Thyroid gland

Generalities
• The surgical management of Graves' disease increased use of total or near-
total thyroidectomy.
• Total thyroidectomy is the surgical treatment of choice for most thyroid
cancers.
• Surgeons must be aware of the potential for false negative fine-needle
aspiration biopsy.
• Focused mini-incision parathyroidectomy, after appropriate localization, has
become the procedure of choice for the treatment of sporadic primary
hyperparathyroidism.
 Thyroid gland
History
• Goiters (from the Latin guttur, throat), defined as an enlargement of the
thyroid, have been recognized since 2700 B.C.
• In 1619, Hieronymus Fabricius ab Aquapendente recognized that goiters
arose from the thyroid gland.
• The term thyroid gland (Greek thyreoeides, shield-shaped) is, however, attributed
to Thomas Warton in his Adenographia (1656).
• The most notable thyroid surgeons were Emil Theodor Kocher (1841–1917)
and C.A. Theodor Billroth (1829–1894).
 Thyroid gland
Embryology

• The thyroid gland arises as an outpouching of the primitive foregut around

the third week of gestation.
• It originates at the base of the tongue at the foramen cecum.
• During its descent, the anlage remains connected to the foramen cecum via
an epithelial-lined tube known as the thyroglossal duct.
• The lateral anlages are neuroectodermal in origin (ultimobranchial bodies)
and provide the calcitonin producing parafollicular or C cells.
Thyroid embryology(from Schwartz’s Principles of Surgery)
 Thyroid Developmental Abnormalities
Thyroglossal Duct Cyst and Sinus

• Thyroglossal Duct Cyst and Sinus,during the fifth week of gestation, starts to
obliterate.
• Rarely, the thyroglossal duct may persist in whole, or in part.
• 80% are found in juxtaposition to the hyoid bone.
• They are usually asymptomatic but occasionally become infected by oral bacteria.
• It is of 1- to 2-cm, smooth, well-defined midline neck mass that moves upward with
protrusion of the tongue.
• Treatment involves the "Sistrunk operation," which consists of en bloc cystectomy
and excision of the central hyoid bone to minimize recurrence.
 Thyroid Developmental Abnormalities
Ectopic Thyroid

• Normal thyroid tissue may be found anywhere in the central neck

compartment, including the esophagus, trachea, and anterior mediastinum.
• Thyroid tissue situated lateral to the carotid sheath and jugular vein,
previously termed lateral aberrant thyroid.
• Thyroid tissue has been observed adjacent to the aortic arch, in the
aortopulmonary window, within the upper pericardium, or in the
interventricular septum.
 Thyroid Anatomy

• The thyroid lobes are located adjacent to the thyroid cartilage and connected in the
midline by an isthmus that is located just inferior to the cricoid cartilage.
• A pyramidal lobe is present in about 50% of patients.
• The strap muscles (sternohyoid, sternothyroid, and superior belly of the omohyoid)
are located anteriorly.
• The thyroid gland is enveloped by a loosely connecting fascia that is formed from
the partition of the deep cervical fascia into anterior and posterior divisions.
• The true capsule of the thyroid is a thin, densely adherent fibrous layer that sends
out septa that invaginate into the gland, forming pseudolobules.
Thyroid anatomy (from Schwartz’s Principles of Anatomy)
 Thyroid anatomy
Recurrent Laryngeal Nerve (RLN)

• The left RLN arises from the vagus nerve where it crosses the aortic arch,
loops around the ligamentum arteriosum, and ascends medially in the neck
within the tracheoesophageal groove.
• The right RLN arises from the vagus at its crossing with the right subclavian
artery.
• The RLNs may branch, and pass anterior, posterior, or interdigitate with
branches of the inferior thyroid artery.
• Injury to one RLN leads to paralysis of the ipsilateral vocal cord.
 Thyroid anatomy
Recurrent Laryngeal Nerve (RLN) in relation with inferior thyroid artery
 Parathyroid Glands

• About 85% of individuals have four parathyroid glands that can be found
within 1 cm of the junction of the inferior thyroid artery and the RLN.
• The superior glands are usually located dorsal to the RLN, whereas the
inferior glands are usually found ventral to the RLN.
Parathyroid Glands
 Thyroid Lymphatic System

