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BENIGN THYROID

DISORDERS
Done by: bashayer m. AL-
Dossari
Lulwah t. Al-Turki
Supervised by: Dr. H. Wadaani
Thyroid Anatomy
The gland as seen from the front is more-1
.nearly the shape of a butterfly

composed of 2 encapsulated lobes, one-2


on either side of the trachea,
.connected by a thin isthmus

The thyroid extending from the level of-3


the fifth cervical vertebra down to
the first thoracic. The gland varies
from an H to a U shape, overlying
.the second to fourth tracheal rings

The pyramidal lobe is a narrow-4


projection of thyroid tissue
extending upward from the isthmus
and lying on the surface of the
.thyroid cartilage
Thyroid Anatomy
The thyroid is enveloped by a thin,-5
fibrous, nonstripping capsule that sends
septa into the gland substance to
produce an irregular, incomplete
.lobulation. No true lobulation exists

The weight of the thyroid of the normal-6


nongoitrous adult is: 10-20 g depending
.on body size and iodine supply

The width and length of the isthmus-7


,average; 20 mm
.and its thickness is ;2-6 mm

The lateral lobes from superior to inferior-8


poles usually measure 4 cm. and their
.thickness is 20-39 mm
Histologically
thyroid tissue is composed of
spherical thyroid follicles. Each
follicle consists of a single layer of
cuboidal follicular cells
surrounding a lumen filled with a
homogenous material called
colloid. With stimulation, the
follicular cells become columnar
and the follicles are depleted of
colloid; with suppression, the
follicular cells become flat and
colloid accumulates. The thyroid
also contains parafollicular C cells
.which produce calcitonin
Relations of the Lobes
:Anterolaterally-1
The sternothyroid*
The superior belly of the omohyoid *
The sternohyoid*
The anterior border of the *
.sternocleidomastoid

:Medially-2
.The larynx & the trachea *
The pharynx & the*
.oesophagus
Associated with these *
structures are the
cricothyroid muscle &
its nerve supply, the
external laryngeal
.nerve
In the groove between *
the esophagus and
the trachea is the
recurrent laryngeal
.nerve
Relations of the Lobes
:Posterolaterally-3
The carotid sheath with: The common carotid artery, the internal
.jugular vein, and the vagus nerve

Relations of the Isthmus


:Anteriorly-1
The sternothyroids
The sternohyoids
The anterior jugular veins
.Fascia & skin

:Posteriorly-2
.The second, third, & fourth rings of the trachea
The arterial supply to the
thyroid gland
Superior thyroid artery and superior-1
:laryngeal nerve
The superior thyroid artery is the first anterior
branch of the external carotid artery. In rare
cases, it may arise from the common carotid
. artery just before its bifurcation
the external branch of the superior laryngeal
.nerve runs with the superior thyroid artery

Inferior thyroid artery and recurrent-2


laryngeal nerve
The inferior thyroid artery arises from the
thyrocervical trunk, a branch of the
. subclavian artery
is closely associated with the recurrent laryngeal
. nerve

:The thyroidea ima, if present-3


May arise from the brachiocephalic artery or the
.arch of the aorta to supply the isthmus
Venous Drainage
:The superior thyroid vein-1
ascends along the superior thyroid artery and
becomes a tributary of the internal jugular
.vein
:The middle thyroid vein- 2
follows a direct course laterally to the internal
.jugular vein
:The inferior thyroid veins- 3
follow different paths on each side. The right
passes anterior to the innominate artery to
the right brachiocephalic vein or anterior to
the trachea to the left brachiocephalic vein.
On the left side, drainage is to the left
brachiocephalic vein. Occasionally, both
inferior veins form a common trunk called
the thyroid ima vein, which empties into the
.left brachiocephalic vein
Lymphatic drainage
The lymph from the thyroid gland drains mainly
laterally into the deep cervical lymph nodes.
A few lymph vessels descend to
the paratracheal
nodes.
innervation of the thyroid gland :
derives from the autonomic nervous system. Parasympathetic fibers come from
the vagus nerves, and sympathetic fibers are distributed from the superior,
middle, and inferior ganglia of the sympathetic trunk
Physiology
The thyroid follicles secretes tri-iodothyronine(T3)and thyroxin(T4)synthesis
involves combination of iodine with tyrosine group to form mono and di-
.iodotyrosine which are coupled to form T3 andT4

