Description

2. Embryology
• The thyroglossal duct develops from the median bud of the pharynx
• The foramen caecum at the junction of the anterior two-thirds and
posterior one-third of the tongue is the vestigial remnant of the duct
• This initially hollow structure migrates caudally and passes in close
continuity with, and sometimes through, the developing hyoid cartilage
• The parathyroid glands develop from the third and fourth pharyngeal
pouches
• The thymus also develops from the third pouch
• As it descends, the thymus takes the associated parathyroid gland with
it

3. Embryology
•The developing thyroid lobes amalgamate with the
structures that arise in the fourth pharyngeal pouch, i.e.
the superior parathyroid gland and the ultimobranchial
body
•Parafollicular cells (C cells) from the neural crest reach the
thyroid via the ultimobranchial body

4. SurgicalAnatomy
•The normal thyroid gland weighs 20–25 g
•The functioning unit is the lobule supplied by a single
arteriole and consists of 24–40 follicles lined with cuboidal
epithelium
•The follicle contains colloid in which thyroglobulin is stored
•The arterial supply is rich, and extensive anastomoses occur
between the main thyroid arteries and branches of the
tracheal and oesophageal arteries

5. SurgicalAnatomy
•There is an extensive lymphatic network within and around
the gland
•Some lymph channels pass directly to the deep cervical
nodes, the subcapsular plexus drains principally to the
central compartment juxtathyroid – ‘Delphian’ and
paratracheal nodes and nodes on the superior and inferior
thyroid veins (level VI), and from there to the deep cervical
(levels II, III, IV and V) and mediastinal groups of nodes (level
VII)

6. SurgicalAnatomy
•The relationship between the recurrent laryngeal nerve
(RLN) and the thyroid is of supreme importance
•The nerve recurs round the arch of the aorta on the left
and the subclavian artery on the right
•The clinical signi
fi
cance of this is that on the left the
nerve has more distance in which to reach the
tracheoesophageal groove and therefore runs in a medial
plane

7. SurgicalAnatomy
•On the right, there is less distance and the nerve runs more
obliquely to reach the tracheoesophageal groove
•The nerve runs posterior to the thyroid and enters the larynx at
the cricothyroid joint
•This entry point is at the level of Berry’s ligament, a
condensation of pretracheal fascia that binds the thyroid to the
trachea
•This is the point at which the nerve is at most risk of injury
during surgery

9. Physiology
•The hormones tri-iodothyronine (T3) and l-thyroxine (T4) are bound to
thyroglobulin within the colloid
•The parafollicular C cells of the thyroid are of neuroendocrine origin
and arrive in the thyroid via the ultimobranchial body. They produce
calcitonin.
•Synthesis and release of thyroid hormones from the thyroid is
controlled by thyroid-stimulating hormone (TSH) from the anterior
pituitary.
•Secretion of TSH depends upon the level of circulating thyroid
hormones and is modi
fi
ed in a negative feedback manner

10. Physiology
•In hyperthyroidism TSH production is suppressed, whereas in
hypothyroidism it is stimulated
• Regulation of TSH secretion also results from the action of
thyrotrophin-releasing hormone (TRH) produced in the hypothalamus
•A family of IgG immunoglobulins bind with TSH receptor sites
(TRAbs) and activate TSH receptors on the follicular cell membrane
•They have a more protracted action than TSH (16–24 versus 1.5–3
hours) and are responsible for virtually all cases of thyrotoxicosis not
due to autonomous toxic nodules

12. ThyroidImaging
•USG: The workhorse investigation in thyroid disease for the
surgeon
•This modality allows assessment of the gland and the
regional lymphatics
•During ultrasound,
fi
ne needle aspiration (FNA) can be
performed more accurately than free-hand techniques allow
•Ultrasound has the advantages that it is not associated with
ionising radiation and is non-invasive and cheap

13. ThyroidImaging
•USG: The workhorse investigation in thyroid disease for the surgeon
•This modality allows assessment of the gland and the regional
lymphatics
•During ultrasound,
fi
ne needle aspiration (FNA) can be performed
more accurately than free-hand techniques allow
•Ultrasound has the advantages that it is not associated with ionising
radiation and is non-invasive and cheap
•Visualisation of the central neck nodes, in particular those behind
the sternum, is however limited

