Thyroid

Contents:

1. Anatomy and Embryology of Thyroid.

2. Physiology of Thyroid, Thyroid Function tests.
3. Benign conditions of Thyroid and its management.
4. Malignant conditions of Thyroid and its management.
 ANATOMY &
EMBRYOLOGY OF
THYROID

Dr. ANUHYA CHODA

1ST YEAR POSTGRADUATE
Introduction
• In the late 19th century, two surgeon-physiologists revolutionized the
understanding and treatment of thyroid diseases.
• Theodor Billroth and Emil Theodor Kocher
• In 1909, Kocher was awarded the Nobel Prize for medicine in
recognition “for his works on the physiology, pathology, and surgery
of the thyroid gland.”
EMBRYOLOGY
Thyroid glands arises as an endodermal diverticulum from the epithelium of floor of the
pharynx

Week 3: Thickening in the floor between the first and second pharyngeal pouches

Week 4: Endoderm evaginates ventrally into the mesoderm to form the thyroid
diverticulum

Week 5-6: Formation of thyroglossal duct . The diverticulum grows down in the midline
into the neck.
Its tip soon bifurcates

Proliferation of the cells of this bifid end

gives rise to the two lobes of thyroid
gland.

Developing thyroid comes into intimate

relationship with the caudal pharyngeal
complex and fuses with it.

Cells arising from this complex gives rise

to parafollicular cells of thyroid

Week 7: Thyroid gland reaches its

definitive position.
Congenital Anomalies
1. Athyreosis
2. Ectopic thyoid
3. Lingual thyroid
4. Thyroglossal cyst
5. Thyroglossal fistula
6. Lateral aberrant thyroid
7. Agenesis
Athyreosis
• Total absence of lateral lobes and isthmus with hypothyroidism
Anomalies of the Shape
• Pyramidal lobe
• Isthmus may be absent
• One of the lobes of the gland may be very small or absent
Ectopic Thyroid
• Ectopic thyroid refers to the presence of
thyroid tissue in locations other than the
normal anterior neck region.
• It lies along the course of the thyroglossal
tract as entire gland or as residual thyroid
tissue.
• Lie anywhere along the line of descent.
• Carcinoma develops more commonly in
ectopic thyroid tissue than normal
thyroid.
Investigations
• Radioisotope scan, CT scan for intrathoracic thyroid will confirm the
diagnosis.
Remnants of Thyroglossal Duct
• Thyroglossal Cyst
• Thyroglossal cyst is a swelling occurring in the neck in any part along the line
of thyroglossal tract.
• It is due to failure of the thyroglossal duct/tract to obliterate completely
• Possible Sites
• Beneath the foramen caecum
• In the floor of mouth
• Suprahyoid
• Subhyoid—commonest site
• On the thyroid cartilage—2nd common site
Thyroglossal Cyst
• Usually Congenital
• It is a tubulodermoid type of Cyst
• Lined by Pseudo straitifed, ciliated columnar epithelium
Clinical Features
• Swelling in the midline, towards the left.
• Moves with deglutition as well as with the protrusion of tongue.
• Tugging sensation can be felt when the patient is asked to protrude the
tongue
• Swelling is smooth, soft, fluctuant (cystic), nontender, mobile, often
transilluminant.
• Thyroglossal cyst can get infected and may form an abscess. Cyst wall
contains lymphatic tissue and so infection is common.
• Malignancy can develop in thyroglossal cyst (papillary carcinoma)—1%.
Investigations
• Radioisotope study.
• Ultrasound neck; T3, T4, TSH estimation.
Differential Diagnosis for Thyroglossal Cyst
• Subhyoid bursa
• Pretracheal lymph node
• Dermoid cyst
• Solitary nodule of thyroid—isthmus
• Submental lymph node
• Collar stud abscess
Treatment
• Sistrunk operation:
• Excision of cyst and also full tract upto the foramen caecum is done along
with removal of central part of the hyoid bone, as the tract passes through it.
• If there is no normal thyroid gland after the surgery, maintenance dose of L-
thyroxine 0.1 mg OD is given life long.
Thyroglossal Fistula
• It is acquired condition
• It either follows infection of
thyroglossal cyst which bursts open
or after inadequate removal of the
cyst
• It is lined by columnar epithelium
• “Hood sign” is characteristic.
• Peculiar crescentic appearance is
called as semilunar sign.
• It secretes mucus discharge
• Site of the fistula is just below the
hyoid bone
Investigations & Treatment
• Investigations:
• Radioisotope study and fistulogram.

