shortness o breath due to
the narrowed airway.
THE ENDOCRINE SYSTEM
Cricoid Cartilage
Inferior
Thyroid Artery
Inferior
Thyroid Veins
Fi GU r e 1 5 - 2 . T bl suppl . (Reproduced, with permission, Mescher AL. Junqueira’s Basic Histology.
14th ed. New York, NY: McGraw-Hill Education; 2016. Figure 20-18.)
Arterial
■ Superior thyroid arteries (on each side).
■ First branch o external carotid artery at the level o the carotid bi urcation.
■ In erior thyroid artery (on each side).
■ From thyrocervical trunk o subclavian artery.
■ Ima (sometimes present).
■ From aortic arch or innominate artery.
Venous
■ Superior thyroid vein (on each side).
■ Drains to internal jugular (IJ).
■ Middle thyroid vein (on each side).
■ Drains to IJ.
■ In erior thyroid vein (on each side).
■ Drains to brachiocephalic vein.
i n n er va t i o n
■ The right recurrent laryngeal nerve (RLN) branches rom the right vagus
nerve, loops under the right subclavian artery, and ascends to the larynx
(posterior to the thyroid) between the trachea and esophagus. It may be
anterior or posterior to the in erior thyroid artery. The le t RLN branches
rom the le t vagus nerve, loops under the aortic arch, and then ascends
along the tracheoesophageal groove to the larynx. Both RLNs innervate
the muscles o the true vocal cords.
■ Sympathetic: Superior and middle cervical sympathetic ganglia (vasomotor).
■ Parasympathetic: From vagus nerves, via branches o laryngeal nerves.
h o r Mo n es
The thyroid gland produces thyroid hormone (TH) using iodide and tyrosine.
h r gulat
■ TSH causes:
■ Increased ormation o TH.
■ The release o TH into circulation within 30 minutes.
 THE ENDOCRINE SYSTEM HIGH-YIELD FACTS IN 237

■ The increased TH level in blood then eeds back to the pituitary and
results in decreased TSH secretion, by an incompletely understood WARD TIP
mechanism.
Thyroid ollicles store enough hormone
to last 2–3 months. Thus, there is no
e ts T h
need to worry about your postop
■ Cardiovascular system: Increased heart rate (HR), cardiac output (CO), hypothyroid patients who are NPO or
blood f ow, blood volume, pulse pressure (no change in mean arterial several days. They can resume taking
pressure [MAP]). their levothyroxine when they begin a
■ Respiratory system: Increased respiratory rate (RR), depth o respiration. PO diet.
■ Gastrointestinal (GI) system: Increased motility.
■ Central nervous system (CNS): Nervousness, anxiety.
■ Musculoskeletal system: Increased reactivity up to a point, then response is
weakened; ne motor tremor.
■ Sleep: Constant atigue but decreased ability to sleep. WARD TIP
■ Nutrition: Increased basal metabolic rate (BMR), need or vitamins,
metabolism o carbohydrate, lipid, and protein; decreased weight. Palpation o the thyroid is easiest i you
stand behind the patient and reach
your arms around to the ront o the
a s s es s Men t o f f u n Ct i o n
neck. Expect the isthmus to be about
one ngerbreadth below the cricoid
■ I T 4 production is increased, both total T 4 (tT 4) and ree T 4 ( T 4) increase. cartilage. In addition, make sure to
■ I production decreases, both tT 4 and T 4 decrease. palpate or cervical lymph nodes.
■ I amount o thyroid-binding globulin (TBG) changes, only tT 4 changes,
not T 4.

Co n Gen i t a l a n o Ma l i es
WARD TIP
■ Persistent sinus tract remnant o developing gland: Thyroglossal duct
cyst—may occur anywhere along course as a midline structure with thy- In 70% o cases o lingual thyroid, it is
roid epithelium, usually between the isthmus and the hyoid bone: the patient’s only unctioning thyroid
■ Most common congenital anomaly. tissue. This means that it is important to
■ Few symptoms but may become in ected. look or other unctioning thyroid tissue
■ Easier to see when tongue is sticking out. prior to removing a lingual thyroid.
■ Surgical treatment: Excision o duct remnant and central portion o
hyoid bone (Sistrunk’s operation).
■ Complete ailure to develop.
■ Incomplete descent: Lingual or subhyoid position (i gland enlarges,
patient will have earlier respiratory symptoms).
■ Excessive descent: Substernal thyroid.
■ Mal ormation o branchial pouch.

h yper t h yr o i Di s M

c aus s EXAMTIP
■ Graves’ disease.
■ Toxic nodular goiter. Ten percent o patients will have
■ Toxic thyroid adenoma. atrial brillation that may be
■ Subacute thyroiditis. re ractory to medical treatment until
■ Functional metastatic thyroid cancer. hyperthyroidism is controlled.
■ Struma ovarii (abnormal thyroid tissue in ovary).

G av s’ d s as
■ Most common cause o hyperthyroidism in the United States.
■ Mechanism: Autoimmune disorder that causes an excess o TH to be pro-
duced due to the presence o thyroid-stimulating immunoglobulins that
stimulates production o TSH.