THYROID/PARATHYROID

Thyroid gland,

1. Pretracheal fascia:
a. surrounds thyroid b. Extends from hyoid bone to fibrous pericardium c. Encloses trachea, larynx, pharynx, thyroid d. Parathyroids and venous plexus lie between layers

Investing layer of DCF

Pretracheal fascia

Investing layer of deep cervical fascia

Muscular portion of pretracheal layer of DCF

Pretracheal layer of dcf

Thyroid gland
• Surrounded by thin fibrous capsule of connective tissue • External to this is pretracheal fascia derived from deep cervical fascia • Attached to cricoid and thyroid cartilages • Thus, moves up and down with larynx during swallowing

omohyoid

Investing layer

sternohyoid

scm

sternothyroid

omohyoid

sternohyoid sternothyroid

I. Introduction/General Information A. Thyroid 1. Endocrine gland a. Lobes are cone shaped b. Apex extends to oblique line of thyroid cartilage 2. Highly vascular

Thyroid, General Information, continued …

3. Anterior & lateral to larynx, trachea 4. Lobes connected by an isthmus 5. Pyramidal lobe may be present 6. Normally not palpable

The Thyroid Gland • Located in the anterior region of the neck

Thyroid Gland, Anterior and Posterior Views

Thyroid Gland: anterior view (left); and posterior view (right)

Thyroid, General Information, continued …

8. Isthmus crosses tracheal cartilages 2-4 9. Base located ~4-6th tracheal cartilage 10. Thyroxin function: regulates basic metabolism in all cells

II. Detailed Anatomy A. Thyroid 1. Largest endocrine gland 2. Extends fr C-5 to T-1 3. Highly vascular 4. Weighs ~20 - 30 grams

Thyroid gland
• Clasps the pharynx, larynx, esophagus and trachea like a shield • Lies deep to sternothyroid and sternohyoid • Each lobe [5cm] extends to level of 6th tracheal cartilage

Thyroid gland
• • • • Size varies greatly Larger in women Enlarges dur pregnancy May enlarge slightly dur menstruation

Thyroid, Detailed Anatomy, continued …

5. Pyramidal lobe a. present in ~ 33% of population. b. Extends upward from isthmus c. anterior to thyroid cartilage

Thyroid, Detailed Anatomy, continued …

d. Embryologic remnant of thyroglossal duct e. formerly connected cecum of tongue to thyroid diverticulum f. Site of developing gland

Pyramidal Lobe of the Thyroid Gland

Pyramidal Lobe

Thyroid Gland, Anterior View

Thyroid, Detailed Anatomy, continued …

c. Lobes: 1. Attached to cricoid cartilage by ligaments 2. Medial surface adapted to larynx and trachea

Thyroid, Detailed Anatomy, cont …

3. Lobes related posteriorly to the esophagus 4. Posterolateral surface a. related to carotid sheath b. overlaps carotid artery

Thyroid, Detailed Anatomy, con’t…

d. Isthmus
1. 1.25 cm x 1.25 cm 2. Crosses @ tracheal rings ~2-4 3. Rarely absent

Thyroid gland vascular, continued …

6. Highly vascular gland supplied by four large arteries a. R & L inferior thyroid artery b. R & L superior thyroid artery

BLOOD SUPPLY (THYROID GLAND)
• Superior thyroid artery • 1st anterior branch of External Carotid Art • Descends the lateral part of the neck under the superior belly of omohyoid and sternothyroid muscles • Above the level of the superior pole, accompanied by the external laryngeal branch of the superior laryngeal nerve

• Nerve parallels artery until it reaches the superior lobe where it courses under the sternothyroid to insert in the cricothyroid muscle • High ligation of STA may affect nerve • Dysphonia, denervates CT muscle (regulation of pitch) • No sensation to mucosa of pyriform sinus and false vocal cords

BLOOD SUPPLY (THYROID GLAND)

BLOOD SUPPLY (THYROID GLAND)
• Inferior thyroid artery • Arises from the thyrocervical trunk • Branch of 1st part of subclavian artery level of the 1st rib • Ascends vertically for a short distance before turning medially, forming an arching loop and entering the tracheoesophageal groove

