Thyroid gland anatomy, diseases , history and treatment

1. THYROID GLAND
Abdelrahman Al-daqqa
Dr Abdul Jabbar Samar ,

2.  This is the normal
appearance of the
thyroid gland on the
anterior trachea of the
neck..

4. Normal thyroid seen microscopically consists of follicles
lined
by a cuboidal epithelium and filled with pink,
homogenous colloid

5. CONTENTS:
 Thyroid gland
Anatomy
Physiology
history
Examination
Tumors

6. Anatomy of Thyroid gland

7. Anatomy
 Blood Supply
:Superior and inferior thyroid arteries
 Venous drainage
Superior, middle and inferior thyroid veins

8. Nearby structures
 Recurrent and external laryngeal
nerves
 Parathyroid glands
 Trachea / larynx
 Oesophagus / pharynx
 Carotid sheath

10. Physiology of Thyroid
 TRH
 TSH
 T4,T3

12. Hyper vs Hypo
 TSH
 T3,T4
 Most common causes
 Clinical manifestations

29. THYROID TUMOURS
1-BENIGN:
Follicular adenoma
2-MALIGNANT:
 Carcinoma of thyroid
 Papillary carcinoma
 Follicular carcinoma
 Medullary carcinoma
 Anablastic carcinoma
Lymphoma
Others – rare (sq. ca, sarcomas,
metastasis)

30. ADENOMA
 Always follicular adenoma
 No papillary adenoma of thyroid.
 Solitary & encapsulated.
 No capsular invasion.
 Histology: Follicles –> macro (colloid), micro (fetal),
normal size (simple), trabecular (embryonal).
 Sometimes composed of Hürthl cells (oncocytic)
Hurthle cell adenoma.

31. ADENOMA

32. CARCINOMA OF THYROID
 Causes:
Ionizing radiation
Hashimoto’s thyroiditis
Grave’s disease?

33. Papillary Carcinoma 60-70%
• The most common type
• Young age 20-50y , F:M=3:1
• Forming papillae and psammoma bodies
• 50% at presentation  Cervical LN
metastasis
• Haematogenous spread is rare (not
common)

34. • Follicular variant of papillary
carcinoma :
• No papillary formation .
• The nuclei shows typical nuclear ground glass
appearance of papilary crcinoma.
• Grow slowly with indolent course
• Occult microscopic variant

35. Follicular Carcinoma
 Macroscopically often encapsulated
similar to adenoma
 Histologically : composed of follicles
with no
papillary formation and no
groundglass nuclear changes.
 sometimes the cells are oncocytic
(Hurthle cell carcinoma).

36. Follicular Carcinoma
 Haematogenous spread (lung, bone, liver. . )
 Poorer in prognosis than papillary carcinoma.
 Represent approximatly 15%
 Most patients are >40y
 TYPES:
1- minimally invasive FC.
2- widely invasive FC.

37. Medullary Carcinoma of thyroid <5%
 Derived from calcitonin – secreting
C-cells
 Characterized by formation of amyloid
material from calcitonin, surrounded
by small to medium sized cells with
round to spindle shaped nuclei
forming sheets, nests or cords

38. Medullary Carcinoma
amyloid

39. Medullary Carcinoma
 It has slow but progressive growth
 Both lymphatic and hematogenous
metastasis occurs
 10-20% are familial, multicenteric in
young age.
 Immuno: +ve calcitonin
 80-90% sporadic, solitary, old age

40. Anablastic carcinoma 5-10%
0ccurs in patient > 60 y
 Poorly differentiated, highly malignant tumour usually
forms bulky necrotic mass often disseminate extensively
through blood
 death occurs within 1-2 years (<10% survive for 10y)
• Histological variants:
 Giant cells, spindle cells(sarcomatoid), squamoid cells