• Intraglandular lymphatic vessels connect both thyroid lobes through the

isthmus and also drain to perithyroidal structures and lymph nodes.
• Regional lymph nodes include pretracheal, paratracheal, perithyroidal, RLN,
superior mediastinal, retropharyngeal, esophageal, and upper, middle, and
lower jugular chain nodes.
• The central compartment includes nodes located in the area between the two
carotid sheaths, whereas nodes lateral to the vessels are present in the lateral
compartment.
Thyroid Lymphatic System
Thyroid Lymphatic System
 Thyroid Histology

• Microscopically, the thyroid is divided into lobules that contain 20 to 40

follicles.
• Each follicle is lined by cuboidal epithelial cells and contains a central store
of colloid secreted from the epithelial cells under the influence of the
pituitary hormone TSH.
• The second group of thyroid secretory cells is the C cells or parafollicular
cells, which contain and secrete the hormone calcitonin.
Thyroid Histology
 Thyroid Physiology
Iodine Metabolism

• The average daily iodine requirement is 0.1 mg, which can be derived from foods
such as fish, milk, and eggs or as additives in bread or salt.
• In the stomach and jejunum, iodine is rapidly converted to iodide and absorbed
into the bloodstream, and from there it is distributed uniformly throughout the
extracellular space.
• Iodide is actively transported into the thyroid follicular cells by an adenosine
triphosphate (ATP)–dependent process.
• The thyroid is the storage site of >90% of the body's iodine content and accounts
for one third of the plasma iodine loss. The remaining plasma iodine is cleared via
renal excretion.
 Thyroid Hormone Synthesis, Secretion, and Transport

• The first step:iodide trapping, involves active (ATP-dependent) transport of

iodide across the basement membrane of the thyrocyte.
• Step two: oxidation of iodide to iodine and iodination of tyrosine residues
on Tg, to form monoiodotyrosines (MIT) and diiodotyrosines (DIT). Both
processes are catalyzed by thyroid peroxidase.
• The third step leads to coupling of two DIT molecules to form tetra-
iodothyronine or thyroxine (T4 ) and one DIT molecule with one MIT
molecule to form 3,5,3'-triiodothyronine (T3).
 Thyroid Hormone Synthesis, Secretion, and Transport

• The secretion of thyroid hormone is controlled by the hypothalamic-

pituitary-thyroid axis.
• The hypothalamus produces a peptide, the thyrotropin-releasing hormone
(TRH), which stimulates the pituitary to release TSH or thyrotropin.
• TSH secretion by the anterior pituitary is also regulated via a negative
feedback loop by T4 and T3.
• Thyroid hormones affect almost every system in the body. They are
important for fetal brain development and skeletal maturation. It also has
positive inotropic and chronotropic effects.
 Tests of Thyroid Function

• Serum TSH is 0,5-5 micro units per ml.

• Total T4 is 55-150 nmol/liter and T3 is 1.5-3.5 nmol/liter.
• Free T4 is 12-28 picomol/l and free T3 is 3-9 picomol/l.
• Thyroid antibodies include anti-Tg, antimicrosomal, or anti-TPO and
thyroid-stimulating immunoglobulin (TSI).
• Serum Thyroglobulin
• Serum Calcitonin (0–4 pg/mL Basal)
 Thyroid Imaging
Radionuclide Imaging

• Both iodine 123 (123I) and iodine 131 (131I) are used to image the thyroid
gland.
• The images obtained by these studies provide information not only about the
size and shape of the gland, but also the distribution of functional activity.
• Areas that trap less radioactivity than the surrounding gland are termed cold,
whereas areas that demonstrate increased activity are termed hot.
• The risk of malignancy is higher in "cold" lesions (20%).
Radioactive iodine scan of the thyroid, with the arrow showing an area of
decreased uptake, a cold nodule.
 Thyroid Imaging
Ultrasound