14. ThyroidImaging
•CT Scan: Required when metastatic disease is detected and cross-
sectional imaging is required to fully stage the disease
•Retrosternal extension also requires more advanced techniques to
determine the extent adequately prior to considering management
•In the setting of an invasive primary thyroid cancer, both CT and
magnetic resonance imaging (MRI) may have a role
•CECT is useful for determining the extent of airway invasion
•MRI is superior at determining the presence of prevertebral fascia invasion
•PET scans have limited application in thyroid disease

15. IsotopeScanning
•The uptake by the thyroid of a low dose of either radiolabelled iodine
( I131) or the cheaper technetium (99mTc) will demonstrate the
distribution of activity in the whole gland
•Routine isotope scanning is unnecessary and inappropriate for
distinguishing benign from malignant lesions because the majority
(80%) of ‘cold’ swellings are benign and some (5%) functioning or
‘warm’ swellings will be malignant
•Its principal value is in the toxic patient with a nodule or nodularity of
the thyroid
•Whole-body scanning is used to demonstrate metastases

16. IsotopeScanning

17. ThyroidEnlargement
•Normal thyroid gland is impalpable
•Goitre ( Latin guttur = the throat ) is generalised
enlargement of the thyroid gland
•A discrete swelling (nodule) in one lobe with no palpable
abnormality elsewhere is termed an isolated (or solitary)
swelling
•Discrete swellings with evidence of abnormality
elsewhere in the gland are termed dominant

18. SimpleGoitre
•Develops as a result of stimulation of the thyroid gland by TSH, either as
a result of inappropriate secretion from a microadenoma in the anterior
pituitary (which is rare), or in response to a chronically low level of
circulating thyroid hormones
•The most important factor in endemic goitre is dietary de
fi
ciency of
iodine
•Defective hormone synthesis also accounts for many sporadic goitres
•The daily requirement of iodine is about 0.1–0.15mg
•In nearly all districts where simple goitre is endemic, there is a very low
iodide content in the water and food.

19. SimpleGoitre
•Endemic areas are in the mountainous ranges, such as the Rocky Mountains, the Alps,
the Andes and the Himalayas
•Calcium is also goitrogenic and goitre is common in low-iodine areas on chalk or
limestone
•Although iodides in food and water may be adequate, failure of intestinal absorption
may produce iodine de
fi
ciency
•DYSHORMONOGENESIS: Enzyme de
fi
ciencies of varying severity may be responsible
for many sporadic goitres, i.e. in non-endemic areas
•Enzyme de
fi
ciencies of varying severity may be responsiblefor many sporadic goitres,
i.e. in non-endemic areas
•Environmental factors may compensate in areas of high iodine intake; for example,
goitre is almost unknown in Iceland where the
fi
sh diet is rich in iodine

20. Goitrogens
•Well-known goitrogens are the vegetables of the brassica
family (cabbage, kale and rape), which contain thiocyanate
•Drugs such as para-aminosalicylic acid (PAS) and the
antithyroid drugs
•Iodides in large quantities are goitrogenic because they inhibit
the organic binding of iodine and produce an iodide goitre
•Excessive iodine intake may be associated with an increased
incidence of autoimmune thyroid disease.

21. StagesofGoitreFormation
•Persistent growth stimulation causes di
ff
use hyperplasia; all lobules are composed
of active follicles and iodine uptake is uniform. This is a di
ff
use hyperplastic goitre,
which may persist for a long time but is reversible if stimulation ceases
•Later, as a result of
fl
uctuating stimulation, a mixed pattern develops with areas of
active lobules and areas of inactive lobules
•Active lobules become more vascular and hyperplastic until haemorrhage occurs,
causing central necrosis and leaving only a surrounding rind of active follicles
•Necrotic lobules coalesce to form nodules
fi
lled either with iodine-free colloid or a
mass of new but inactive follicle
•Continual repetition of this process results in a nodular goitre. Most nodules are
inactive, and active follicles are present only in the inter nodular tissue

