Surgical Anatomy _ | a 00:00:27
Thyroid is a buttery Shaped gland in front of the neck,
Arteries related to the gland :
l. Superior thyroid artery
Related to the superior pole.
Branch of External carotid artery,
external carotid artery gives branches in the neck
and intemal] carotid artery gives no branches in the
neck.
a. Interior thyroid artery §
Related to the lower pole.
Branch of thyrocer vical trunk Which in turn is a branch
of subclavian artery, Hkebiso supplies the parathyroid
gland. RS
3, Thyroid Imo artery :
Direct branghib? arch of aorta.
enters the%aland at the level of isthmus.
@marrowedition6notes
Sup. thyroid Artery
external laryngeal NL
Internal thyroid
artery
60c6b$ecaa8ded0ede7e5ea7
eoeds 8
Surgery * v4.0 © Marrow 6.0 * 2022
Veins related to the gland :
Superior thyroid vein :
Drains into Internal Juguiar vein (Jv).
a.
Herortyocters:
Drain into brachiocephalic veins,
middle thyroid vein :
Present in 20% of individuals.
Short stout vein raining into WV.
It is the frst vessel which is ligated during thyroid
surgery,
Nerves associated with the gland :
Sema branch of superior
laryngeal nerve / external laryngeal nerve :
Supplies cricothyroid muscle, acts as oa. tensor of the
vocal cord and controls the pitch of the voice.
a. Recurrent laryngeal nerve (RLN) :
Lies posterior to the interior thyroid artery
Closely related to tubercle of 2uckerhanel and berry’s
ligament. &
On left side it winds around the arch of aorta.
On right Side it winds areiind the SUSPICWOEe ASAEUVC 4e7e5ea7
@marrowedition6notes
oe)
Since lett side has a longer course, injury to the let
RLN is more Common.
In a% of patients, non-recurrent nerve is present on
the right side, this is associoted with an aberrant right
subclavian artery,
It has sensory supply below the cord and supplies all
muscles of larynx except cricothyroid
Tubercle of Zuckerkandl :
Kt is the posterolateral projection of thyroid gland.
The RLN runs posterior to this tubercle.
It serves oS a guide to identify the nerve.
Berry's ligament :
it is the condensation of the pre-tracheal fascia posteriorly.
Thyroid is adherent to the trachea through this.
The RLN is injured most commonly ot this site.
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214 Endocrine 20
System
Beahrs Triangle i814
Triangle formed by :
l. Common carotid artery.
‘2. Interior thyroid arteru.
%. Recurrent laryngeal nerve.
dlood supply to Thyroid gland
external carotid
artery
Superior thyroid
artery
Thyroid gland
inferior thyroid
artery YY pte Arteria
trunk ~ if
@rachiocephalic .
trunk
ww Vengus drainage of the thyroid gland
@marrowedition6notes
©
Superior thyroid
vein
Internal jugular
vein
Middle thyroid
vein
Inferior thyroid
vein
brachiocephalic
MARROW
g
3 The superior thyroid vessels are ligated close to the gland
H during surgery, to prevent injury to extemal laryngeal nerve,
kumarankitindial QgmeHece Per ior thyroid vessels, the capsular branches close
to the gland ore ligated during surgery.
Surgery * v4.0 * Marrow 6.0 * 2022
Pay
20 Thyroid, Part - 4
Examination of Thyroid swellings 7 00:11:43
Inspection
Done from at a distance.
Normal gland is not visible.
The swelling will have vertical mobility on Swallowing,
Inspection also determines the lower limit of the swelling,
If lower limit is not visible, a post swallow palpation for lower
limit is done, if still not palpable it signiftes retrosternal goitre.
Palpation :
Done by standing behind the patient.
Pizzillo’s method :
Patient's hands behind the head, and is asked to push
against clasped hand on the occiput.
Uniform enlargement of whole gland :
Phusiological goitre, colloid goitre, 60c6bseeaasdeddede7e5ea7
Hashimoto's disease. Se
isolated nodules of diferent sizes : s
Nodular Qoitre. Ss Both lobes + isthmus.
Subtotal Thyroidectomy : Majority oF the gland is removed,
only S-8g of gland is lett behind
@marrowedition6notes
Near total thyroidectomy/ Hartley-Dunhill procedure :
Lobectomy + isthmusectomy + Subtotal lobectomy.
