By: Dr Karthik Surendran

Under the guidance of: Dr Vimla Doshi Madam Dr Devendra Verma Sir Dr Hemlata Ameta Madam

Thyroid gland
Single, bilobed gland in the neck Largest of all endocrine glands Produces hormones thyroxine (T4) and tri-iodothyronine (T3) are dependent on iodine and regulate basal metabolic rate calcitonin which has a role in regulating blood calcium levels Unique among human endocrine glands it stores large amount of inactive hormone within extracellular follicles

Surface anatomy

Embryology and development

First endocrine gland to appear in embryonic development Begins to develop ~24 days after fertilisation from median endodermal thickening of pharynx forms a downgrowth called the thyroid diverticulum Descends into the neck as the embryo and tongue grows passes anteriorly to developing hyoid and laryngeal cartilages Connected to tongue by thyroglossal duct Thyroid diverticulum is initially hollow but becomes solid and divides into L and R lobes connected by isthmus

 Assumes definitive shape and final location by 7 weeks gestation, and the thyroglossal duct disappears Initially consists of solid mass of endodermal cells, which are broken up into network of epithelial cords by invasion of surrounding vascular mesenchyme lumen forms colloid forms by 11th week and thyroid follicles are formed, Synthesis of hormones commences

Structure - macro
Brownish-red and soft during life Usually weighs about 25-30g (larger in women) Surrounded by a thin, fibrous capsule of connective tissue
External to this is a false capsule formed by pretracheal fascia

Right and left lobes

United by a narrow isthmus, which extends across the trachea anterior to second and third tracheal cartilages

In some people a third pyramidal lobe exists, ascending from the isthmus towards hyoid bone

Position and relations

Clasps anterior and lateral surface of pharynx, larynx, oesophagus and trachea like a shield Lies deep to sternothyroid and sternohyoid muscles Parathyroid glands usually lie between posterior border of thyroid gland and its sheath (usually 2 on each side of the thyroid), often just lateral to anastomosis between vessel joining superior and inferior thyroid arteries Internal jugular vein and common carotid artery lie postero-lateral to thyroid

Position and relations

Recurrent laryngeal nerve is an important structure lying between trachea and thyroid
may be injured during thyroid surgery p ipsilateral VC paralysis, hoarse voice

Each lobe
pear-shaped and ~5cm long extends inferiorly on each side of trachea (and oesophagus), often to level of 6th tracheal cartilage

Attached to arch of cricoid cartilage and to oblique line of thyroid cartilage

moves up and down with swallowing and oscillates during speaking

Arterial supply
highly vascular main supply from superior and inferior thyroid arteries
lie between capsule and pretracheal fascia (false capsule)

all thyroid arteries anastomose with one another on and in the substance of the thyroid, but little anastomosis across the median plane (except for branches of superior thyroid artery)

Arterial supply
superior thyroid artery
first branch of ICA descends to superior pole of gland, pierces pretracheal fascia then divides into 2-3 branches

inferior thyroid artery

branch of thyro-cervical trunk runs superomedially posterior to carotid sheath reaches posterior aspect of gland divides into several branches which pierce pretracheal fascia to supply inferior pole of thyroid gland intimate relationship with recurrent laryngeal nerve in ~10% of people the thyroid ima artery arises from aorta, brachiocephalic trunk or ICA, ascends anterior to trachea to supply the isthmus

Venous drainage
usually 3 pairs of veins drain venous plexus on anterior surface of thyroid superior thyroid veins drain superior poles middle thyroid veins drain lateral parts superior and middle thyroid veins empty into internal jugular veins inferior thyroid veins drain inferior poles empties into brachio-cephalic veins often unite to form a single vein that drains into one or other brachio-cephalic vein

Lymphatic drainage
lymphatics run in the interlobular connective tissue, often around arteries communicate with a capsular network of lymph vessels pass to prelaryngeal LNs p pretracheal and paratracheal LNs lateral lymphatic vessels along superior thyroid veins pass to deep cervical LNs some drainage directly into brachio-cephalic LNs or directly into thoracic duct

