A- lingual thyroid

C/P :tongue swellingimpaired speechdyshpagiarespiratory obestruction

INVESTIGATIONS :INVESTIGATIONS :thyroid scanthyroid scan

C.T. neck lateral view showingLingual thyroid

TTT. :IF only thyroid tissue medical ttt. & if failed surgical excision

Thyroglossal cyst & fistulaThyroglossal cyst & fistula

INDEX

The classical site for a

thyroglossal cyst

Thyroglossal cystsThyroglossal cystsEmbryology

•The thyroglossal tract arises form foramen caecum  at junction of anterior 2/3 and posterior 1/3 of the tongue. •Any part of the tract can persist causing a sinus, fistulae or cyst. •Most fistulae are acquired following rupture or incision of infected thyroglossal cyst

INDEX

•Usually found in subhyoid portion of tract •75% present as midline swellings •Remainder can be found as far lateral as lateral tip of hyoid bone •The cyst elevates on protrusion of the tongueThe cyst elevates on protrusion of the tongue •Can present as an infected cyst due lymphoid tissue in the cyst wall •If infected, aspirate cyst rather than incise prevents formation of thyroglossal fistula

TreatmentTreatmentSistrunk OperationSistrunk Operation •Transverse skin crease incision •Platysma flaps raised. •Cyst dissected •Middle 1/3 of hyoid and any suprahyoid

tract extending into the tongue dissected

Clinical features of Thyroglossal cystsClinical features of Thyroglossal cysts

INDEX

Fistulography: “note the position of the fistula anterior to the trachea (black air)”

The classical site for a thyroglossal fistula

Thyroglossal Thyroglossal fistulafistula

INDEX

Anatomy:

Site

In front of lowerPart of neck

Shape

butterfly

Structure

Each lobePear shaped2 *1*1 inches

Its apex lies atLevel of oblique lineOf thyroid cartilage

&base reach 5th .Or 6th. Tracheal

ring

Isthmus lies on2nd. ,3rd. ,4th,

Tracheal rings

Pyramidal lobeIt is connected to hyoid bone

By fibrous band ( levator glandulae )

thyroid

2 capsules: *true C.T. capsule around gland

*false outer capsule from pretracheal fascia

Pretracheal fascia

•*Skin , superficial fascia (containing platysma), deep fascia.* sternomastoid

* sternothyroid

& sternohyoid

* superior belly of omohyoid

Relations

Antero lateral

Upper partlower part

medial

pharynx

larynx

R.L.N.

trachea

esophagus

posterior

Carotid sheath

C.C.A

I.J.V.

Sympathetic chain

Vagus nerve

Anasa cervicalis

Inferior thyroid artery

1- arterial :

Blood supply

• superior thyroid artery

• Branch from E.C.A.

• Related to E.L.N.

– Inferior thyroid artery

– Branch from thyrocervical trunk

– Which is branch of 1st. Part of subclavian

– Related to R.L.N.

OthersThyroid ima artery from aorta ( may be abscent )

Accessory tracheal & esophageal braches

2- venous :

Superior thyroid veindrain to I.J.V.

middle thyroid veindrain to I.J.V.

inferior thyroid veinsdrain to left innominate vein

The middle thyroid veinIs the shortest soit is the

1st. To be ligated

3- lymphatic :

Medial partPeripheral part

Prelaryngeal L.N. )Poirier(

Pretracheal L.N. )Delphie(

Mediastinal L.N.

Upper deep cervical L.N.Lower deep cervical L.N.

Superior laryngeal nerve

internal laryngeal nerve Sensory to m.m of

Larynx above vocal cords

external laryngeal nerve

Motor to cricotyroidMuscle

It is closely related To

Superior thyroid artery

Right R.L.N.Turns around 1st. PartOf subclavian artery

Left R.L.N.Turns around arch of

aorta

Both supply all Intrinsic musclesOf larynx except (cricothyroid )

&m.m below vocal cords

Nodular goitre

ThyrotoxicosisThyrotoxicosis

Def.:It is an increase in the thyroxin production by the thyroid gland & this is either due to the

whole gland enlargement or a thyroid nodule

thyroxin

What happens?

An increase in thyroxin secretion.

Increase of response of the body cells to adrenaline.

So signs & symptoms of the disease occur.

Symptoms

1-Neurological manifestations:

Which usually occur in the young age. These manifestations are :

*Inosomnia.

*Nightmares.

*Tremors in hand and feet.

*Nervousness

2-Cardiologic manifestations:

It occurs to the elder patients.

It is represented by:

Tachycardia & arrythmia.

It may reach heart faliure.