The incidence of hypothyroidism, RLN injury and
hypoparothyroidism is similar ofter total thyroidectomu,
subtotal thyroidectomy and near total thyroidectomy.
if recurrence ocCurs in tissue left behind in subtotal
thyroidectomy and near total thyroidectomy, it becomes very
difficult to operate on a previously operated neck.
Therefore, only hemi and total thyroidectomy are preferred.
Position : Rose position.
Patient lies supine, with o
shoulder roll and head
elevation of 20 degrees.
Head end elevation is done
to achieve a bloodless feld
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222 Endocrine 20
as venous drainage comes down due to gravity,
Head end elevation also produces increased risk of air
embolism,
Procedure :
Incision : Collar incision.
a {inger breadths above
the suprasternal notch or
lem below the cricoid
cartilage.
From one sternocleidomastoid
+0 the other.
Then subplatysmal Slaps
are raised,
The superior {lap is raised
till tne thyroid cartilage and
inferior “lap till the
suprasternal notch.
The strap muselestare Split.
It more expo is required,
@marrowedition6notes
strap muscles can be cut.
They are cut high up to
prevent injury to
Ansa. cervicalis.
Ligate the middle Thyroid vein first.
Dissect at the space of Reeves at the superior pole to liqate
— superior cies ses Teas gland Dectaneased e4e7e5ea7
Injury to the superior laryngeal nerve should be prevented at
the superior pole.
Next, ligate the interior pole vessels.
eoeds Banoy
Surgery * v4.0 « Marrow 6.0 * 2022
20 _ Thyroid. pa
Parathyroid glands are
identified using the sentinel
pad of Fat.
Once freed from the vessels
the gland can be cut out.
Identity trachea and RLN.
Trachea
RLN
Close the incision.
Insert a Romovac suction
drain, which is a closed
suction drain.
@marrowedition6notes
. ©
Joll’s thyroid retractor :
used in thyroid surgeries.
To retract the Slaps on
both sides.
Minimally invasive video assisted
Thyroid surgery (MIVAT) 00:57:00
Most common oach is through the axilla.
kumarankitindia1@gmail.com MIVAT
rs:
|. Transoral thyroidectomy
a. Retroouriculay.
3, Through nipples.
Active space
Surgery * v4.0 * Marrow 6,0 * 2022
224 Endocrine 20
System
Indications :
. TI papillary thyroid cancer,
eee Pee RES CIR BEART Aiyroid swellings.
Contraindications :
l, Thyroiditis.
eoeds Baloy
Complications of thyroid surgery 01:05:16
l. Hemorrhage.
Primary hemorrhage.
Reactionary hemorrhage : Few hours aster surgery,
Presents as a tension hematoma. in the neck.
a. Injury to the nerves.
external laryngeal nerve :
* More common.
* Unilateral or bil al injury aives rise to
@marrowedition6notes
ronssness foe, _e
* Not life tenina.
Recurrent lar eee °
Unilateral injury + Hoarseness of voice.
Bilaterabinjury
° Aphonia
* Aspiration.
* Therefore life threatening,
Permanent RLN injury + OS-a%.
Temporary RLN injury ! 410%,
Intraoperative nerve monitoring can be done, although
studies have shown thot there is no difference in
incidence of nerve injuries.
3. Post operative respiratory distress:
Couses :
* Laryngeal edema ! MC complication.
Tension hemoatomoa :
Occurs few hours after surgery. Tense swelling in
the neck. Increased amount of blood in drain.
Open sutures and evacuate the hematoma.
. Laryngomalacia.
Surgery * v4.0 * Marrow 6.0 * 2022
© G/L RLN injury,
* Huypoparathyroidism (late cause + 48-Tah)
4, Hypothyroidism.
S. Keloid.
bo. Recurrence.
7. Hypoparathyroidism 01:13:27
Occurs due to vascular injury to the parathyroid gland,
Presents 48-74 hours loter.
Symptoms :
60c6b3eeaa8ded0e4e7e5ea7
l. tarliest : Perioral numbness.
a. Tingling and paraesthesia.
3, Tetany.
4. Respiratory paralysis.
Clinical signs of hypocalcemia. :
They occur due to neuromuscular
hyperexcitability.