Innervation
nerves derived from superior, middle and inferior cervical sympathetic ganglia
reach thyroid through cardiac and laryngeal branches of vagus nerve which accompany arterial supply

postganglionic fibres and vasomotor indirect action on thyroid by regulating blood vessels

Thyroid hormones function

Likely that all cells express thyroid hormone receptors Metabolism
Increases basal metabolic rate Increases carbohydrate and lipid metabolism

Normal growth Normal development

Especially CNS

Other systems
CVS increases heart rate, cardiac output CNS mental acuity Reproduction fertility requires normal thyroid function

Thyroid hormones structure

Derivatives of the amino acid tyrosine bound covalently to iodine 2 principal thyroid hormones
thyroxine (T4 or L-3,5,3',5'-tetraiodothyronine) triiodotyronine (T3 or L-3,5,3'-triiodothyronine)

 Thyroid hormones stored conjugated to thyroglobulin, but are cleaved by pinocytosis before being released into circulation Majority of the thyroid hormone secreted is T4 (90%), but T3 is the considerably more active hormone Although some T3 is also secreted, most is derived by deiodination of T4 in peripheral tissues, especially liver and kidney Deiodination of T4 also yields reverse T3 (no known metabolic activity) Both are poorly water soluble 99% of circulating thyroid hormone is bound to carrier protein (mostly thyroxine-binding globulin, but also transthyrein and albumin)
Provides a stable pool from which unbound/free hormone is released for uptake by target organs

Structure - micro
Functional units are follicles responsible for synthesis and secretion of T3 and T4
Irregular spheroidal structures consisting of a single layer of cuboidal epithelium + basement membrane Variable in size.

Occasional scattered clear cells/parafollicular cells/C cells produce and secrete calcitonin Gland enveloped by outer capsule of loose supporting connective tissue and an inner fibroelastic capsule Fine collagenous septa extend into the gland dividing into lobules and conveying blood supply, lymphatics and nerves Colloid is the secretory product of follicular cells
Extra-cellular proteinaceous substance composed of thyroid hormones linked together with protein (thyroglobulin)

Thyroid regulation

Effects of TSH on thyroid gland

Increased thyroglobulin proteolysis p increased circulating thyroid hormones Increased activity of iodide pump - increases cellular iodine uptake Increased iodination of tyrosine and coupling Increased size and secretory activity of thyroid cells Increased number of thyroid cells, plus change from cuboidal to columnar epithelial structure

Basic Thyroid Gland Physiology

Hormones triiodothyronine (T3) and thyroxine (T4) are bound to proteins and stored in the thyroid gland. T3 is more potent and less protein bound, most T3 is made in peripheral tissues from the de-iodination of T4 Both hormones increase carbohydrate and fat metabolism, increasing metabolic rate, minute ventilation, heart rate and contractility, water / electrolyte balance, normal function of CNS.

Thyroid pathology
Normal thyroid function - euthyroidism Disease states may result in hyper- or hypothyroidism - relative excess or deficiency of thyroid hormones Any swelling of the thyroid may be termed a goitre
Toxic goitre: associated with increased thyroid hormone output Non-toxic goitre: normal hormone levels (Non-specific terms; dont relate to a particular pathology)

Hyperthyroidism
Causes Graves Disease-most common toxic multinodular goiter TSH hormone secreting pituitary tumors functioning thyroid adenomas overdose of thyroid replacement medication

Hyperthyroidism
Diagnosis : made by abnormal TFTs,
elevated total and free T4, T3 low TSH, elevated free thyroxine index consists of drugs that inhibit hormone synthesis (propylthiouracil, methimazole), inhibit hormone release (potassium, or sodium iodide) or mask the signs of adrenergic activity (Beta-blocker) While Beta blockade does not affect thyroid gland function, it does decrease the peripheral conversion of T4 to T3( specifically propranolol) Radioactive iodine and subtotal thyroidectomy are other alternatives to medical therapy

Clinical Manifestations
Weight loss heat intolerance muscle weakness diarrhea hyperactive reflexes nervousness / anxiety Physical: fine tremor, exophthalmos, goiter, warm clammy skin, fine brittle hair Cardiac: sinus tachycardia , A Fib, increase in contractility, CO