23. DiffuseHyperplastic Goitre
•The goitre appears in childhood in endemic areas but, in sporadic
cases, it usually occurs at puberty when metabolic demands are
high
•If TSH stimulation ceases the goitre may regress
•May recur later at times of stress such as pregnancy
•It is soft, di
ff
use and may become large enough to cause discomfort
•A colloid goitre is a late stage of di
ff
use hyperplasia, when TSH
stimulation has fallen o
ff
and when many follicles are inactive and
full of colloid

24. Nodular Goitre
•Nodules are usually multiple, forming a multinodular goitre
•Occasionally, only one macroscopic nodule is found
•Nodules may be colloid or cellular, and cystic degeneration and
haemorrhage are common, as is subsequent calci
fi
cation
•Nodules appear early in endemic goitre and later (between 20 and
30 years) in sporadic goitre
•All types of simple goitre are more common in the female than in
the male due to the presence of oestrogen receptors in thyroid
tissue

25. Diagnosis
•The patient is euthyroid, the nodules are palpable and often visible
•They are smooth, usually
fi
rm and not hard and the goitre is painless
and moves freely on swallowing
•Hardness and irregularity, due to calci
fi
cation, may simulate carcinoma
•Pain, sudden appearance or rapid enlargement of a nodule raises
suspicion of carcinoma but is usually due to haemorrhage into a
simple nodule
•Di
ff
erential diagnosis from autoimmune thyroiditis may be di
ffi
cult
and the two conditions frequently coexist

26. Investigations
•Thyroid Function Tests and Thyroid antibody tests to
di
ff
erentiate with auto-immune thyroiditis
•USG is the gold standard
•FNAC, preferably USG guided
•If there are swallowing or breathing symptoms then a CT
scan of the thoracic inlet to assess tracheal or
oesophageal compression

27. Complications
•Tracheal obstruction is due to gross lateral displacement or compression
in a lateral or anteroposterior plane by retrosternal extension of the goitre
•Acute respiratory obstruction may follow haemorrhage into a nodule
impacted in the thoracic inlet
•Transient episodes of mild hyperthyroidism are common, occurring in up
to 30% of patients - Secondary Thyrotoxicosis
•Carcinoma: Increased incidence of cancer (usually follicular) has been
reported from endemic areas.
•Rapidly growing nodules in longstanding goitres should always be
subjected to aspiration cytology.

28. Prevention&Treatment
•In endemic areas the incidence of goitre has been strikingly
reduced by the introduction of iodised salt
•In the early stages, a hyperplastic goitre may regress if thyroxine
is given in a dose of 0.15–0.2 mg daily for a few months
•Nodular stage of simple goitre is irreversible but more than half
of benign nodules will regress in size over 10 years
•Most patients with multinodular goitre are asymptomatic and
do not require operation

29. Prevention&Treatment
•Surgery is indicated i) for nodular goitres with features of underlying
malignancy ii) for swallowing symptoms if other causes have been
excluded iii) for cosmetic reasons iv) for tracheal compression
•Choice of treatment 1) Total Thyroidectomy with lifelong
replacement therapy 2) Subtotal thyroidectomy involves partial
resection of each lobe removing the bulk of the gland, leaving up to
8g of relatively normal tissue in each remnant 3) total lobectomy on
the more a
ff
ected side is the appropriate management with either
subtotal resection (Dunhill procedure) or no intervention on the less
a
ff
ected side

30. ChoiceofTreatment
•Total thyroidectomy with immediate and lifelong replacement
of thyroxine
•Partial resection to conserve su
ffi
cient functioning thyroid
tissue
•Subtotal thyroidectomy involves partial resection of each lobe
removing the bulk of the gland
•Total lobectomy on the more a
ff
ected side is the appropriate
management with either subtotal resection (Dunhill procedure)
or no intervention on the less a
ff
ected side

31. ChoiceofTreatment
•In many cases, the causative factors persist and
recurrence is likely
•Reoperation for recurrent nodular goitre is more di
ffi
cult
•and hazardous
•The recent trend is total thyroidectomy in younger
patients