I. Chvostek Sign + Tapping on the
facial nerve produces facial
twitching,
@marrowedition6notes
a. Trousseau. Sign * Carpopedal
spasm on occlusion with 6P
cuff, Also Known as
Obstetrician’s
hand deformity,
Management of hyperparathyroidism :
Monitor the symptoms and serum calcium :
I. Rminor symptoms ond S.Co.? @ro/ds
Oral calcium + oral vitamin D3.
a. If major symptoms and [or S. Ca. 8mo/AL #
iN. Calcium gluconote + Oral calcium + oral vitamin D3.
Active space
Permanent hypoparaxhyroidism :
Seen in I% of cases.
\f symptoms persist for more than | year,
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226 Endocrine
System
20
eoeds ealpy
Intra, operative nerve monitoring (ONM) can help identity
nerves and prevent injuries to the nerve during thyroid
surgeries.
Though, lotest update of Sabiston tales that IONM has not
shown any Aramotic results.
Syndromes associated with thyroid cancers !
l. Familial adenomatous polyposis — Papillary thyroid
cancer(PTC) due to APC gene mutotionon
Chromosome S.
a. Gardner’s syndrome — Follicular thyroid cancer
(FTC).
3, Werner syndrome :
WRN | gene.
Adult progeroid syndrome.
Associated with PTC/FTC/hurthle cell cancer.
4.MEN 3 syndrome oF
medullary thyroid Gancer (MTC) due to RET
proto-oneogeng tnutation
S. Cowden $s Adrome : PTEN mutation.
ssthonmadosne ts ips.
@marrowedition6notes
S
WwW
Breast cancer.
Thyroid cancer + FTC / PTC.
bo. MeCune Albright syndrome :
Fibrous dysplasia.
1. Carney complex +
Gamma PPAR gene mutation. Can give rise to Batman
syndrome.
Mnemonic : Botman
. Breast.
2 Adrenal.
: Thyroid.
MA + Atrial mMyUXOMAS.
Noevus.
Surgery * v4.0 * Marrow 6.0 * 2022
Staging of thyroid cancers 00:02:30
TNm definition (ace Be)
For papillary, Follicular, poorly differentiated, Hurthle cell,
medullary, and anaplastic thyroid carcinoma.
T™X
TO
TI
Tla
Tib
Ta
13
T30
Tab
T4
T40
Primary tumor cannot be assessed.
No evidence of primary tumor.
Tumors ¢ acm in greatest dimension limited to the
thyroid.
Tumors | em in greatest dimension limited to the
thyroid
Tumor ? | cm buts acm in greatest dimension
limited to the thyroid,
Tumor 72 em but $ 4 em in greatest dimension
limited +o the thyroid. ev
Tumor ? 4 cm limited to the thyroad or gross
extra-thyroidal extension inven only strap
muscles. wW ©
Tumor 7 4 cm limited dhe thyroid,
@marrowedition6notes
Gross extra-thurolds! extension invading only strap
muscles (sternohyoid) from a tumor of any size.
Includes gross extra—thyroidal extension into major
neck structures,
Gross extra—thyroidal gy seOSUdMePSea7
subcutaneous sot tissues, larynx, trachea,
esophagus, or recurrent laryngeal nerve from a
tumor of any size.
Tol gross extrathyroidal extension invading prevertebral
fascia or encasing carotid artery or mediastinal vessels
from a tumor of any size.
Nodal involvement :
N fe) : No nodes.
N + Level & lymph nodes/Delphian nodes.
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230 Endocrine ?1
NX Regional lymph nodes cannot be assessed.
NO _No evidence of regional lymph nodes metastasis.
NOa One or more cytologic or histologically confirmed
benign lymph node.
NOb No radiologic or clinical evidence of locoregional
lymph node metastasis.
NI metastasis to regional nodes.
Nia. metastasis to level vi or vil (pretracheal,
paratracheal, or prelaryngeal/Delphian, or upper
mediastinal) lymph nodes, this can be unilateral or
bilateral disease.
Nib metastasis to unilateral, bilateral, or contralateral
lateral ReAKraytanhunAgepda Nam |, II, Il, IV or V) or
retropharungeal lymph nodes.
mo No distant metastasis”
mm Distant metastasi
cancer. &
©
@marrowedition6notes
@
bitferential Thyroid Cancer (OCT) : PCT, FTC, hurthle cell
3” American joint committee on cancer changes :
eoeds sanoy
I. The age cut of £ used Lor Staging was increased
from 4S to SS years of age at diagnosis.
a. | minor extra thyroidal extension detected only on
histological examinotion was removed trom the
definition of T3 disease and therefore has no impact
on either T category or overall stage.