41. Approach?

42. History (neck swellingHistory (neck swelling))
-When was it first noticed? (appear )When was it first noticed? (appear )
- What made the patient notice the lump?What made the patient notice the lump?
- What are the symptoms of the swelling? (pain / discharge/ interfere withWhat are the symptoms of the swelling? (pain / discharge/ interfere with
breathing/swallowing?)breathing/swallowing?)
- Has the swelling changed since it was first noticed? (bigger / smaller / fluctuateHas the swelling changed since it was first noticed? (bigger / smaller / fluctuate
in size?)in size?)
- Does the swelling ever disappear? (on lying down / exercise?)Does the swelling ever disappear? (on lying down / exercise?)
- Has the patient ever had any other swelling? (in the past / concurrent?)Has the patient ever had any other swelling? (in the past / concurrent?)
- What does the patient think caused the swelling? (injury / systemic illness?)What does the patient think caused the swelling? (injury / systemic illness?)

45. Physical examinationPhysical examination
 Examination of the head and neck is
challenging in that much of the area to
be examined is not easily visualized.
Patience and practice are necessary
to master the special instruments and
techniques of examination

46. Physical examinationPhysical examination
--InspectionInspection
--PalpationPalpation
--PercussionPercussion
--AuscultationAuscultation

47. inspection
 Site
• Also, single vs. multiple.
• Distance from a bony prominence landmark.
 Size
 Shape
 Surrounds
• Remote surrounds first, then local surrounds.
• Also, surrounding neurological or motor deficits.
 Surface
• Smooth vs. rough vs. indurated.
• Skin, scars.
 Edge
• Clear vs. poorly defined.
 Transillumination, if applicable.
• Whether a torch behind lump will allow light to shine through.
• Esp. used in testicular mass.

48. Palpation
 Temperature
• Feel with back of fingers on surface, surrounds.
 Tenderness
• Ask to tell when feel pain.
• Nerve: can cause pins and needles.
 Consistency
• Soft, spongy, firm.
 Mobility and attachment
• Move lump in two directions, right-angled to each other. Then repeat exam when muscle
contracted:
• Bone: immobile.
• Muscle: contraction reduces lump mobility.
• Subcutaneous: skin can move over lump.
• Skin: moves with skin.
 Pulsatile
• Assess with 2 fingers on mass:
• Transmitted pulsation: both fingers pushed same direction.
• Expansile: fingers diverge (esp for AAA).
 Fluctuation [fluid-containing]
• Assess by placing 2 fingers in "peace sign" on either edge of lump, then tapping lump center
with index finger of other hand: fluctuant lump will displace peace sign fingers.
• Very large masses can be assessed by a fluid thrill. See Ascites examination.
 Irreducible
• Compressible: mass decreases with pressure, but reappears immediately upon release.
• Reducible: mass reappears only on cough, etc.

49. Percussion and auscultation
 Percussion:
• Dullness.
• Resonance.
 Auscultation:
• Bruit.

50. 11..CBC :-CBC :- ( infection , lymphoma( infection , lymphoma
……..etc……..etc. ( .. ( .
33..TFT :-TFT :- ( Thyroid( Thyroid( .( .
44..PTH :-PTH :- ( Parathyroid( Parathyroid((
55..Calcitonin . Thymoglobulin :-Calcitonin . Thymoglobulin :-
( Thyroid( Thyroid( .( .
66..Tuberculine test :-Tuberculine test :- ( T.B( T.B. ( .. ( .
77..CXR :-CXR :- ( Lung lesions( Lung lesions( .( .
..

51. •History
•Physical exam.
•Tests of thyroid function
a. TSH ( thyrotropine( single most sensitive
test
b. TT4 ( total thyroxine(
c. FT4 ( free thyroxine(
d. TT3 ( total triioddthyronine(
e. FT3
•Ultrasound
• Isotope scanning
Assessment of pts with thyroid disease

52. 90% of nodules categorized as
1. benign group 65%
2. suspicious 15%
3. malignant 5%
4. nondiagnostic 15%
• Thyroglobulin levels
• Serum calcitonin
• CT. scan & MRI
•FNAC

55. Recurrent laryngeal nerve
injury

56. Thank you!