32. Clinicallydiscreteswellings
•Discrete thyroid swellings (thyroid nodules) are common
•3-4 times more frequent in women than men
•A discrete swelling in an otherwise impalpable gland is termed
isolated or solitary
•Termed dominant for a similar swelling in a gland with clinical
evidence of generalised abnormality in the form of a palpable
contralateral lobe or generalised mild nodularity
•Demonstrating the presence of impalpable nodules does not
change the management of palpable discrete swellings

33. Clinicallydiscreteswellings
•The importance of discrete swellings lies in the risk of
neoplasia compared with other thyroid swellings
•15% of isolated swellings prove to be malignant and 30–
40% are follicular adenomas
•Remainder are non-neoplastic, thyroiditis or cysts
•The incidence of malignancy or follicular adenoma is
substantial and cannot be ignored

34. Clinicallydiscreteswellings-Investigations
•Thyroid Function Tests
•Autoantibody Titres
•Isotope Scan
•USG
•FNAC - preferably USG guided
•CT scan
•Flexible Laryngoscopy
•Core Biopsy

35. ThyroidCysts
•30% of clinically isolated swellings contain
fl
uid and are cystic
or partly cystic
•Bleeding into a cyst presents with a history of sudden painful
swelling
•Aspiration yields altered blood but re-accumulation is frequent
•About 50% of cystic swellings are the result of colloid
degeneration, or of uncertain aetiology
•10–15% of cystic follicular swellings are histologically malignant

36. ThyroidCysts
•Papillary carcinoma is often associated with cyst
formation
•USG is the most useful tool for assessing cysts
•If there is no solid element then the cyst is almost
certainly benign and does not need further investigations
•If there is an associated solid element then ultrasound
guided FNAC should be done

37. RetrosternalGoitre
•Arises from the slow growth of a multinodular gland
down in to the mediastinum
•As the gland enlarges within the thoracic inlet, pressure
may lead to dysphagia, tracheal compression and
eventually airway symptoms
•Majority of patients have minimal or no symptoms
•Surgery should be considered if there is signi
fi
cant airway
compression

38. RetrosternalGoitre
•If a decision is made to proceed to surgery, assessment of
the extent of disease is critical
•>95% of retrosternal goitres can be removed transcervically
•Open sternotomy approach include malignant or revision
cases, extent into the posterior mediastinum, the diameter
of the goitre exceeds that of the thoracic inlet
•In such cases it should be a joint venture with a thoracic
surgeon

39. Hyperthyroidism
Thyrotoxicosis
•Diffusetoxicgoitre(Graves’disease)
•Toxicnodulargoitre
•Toxicnodule
•Hyperthyroidismduetorarercauses

40. DiffuseToxicGoitre-Grave’sDisease
•Di
ff
use vascular goitre with hyperthyroidism
and primary thyrotoxicosis
•More common in women - frequently
associated with eye signs
•50% of patients have a family history of
autoimmune endocrine diseases
•Whole of the functioning thyroid tissue is
involved

41. DiffuseToxicGoitre-Grave’sDisease

42. ToxicNodularGoitre
•A simple nodular goitre, present for a long time
before the hyperthyroidism, usually in the middle-
aged or elderly
•Very infrequently is associated with eye signs
•The syndrome is that of secondary thyrotoxicosis
•In many cases the nodules are inactive, and it is
the inter nodular thyroid tissue that is overactive
•In some toxic nodular goitres, one or more
nodules are overactive

43. ToxicNodule
•A toxic nodule is a solitary overactive nodule
•May be part of a generalised nodularity or a
true toxic adenoma
•TSH secretion is suppressed by the high level
of circulating thyroid hormones and the normal
thyroid tissue surrounding the nodule is itself
suppressed and inactive

44. Treatment of Thyrotoxicosis - Anti thyroid Drugs
•Common Antithyroid drugs used are
carbimazole and propylthiouracil
•Aim is to restore the patient to a euthyroid state
and to maintain this for a prolonged period in
the hope that a permanent remission will occur
•Advantages: No surgery and no use of
radioactive materials
•Disadvantages. Treatment is prolonged and the
failure rate is at least 50%

