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Thyroid and Suprarenal Glands Ahmed Abdellatif, MD, PhD Anatomy of Thyroid Gland Thyroid Gland • Location • 2 lobes • Isthmus • Capsule – – Glandular capsule Pretracheal fascia • • Development Blood vessels, nerves & lymphatics • Important structures & relations • • • • • • Recurrent laryngeal n External laryngeal n Thyroidae ima artery Parathyroid glands Surgical importance Function Location Isthmus lies Anterior to tracheal rings 2,3,4 Lobes Normally extend down to the level of 6th tracheal ring. Muscles Covering the thyroid. - Infra-Hyoid (Strap)Muscles cover the lobes of the Thyroid, specifically Sterno-thyroid and -Sterno-hyoid. - Sternocleidomastoid overlaps the strap muscles. Development of Thyroid Q. What is the embryological Origin of Parafollicular & C cells? Development of thyroid What is??? * Pyramidal Lobe. * Thyroglossal duct * Thyroglossal cysts Clinical Examination of Thyroid Gland Why do you ask the patient to swallow, to test for thyroid swelling? http://www.youtube.com/watch?v =fHR2Tw6DxEg Fascial coverings of the neck & Thyroid gland Vessels and Nerves Arteries • Superior Thyroid from Ext. Carotid and • Inferior Thyroid from thyrocervical trunk of the subclavian • Thyroidea ima from the brachiocephalic artery or the arch of the aorta. Veins • Superior ends in the internal jugular • Middle ends in the internal jugular, and • Inferior thyroid veins ends in the brachiocephalic vein. Lymphatic vessels accompany arteries. Why ??? Nerves from the middle and inferior cervical ganglia of the sympathetic trunk. Blood Supply Nerves Nerves related to the thyroid gland • External laryngeal n. (function ??) & Sup. Thyroid a. • Recurrent laryngeal n. (function ??) & inf. Thyroid artery. • Sympathetic Nerves are subject to injury during thyroid surgery. Q. What happens if the external laryngeal n. is cut? Q. What happens if the recurrent laryngeal n. is cut? Posterior Relations Surgical importance of Thyroid Gland During Tracheotomy which part of the thyroid gland is/should be excised? (http://www.youtube.com/watch?v=d_5eKkwnIRs) Surgical importance of Thyroid Gland What layers do you need to cut through to reach thyroid, what muscles need to be pushed away/cut? What are the structures at risk? Parathyroid Glands Following surgery to remove a massive tumor of the thyroid gland, Mr. Smith started to complain of; - Tingling and burning (paresthesias) in fingertips, toes and lips - Muscle aches and leg cramps - Twitching (spasms) of muscle, especially around mouth. - Fatigue Following clinical exam & investigation he was diagnosed with hypo-parathyroidism ???? Control of Thyroid Hormones Sign / Symptom BODY WEIGHT TEMPERATURE SENSITIVITY HEART RATE Hypothyroidism Weight gain. Cold intolerance Bradycardia. Hyperthyroidism Weight loss. Heat intolerance Tachycardia. BLOOD PRESSURE Hypertension/hypotension. Hypertension. SEXUAL/REPRODUCTIVE FUNCTIONING Infertility. Loss of libido. Erectile dysfunction. Infertility. Loss of libido. Erectile dysfunction. ENERGY LEVELS Fatigue. Slow and sluggish. Sleepiness. Fatigue but hyperactive. Cannot sit still. BOWEL MOVEMENTS MENTAL STATE Constipation. Depression. Poor memory. Inability to concentrate. Diarrhea. Anxious. Irritable. FLUID ACCUMULATION Leg, hands, eyelid swelling (non-pitting edema) Myxedema. Round, puffy face. pleural effusion and pericardial effusion. Ankle swelling. Protruding eyeballs (exopthalmos). SKIN & HAIR Dry, pale skin. Dry, coarse hair. Hair loss. Loss of lateral eyebrows. Warm, sweaty skin Hair loss. Redness of the palms. REFLEXES/ MUSCLES Delayed relaxation of reflexes. Overactive reflexes (hyperreflexia). Tremors. http://www.healthhype.com/hypothyroidism-vs-hyperthyroidism-differences-in-signs-symptoms.html Suprarenal Glands Anatomy of Suprarenal glands Common disorders of suprarenal glands Anatomy of Suprarenal Glands Retroperitoneal Yellowish color. Superior to & slightly anterior to the upper pole of each kidney. Right one is triangular left is semilunar, larger, and at a higher level. T12 level 3-5 cm X 5mm