Anesthetic considerationsPreoperative
Ideally patient should be rendered euthyroid prior to any elective procedure. Normal thyroid function tests, and a resting heart rate less than 85 beats/min has been recommended Beginning pre-op antithyroid meds take 2-6weeks for effect, can use KI with Beta-blocker in addition, or as alternative Benzodiazepines are good choice for pre-operative sedation Careful evaluation of patients airway

Preoperative
Patient with a large goiter and an obstructed airway can be handled in the same way as any other patient with problematic airway management an airway should be established, often with the patient awake. A firm armored endotracheal tube is preferable and should be passed beyond the point of extrinsic compression. Examine CT scans of the neck preoperatively to determine the extent of compression

Preoperative
Glucocorticoids such as dexamethasone (8 to 12 mg/day) are used in the management of severe thyrotoxicosis They reduce thyroid hormone secretion and the peripheral conversion of T4 to T3 For emergency surgery hyperdynamic circulation can be controlled by titration of an esmolol infusion.

Intraoperative

Drugs that stimulate sympathetic nervous system should be avoided because of the possibility of large increases in blood pressure and heart rate. Eg : Ketamine. Pancuronium, atropine, ephedrine, epinephrine Thiopental may be induction agent of choice as it possess antithyroid activity at high doses.

Intraoperative
Close monitoring of cardiac function and body temperature is required Adequate anesthetic depth should be obtained prior to laryngoscopy or surgical stimulation to avoid tachycardia, hypertension, ventricular dysrhythmias Eye protection as the exophthalmos of Graves' disease increases the risk of corneal abrasion or ulceration The head of the operating table can be raised 1520 to aid venous drainage and decrease blood loss,with increased risk of venous air embolism

Intraoperative
Anticipate exaggerated hypotensive response during induction as patient may be chronically hypovolemic and vasodilated (NMBAs) administered cautiously, as thyrotoxicosis is associated with an increased incidence of myopathies and myasthenia gravis Hyperthyroidism does not increase MAC requirements, volatile agents can be used safely

Postoperative
Thyroid Storm is most serious post-op problem Characterized by: hyperpyrexia, tachycardia, altered consciousness, and hypertension Precipitating factors: infection, trauma, surgery Incidence is 10% in patients hospitalized for thyrotoxicosis Onset is usually 6-24 hours after surgery, but can happen intraoperatively mimicking malignant hyperthermia Unlike MH, not associated with muscle rigidity, elevated CPK, or marked degree or lactic or respiratory acidosis

Treatment : IV Hydration IV propanolol (.5mg increments)/esmolol infusion to control heart rate until less than 100. Propylthiouracil 250-500 mg 6hrly orally or by NG tube Sodium Iodide 1g IV over 12 hours correction of any precipitating events (infection) Cortisol (100-200mg 8hrly) is recommended if there is any coexisting adrenal gland suppression Mortality rate is approximately 20%

 Cooling blankets meperidine (2550 mg) IV every 46h may be used to prevent shivering. Use digoxin for heart failure especially in the presence of atrial fibrillation with rapid ventricular response

Anesthetic Considerations Subtotal Thyroidectomy

Associated with several complications: Recurrent laryngeal nerve palsy may cause hoarseness if unilateral, or stridor if bilateral Vocal cord function may be evaluated by DL after deep extubation if there is concern Hematoma formation may cause airway compromise. May require immediate opening of neck wound Hypoparathyroidism may result from unintentional removal of parathyroid glands. Hypocalcemia will result within 24-72 hours Pneumothorax

Hypothyroidism
Incidence : 1% of adult population, ten times more prevalent in women Diagnosis : can be confirmed by low free thyroxine levels and elevated TSH (if primary) Medical Treatment : consist of oral hormone replacement therapy

Causes
Primary : Autoimmune Irradiation to the neck Previous Iodine therapy Surgical removal Thyroiditis (Hashimoto disease) Severe iodine depletion Medications (iodines, propylthiouracil, methimazole) Hereditary defects in biosynthesis Congenital defects in gland development Secondary : Pituitary Hypothalamic

Clinical Manifestations
Hypothyroidism in early neonatal development may result in cretinism. In adults, manifestations can be subtle: weight gain, cold intolerance, muscle fatigue, lethargy, constipation, hypoactive muscle reflexes, depression, periorbital or pretibial swelling Heart rate, contractility, stroke volume, and cardiac output decreases, extremities may be cold, hair may be coarse and brittle.