45. Treatment of Thyrotoxicosis - Surgery
•Surgery cures by reducing the mass of
overactive tissue by reducing the thyroid below
a critical mass
•After subtotal thyroidectomy the patient should
return to a euthyroid state
•There is a long-term risks of recurrence
•Total/near total thyroidectomy and lifelong
thyroxine replacement eliminate the risk of
recurrence and simplify follow-up

46. Treatment of Thyrotoxicosis - Surgery
•Advantages: The goitre is removed, the cure is rapid
and the cure rate is high if surgery has been
adequate
•Disadvantages: Recurrence of thyrotoxicosis occurs
in at least 5% of cases after subtotal thyroidectomy
•Risk of permanent hypoparathyroidism and nerve
injury
•Young women tend to have a poorer cosmetic result
from the scar

47. Radioiodine
•Destroys thyroid cells and, as in thyroidectomy,
reduces the mass of functioning thyroid tissue to
below a critical level
•Advantages: No surgery and no prolonged drug
therapy
•Disadvantages: 1) Isotope facilities must be
available 2) The patient must be quarantined while
radiation levels are high 3) Must avoid pregnancy
and close physical contact, particularly with
children

48. Choice of Treatment
•Choice to tailored for each individual patient
•Age, Sex, facilities available, co-existence of
other medical/surgical conditions and choice of
patient to be considered
•Access to post-treatment care and availability
of replacement thyroxine to be considered
•Many patients cannot be trusted to take drugs
regularly if they feel well after radioiodine or
subtotal thyroidectomy

49. Choice of Treatment
•DIFFUSE TOXIC GOITRE : Initial course of antithyroid
drugs with radioiodine for relapse
•Exceptions are patient refusal of radio iodine, large
goitres, progressive eye signs or pregnancy
•TOXIC NODULAR GOITRE : Toxic nodular goitre is
often large and uncomfortable and enlarges still
further with antithyroid drugs
•Should be treated surgically
•Does not respond well or as rapidly to radioiodine or
antithyroid drugs as does a di
ff
use toxic goitre

50. Choice of Treatment
•TOXIC NODULE : Surgery or radioiodine
treatment
•FAILURE OF PREVIOUS TREATMENT WITH
ANTITHYROID DRUGS OR RADIOIODINE :
Surgery or thyroid ablation with I 23I

51. POSTOPERATIVE COMPLICATIONS
•Haemorrhage : Most frequent life-threatening
complication
• In arterial bleed the tension in the central
compartment pressure can rise until it exceeds
venous pressure
•Venous oedema of the larynx then develop and
cause airway obstruction leading to death
•Endotracheal intubation should be used to secure
the airway while the haematoma is evacuated and
the bleeding point controlled.

52. POSTOPERATIVE COMPLICATIONS
•Recurrent laryngeal nerve paralysis and voice
change
•Thyroid insu
ffi
ciency
•Parathyroid insu
ffi
ciency
•Thyrotoxic crisis (storm) : An acute exacerbation
of hyperthyroidism. Occurs if a thyrotoxic patient
has been inadequately prepared for thyroidectomy
•Symptomatic and supportive treatment is for
dehydration, hyperpyrexia and restlessness

53. POSTOPERATIVE COMPLICATIONS
•IV
fl
uids, cool the patient with ice packs,
administer oxygen, give diuretics for cardiac
failure, digoxin for uncontrolled atrial
fi
brillation,
sedate and give IV hydrocortisone
•Speci
fi
c treatment is by carbimazole 10–20mg
6-hourly OR
•Lugol’s iodine 10 drops 8-hourly by mouth OR
1g IV sodium iodide
•Propranolol IV or orally

54. POSTOPERATIVE COMPLICATIONS
•Wound infection
•Hypertrophic or keloid scar : More likely to form
if the incision overlies the sternum and in dark
skinned people

55. Neoplasms of the Thyroid

56. Neoplasms of the Thyroid - Benign
•Follicular adenoma - Present as clinically solitary
nodule
•Distinction between a follicular carcinoma and an
adenoma can only be made by histological
examination
•In adenoma there is no invasion of the capsule or of
pericapsular blood vessels - FNAC only gives
cytology and the architecture
•Diagnosis and treatment is therefore, by wide
excision, i.e. total lobectomy