3- thyroid paradox:Decrease in weight although increase in appetite.

4- increase sweating & sense of hotness in weather

5-Polyurea & diahrea

6-Fatigability

7-oesteoporosis.

8- Thyrotoxic goiter

Signs:

(a) General examination :

Body mass index ( BMI ) is usually less than 20 Kg/m2

))II ( (UnderweightUnderweight: :

(II) Cutaneous changes :

* Moist warm extremities.* Moist warm extremities.

* Profuse sweating & flushed face* Profuse sweating & flushed face

* Falling of hairs* Falling of hairs

* Clubbing of fingers & toes* Clubbing of fingers & toes* Soft and brittle nails .* Soft and brittle nails .

* Pretibial myxoedema : * Pretibial myxoedema : Usually bilateral.Usually bilateral.Non pitting.Non pitting.Self limiting.Self limiting.

Irritability and anxiety.Fine tremors in the tongue & in the fingers hands •Reflexes are exaggerated. Myopathy weakness of the proximal limb muscles.

)III (Nervous signs:

)IV (cardiovascular signs:

1-PULSE Rate : Tachycardia with sleeping pulse up to 100 – 120 / min. Character : Big pulse volume (water - hummer character).

Rhythm : All types of arrhythmia except heart block & V.F.

2- B.P. :

Systolic B.P. is high but diastolic is usually low or normal (due to peripheral V.D) that Increase pulse pressure.

3. HEART : Accentuation of heart sounds.Functional soft systolic murmur maximum over pulmonary & aortic area.

(V) Eye manifestations :

A. Exophthatmos ( > 50 % of cases ) :

TYPES :

a)Apparent ( mild = false) exophthalmos : widening of the palpebral fissure due to spasm of Muller's muscle.

b)True exophthalmos : actual protrusion of the eyeballs.

It is an autoimmune diseaseInfiltration of retro bulbar tissue with inflammatory cells & accumulation of inflammatory fluids. Probably due to cross- reaction of thyroid antigen & eye (Schwartz )

C.T showing infiltration of Retro bulbar spaces

True exophthalmosTrue exophthalmos

B. Certain eye signs :B. Certain eye signs :

2. Stellwag's sign :2. Stellwag's sign : Staring look with infrequent blinking.Staring look with infrequent blinking.

33 . .Dalrymple's signDalrymple's sign: : rim of sclera is seen between rim of sclera is seen between cornea and the upper lid. cornea and the upper lid.

4. Von Graef's sign :4. Von Graef's sign : Lagging of the upper eye lidLagging of the upper eye lid

5. Joffroy's sign :5. Joffroy's sign : loss of forehead corrugation when loss of forehead corrugation when looking up looking up

1. Rosenbach's sign: Tremors on closing eye lids.

6. Moebius' sign : Lack of convergence (due to ocular myopathy )

(b) Local examination :

Site :Site : Swelling in the lower part of the front of the neckSwelling in the lower part of the front of the neck..

Size :Size : slight to moderate enlargementslight to moderate enlargement..

Shape :Shape : symmetricalsymmetrical..

Surface:Surface: smoothsmooth..

Skin overlying:Skin overlying: is is warmwarm..

Special character :Special character : moves up & down withmoves up & down with deglutitiondeglutition..

Consistency :Consistency : softsoft..

Edge:Edge: well defined.well defined.

Pulsations & thrills :Pulsations & thrills : are detected usually at the upper polesare detected usually at the upper poles

(V) Reticulo - endothelial signs: Just palpable spleen and may be generalized lymphadenopathy

Lid retraction

What are investigations?

*Free T3 , T4 & TSH. .

*Neck ultrasound.

*Thyroid scan using radioactive iodine or Tc99

Increased uptake scan

TreatmentThere are 3 lines of treatment:

1-Medical treatment:

A-Thiourea group.

B-Indral.

2- Surgical intervention:

We make subtotal

thyroidectomy after

preparation.