3. | NI disease no longer upstages a patient to stage |. \f
“ af
ere? aes
af Sat '® Bernas
Wp he r]
f S| iff ve pS eg
3 ; Ce ‘
ernernia + S Prophulactic CND
es Hemithyroidectothy @marrowedition6notes
3) : . :
oe \f T3, T4 disease +:
I Iymph nodes other than
— + level +:
TT + CND + modified radical
neck dissection (MRND)
eoeds ealoy
Management post-surgery 00:19:42
Whole body iodine scan.
To look for :
* Residual disease.
* metastatic disease.
Pre requisites : TSH 7 a0 IU/L.
Preparation for iodine scan :
conventional : Thyroxine not given for 4-b weeks
ofter surgery.
New method : Recombinant TSH injection.
Surgery * v4.0 * Marrow 6.0 * 2022
whole body iodine scan rn { 1
\f residual disease or No residual disease
metastasis + “ or metastasis
Radioiodine ablation (-13)) Follow - up:
/a We: 7-8 days & monthly :
B rays US neck —
SO - 100 mCi serum thyrogjobin (Ta) TSH Suppression :
Thyroxin iS given.
| |, t0 prevent
kumarankitindia1@gmail.com a Hypothyroidism
if serum Thyroglobin > ang/mi. a. \f TSH is raised it can
Single-dose of Radioiodine ablation stimulate cancer growth
In patients vith
extracapsular spread Scan to see for Recurrence
Persist raised thyroglobulin TSH level bought to
surgery lower limit of normal.
Thyroglobulin ? Tumour marker for DTC.
Before thyroglobulin is used as a tumour mars
Anti-Thyroglobulin antibody test should be done.
It is seen in patients with Hashimoto's tajroiditis.
@marrowedition6notes
aS
TSH Suppression : Improves surgi Stage Ii, IM, IV DCT.
Side effects of radioiodine aston
* Sialadenitis.
* Nasolacrimal duct blockage.
* Infertility.
* Secondary cancers,
\f tumouris resistant to radioiodine ablation :
* sorafenib, levantinib.
* eBRT (external Beam Radiotherapy) in metastatic
disease,
° Chemotherapy > Doxorubicin.
Lindsay t4urmour +
Follicular variant of papillary cancer.
Same Prognosis as PTC.
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236 Endocrine
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21
Subtupes of PTC with poor prognosis :
* Tall cell.
* Hobnail.
Whole body iodine scan :
Ss
Left : Resi disease Riaht : After eAl
@marrowedition6notes
@
Ss
© 60c6b3eeaa8ded0ed4e7e5ea7
Follicular Thyroid Cancer (FTC) 00:33:20
a™ most common overall.
Most commonin iodine deficient areas.
eoeds BAO
Lymph nodes and bony metastasis in FTC
Surgery * v4.0 ¢ Marrow 6.0 * 2022
Genetics :
* Upregulation of miRNA 197, 346.
* PTEN gene.
* BAX gene.
Risk factors : Long standing multinodular goitre.
Presentation :
Neck swelling,
Spread: Hematogenous 7 Lymphatic.
® most common site : Bones (me).
° Highly vascular : Pulsatile bony metastasis (other
metastasis : Renal cell carcinoma).
* Osteolytic (usually).
Lymphatic spread > 20-20 %,
To level & lymph nodes. Diagnosis §
FNAC : Cannot differentiate between Follicular adenoma
and carcinoma. &
@marrowedition6notes
OP
&
Both diagnosed as sotioular Seoplasm on FNAC.
Hemithyroidecctomy
Follicular Carcinoma | |_ Follicular adenoma
Completion Surgery No Further Surgery
exactly same oS PTC
Post-surgery management : Same as PTC.
Prognosis : Poor compared to PTC.
60c6b3eeaa8ded0e4e7e5ea7
Hurhtle cell carcinoma :
* €arlier considered a variant of FTC.
* ©-1" decade of |ife.
* Presence of oxyphilic Hurthle cell = cosinophilic
cytoplasm, rich in mitochondria
Surgery * v4.0 © Marrow 6.0 * 2022
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238 Endocrine
et
21
* more agaressive than classical FTC.
e Higher rate of bony metastasis.
6Oc6b3eeaa8dedded ess} avid than other OTC.
Hurthle cells are seen in:
* Hurthle cell carcinoma.