.The hormones are stored in follicles bound to thyrogobulin


When hormones released in the blood they are bound to plasma proteins and
.small amount remain free in the plasma

.The metabolic effect of thyroid hormones are due to free (unbound)T3 and T4
90%of secreted hormones is T4 but T3is the active hormone so, T4is converted
.to T3 peripherally
Physiological control of
secretion
Synthesis and libration of T3 and T4 is controlled by thyroid stimulating
.hormone(TSH)secreted by anterior pituitary gland

TSH release is in turn controlled by thyrotropin releasing hormone


.(TRH)from hypothalamus

Circulating T3and T4 exert ve feedback mechanism on hypothalamus


.and anterior pituitary gland

So, in hyperthyroidism where hormone level in blood is high ,TSH


.production is suppressed and vice versa
Clinical presentation of
specific condition
;HYPOTHYRODISM

Hypothyroidism is the disease state in humans and animals caused by insufficient


. production of thyroid hormone by the thyroid gland

Fatigue
Depression
Modest weight gain
Cold intolerance
Excessive sleepiness
Dry, coarse hair
Constipation
Dry skin
Muscle cramps
Increased cholesterol levels
Decreased concentration
Swelling of the legs
Clinical presentation of
specific condition
;Hyperthyroidism
Hyperthyroidism is a condition caused by the effects of too much thyroid hormone on
tissues of the body. Although there are several different causes of hyperthyroidism,
.most of the symptoms that patients experience are the same regardless of the cause

Increase appetite ,weight loss


Palpitations
Heat intolerance
Nervousness
Insomnia
Breathlessness
Increased bowel movements
Light or absent menstrual periods
Fatigue
, Eye: lid retraction
, lid lag
,exophthalmos
. ophthalmoplegia,chemosis
Clinical presentation of specific
condition
:THYROIDITIS
. Thyroiditis is an inflammation (not an infection) of the thyroid gland. Several types of thyroiditis exist

Hashimoto's Thyroiditis. Hashimoto's Thyroiditis (also called autoimmune or chronic -1


.lymphocytic thyroiditis) is the most common type of thyroiditis
Fatigue-Depression-Modest weight gain--Cold intolerance-Excessive sleepiness-Dry, coarse hair-
Constipation-Dry skin-Muscle cramps-Increased cholesterol levels-Decreased concentration-
Vague aches and pains-Swelling of the legs

De Quervain's Thyroiditis. (also called subacute or granulomatous thyroiditis). The thyroid -2


.[gland generally swells rapidly and is very painful and tender

Patients will experience a hyperthyroid period as the cellular lining of colloid spaces fails, allowing
abundant colloid into the circulation, with neck pain and fever. Patients typically then become
hypothyroid as the pituitary reduces TSH production and the inappropriately released colloid is
depleted before resolving to euthyroid. The symptoms are those of hyperthyroidism and
hypothyroidism. In addition, patients may suffer from painful dysphagia. There are multi-nucleated
giant cells on histology.Thyroid antibodies can be present in some cases.There is decreased
.uptake on isotope scan
Clinical presentation of
specific condition
Silent Thyroiditis. Silent Thyroiditis is the third and least common type of-3
..thyroiditis

Silent thyroiditis features a small goiter without tenderness and, like the other types of
resolving thyroiditis, tends to have a phase of hyperthyroidism followed by a phase of
hypothyroidism then a return to euthyroidism. The time span of each phase is not
.concrete, but the hypo- phase usually lasts 2-3 months
References
http://home.comcast.net/~wnor/lesson5.htm
en.wikipedia.org/wiki/Neck
www.answers.com/topic/sternothyroid-muscle
www.thyroidmanager.org
www.pitt.edu/~anat/Head/Thyroid/Thyroid.htm
Clinical medicine (kumar and clark)
Grants atlas of anatomy
:Pressure effect
. Dysphagia
. breathlesness & orthopnoea
.Hoarseness
.Facial congestion
Goitre
. Enlargement of thyroid gland
:Classification
.Simple (non-toxic) goitre
.Toxic goitre
.Neoplastic goitre
.Inflammatory goitre
Simple (non-toxic) goitre