BLOOD SUPPLY (THYROID GLAND) • Most of branches penetrate posterior aspect of lateral lobe • Anastomoses with STA near the superior pole • Small vessels intermingle with recurrent laryngeal nerve

Thyroid gland vascular, continued …

Venous drainage a. Superior thyroid vein  int jugular vein [ IJV ] b. Middle thyroid vein IJV c. Inferior thyroid veinbrachiocephalic vein

Inferior Thyroid Vein

BLOOD SUPPLY (THYROID GLAND) • 2 pairs of arteries
– Superior thyroid a – Inferior thyroid a

• 3 pairs of veins
– Superior thyroid v – Middle thyroid v – Inferior thyroid v

Sup thyroid art and vein

Middle thyroid vein

Inf thyroid artery

Inf thyroid vein

Thyroid gland, continued …

Lymph vessels
1. In interlobular connective tissue between lobes 2. Connect with network in wall of gland 3. terminate in thoracic and right lymphatic ducts

Surgical Anatomy: Lymphatics

Thyroid gland, continued …

Muscular landmarks
a. Sternocleidomastoid muscles lie laterally b. Longus colli (prevertebral) muscles lie posteriorly c. “Strap” muscles lie anteriorly

Strap Muscles

Thyroid gland, continued …

Autonomic innervation via a. Cervical portion of sympathetic trunk b. Parasympathetic fibers arise from Vagus X

INNERVATION (THYROID GLAND)
• Autonomic nervous system • Parasympathetic fibers ~ vagus nerve • Sympathetic fibers ~ superior, middle, inferior sympathetic ganglia of the sympathetic trunk

Sympathetic trunk

Recurrnt laryngeal nerve [Vagus]

Detailed Anatomy, continued …

Treatment considerations
a. Superior thyroid artery is accompanied by superior laryngeal nerve b. Inferior thyroid artery is accompanied by recurrent laryngeal nerve

Detailed Anatomy, continued …

c. Damaging nerves results in partial or total paralysis of larynx SLN injury – unable to reach high pirch RLN injury –VC paralysis, hoarse voice

II. Parathyroid glands 1. Usually four – two on each side (2 to 8 is normal) 2. Posterior surface of thyroid 3. Embedded w/in thyroid gland 4. Regulate calcium/phosphate levels 5. Required for life

Parathyroid Glands (Post. view of thyroid)

Parathyroid Glands are located on the posterior aspect of the thyroid; sometimes the tissue is embedded within thyroid tissue.

Parathyroid Gland, Detailed Anatomy

B. Parathyroid glands 1. Yellow-brown 2. ovoid or lentiform structures 3. weigh ~ 50 mg each 4. Measure 3-10 mm x 2-6 mm x 1-4 mm

Parathyroid Glands, con’t….

5. Lie between posteromedial thyroid lobes and carotid sheath 6. Close proximity to: a. Tracheoesophageal groove b. longus colli muscles

Parathyroid Glands, continued …

7. Position of superior glands is more predictable 8. Aberrant glands may lie between trachea and thyroid 9. Blood, lymphatic and nerve supply: same as for thyroid

Parathyroid Gland Anatomy
• Four Parathyroid glands are usually found posterior to the thyroid gland • Weight =50mg each • Parathyroid hormone (PTH) is made by these glands

PARATHYROID GLAND
• Superior pair ~ posterior aspect of the superior pole of the lateral lobes of the thyroid gland and close to the recurrent laryngeal nerve (constant location)

ANATOMY (PARATHYROID GLAND)
• Inferior pair ~ posterior aspect of the inferior pole of the lateral lobes of the thyroid gland • Pathologic enlargements of the inferior PTG may extend to the trachea and esophagus • Maintain serum calcium and phosphorus levels

Parathyroid g

34F w/ anterior neck mass

III. Thyroid/Parathyroid Diseases
A. B. Ultrasound useful in differentiating cystic from complex or solid masses Thyroid Cysts 1. Typical cystic appearance 2. Colloid cysts 3. Thyroglossal duct cysts

Pathology, cont…

3. Thyroid scan Warm, hot or cold nodule 4. Only 20% of thyroid masses are simple cysts

END
• • • • Lab on Monday Radioanatomy lec on Tue/Thurs Lab again on Friday Exam on Jan 22

