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Neck Diseases

Affiliated Hospital of Jining Medical Colledge


Dep.Mammary and Thyroid Surgery
Zhu KunBing
朱坤兵
The Thyroid Gland
The Thyroid Gland
Shape and position
 H-shape
 Left and right lobes: lie on either
side of inferior part of larynx and
superior part of trachea, extend
from middle of thyroid cartilage to
level of sixth trachea cartilage
 Isthmus: overlies 2nd to 4th
tracheal cartilage
 Pyramidal lobe: some times arises
from isthmus
Fibrous capsule:
A sheath of pretracheal fascia which
is attached to arch of cricoid and
thyroid cartilages, hence, the
thyroid gland moves with larynx
during swallowing and oscillates
during speaking
Relations
 Anteriorlly - skin , superficial fascia,

investing fascia, infrahyoid muscles


and pretracheal layer
 Posteromedialy - larynx and trachea,

pharynx and esophagus, recurrent


laryngeal n.
 Posterolateraly - carotid sheath and

cervical part of sympathetic trunk


Pyramidal lobe
Superior thyroid artery/vein

external carotid
Lateral lobe

Isthmus
Inferior thyroid artery/vein

Arteria thyroidea ima


Superior laryngeal
n.

parathyroid gland

Esophagus

Trachea

Recurrent laryngeal n.
Arteries of thyroid gland and nerves of larynx
Superior thyroid a.
 Branch of external carotid a.
 Runs superficial and parallel
to the external branch of
superior laryngeal n. to reach
the upper pole of thyroid
gland
 Gives off superior laryngeal
a. in company with internal
branch of superior laryngeal
n.
Superior laryngeal nerve
 Internal branch which
pierces thyroid membrane
to innervates mucous
membrane of larynx above
fissure of glottis
 External branch is fine n.,
which descends in company
with the superior thyroid a.
and supplies cricothyroid
Inferior thyroid artery
 Branch of thyrocervical trunk off subclavian a.
 Turns medially and downward, reaches the posterior
border of the thyroid gland and is closely related to the
recurrent laryngeal n.
 Supplies inferior pole of thyroid gland

Recurrent laryngeal nerves


 Ascend in tracheo-esophageal groove
 Pass deep to the lobe of the thyroid gland and come into
close relationship with the inferior thyroid a.
 Cross either in front of or behind the artery of may pass
between its branches
 Nerves enter larynx posterior to cricothyroid joint, the
nerve is now called inferior laryngeal nerve
 Innervations: laryngeal mucosa below fissure of glottis ,
all laryngeal laryngeal muscles except cricothyroid
Arteria thyroid ima
 May arise (4%) from the brachiocephalic a. or aortic arch
Venous drainage
 Superior and middle thyroid veins into internal jugular vein
 Inferior thyroid veins to left brachiocephalic vein
Parathyroid gland
 Yellowish-brown, ovoid bodies
 Position
 Two superior parathyroid

glands: lie at junction of superior


and middle third of posterior
border of thyroid gland
 Two inferior parathyroid glands:

lie near the inferior thyroid


artery, close to the inferior poles
of thyroid gland
 Function: regulate calcium and
phosphate balance and is therefore
essential for life
Cervical part of trachea
 Begins at lower end of larynx - level of
C6 vertebra
 Consists of a series of incomplete cartilage
rings
 Extends into thorax
 Relations in the neck
 Anteriorly
The skin , superficial fascia, investing
fascia, suprasternal space and jugular
arch, infrahyoid muscles and pretracheal
fascia, isthmus of thyroid gland ( in front
of the 2nd to 4th tracheal cartilage),
inferior thyroid v. and unpaired thyroid
venous plexus, arteria thyroid ima ( if
present), and left brachiocephalic v. in
child
 Laterally
The lobes of the thyroid gland ( down as far as the sixth ring) and the
carotid sheath
 Posteriorly
The right and left recurrent laryngeal nerves, the esophagus
Thyroid Function

Synthesize 、 Store&Secrete
triidothyronine(T3 )
thyroxine (T4 )
Physiology Control
 Hypothalamus:TRF

 Pituitary:Thyrotropin(TSH)
adenylyl cyclase activity
 Thyroid: T3 、 T4
Thyroid Hormones Function
 Accelerate cellular oxygenization rate;
boost body's metabolism overall.
 Promote protein,carbohydrate &fat

disintegrate
 Promote body's growth and development

,histodifferentiation 。
Evaluation of the Thyroid
 History-taking
 Systematic mathod of palpating thyroid
size, contour, consistency, nodularity
fixation, displacement of trachea,
cervical lymph nodes.
 The serum level of T3 、 T4
 Radioactive iodine uptake(RAI)
Goiter
Etiology

 Material iodine deficiency


 Thyroid hormones requirement increase
 synthesis&secretary disorder
Pathology
Follicle distend,filled with a lot of colloid;
Follicular parietal cell become thin and flat.
Pathology

