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Generalities
• The surgical management of Graves' disease increased use of total or near-
total thyroidectomy.
• Total thyroidectomy is the surgical treatment of choice for most thyroid
cancers.
• Surgeons must be aware of the potential for false negative fine-needle
aspiration biopsy.
• Focused mini-incision parathyroidectomy, after appropriate localization, has
become the procedure of choice for the treatment of sporadic primary
hyperparathyroidism.
Thyroid gland
History
• Goiters (from the Latin guttur, throat), defined as an enlargement of the
thyroid, have been recognized since 2700 B.C.
• In 1619, Hieronymus Fabricius ab Aquapendente recognized that goiters
arose from the thyroid gland.
• The term thyroid gland (Greek thyreoeides, shield-shaped) is, however, attributed
to Thomas Warton in his Adenographia (1656).
• The most notable thyroid surgeons were Emil Theodor Kocher (1841–1917)
and C.A. Theodor Billroth (1829–1894).
Thyroid gland
Embryology
• Thyroglossal Duct Cyst and Sinus,during the fifth week of gestation, starts to
obliterate.
• Rarely, the thyroglossal duct may persist in whole, or in part.
• 80% are found in juxtaposition to the hyoid bone.
• They are usually asymptomatic but occasionally become infected by oral bacteria.
• It is of 1- to 2-cm, smooth, well-defined midline neck mass that moves upward with
protrusion of the tongue.
• Treatment involves the "Sistrunk operation," which consists of en bloc cystectomy
and excision of the central hyoid bone to minimize recurrence.
Thyroid Developmental Abnormalities
Ectopic Thyroid
• The thyroid lobes are located adjacent to the thyroid cartilage and connected in the
midline by an isthmus that is located just inferior to the cricoid cartilage.
• A pyramidal lobe is present in about 50% of patients.
• The strap muscles (sternohyoid, sternothyroid, and superior belly of the omohyoid)
are located anteriorly.
• The thyroid gland is enveloped by a loosely connecting fascia that is formed from
the partition of the deep cervical fascia into anterior and posterior divisions.
• The true capsule of the thyroid is a thin, densely adherent fibrous layer that sends
out septa that invaginate into the gland, forming pseudolobules.
Thyroid anatomy (from Schwartz’s Principles of Anatomy)
Thyroid anatomy
Recurrent Laryngeal Nerve (RLN)
• The left RLN arises from the vagus nerve where it crosses the aortic arch,
loops around the ligamentum arteriosum, and ascends medially in the neck
within the tracheoesophageal groove.
• The right RLN arises from the vagus at its crossing with the right subclavian
artery.
• The RLNs may branch, and pass anterior, posterior, or interdigitate with
branches of the inferior thyroid artery.
• Injury to one RLN leads to paralysis of the ipsilateral vocal cord.
Thyroid anatomy
Recurrent Laryngeal Nerve (RLN) in relation with inferior thyroid artery
Parathyroid Glands
• About 85% of individuals have four parathyroid glands that can be found
within 1 cm of the junction of the inferior thyroid artery and the RLN.
• The superior glands are usually located dorsal to the RLN, whereas the
inferior glands are usually found ventral to the RLN.
Parathyroid Glands
Thyroid Lymphatic System
• The average daily iodine requirement is 0.1 mg, which can be derived from foods
such as fish, milk, and eggs or as additives in bread or salt.
• In the stomach and jejunum, iodine is rapidly converted to iodide and absorbed
into the bloodstream, and from there it is distributed uniformly throughout the
extracellular space.
• Iodide is actively transported into the thyroid follicular cells by an adenosine
triphosphate (ATP)–dependent process.
• The thyroid is the storage site of >90% of the body's iodine content and accounts
for one third of the plasma iodine loss. The remaining plasma iodine is cleared via
renal excretion.
Thyroid Hormone Synthesis, Secretion, and Transport
• Both iodine 123 (123I) and iodine 131 (131I) are used to image the thyroid
gland.
• The images obtained by these studies provide information not only about the
size and shape of the gland, but also the distribution of functional activity.
• Areas that trap less radioactivity than the surrounding gland are termed cold,
whereas areas that demonstrate increased activity are termed hot.
• The risk of malignancy is higher in "cold" lesions (20%).
Radioactive iodine scan of the thyroid, with the arrow showing an area of
decreased uptake, a cold nodule.
Thyroid Imaging
Ultrasound
• Toxic multinodular goiters usually occur in older individuals, who often have a
prior history of a nontoxic multinodular goiter. Over several years, enough
thyroid nodules become autonomous to cause hyperthyroidism.