:include
simple hyperplastic goitre (colloid goiter)
Cause: -physiological in pregnancy, puberty
.iodine definiecy -
Appearance: Large, smooth firm, non-tendern
goitre
.Effect: eythyroid & pressure effect

.Multinodular goitre
Cause: presence of areas of hyperplasia & areas
.of hypoplasia in gland
Appearance: Large, irregular, nodular goiter
. Effect: eythyroid & pressure effect
Toxic goitre
Graves disease
Cause: Autoimmune disease characterizeby
presence of antibodies stimulate TSH
.receptors in gland
.Appearance: Diffuce, nodular, hyperemic gland
.Effect: hyperthyroidism
Toxic Multinodular goiter
(plummers disease)
Cause: Toxic effect of MNG
.Appearance: Large, irregular, nodular goiter
Effect: hyperthyroidism
Neoplastic goitre
:Include
benign: adenoma-
malignant: papillary, follicular, anaplastic, medullary and -
lymphoma
.Cause: -complication of MNG
radiation-
Appearance: Enlarged goiter associated with
lymphadenopathy
. Effect: -pressure effect
.euthyroid-
invasive effect-
Inflammatory goitre
Rediels thyroditis
Cause: Fibrosis of thyroid
Appearance: Enlarged stony hard thyroid
Effect: Pressure effect

De quervains thyroiditis
Cause: Viral infection
Appearance: Diffuse, firm, tender swelling
Effect: Mild hyperthyroidism

Hashimotos thyroiditis
. Cause: Autoantibody against thyroid gland
Appearance: Diffuse, enlarged, non-tender goitre
Effect: Hypothyroidism
:Investigation
: Laboratory investigation
.serum T3, T4-
. serum TSH-
:serum LATS-
in graves disease
:thyroid antibodies-
.in hashimotos disease
serum cholesterol-
increase cholesterol level in hypothyroidism
:Radiological investigation

:chest and neck x-ray-


Show descend of thyroid gland to
thorax and mediastanal shifting in
. retrosternal goitre
iodine isotopes-
By i.v injection of I131. Then, use gama
. rays to show hot and cold nodules
CT scan-
Show thyroid size and if there is
compression to trachea
:Endoscopic investigation
bronchoscopy: show compression and -
infiltration of trachea by tumer
: Biopsy
.fine needle aspiration biopsy-
. true-cut biopsy-
Medical Treatment
:Antithyroid drugs
.e.g: carbimazole, propylthiouracil
It use to treat hyperthyroidism
:Mechanism
Inhibit thyroid hormones synthesis by block iodine
organification and also PTU inhibit conversation of T4
toT3
:Side effect
Drug rash
Lymphadenopathy
N/V
Agranulocytosis
:Beta-adernergic blockers
e.g: propranolol
it is control sympathetic over activty to control
.cardiovascular feature
:Radioactive iodine
Taken orally in solution
.Given for 8-12 wks
Use for recurrent hyperthyroidism
:Contraindication
Pregnant women
. Nursing mothers
:Surgical treatment

:Indication
.Failure of medical treatment
.Drug sensitivity in young patients
.Large goiter with compression symptoms
.Malignancy
:Preoperative preparation
Patient should become euthyroid before
.surgery to prevent thyroid crisis
.Assimment vocal cord condition
:Operation
.For solitary benign nodule: lobectomy
.For cancer: total thyroidectomy
For thyrotoxicosis: subtotal thyroidectomy
:Complication of operation
Hemorrhage
.Recurrent laryngeal nerve damage
Superior laryngeal nerve damage
Hypoparathyrodism
Hypothyroidism
Septesis
Postoperative infection
Hypertrofic scaring (keloid)
!!Thank You