Pathology, cont…

C. Structures of Carotid Sheath 1. Jugular vein, carotid artery 2. Delineate lateral aspect of thyroid 3. Jugular vein lateral to carotid artery a. vein has greater diameter b. Is distensible on valsalva maneuver

Transverse Section of Thyroid Gland
Trachea Sternocleidomastoid Muscle Internal Jugular Vein Common Carotid Artery Thyroid Gland, Left Lobe

Brachial Plexus Esophagus

Gray-Scale anatomy, continued

D. Thyroid is more homogeneous and echogenic than surrounding muscle
1. Sternocleidomastoid (lateral) 2. Longus colli (posterior)

E. US is less helpful w/ complex masses or diffuse parenchymal disorders

Gray-Scale Anatomy, continued …

F. Parathyroids are difficult to see 1. Size and location are variable 2. Usually: a. moderately echogenic
b. c. d. e. well-circumscribed capsule around anterior to longus colli medial to common carotid a.

Parathyroids, continued …

3. Longus Colli (“prevertebral”) Muscles a. Attachments: 1. O = cervical vertebrae 2. I = cervical vertebrae b. Action: twists, bends neck c. Lie posterior

IV. Thyroid Diseases A. Metastasis from thyroid cancer 1. May invade local structures a. trachea b. esophagus c. carotid artery d. jugular vein

Thyroid Diseases, con’t…

2. Innervation may be involved a. Voice, speech changes b. Horner’s Syndrome of eye 1. droopy eye 2. dryness 3. small pupil

Thyroid Diseases, continued …

B. Cystic Masses 1. Colloid cyst: a. Contains thyroglobulin b. May have hemorrhagic center c. May be aspirated

Thyroid Follicles showing Colloid

Thyroid Follicles with colloid containing Thyroid hormones

Thyroid Diseases, continued …

2. Branchial cleft cyst a. Usually more cephalic b. Non-closure of a branchial cleft c. lie laterally

Thyroid Diseases, continued …

3. Thyroglossal Duct Cyst a. Lies @ midline b. Represents non-closure of thryoglossal duct c. Congenital anomaly:
1. retention of tract 2. between thyroid and foramen cecum

Thyroglossal Duct Cyst, Thyroid Disease, continued …

d. Usually surrounded by hyoid bone e. More frequently diagnosed in pediatric age groups f. may be asymptomatic

Thyroid, continued …

g. Incidence in patients undergoing thyroid surgery:
1. 4% have this cyst 2. 28% of those with the cyst are > 50 years old

h. Symptoms: painless swelling at midline of neck

Thyroid, continued …

i. Treatment:
1. excision of cyst & central hyoid bone 2. < 1% accompanied by cancer

j.

Account for ~ 70% of congenital cysts of neck

k. may appear at any location along duct

Thyroid Diseases, continued …

C. Complex/Solid Masses (Neoplasm) 1. Adenoma a. Well-encapsulated b. Usually solitary c. Homogeneous

Thyroid Diseases, Adenomas, continued …

c. May be complex, with
1. sonolucent halo 2. echogenic center

d. 50% of thyroid cancers are papillary adenocarcinomas 2. Complex  solid masses show increased malignancy

Adenoma of the Thyroid Gland

• Note atrophy of the left lobe with the tumor protruding from it • Right lobe may hypertrohy to compensate for loss of function in L. lobe

Thyroid, continued …

3. Goiter a. Enlargement of thyroid gland b. due to insufficient iodine c. Gland appears nodular with irregular outline d. Grossly enlarged

Goiter, continued …

e. Nodules have variable echogenicity f. Treatable with iodine in diet g. More common inland, and before iodized salt

Types of Goiters

Simple Goiter (L) and Nodular (Toxic) Goiter (R)

D. Parathyroid Diseases 1. Benign adenoma a. Relatively common b. usually results in hyperparathyroidism 2. Cancers are rare 3. Surgical excision gives > 90% cure rate

Parathyroid Diseases

• Pathogenesis of Hyperparathyroidism
– PTH increases blood calcium levels – Acts on bone, kidneys, small intestines

Hyperparathyroidism

Long-term Effects on the Skeletal System

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