• Treatment:
• Sistrunk operation
Lateral Aberrant Thyroid
• Misnomer.
• It is the metastasis into cervical lymph node from a papillary
carcinoma of thyroid.
• FNAC done
• Treated as papillary carcinoma of thyroid.
Agenesis
• Total agenesis of one thyroid lobe may occur.
Anatomy
• The name thyroid is derived from the
greek description of a shield-shaped
gland in the anterior aspect of the neck
• One of the largest of the endocrine
glands
• Brownish-red
• It usually weighs 20- 25 g
• Right lobe
• Left lobe
• Isthmus
• Pyramidal lobe (50%)
Position & Extent
• C-5 to the T-1 vertebrae
• Each lobe extends from
middle of thyroid
cartilage to 4 or 5th
tracheal rings.
• The isthmus extends
from 2nd to 4th tracheal
rings.
Dimensions
• Each lobe measures about 5*2.5*2.5cm.
• Isthmus is 1.2*1.2 cm.
• Glands weighs about 20-25grms.
• Slightly larger in females.
• Increases in size during menstruation and pregnancy.
Capsules
• FALSE capsule: Pre tracheal
layer of deep cervical fascia
thin along posterior border,
thick along inner surface
and forms a suspensory
ligament of Berry

• TRUE capsule: Peripheral

condensation of connective
tissue of gland
 Levator Glandulae Thyroidae
• Knowledge about levator
glandulae thyroideae is important
during neck surgeries.
• This structure could represent the
persistng distal end of thyroglossal
duct.
• Anterior cervical region should
hence be clearly examined during
total thyroidectomy in order not to
leave behind residual thyroid tissue
Relations
Lobes are conical in shape having
A) An apex
B) A base
C) Three surfaces: lateral, medial, postero lateral
D) Two borders : anterior , posterior
 Relations
• Apex :
• Directed upwards and slightly laterally.
• Limited superiorly by attachment of sternothyroid to the oblique line of
thyroid cartilage

• Base:
• Is on level with 4th or 5th tracheal rings
Lateral Surface
• Convex is covered by:
• Superior belly omohyoid
• Anterior border of Sternocleidomatoid
• Sternohyoid
• Sternothyroid
Medial Surface
• Two muscles
• Inferior constrictor, Cricothyroid
• Two tubes
• Trachea, Esophagus
• Two nerves
• External laryngeal nerve
• Recurrent laryngeal nerve
Posterior Surface
• Carotid sheath
• Common and internal carotid arteries,
• The internal jugular vein,
• Vagus nerve and the constituents of the ansa
cervicalis

• Anterior border
• Anterior branch of superior thyroid artery

• Posterior border
• Inferior thyroid artery
• Anastomosis of superior, inferior thyroid
arteries.
• Parathyroid glands
• Thoracic duct on left side
Isthmus
• Two Surface = anterior, posterior
• Two Borders = superior, inferior
• Anterior surface is related to
• Skin and fascia
• Anterior jugular vein
• Rt, Lt sternohyoid, sternthyroid muscles
• Posterior surface is related to
2-4 tracheal rings
• Superior border : anastomosis
between rt, lt superior thyroid
arteries
• Inferior border : inferior thyroid veins
leave the gland
Pyramidal Lobe

• Thyroglossal duct, which is usually reabsorbed after 6 weeks of age.