• Ultrasound is an excellent noninvasive and portable imaging study of the

thyroid gland with the added advantage of no radiation exposure.
• It is helpful in the evaluation of thyroid nodules, distinguishing solid from
cystic ones, and providing information about size and multicentricity.
• Ultrasound also can be used to assess for cervical lymphadenopathy and to
guide FNAB.
• An experienced ultrasonographer is necessary for the best results.
 Thyroid Imaging
Ultrasound
Thyroid ultrasound showing a lymph node (arrow) along the carotid artery
 Thyroid Imaging
Computed Tomography/Magnetic Resonance Imaging Scan

• Computed tomography (CT) and magnetic resonance imaging (MRI) studies

provide excellent imaging of the thyroid gland and adjacent nodes, and are
particularly useful in evaluating the extent of large, fixed, or substernal goiters
(which cannot be evaluated by ultrasound) and their relationship to the airway and
vascular structures.
• Noncontrast CT scans should be obtained for patients who are likely to require
subsequent RAI therapy. If contrast is necessary, therapy needs to be delayed by
several months.
• Combined PET-CT scans are increasingly being used for Tg-positive, radioactive
iodine–negative tumors.
 Benign Thyroid Disorders
Hyperthyroidism
Diffuse Toxic Goiter (Graves' Disease)

• Graves' disease is by far the most common cause of hyperthyroidism in

North America, accounting for 60 to 80% of cases.
• It is an autoimmune disease with a strong familial predisposition, female
preponderance (5:1), and peak incidence between the ages of 40 to 60 years.
• Graves' disease is characterized by thyrotoxicosis, diffuse goiter, and
extrathyroidal conditions including ophthalmopathy, dermopathy (pretibial
myxedema), thyroid acropachy, gynecomastia, and other manifestations.
 Diffuse Toxic Goiter (Graves' Disease
This patient demonstrates exophthalmos, proptosis, periorbital swelling,
congestion, and edema of the conjunctiva
 Diffuse Toxic Goiter (Graves' Disease)

• Diagnostic Tests.The diagnosis of hyperthyroidism is made by a suppressed

TSH with or without an elevated free T4 or T3 level. If eye signs are present,
other tests are generally not needed.
• Anti-Tg and anti-TPO antibodies are elevated in up to 75% of patients, but
are not specific. Elevated TSH-R or thyroid-stimulating antibodies (TSAb)
are diagnostic of Graves' disease and are increased in about 90% of patients.
• Graves' disease may be treated by any of three treatment modalities—
antithyroid drugs, thyroid ablation with radioactive 131I, and thyroidectomy.
 Toxic Multinodular Goiter

• Toxic multinodular goiters usually occur in older individuals, who often have a
prior history of a nontoxic multinodular goiter. Over several years, enough
thyroid nodules become autonomous to cause hyperthyroidism.
• Some patients have T3 toxicosis, whereas others may present only with atrial
fibrillation or congestive heart failure.
• Hyperthyroidism must be adequately controlled.
• Surgical resection is the preferred treatment of patients with toxic
multinodular goiter with subtotal thyroidectomy being the standard procedure.
 Toxic Adenoma (Plummer's Disease)

• Hyperthyroidism from a single hyperfunctioning nodule typically occurs in younger patients

who note recent growth of a long-standing nodule along with the symptoms of
hyperthyroidism.
• Physical examination usually reveals a solitary thyroid nodule without palpable thyroid tissue
on the contralateral side. RAI scanning shows a "hot" nodule with suppression the rest of
the thyroid gland.
• These nodules are rarely malignant.
• Smaller nodules may be managed with antithyroid medications and RAI.
• Surgery (lobectomy and isthmus-ectomy) is preferred to treat young patients and those with
larger nodules.
 Thyroiditis
Acute (Suppurative) Thyroiditis

• Infectious agents can seed it

(a) via the hematogenous or lymphatic route,
(b) via direct spread from persistent pyriform sinus fistulae or thyroglossal duct cysts,
(c) as a result of penetrating trauma to the thyroid gland,
or (d) due to immunosuppression.
• Streptococcus and anaerobes account for about 70% of cases.
• It is characterized by severe neck pain radiating to the jaws or ear, fever, chills, odynophagia,
and dysphonia.
• Treatment consists of parenteral antibiotics and drainage of abscesses.
 Subacute Thyroiditis