Simple

Nodosity
Nodular Goiter
Cystic degeneration

Secondary hyperthyroidism

Canceration
Evaluation of Thyroid Nodules
and Goiters
(1)Sensitive TSH
(2)Percutaneous fine-needle biospy

Indeterminate Benign Inadequate


% Cancer or suspicious
Cancer 99% 20% <5% specimen

Usually TSH-
Operate suppressive Repeat
operate treat and
observe
Operation Indication
 Symptoms of pressure
 Substernal extension
 Cosmetic deformity
 Secondary hyperthyroidism
 Suspicion of cancer
Nodular Goiter
Specimen
After
operatoin
Goiter of Substernal extension
operating
Hyperthyroidism
Definition
Disorders

Feedback control mechanism of


the secretion of thyroid hormone
out of work

The level of thyroid hormone


of blood circulation

Systematic hypermetabolism
Types
 Primarily hyperthyroidism ( Graves'disease )
 Secondary
hyperthyroidism ( Pulmmer'disease )
 Hyperactive adenoma
 Iodine
 Thyroiditis
Primary Hperthyroidism

Manifestation:Diffuse thyromegaly
Hypermetabolism

Cause: Autoimmune disease


Long-acting thyroid stimulator (LATS)
Thyroid-stimulating immunoglobulinsTSI
Secondary Hperthyroidism

Usually due to nodular goiter


Hyperactive Thyroid Adenoma

 Solitary autonomic hyperfunctional nodule


 Tissues around nodule become atrophia 。
 Usually not with ophthalmoptosis
Diagnosis

Clinical manifestation

Special examination
Clinical Manifestation
 Nervousness,weight loss with increased appetite,heat
intolerance,increasing sweating,muscular weakness and
fatigue,increased bowel frequency,polyuria,menstrual
irregularities,infertility .
 Goiter,tachycardia,aterial fibrillation,warm mosit
skin,thyroid thrill and bruit,cardiac flow
murmur,gynecomastia.
 Eyes signs:stare,lid lag,exophthalmos.
 TSH low or absent;TSI,iodine upake,T3 and T4
increased;T3 suppression test abnormal.
Special Examination
 Basal metabolic rate
BMR = (PR+PP) - 111

 131I uptake ratio: 2h>25% 24h>50%

 T3 、 T4
Treament
 Drugs treatment : PTU,Tapazol 50 %
 Radioiodine therapy : 131I 90 %
 Operation
Operation Indicatio
 Secondary hyperthyroidism&hyperactive adenoma ;
 Primary hyperthyroidism of midrange or above ;
 Thyromegaly with symptoms of pressure
 Recidivist after ATD or 131I post-treatment ;
 Can not persist on medication
Surgical Contraindication

 Teenagers
 Lower symptom
 Elderly patient or can not suffer operation 。
Preoperative preparation
 General preoperative preparation

 Drugs:ATD ,lugol's iondine solution,Propranolol


Operation opportunity
 Symptom get baisc controll ( moodstable,good sleep,
weight gain )
 PR<90/min , BMR< + 20 % ;T3,T4 in normal level.
 Thyroid become small, stiff;vascular murmur
decrease.
Operation

 Anesthesia: general anaesthesia ;


cervical plexus regional analgesia

 Operation
Postoperative Complications
 Dyspneic respiration&choke
 Recurrent laryngeal nerve (RLN) injure
 superior laryngeal nerve ( SLN ) injure
 Rheumatic contraction
 Thyroid crisis
Rheumatic Contraction
Thyroid Neoplasm
Benign Tumor:adenoma
 Secondary hyperthyroidism ( 20 %)
 Canceration ( 10 %)
 Fast freezing pathological section
Thyroid Carcinoma
Pathology
 Papillary adenocarcinoma : 60-80 % ;age:30 ~
45 years female; 80 % :multinodular 。
 Follicular adenocarcinoma : 10-
20 %, age:50years
 Undifferentiated carcinoma : 1 %, age:70
years 。
 Medullary carcinoma : 7 %
Papillary adenocarcinoma

Papillary adenocarcinoma : 60-80 % ;


age:30 ~ 45 years female; 80 % :multinodular 。
Follicular adenocarcinoma
Follicular adenocarcinoma : 10-20 %, age:50years
Undifferentiated carcinoma
Undifferentiated carcinoma : 1 %, age:70 years 。
Clinical Manifestation
 early stage : hard nodule
 Advanced stage : Symptoms of
pressure
 Local metastasis : palpable lymph
nodes 。
 Metastasis : to lungs or bone
Therapy
 Differentiated thyroid carcinoma

 Undifferentiated thyroid carcinoma


Operation
 Total lobectomy with isthmectomy
 Neartotal thyroidectomy
 Total thyroidectomy
 Peripheral lymph node disscetion
No
Central lymph nodes disscetion
Modified radical neck disscetion
Radical neck dissection 。
Modified radical neck disscetion
Thyroid operation by endoscope