* Hashimoto's thyroiditis. S
° Thyroid Iympho xe
\Yyroid lymphoma. &
Prognosis of Thyroid Cancers 00:42:30
Prognostic $ Ss:
@marrowedition6notes
©
se
&
A Hoarseness of voice MC — Lungs
a. Trachea — Stridor, dyspnoea.
3, Dysphagia
4. Very hard swelling (d/d : Riedel’s thyroiditis)
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240 Endocrine
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21
Diagnosis > FNAC
if FNAC inconclusive —> Tru-Cut/ core needle biopsy,
Thyroid isa very vascular gland With major vessels { nerves
closeby. So, needle biopsies usually not preferred,
indications for Tru-cut/ core needly biopsy in thyroid :
inconclusive case of anaplsatic carcinoma.
Reidel’s brosing thyroiditis.
Lymphoma.
Management :
(Staging same as differentiated thyroid cancers).
I. If tumor restricted to thyroid/ localized disease.
|
Agaressive Surgery + Total Thyroidectomy + Central Neck
Dissection + Modified Radical Neck Dissection.
a. IF tumor is beyond thyfoid/ advanced disease :
Palliative management.
Radioactive iodine niotansedtina ineadanantonince
Chemotherapy : Doxorubicin
Dabrafenib { Trametinib ‘Tyrosine kinase inhibitor used
@marrowedition6notes
in metaplastic 4 anaplastic carcinoma)
Tumour debulking : If pressure over trachea is present
Isthmusectomy,
eoeds eanoy
Surgery * v4.0 ¢ Marrow 6.0 ¢ 2022
Thyroidlymphoma > 7 00:49:30
* Rare
* s-7" decade
* mc: diffuse large 6 - cell lymphoma or small blue cell
lymphoma.
Risk Factors : Long standing Hashimotos’ thyroiditis.
Clinical Features : Thyroid swelling (mc presentation.
®’ symptoms : Fever, night sweats and weight loss.
Investigations :
FNAC cannot characterize lymphoma.
Hence, Tru-Cut biopsy done.
FNAC : Hurthie cells can be seen. (Also seen in Hurthle cell
cancer, Hashimoto’s thuroiditis, thuroid lumphortias as well)
, J ms ~ 60c6b3eeaa8ded0e4e7e5ea7
Management : ©
Chemotherapy
t calcitonin. > MTC.
* Associated with RET proto
oncogene mutation.
eoeds svnoy
Feotures :
Thyroid swelling (mc presentationy..
Atypical symptoms :
kumarankitindial@gmail.com
Diarrhoea Cdue to serotonin].
Flushing Chistamine].
Cushing disease CACTHI.
Other compunds secreted by MTC : Chromogranin A
Raised CEA : Sign ot de differentiation. more agressive.
Lymphatic { hematogenous spread.
| |
Level nodes (via reine iy
Liver (mec hematogengés)
Diagnosis : x
FNAC : Amyloid cero
Management Ne
Surgery ©
@marrowedition6notes
oS SNES
©)
2)
I. If restricted to thyroid + TT + CND.
a. If thyroid + level © nodes? TT + CND + MRND
or
thyroid + level & nodes + other nodes.
3. Prophylactic neck dissection should be done if serum
calcitonin is >200po/m.
4. No role of lodine scan and Radiciodine ablation (RIA) in MTC
S. Advanced disease : Tumor debulking has shown to improve
survival,
b. Radiotherapy for local symptoms.
7. metastatic MTC !
Vondetanil
Tyrosine Kinase inhibitors
Cabozantinilb
Note :
I. Always rule out pheochromocytoma in patients with MTC.
Surgery * v4.0 © Marrow 6.0 * 2022
21
If present, treat pheochromocytoma frst.
a. Always rule out hyper parathuyroidism as well!
Serum calcium.
Parathyroid adenoma present > Treat simultaneous
Prognosis 4 Follow up :
CEA.
markers).
Calcitonin : Caaleitonin dobling time (one of the most sensitive
MEN syndrome 01:01:40
Multiple Endocrine Neoplasia Syndrome
men | / Wermer syndrome :
* menin gene mutation : Chromosome
. Pituitary adenoma : Me — Prolactinoma.
* Parathyroid adenoma. + me clinical associétion (9S%).
* Pancreatic endocrine tumours &
(me pancreatic endocrine neopii.
MEN | & overall
Gastrinoma & insulinoma.
MC non Functional : PPomoa.