• Painful thyroiditis most commonly occurs in 30- to 40-year-old women and is characterized
by the sudden or gradual onset of neck pain, which may radiate toward the mandible or ear.
• History of a preceding upper respiratory tract infection often can be elicited.
• The gland is enlarged, exquisitely tender, and firm.
• The disorder classically progresses through four stages.
• An initial hyperthyroid phase, due to release of thyroid hormone, is followed by a second,
euthyroid phase.
• The third phase, hypothyroidism, occurs in about 20 to 30% of patients and is followed by
resolution and return to the euthyroid state in >90% of patients.
• A few patients develop recurrent disease.
 Chronic Thyroiditis
Lymphocytic (Hashimoto's) Thyroiditis

• Lymphocytic thyroiditis was first described by Hashimoto in 1912 as struma

lymphomatosa—a transformation of thyroid tissue to lymphoid tissue.
• It is the most common inflammatory disorder of the thyroid and the leading cause
of hypothyroidism.
• Hypothyroidism results not only from the destruction of thyrocytes by cytotoxic T
cells but by autoantibodies, which lead to complement fixation and killing by natural
killer cells or block the TSH-R.
• Antibodies directed against three main antigens—Tg (60%), TPO (95%), the TSH-
R (60%).
 Chronic Thyroiditis
Lymphocytic (Hashimoto's) Thyroiditis

• The most common presentation is that of a minimally or moderately enlarged firm

granular gland discovered on routine physical examination.
• In classic goitrous Hashimoto's thyroiditis, physical examination reveals a diffusely
enlarged, firm gland, which also is lobulated.
• An elevated TSH and the presence of thyroid autoantibodies usually confirm the diagnosis.
• Thyroid hormone replacement therapy is indicated with a goal of maintaining normal TSH
levels.
• Surgery may occasionally be indicated for suspicion of malignancy or for goiters causing
compressive symptoms or cosmetic deformity.
 Riedel's Thyroiditis

• Riedel's thyroiditis is a rare variant of thyroiditis also known as Riedel's struma

or invasive fibrous thyroiditis that is characterized by the replacement of all or
part of the thyroid parenchyma by fibrous tissue, which also invades into
adjacent tissues.
• It typically presents as a painless, hard anterior neck mass, which progresses
over weeks to years to produce symptoms of compression, including
dysphagia, dyspnea, choking, and hoarseness.
• Surgery is the mainstay of the treatment. The chief goal of operation is to
decompress the trachea.
 Goiter

• Any enlargement of the thyroid gland is referred to as a goiter.

• Goiters may be diffuse, uninodular, or multinodular.
• The term endemic goiter refers to the occurrence of a goiter in a significant
proportion of individuals in a particular geographic region.
• As the goiters become very large, compressive symptoms such as dyspnea
and dysphagia ensue.
• Patients usually are euthyroid with normal TSH and low-normal or normal-
free T4 levels.
 Goiter

• If some nodules develop autonomy, patients have suppressed TSH levels or become
hyperthyroid.
• RAI uptake often shows patchy uptake with areas of hot and cold nodules.
• FNAB is recommended in patients who have a dominant nodule or one that is painful or
enlarging, as carcinomas have been reported in 5 to 10% of multinodular goiters.
• CT scans are helpful to evaluate the extent of retrosternal extension and airway
compression.
• Endemic goiters are treated by iodine administration.
• Surgical resection is reserved for goiters that (a) continue to increase despite T4
suppression, (b) cause obstructive symptoms, (c) have substernal extension, (d) have
malignancy suspected or proven by FNAB, and (e) are cosmetically unacceptable.
• Subtotal thyroidectomy is the treatment of choice and patients require lifelong T4 therapy
to prevent recurrence.
 Malignant Thyroid Disease

• In the United States, thyroid cancer accounts for <1% of all malignancies
(2% of women and 0.5% of men) and is the most rapidly increasing cancer
in women.
• Thyroid cancer is responsible for six deaths per million persons annually.
• Most patients present with a palpable swelling in the neck, which initiates
assessment through a combination of history, physical examination, and
FNAB.
• The RET proto-oncogene plays a significant role in the pathogenesis of
thyroid cancers.
 Malignant Thyroid Disease
Papillary Carcinoma

• Papillary carcinoma accounts for 80% of all thyroid malignancies.

