Download Thyroiditis

Department of Surgery
Ruijin Clinical Medical College
Shanghai Jiao Tong University
Theodor Kocher（1841~1917）
Embryology
Langue
Conduit auditif exterme
Tympan
Amygdal
Parathyroide III
thyeo-glosse tube
Parathyroide IV
Thymus
Thyroidien lobe
Corps ultimo-branchial
Lateral thyroid
Esophage
Thyroid anatomy
Superficial veins and cutaneous
nerves of neck
Recurrent Laryngeal Nerve
Recurrent laryngeal nerve
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On either side of the trachea
Lateral to the ligament of Berry
Entering the larynx
Right side: separating from the vagus when
crossing the subclavian artery
• Left side: separating from the vagus when
traversing over the arch of the aorta
Recurrent Nerve
Anomalous variations in the course of the right recurrent laryngeal nerve.
A, A nonrecurrent laryngeal nerve arises from the vagus.
B, The normal course of the recurrent laryngeal nerve arises from the vagus after it passes beneath the
subclavian artery.
C, The unusual nonrecurrent nerve and recurrent laryngeal nerve join to form a common distal nerve.
Superior Laryngeal Nerve
• separated from the vagus nerve
• two branches:
The larger internal branch
-sensory function and it innervates the larynx.
The smaller external branch
-the cricothyroid muscle
Blood supply
• Four main arteries, two superior and two
inferior :
The superior thyroid artery
The inferior thyroid artery
• Three pairs of venous systems drain the
thyroid.
Blood supply
Parathyroid Glands
superior thyroid artery
Superior Laryngeal Nerve
external branch
Common carotid
superior
parathyroid
gland
Internal jugular
inferior thyroid artery
Recurrent nerve
inferior
parathyroid
gland
Benign Thyroid Disease
• Endemic Goiter
• Thyroiditis
• Hyperthyroidism
Endemic Goiter
• Etiology
1/3 of the world’s population, specifically
in underdeveloped countries.
• Cause
Iodine deficiency
Endemic Goiter
• diffuse goiter
• nodular goiter
Thyroiditis
• Acute Suppurative Thyroiditis
• Subacute Thyroiditis
De Quervain’ s thyroiditis)
• Chronic thyroiditis
Hashimoto’s thyroiditis
Riedel’s thyroiditis (struma)
Hashimoto’s thyroiditis
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A cause of hypothyroidism in adult
Immune complex and complement
An exacerbation of immune response.
An infiltration of lymphocytes
TSH-blocking antibodies.
A hypothyroid clinical state
Hyperthyroidism
• Graves’ disease
• toxic nodular goiter
• toxic thyroid adenoma
Grave’s disease
• Most hyperthyroid states are caused by
Graves’ disease (diffuse toxic goiter).
Clinical Presentation of
Hyperthyroidism
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Physical examination
Increased hyper metabolic state
Cardiovascular stress
Gastrointestinal sign
Psychiatric signs
Genital disorders
Hematopoietical modification
Extrathyroid Presentation
Extrathyroid Presentation
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vitiligo
pretibial myxoedema
digital hippocratisme
ophtalmopathy
Biology
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T3L↑, T4L↑, TSH↓
Anti-thyroglobuline antibody ↑
Anti-microsomal antibody ↑
Anti-TSH-recepter immunoglobuline
Diagnosis
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An extensive history
Physical examination
Signs and symptoms of thyrotoxicosis
Thyroid function tests
Traitement
• Radioiodine ablation
• Surgery
• Antithyroid medication
Toxic nodular goiter-toxic adenoma
(Plummer’s disease )
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Autonomous function.
Independent of TSH control.
Symptoms : mild, peripheral
Thyroid hormone ↑, TSH ↓
Antithyroid antibody ↓
• Diagnosis confirmed after:
clinical suspicion
131 I radionuclide scan
• Treatment
lobectomy or near-total thyroidectomy
antithyroid medication
radioiodine therapy is not effective
Nontoxic goiter
• Multinodular Goiter
• Substernal Goiter
The work-up of a solitary thyroid
nodule
FNA, fine-needle aspiration; Rx, therapy.
Preoperative preparation
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ORL exam and general exam
Antithyroid medication
The lugos
The beta-blockage
Operation Complications
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Bleeding
Recurrent laryngeal nerve injury
Superior laryngeal nerve injury
Hypoparathyroidisme
Thyrotoxic storm
Infection
Hypothyroidism
Thyroid malignancie
• Less than 1% of all malignancies in the
U.S.
• 40/1,000,000 occur per year.
• 6/1,000,000 die per year
• Thyroid oncogenesis
Histo-pathology
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Papillary
Follicular
Hürthle cell carcinomas
Medullary thyroid cancer (MCT)
Anaplastic carcinoma
Thyroid nodules
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Ultrasound
Scintigraphy
CT
L’MRI
FNA
Scintigraphy
Cold nodule
Hot nodule
Papillary Carcinoma
• Epidemic
the most common
of the thyroid
neoplasms and
usually associated
with an excellent
prognosis
Prognostic Risk Classification for Patients with Well-Differentiated Thyroid
Cancer (AMES or AGES * )
Low risk
High risk
Age
<40 years
>40 years
Sex
Female
Male
Extent
No local extension, intrathyroidal,
no capsular invasion
Capsular invasion,
extrathyroidal
extension
Metastasis
None
Regional or distant
Size
<2 cm
>4 cm
Grade
Well differentiated
Poorly differentiated
Clinical Presentation
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Solitary painless masses
Dysphagia
Cervical tenderness,
Painful neck mass,
Superior vena cava syndrome
(extremely rare)
Treatment
• The main treatment : surgical ablation.
Follicular Carcinoma
• Second category of well-differentiated
thyroid cancers
• Follicular, and mixed papillaryfollicular
cancers (90% of all thyroid cancers)
• A malignant neoplasm of the thyroid
epithelium
Clinical presentation
• Solitary painless mass
• The coexistence of lymph node
involvement (extremely rare)
• Cervical adenopathy (rare)
Treatment
• Primarily surgical.
Thyroid lobectomy and Isthmectomy
<2cm,well contained within one thyroid lobe
Total thyroidectomy
>2 cm, (>4 cm, the risk for cancer >50%)
• Lymph node dissection
• Radioiodine treatment
Hürthle Cell Carcinoma
• A subtype of follicular carcinoma
• Presents in much the same fashion as
follicular cell neoplasms.
• Preoperative FNA
• Principal treatment is surgical
Medullary Carcinoma
• 5% to 10% of thyroid malignancies
• A biological marker, Calcitonin
• Presentation: a palpable mass
an elevated calcitonin level
• Single and unilateral
Diagnosis
• MCT :
a mass and an elevated calcitonin level
• Detailed and in-depth family history
• Signs and symptoms
• Screening for pheochromocytoma with 24hour urinary catecholamines
Anaplastic Thyroid Cancer
• Less than 1% of all thyroid malignancies
• Most aggressive form of thyroid cancer
• Typical presentations :
dysphagia
cervical tenderness
painful neck mass
superior vena cava syndrome
Treatment
• Most reports with resection are not
optimistic .
• less than one third of them are resectable
• chemotherapy adds little to the overall
prognosis
• Prognosis is bad
Minimally invasive surgery
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