@marrowedition6notes
* Adrenocortical tumors
° Thymic tunvirtr6 b3eeaa8ded0e4e7e5ea7
. Collagenoma.men a syndrome * RET proto-oncogene
mutation
(chromosome 10)
f Y )
MTC only MEN oA MEN 26
| | |
EXON GIB A/H/A sipple syndrome A/K/a MEN 2 /
mutotion © mTc (mc) Gorlin syndrome
° Parathyroid adenoma * MTC
. Pheochromocytoma., * medullated cormeal
* Megacolon @A7 ae) —_ nerve Mbres.
* Exon 634 mutation * mucosal neuwromas
* marfanoid features
. megacolon.
Active space
Surgery ¢ v4.0 © Marrow 6.0 * 2022
244 Endocrine 1
System
* Exon IIB mutation.
* most agoressive
Any patient with MEN a syndrome
|
I“ degree relatives screened For RET mutation.
Low risk medium risk High risk.
| EXON 18, 790 EXON IB, 034 Exon 918
60c6b3eeaahAepOEeeGea7 Prophylactic Prophulactic
| thyroidectomy thyroidectomy thyroidectomy
: at AO years : ak S-lo urs at | year.
MEN 4 syndrome :
CDANI& gene mutation in chromosome la
. Pituitary adenomas
. Parathyroid adenomas
* Renal tumours ae
* Adrenal tumors &
* Reproductive organ tumors
Hyperthyroidism 00:00:28
Features :
Thin.
writable.
Heat intolerance,
Weight loss despite a good appetite.
Tachycardia and palpitations.
Diarrhoea.
Tremors.
Oligomenorrhea 7 menorrhagia.
Thyroid function test : Raised T3, T4 and Low TSH.
Causes of hyperthyroidism ;
Most common cause : Grave's disease/fimary
thyrotoxicosis. | S&S
Solitary toxic nodule. cS
Toxic nodular goiter/ Purrmers disease.
Factitious hyperthyroidise? Due to increased
@marrowedition6notes
thyroxine intake.
Jod-Basedow phenomenon : lodine induced
hyperthyroidism.
TSH secreting pituitary adenoma : Raised TSH.
Struma. ovarii + Ectopic thyroid tissue in the ovary,
Thyroid scan :
Graves’ disease : Diffuse increase in uptake.
Solitary toxic nodule + Single hot nodule.
Toxic nodular goiter + Multiple hot and cold nodules.
Factitious hyperthyroidism + Decreased uptake.
Jod-Basedow phenomenon : Increased uptake.
TSH secreting pituitary adenome. : Diffuse increase in
uptake.
Str WRK RBGAFA BURG ORSELE Poke in thyroid gland
Management of hyperthyroidism :
* Drugs only,
Surgery * v4.0 « Marrow 6.0 * 2022
Active space
248 Endocrine a2
System
* Drugs Followed by radio iodine ablation,
* Drugs Followed by surgery.
Drugs :
pTU/ Propytthiouracil :
cre hthibits the thyroid peroxidase (TPO) enzyme.
60c6b3eeaa8ded0e4
* Safer in pregnancy and lactation.
* Side effect : Agranulocutosis.
Corbimazole :
* Inhibits the thyroid peroxidase (TPO) enzyme.
* Side effect : Agranulocytosis.
Drugs are used before the start of any other treatment
modality / intervention to render the potient euthyroid and
prevent thyroid storm .
Drugs Followed by radio iodine ablation : |" (acts by B rays
with a. half-life of 7-8days).
Drugs Followed by surgery } ae
Preparation of the patienk@or surgery :
* Start the patiention antithyroid medications &-8
weeks befor, suraeru,
° Antithyro} rete xg we combined with long acting
B alockérs (because of the super sensitization of the
@marrowedition6notes
sympathetic receptors).
Nodolol is preterred due to its OD dose.
* Last dose of the antithyroid medication is given on the
previous evening of the dou of surgery,
* Geta blockers administered pre-operatively should be
continued for 7 days post-operatively as well (to
prevent the risk of thyroid storm as half-life of tne
circulating thyroid hormones is 7 days).
* 7-10 days before the surgery, Lugol’s iodine /
Potassium iodide (41) should be given which helps to
reduce the vascularity of the thyroid gland.
eoeds eanoy
Thyroid storm 00:11:20
Thyroid storm is uncontrolled thyrotoxicosis .
Clinical features :
. Dehydration.