Other abnormalities include anemia, coagulopathy, hypothermia, sleep apnea, and impaired renal free water clearance with hyponatremia Decreased GI motility the stress response may be blunted and adrenal depression may occur

Anesthetic considerations
Patients with uncorrected severe hypothyroidism (T4<1 g/dL) or myxedema coma should not undergo elective surgery. Potential for severe cardiovascular instability intraoperatively and myxedema coma. If emergency surgery is necessary, in patients with overt disease or myxedema coma, IV thyroxine and steroid coverage. Euthyroid state is ideal, however, subclinical cases of hypothyroidism have not shown to significantly increase risk of surgery Continue thyroid replacement meds till morning of surgery

Preoperative
Airway evaluation: patients tend to be obese, large tongue, short neck, goiter, swelling of upper airway Pre-op sedation should be administered cautiously if at all, as patients are more prone to drug induced respiratory depression from sedatives and narcotics Consider aspiration prophylaxis with H2 antagonists, Metoclopromide as many hypothyroid patients have delayed gastric emptying times

Intraoperative
Patients are more sensitive to hypotensive effects of anesthetic agents because of decreased cardiac output, blunted baroreceptor reflexes, and decreased intravascular volume. Ketamine may be induction agent of choice Succinylcholine and non-depolarizing muscle relaxants are generally safe for use. Monitor with peripheral nerve stimulator . Controlled ventilation is recommended as patients tend to hypoventilate

Intraoperative
Ventilatory responsiveness to hypoxia and hypercapnia is depressed in hypothyroid patients. This depression is potentiated by sedatives, opioids, and general anesthesia. Postoperative ventilatory failure requiring prolonged ventilation is rarely seen in hypothyroid patients in the absence of coexisting lung disease, obesity, or myxedema coma

Intraoperative
Scrupulous attention should be paid to maintaining normal body temperature Hypothermia occurs quickly and difficult to prevent and treat MAC is essentially unchanged Hematological, electrolyte imbalances, and hypoglycemia is common and require close monitoring intraoperatively Consider co-existing adrenal insufficiency in cases of refractory hypotension

Myxedema Coma
Rare form of decompensated Hypothyroidism characterized by stupor or coma, hypoventilation, hypothermia, bradycardia, hypotension, and severe dilutional hyponatremia(SIADH), CHF Medical emergency with mortality rate of 15-25% Infection, trauma, cold, CNS depressants predispose hypothyroid patients, especially in elderly

Myxedema Coma
Treatment :
Tracheal intubation and controlled ventilation as needed Levothyroxine, 200300 g IV loading dose, followed by 50-200 g IV/day The ECG must be monitored during therapy to detect myocardial ischemia or arrhythmias Hydrocortisone, 100 mg IV, then 25 mg IV q6h

 Fluid and electrolyte therapy as indicated by serum electrolytes Cover to conserve body heat; no warming blankets Support cardiovascular and pulmonary systems as necessary

Myxedema Coma (contd)

Improvements in heart rate, blood pressure, and body temperature may occur within 24 hours. However, replacement therapy may precipitate myocardial ischemia. Increased likelihood of acute primary adrenal insufficiency in these patients, so they receive stress doses of hydrocortisone. Steroid replacement continues until normal adrenal function can be confirmed.

Postoperative
Extubation/Emergence may be delayed secondary to hypothermia, respiratory depression, or slowed drug metabolism Awake extubation, try to maintain normothermia Patients often require prolonged mechanical ventilation Cautiously administer opioids post-op, consider regional techniques or Ketorolac for post-op pain control

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