• Most patients are euthyroid and present with a slow-growing painless mass in the neck.
• Dysphagia, dyspnea, and dysphonia usually are associated with locally advanced invasive
disease.
• Lymph node metastases are common.
• Suspicion of thyroid cancer often originates through physical examination of patients and a
review of their history.
• Diagnosis is established by FNAB of the thyroid mass or lymph node.
 Malignant Thyroid Disease
Papillary Carcinoma
• Once thyroid cancer is diagnosed on FNAB, a complete neck ultrasound is strongly
recommended to evaluate the contralateral lobe and for lymph node metastases in the
central and lateral neck compartments.
• Distant metastases are uncommon at initial presentation, but may ultimately develop in up
to 20% of patients. The most common sites are lungs, followed by bone, liver, and brain.
• Proponents of total thyroidectomy argue that the procedure
• (a) enables the use of RAI to effectively detect and treat residual thyroid tissue or metastatic
disease,
• (b) makes serum Tg level a more sensitive marker of recurrent or persistent disease,
• (c) eliminates contralateral occult cancers as sites of recurrence (because up to 85% of
tumors are bilateral),
• (d) reduces the risk of recurrence and improves survival,
• (e) decreases the 1% risk of progression to undifferentiated or anaplastic thyroid cancer,
• and (f) reduces the need for reoperative surgery with its attendant risk of increased
complication rates.
 Follicular Carcinoma

• Follicular carcinomas account for 10% of thyroid cancers and occur more
commonly in iodine-deficient areas.
• Follicular cancers usually present as solitary thyroid nodules, occasionally with a
history of rapid size increase, and long-standing goiter.
• Patients diagnosed by FNAB,a total thyroidectomy should be performed when
thyroid cancer is diagnosed microscopically.
• Poor long-term prognosis is predicted by age over 50 years old at presentation,
tumor size >4 cm, higher tumor grade, marked vascular invasion, extrathyroidal
invasion, and distant metastases at the time of diagnosis.
 Thyroid Surgery
Conduct of Thyroidectomy
• Patients with any recent or remote history of altered phonation or prior neck surgery
should undergo vocal cord assessment by direct or indirect laryngoscopy before
thyroidectomy.
• A Kocher transverse collar incision, typically 4 to 5 cm in length, is placed in or parallel to a
natural skin crease 1 cm below the cricoid cartilage.
• The strap muscles are divided in the midline along the entire length of the mobilized flaps,
and the thyroid gland is exposed.
• The superior thyroid pole is identified by retracting the thyroid first inferiorly and medially
and then the upper pole of the thyroid is mobilized caudally and laterally. The dissection
plane is kept as close to the thyroid as possible and the superior pole vessels are individually
identified, skeletonized, ligated, and divided low on the thyroid gland to avoid injury to the
external branch of the superior laryngeal nerve.
 Thyroid Surgery
Conduct of Thyroidectomy

• The inferior thyroid vessels are dissected, skeletonized, ligated, and divided as close
to the surface of the thyroid gland as possible to minimize devascularization of the
parathyroids (extracapsular dissection) or injury to the RLN.
• Once the ligament is divided, the thyroid can be separated from the underlying
trachea by sharp dissection.
• The pyramidal lobe, if present, must be dissected in a cephalad direction to above
the level of the notch in the thyroid cartilage or higher in continuity with the thyroid
gland.
 Thyroid Surgery
Minimally Invasive Approaches

• Several approaches to minimally invasive thyroidectomy have been described.

• Mini-incision procedures use a small, 3-cm incision with no flap creation and
minimal dissection to deliver the thyroid into the wound and then perform the
pretracheal and paratracheal dissection.
• Video assistance can be used to improve the visualization via the small incision.
• Totally endoscopic approaches also have been described, via the supraclavicular,
anterior chest, axillary, and breast approach.
• The axillary, anterior chest, and breast approaches eliminate the skin incision in the
neck but are more invasive.