Surgery ¢ v4.0 « Marrow 6.0 « 2022
* Palpitations (due to arrhythmias) ‘ Leading couse of
deoth.
. Hypertensive crisis.
Most common cause : Inadequate preparation of the
patient before the surgery .
Triggers :
* URTI due to a viral infection (mc).
° Trauma / surgery,
* Anaesthetic agents.
Management :
* 1 Muids.
* management of hyperthermia.
* |v steroids.
* |v Propranolol.
° PTU/ Carbimazole.
Graves' disease Ro 00:14:13
againstithe thyroid receptors
(LATS- Long acting thyroid @marrowedition6notes
or
It is the most common cause of hyperthyroidism,
AKA primary thyrotoxicosis. An autoinrune condition where
the autoantibodies are shifting antibody).
Associations : Pernicious anaemia, myasthenia Qronis.
Clinical features :
* pitfuse enlargement of the thyroid gland.
kumarankitfictai @gmail.com
* Eye Signs :
I. exophthalmos.
a. Stellwag’s sign : Infrequent blinking,
3. Dalrymple’s sign : Lid retraction with the visible
upper sclera.
4. von Graefe’s sign + Lid lag on down gaze.
Lid retraction and lid lag occur due to spasm of the
muller’s muscle (autonomic component of levator palpebrae
superioris).
on upgaze (due to increase in the Keld of
upper vision of eye due to exophthalmos).
Surgery * v4.0 « Marrow 6.0 * 2022
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250 Endocrine 22
System
6, Moebius sign (severe toxicity) > Loss of
accommodation reflex.
method of examination of Ye SIQNS §
Von Graefe’s sign :
examiner should be at the same eye level as tne patient.
Ask the potient to follow a pen as it is moved up and down
slowly .
Head of the patient is supported with the other hand.
When the patient looks down, there is a lag which is noticed in
the lid movement edmpared to the eyeball movement.
Stell wags Sign + Count the number of blinks per minute.
@marrowedition6notes
This is compared to the examiner’s blinks.
Moebius sign : The patient is asad te. Taeus ON GedSeota7
object, then a pen is suddenly introduced in the line of sight
and the patient is asked to focus on the tip of the pen and
look for convergence.
* Pre tibial myxedema HHisa dermopathy Which
involves the lower limbs .
* Acropathy + Swelling, dermopathy and subperiosteal
bone formation of the digits.
eoeds annoy
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22 Thyroid: F __ males. >
Surgery * v4.0 © Marrow 6.0 ¢ 2022
management :
Drugs followed bu radio iodine ablation (majority of the
radio iodine gets concentrated in the hyperfunctioning
nodule itself and destroys iD.
Hemithyroidectomy .
Associations : G coupled shock proteins.
Hypothyroidism
00:33:02
Clinical features :
Dull.
Lethar gic person.
Alopecia.
Braducardia.
Constipation.
Weight gain.
Cold intolerance. S
x&
menorrhagia. ge
myxedema attack : Bradycardia, altered Sensorium,
constipation . &
Can get predisposed by viral ifeghons.
TFT : Reduced T, and T andéised TSH levels.
@marrowedition6notes
Causes of hypothyroidism :
Most common overall : lodine deficiency.
In the western world : Hashimoto's thyroiditis /
Lyumphocutic thyroiditis.
Wolf Chaikof$ phenomena. : lodine induced
hypothyroidism.
Non-functioning pituitary adenoma.
Sheehan syndrome Postpartum pituitary apoplexy
leading to global decline in pituitary function.
Dyshormonogenesis : Defect in the TPO enzyme.
euthyroid sick syndrome: In patients with chronic
non thyroidal illness leading to decreased thyroid
6OcGbseeaahded0e4e7esea7
Refetolt syndrome : Seen in elderly patients, it is an
end organ resistance to T4.
Surgery * v4.0 * Marrow 6.0 « 2022
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254 Endocrine 22
System
Hashimoto’s thyroiditis 00:38:34
AKA Lymphocytic thyroiditis.
It the most common thyroiditis and most common couse of
hypothyroidism, Females7Males. An autoimmune condition
which is associated with HLA DR 3/88.
Associated with Down's and Turmer syndromes.
Strong hereditary component : There is a 9 times risk of
Hashimoto's if it is present in a. * degree relative.
Autoantibodies (block AQ) tHe earATed LEG anRRe? 7
* The thyroid receptors.