thick, ~2 gms. Both glands are covered by fat and a fibrous capsule. Vessels and Nerves Arteries Superior Suprarenal artery, from inferior phrenic a. (which are branches of the aorta) Middle Suprarenal artery from the aorta, and Inferior Suprarenal artery from the renal a. Suprarenal veins - On the right side opens into the inferior vena cava, - On the left into the renal vein. Lymphatics end in the lumbar glands. Nerves from the celiac and renal plexuses, and from the phrenic and vagus nerves. Sympathetic fibers supply the medulla. Blood Supply of Suprarenal Glands Suprarenal Hormones • Sympathetic or Parasympathetic ??? Suprarenal Hormones Control by Zona glomerulosa, 15% of cortex Zona fasciculata, 75 % of cortex Zona reticularis, Deep layer of cortex Secretes aldosterone synthase Secretes the glucocorticoids cortisol and corticosterone, + small amounts of adrenal androgens & estrogens. secretes the adrenal androgens dehydroepi-androsterone (DHEA) and androstenedione, small amounts of estrogens and some glucocorticoids. Extracellular fluid concentrations of angiotensin II and potassium Hypothalamicpituitary axis via Adreno-corticotropic hormone (ACTH) ACTH & cortical androgenstimulating hormone Disturbances of Adrenal Cortical hormones EXCESS • 1. Cushing syndrome – excess of cortisol • 2. Hyperaldosteronism – excess of aldosterone • 3. Virilization syndrome – excess of androgens INSUFFICIENCY • 1. Primary acute adrenocortical insufficiency – adrenal crisis • 2. Primary chronic adrenocortical insufficiency – Addison disease • 3. Secondary adrenocortical insufficiency Primary Aldosteronism (Conn’s Syndrome) Tumors of the zona glomerulosa secretes large amounts of aldosterone Hypokalemia Increase in plasma Na concentration. Increase in extracellular fluid volume and blood volume Hypertension Hyperadrenalism-Cushing’s Syndrome Hypercortisolism can occur from; (1) Adenomas of: - Anterior pituitary ↑ ACTH, adrenal hyperplasia and excess cortisol secretion; Hypothalamus high levels of corticotropin- releasing hormone (CRH), ↑ ACTH release; Tumors “ectopic secretion” of ACTH by a tumors, Adenomas of the adrenal cortex. (low ACTH). (2) Administration of large doses of exogenous synthetic glucocorticoids for therapeutic uses. Signs & Symptoms of Cushing’s - Moon face - Buffalo torso (Buffalo hump) - Acne, hirsutism, and purplish striae in the skin - Hypertension - Suppressed immune system - Osteoporosis Adrenogenital Syndrome Excessive quantities of androgens that cause intense masculinizing effects throughout the body. Female - Growth of a beard, deeper voice, - Baldness if she also has the genetic trait, - Masculine distribution of hair, - Growth of the clitoris to resemble a penis. Prepubertal male, Growth of a beard, deeper voice Masculine distribution of hair Rapid development of the sexual organs. Adult male, difficult to make a diagnosis of adrenogenital syndrome in the adult male. In adrenogenital syndrome, the excretion of 17-ketosteroids in the urine may be 10 - 15 times normal. Hypoadrenalism-Addison’s Disease Addison’s disease results from failure of the adrenal cortices to produce adrenocortical hormones, caused by: Primary atrophy of the adrenal cortices. In 80 % of the cases, autoimmune. Tuberculous destruction of the adrenal glands, or Invasion of the adrenal cortices by cancer. Mineralocorticoid Deficiency. Decreases renal tubular sodium reabsorption NaCl & water loss. Hyponatremia, Hyperkalemia. Glucocorticoid Deficiency. Impossible to maintain normal blood glucose concentration between meals. Addisonian Crisis. In a person with Addison’s disease, the output of glucocorticoids does not increase during stress. Acute Hyponatremia, Hyperkalemia, Hypoglycemia, Hypercalcemia Disturbances of the Adrenal Medulla EXCESS Pheochromocytoma • Irritability/Nervousness • Pallor • Palpitations • Tachycardia • Hypertension & Blood pressure spikes • Severe headache • Sweating • Weight loss INSUFFICIENCY Congenital absence of adrenal medulla Rarely results in catecholamine insufficiency, because of sympathetic production of catecholamines.