• The very distal end of this remnant may be retained and mature as a
pyramidal lobe in the adult thyroid
• Seen in 50% of individuals
• Lobe extends superiorly from isthmus
Arterial Supply
• Superior thyroid artery
• Inferior thyroid artery
• Thyroid IMA artery (3%)
(Arises from brachiocephalic trunk or directly from arch of aorta)
• Accessary thyroid arteries arising from Tracheal and Oesophageal
arteries.
Superior Thyroid Artery
• The superior thyroid artery arises from the external carotid artery just
above or just below the bifurcation of the common carotid artery
• It passes downward and anteriorly to reach the superior pole of the
thyroid gland
• After piercing pretracheal fascia artery divides into anterior and
posterior branches
Anterior branch :
• Descends on anterior border of lobe continues along upper border of
isthmus anastamose with opposite artery
• Posterior branch descends on the posterior border of the lobe and
anastomose with ascending branch of inferior thyroid artery along the
posterior border
Inferior Thyroid Artery
• Is a branch of thyrocervical trunk (arises from subclavian artery)
• It runs upwards, then medially to reach lower pole of gland
• Terminal part is intimately related to RLN
• Artery divides into 4-5 branches which pierce fascia separately to
reach the lower pole of gland.
Venous Drainage
• Veins of the thyroid gland
form a plexus of vessels
lying in the substance and
on the surface of the
gland
• The plexus is drained by
three pairs of veins, the
superior, middle, and
inferior thyroid veins
Venous Drainage
Superior Thyroid Vein
• Emerging from the superior pole of the thyroid
• Accompanies the superior thyroid artery
• Drains into the internal jugular vein

Middle Thyroid Vein

• Collects blood from the lower part of the gland
• It emerges from the lateral surface of the gland
• No artery accompanies it
• It crosses the common carotid artery to open into the internal jugular vein
Inferior Thyroid Vein
• The inferior thyroid vein is the largest and most variable of the thyroid
veins.
• The right and left sides are usually asymmetric
• Drains into left brachiocephalic vein
• Potential source of bleeding during tracheostomy

• The "fourth" thyroid vein ( Kocher vein)

• It emerges between middle and inferior thyroid veins
• Drains into corresponding IJV
Lymphatic Drainage
• Primary:
A. Prelaryngeal or cricothyroid node also called as Delphian node.
• Located anterior to cricothyroid membrane between cricothyroid muscles
• Important node among level VI nodes.
• Delphian node receives afferent lymphatics from larynx and from upper anterior parts of
the both lobes of the thyroid gland and its isthmus.
• It has got two efferent lymphatics; one towards paratracheal and lower jugular, other
towards pretracheal (sub-Deplhian), mediastinal and supraclavicular lymph nodes.
B. Paratracheal and Pretracheal
C. Perithyroidal
D. Mediastinal nodes
Lymphatic Drainage
• Secondary:
A. Deep cervical nodes.
B. Supraclavicular nodes.
C. Occipital nodes
Nerve supply
• The thyroid gland is innervated by the sympathetic system from the
superior, middle, and inferior ganglia of the cervical chain.
• But in thyroid surgery the recurrent and superior laryngeal nerves of
the parasympathetic (Vagus) system are of utmost importance
Recurrent Laryngeal Nerve
• This is a branch of Vagus nerve
• Right recurrent laryngeal nerve:
• It has oblique course
• Originates from Vagus as it crosses anterior to
the subclavian artery
• It passes inferior and posterior to the right
subclavian artery
• Ascends lateral to trachea along the
tracheoesophageal groove
• Ascends upwards to the mid portion of the
thyroid and found immediately anterior or
posterior to the inferior thyroid artery
Recurrent Laryngeal Nerve
• Left recurrent laryngeal nerve:
• Originates from the Vagus as it passes anterior
to the arch of aorta
• It passes inferior and posteromedial to aorta at
the ligamentum arteriosum
• Ascends towards larynx in the
tracheoesophageal groove
Recurrent Laryngeal Nerve
• Both RLNs are consistently found within tracheoesophageal groove when they are within 2.5 cms of
the entrance into larynx
• Nerve passes either anterior or posterior to the inferior thyroid artery and enters into the larynx at the
level of cricothyroid articulation on the caudal border of the cricothyroid muscle
Non-recurrent Laryngeal Nerve
• 0.5% to 1.5%
• Present on right side
• Arises directly from Vagus and
courses medially into larynx
following the course of superior or
inferior thyroid artery
• Occurs in the setting of arterial
anomalies most commonly an
aberrant right subclavian artery
(arteria lusoria)
• Demonstrated in CT or MRI
Histology
• The thyroid follicle is the structural and functional unit of the thyroid
gland.
• Follicles vary in diameter from 0.2 to 1.0 mm
• Wall formed by a simple cuboidal or low columnar epithelium
• The follicles contain a gel-like mass called colloid
• Colloid consists predominantly of the glycoprotein, thyroglobulin
• Follicular epithelium contains two types of cells:
Follicular cells
Parafollicular cells
Thank You