* TPO enzyme.
° Thyroglobulin.
Clinical course :
Autoantibodies.
Stimulate the lumphocut inttrate the aland
destruction oF the follicles.
Stored typi hormones are released into the circulation.
@marrowedition6notes
Li @
ymphocytes*o 3
& LF
(phase of hyperthyroidism / Hashitoxicosis).
Follicles can not regenerate due to repeated ottacks
from the lymphocytes.
Prolonged hypothyroidism.
Prolonged hypothyroidism.
—? initial phase of hyperthyroidism
eoeds sanoy
\ Prolonged hypothyroidism Phase
Surgery * v4.0 ¢ Marrow 6.0 « 2022
VY mee ena). Add Points From All Categories to Determine TI-RADS t—
[ O points | [ a points | [| points | [4 to & Points | | 7 Points or more |
VY Vv ; N : _Y¥
TRI Benign No TRA Not TR3 mildly TR4 moderotely TRS Highly
FNA if 7 2S em FNA if > 1S cm | |FNA if > 1 em Follow
Follow iF > 1S em| | Follow Fl em if > 0S em*
@marrowedition6notes
eoeds eAnoy
—— -
Spongiform: Composed predominantiy- | cystic or almost, not add. further points For other categories. mixed cystic and Solid : Assign points for predominant Assign 2 points iF composition cannot be determined because oF Anechoic: Applies to @so%) of small | completely RS O hoic/ ic/ iC. ? Compared to adjacent parenchyma. solid cormponent, | very hyupoechor | This can > More hypoechoic than | assessed strap muscles. Assign | point iF echogenicity Talle-sthan- ? Should be | Protrusions ssed on atransverse | measurements | parallel to sound beam for height and | sharp angles.
perpendicular to sound beam | extension’ for width. usually be by visual inspection. Lobuloted: tissue. Irrequiar * Jagged, spiculated, or | shadowing,
Extrathyroidal Obvious invasion =
malignancy. Assign O points if margin cannot be Large comet—tail
artefacts: V-shaped,
into adjacent | 71 mm, in cystic
components.
macrocalcifcations:
Couse acoustic
Peripheral: Complete
or incomplete along
margin
Punctote echogenic
foci + May have
smal\ comet—tail
Large comet-
tail artefacts:
V-shaped, >! mm, in
determined | cystic components.
Cause acoustic
shadowing,
| Peripheral : Complete
or incomplete along,
Margin Punctate
echogenic Foci :
May have small
comet—toul
kumarankitindial@qmail.com
Surgery ¢ v4.0 « Marrow 6.0 ¢ 2022
22
Fine-needle aspiration cytology reports
Benign Malignant
Thy | ; Non-diagnostic
Thy Ie Non-diagnostic, cystic
Thy a Non-neoplastic
Thy 3 Follicular
Thy 4 Suspicious of malignancy
Thy Ss Malignant
Primary retrosternal goitre Secondary retrosternal goitre
1O% cases 90% cases
AKA primary mediastinal goitre(ectopic thyroid tissue in the | neck and tegtre retrosterna!
mediastinum AKA plunging eypeas in the
extension).
Blood supply + mediastinal vessels on Neck vessels
Retrosternal goitre (01:01:40)
Thyroid swelling extends behind the sternum into the mediastinum .
Types 3
&
@marrowedition6notes
Clinical features :
: Swelling : Lower ent fre
swelling cannot be felt.
* Dyspnoea and stridor.
© pevioted trachea Pemberton’s sign
° Pemberton’s sign : Facial congestion
and conjunctival congestion
when the patient is asked to
lift the hands above their heads
which occurs due to pressure over the thoracic outlet.
Chest x ray : Mass in the upper mediastinum, deviation of
trachea.
Imaging |OC + CECT neck and thorax (to ,
Know the extent of the swelling and the
surrounding relations). |
Management : Surgery,
g 2 $ 8 <
diffuse goitre
Surgery ® v4.0 © Marrow 6.0 ® 2022
262 Endocrine
System
22
ededs ealoy
Approach :
* Ccervical/neck incision (because 90% cases are of
secondary retrostemnal goitre type which start from the
neck).
. Median sternotomy indications :
|. Primary mediastinal goitre.
a. Large malignant retrosternal goitre.
3, Recurrence in the mediastinum.
make systematic notes of this that is easy to understand and learn and after summarising all this information you will ask me mcq from this information