3-Treatment using radioactive iodine

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Thyroid Isotope scanThyroid Isotope scan

Cold nodule

Index

Thyroid Thyroid imagingimaging

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Hot nodule – Rt. lobe Cold nodule – Rt. lobe

Thyroid Isotope scanThyroid Isotope scan

Index

Thyroid Thyroid imagingimaging

NORMALIodine uptake is represented

here in a colour scale

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Thyroid USThyroid US

Normal Thyroid nodule

Index

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Fine needle aspiration cytology of thyroid swelling

Index

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Physiological goiter in a 14 year old female

Simple diffuse hyperplastic Simple diffuse hyperplastic (euthyroid) (euthyroid) goitergoiter

Endemic iodine deficiency goiter –starts as diffuse hyperplasia but nodules appear early

•Results from stimulation of the gland by TSH in response to chronically low level of circulating thyroid hormone .•Persistent growth stimulation causes diffuse hyperplasia; all lobules are composed of active follicles. •Iodine uptake is uniform.•Diffuse hyperplasia is reversible if TSH stimulation ceases

With pregnancy

(High metabolic demands)

Index

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Simple Simple (euthroid) (euthroid) multinodular goitermultinodular goiter

Pathology: Pathology: •As a result of flutuating stimulation, a mixed pattern develops in the gland with arias of active lobules & areas of inactive lobules•Active lobules are initialy more active and vascular. Hemorrhage will cause central necrosis•Necrotic lobules coalesce to form nodules•Nodules are either filled with colloid ( which is iodine free), or new but inactive follicles•Repetition of this process results in a NODULAR GOITER•Most nodules are inactive. Active follicles are present only in the internodular tissue.

Index

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Nodular goiter Nodular goiter – (cut section)– (cut section)

This is a cut section of a nodular goiter showing nodules of various sizes with secondary hemorrhage, necrosis and cystic change

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Simple Simple (euthroid) (euthroid) multinodular goitermultinodular goiter

One macroscopic nodule may predominate giving the impression of a solitary thyroid nodule. US is useful to detect other small nodules that are not palpable clinically

Nodules may be colloid or cellular

Common complications in thyroid nodulesCommon complications in thyroid nodules•Cystic degeneration•Hemorrhage (nodule becomes painful and increases in size acutely) (D.D. carcinoma, autoimmune throiditis)

•Calcification ( if extensive may give a hard sensation confusing with malignancy)

Complications of SNGComplications of SNG:•Tracheal obstruction (by gross latera displacement or compression in retrosternal extension)

•2ry thyrotoxicasis•Carcinoma (uncommon but more found in endemic areas – usually follicular)

Index

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Toxic Toxic (hyperthyroid) (hyperthyroid) goitergoiter

1ry (Graves disease) 2ry nodular goiter

Hot nodule Hot nodule in 2ry nodular toxic goiterDiffuseDiffuse and intense uptake of

radioctive iodine

Different appearance in thyroid scan

Index

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EXOPHTHALMUS in GRAVS Ds.

Index

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•Large multinodular toxic goiter: Clinically, one large nodule predominates•Thyroid scan shows: Hot nodules on the apex of the left lobe and on the middle of the right lobe and cold nodules on the right lobe and on the isthmus.•The treatment is surgical

Toxic multinodular goiterToxic multinodular goiter

Index

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Nodular Nodular GoiterGoiter

Index

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Simple Simple nodular goiternodular goiter

What is the D.D. of a cold nodule in a thyroid scan

Index

larger colloid cyst at the left lower pole and a smaller colloid cyst at the right lower pole

Such cysts could appear as "cold" nodules on a thyroid scan.

Index

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Solitary thyroid Solitary thyroid nodulesnodules

Malignant 15%Benign 85%

Papillary (most common)Hyperplastic or colloid nodules (common)

Follicular (less common)Follicular adenoma (less common)

Medullary & anaplastic (rare)Cysts

Index

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A 16-year-old patient with an asymptomatic palpable thyroid nodule noticed on routine physical examination

Surgical specimen of a thyroid lobe of the same patient with

papillary carcinomapapillary carcinoma

Index

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Gross specimen of thyroid gland containing partially cystic mass lesions with papillary projections

What is the significance and differential diagnosis of a cold nodule in the thyroid gland?

Papillary carcinomas of the thyroid Papillary carcinomas of the thyroid

Thyroid

Index

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•Solitary nodule in the base of the left lobe of the thyroid

•The nodule  exceeds the anterior margin of the capsule

•The nodule proved to be malignant

U.S. showing a solitary thyroid nodule. The nodule  is very hypoechoic, inhomogeneous;  irregular

and vague borders, Anterior margin of the capsule looks broken by the nodule

Large cold nodule on the base of the left lobe

Solitary thyroid noduleSolitary thyroid nodule

Index

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Retrosternal Retrosternal GoiterGoiter

Index

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Retrosternal goiter displacing trachea in plain X-ray chest & CT upper chest

Index

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Large nodular goiter, with retrosternal

extension causing mediastinumcompre

ssion of the veinsEnlargement of the upper mediastinum and right deviation

of the trachea owing to large nodular goiter

Large retrosternal

nodular goiter with Rt.

Deviation of the trachea (TT) .

Note calcifications (white spots) in the

gland

TT