• Some patients have T3 toxicosis, whereas others may present only with atrial
fibrillation or congestive heart failure.
• Hyperthyroidism must be adequately controlled.
• Surgical resection is the preferred treatment of patients with toxic
multinodular goiter with subtotal thyroidectomy being the standard procedure.
Toxic Adenoma (Plummer's Disease)
• Painful thyroiditis most commonly occurs in 30- to 40-year-old women and is characterized
by the sudden or gradual onset of neck pain, which may radiate toward the mandible or ear.
• History of a preceding upper respiratory tract infection often can be elicited.
• The gland is enlarged, exquisitely tender, and firm.
• The disorder classically progresses through four stages.
• An initial hyperthyroid phase, due to release of thyroid hormone, is followed by a second,
euthyroid phase.
• The third phase, hypothyroidism, occurs in about 20 to 30% of patients and is followed by
resolution and return to the euthyroid state in >90% of patients.
• A few patients develop recurrent disease.
Chronic Thyroiditis
Lymphocytic (Hashimoto's) Thyroiditis
• If some nodules develop autonomy, patients have suppressed TSH levels or become
hyperthyroid.
• RAI uptake often shows patchy uptake with areas of hot and cold nodules.
• FNAB is recommended in patients who have a dominant nodule or one that is painful or
enlarging, as carcinomas have been reported in 5 to 10% of multinodular goiters.
• CT scans are helpful to evaluate the extent of retrosternal extension and airway
compression.
• Endemic goiters are treated by iodine administration.
• Surgical resection is reserved for goiters that (a) continue to increase despite T4
suppression, (b) cause obstructive symptoms, (c) have substernal extension, (d) have
malignancy suspected or proven by FNAB, and (e) are cosmetically unacceptable.
• Subtotal thyroidectomy is the treatment of choice and patients require lifelong T4 therapy
to prevent recurrence.
Malignant Thyroid Disease
• In the United States, thyroid cancer accounts for <1% of all malignancies
(2% of women and 0.5% of men) and is the most rapidly increasing cancer
in women.
• Thyroid cancer is responsible for six deaths per million persons annually.
• Most patients present with a palpable swelling in the neck, which initiates
assessment through a combination of history, physical examination, and
FNAB.
• The RET proto-oncogene plays a significant role in the pathogenesis of
thyroid cancers.
Malignant Thyroid Disease
Papillary Carcinoma
• Follicular carcinomas account for 10% of thyroid cancers and occur more
commonly in iodine-deficient areas.
• Follicular cancers usually present as solitary thyroid nodules, occasionally with a
history of rapid size increase, and long-standing goiter.
• Patients diagnosed by FNAB,a total thyroidectomy should be performed when
thyroid cancer is diagnosed microscopically.
• Poor long-term prognosis is predicted by age over 50 years old at presentation,
tumor size >4 cm, higher tumor grade, marked vascular invasion, extrathyroidal
invasion, and distant metastases at the time of diagnosis.
Thyroid Surgery
Conduct of Thyroidectomy
• Patients with any recent or remote history of altered phonation or prior neck surgery
should undergo vocal cord assessment by direct or indirect laryngoscopy before
thyroidectomy.
• A Kocher transverse collar incision, typically 4 to 5 cm in length, is placed in or parallel to a
natural skin crease 1 cm below the cricoid cartilage.
• The strap muscles are divided in the midline along the entire length of the mobilized flaps,
and the thyroid gland is exposed.
• The superior thyroid pole is identified by retracting the thyroid first inferiorly and medially
and then the upper pole of the thyroid is mobilized caudally and laterally. The dissection
plane is kept as close to the thyroid as possible and the superior pole vessels are individually
identified, skeletonized, ligated, and divided low on the thyroid gland to avoid injury to the
external branch of the superior laryngeal nerve.
Thyroid Surgery
Conduct of Thyroidectomy
• The inferior thyroid vessels are dissected, skeletonized, ligated, and divided as close
to the surface of the thyroid gland as possible to minimize devascularization of the
parathyroids (extracapsular dissection) or injury to the RLN.
• Once the ligament is divided, the thyroid can be separated from the underlying
trachea by sharp dissection.
• The pyramidal lobe, if present, must be dissected in a cephalad direction to above
the level of the notch in the thyroid cartilage or higher in continuity with the thyroid
gland.
Thyroid Surgery
Minimally Invasive Approaches