57. Neoplasms of the Thyroid - Malignant
•Majority of primary malignancies are carcinomas
derived from the follicular cells
•Di
ff
erentiated - i) papillary ii) follicular and iii)
Hürthle cell
•Undi
ff
erentiated - poorly di
ff
erentiated carcinoma
•Medullary carcinoma - Parafollicular C cells
undergo malignant transformation
•Thyroid lymphoma

58. Neoplasms of the Thyroid - Malignant
•Secondary : i) Direct spread from Larynx or
Oesophagus ii) Metastatic - most commonly
from renal cell carcinoma
•Spread : Blood borne or Lymphatic spread to
bone and lung
•The
fi
rst presentation may be the metastatic
lesion with no visible tumour in the gland

59. Neoplasms of the Thyroid - Malignant
•Secondary : i) Direct spread from Larynx or
Oesophagus ii) Metastatic - most commonly
from renal cell carcinoma
•Spread : Blood borne or Lymphatic spread to
bone and lung
•The
fi
rst presentation may be the metastatic
lesion with no visible tumour in the gland

60. Clinical Features
•Incidence of papillary thyroid cancer is
increasing rapidly across the world mostly due
to increased rates of imaging detecting
previously occult disease
•Mortality rates remain static at over 80% 5-year
survival
•Anaplastic carcinoma predicts poor outcome
with di
ff
erentiated carcinomas generally having
excellent outcome

61. Clinical Features
•Most common presenting symptom is a thyroid
swelling
•Cervical lymph nodes may be the presentation
of papillary carcinoma
•RLN paralysis suggests locally advanced
disease
•Anaplastic growths are usually hard, irregular
and in
fi
ltrating

62. Clinical Features
•Di
ff
erentiated carcinoma is
fi
rm and irregular,
often indistinguishable from a benign swelling
•Small papillary tumours may be impalpable,
even when lymphatic metastases are present
•Pain suggests tumour in
fi
ltration into nerves -
often referred to the ear

63. Investigations
•Clinical history and examination
•Examination of the central neck and regional
lymph nodes
•Assessment of vocal cord function by ENT
•Thyroid function tests
•USG - shows lesion to be either benign,
intermediate or malignant
•FNAC for intermediate or malignant lesions

64. Investigations
•In a thyrotoxic patient a radio iodine uptake
scan will show a nodule to be hot or cold
•Hot nodules are rarely malignant
•CECT of neck and chest for patients with
widespread nodal disease or suspicion of
locally invasive disease
•Core biopsy to di
ff
erentiate between anaplastic
carcinoma, lymphoma or thyroiditis

65. Papillary Carcinoma
•Most common thyroid malignancy
•30% of patients who die of non-thyroid disease
have deposits of PTC in autopsy suggesting
that many patients live with this disease
undetected
•Metastasise frequently to lymph nodes but has
excellent survival rates in-spite of that
•Distant metastases are uncommon in PTC

66. Follicular Carcinoma
•Can only be di
ff
erentiated from follicular adenoma
by the architecture on histology
•Lymph node involvement is much less common
than in papillary carcinoma
•Blood-borne metastases are more common
•Mortality rate, is twice that of papillary cancer
•Hürthle cell tumours are a rare variant of follicular
neoplasm
•Hürthle cell cancers have poorer prognosis

67. Treatment
•In high-risk patients with nodal or distant
metastases - total thyroidectomy
•In low-risk patients with a single focus of
disease limited to the thyroid - lobectomy
•For metastatic disease, therapeutic
compartment-orientated neck dissection
•Patients diagnosed with thyroid cancer
following a diagnostic lobectomy risk
assessment is to be done

68. Treatment
•Low risk, further surgery is unlikely to be bene
fi
cial
•High risk, radioactive iodine is recommended, with
completion thyroidectomy
•Thyroxine : Thyroid cells (both normal and
malignant) can be suppressed using high doses of
thyroxine following surgery
•Used in high risk patients to suppress TSH
production and prevent recurrence
•Low risk lobectomy patients do not require it

69. Treatment - Radioiodine
•131I can be given in order to deliver tumoricidal
doses of radioactivity directly to thyroid tissue
•In thyroid cancer it is used to kill residual
microscopic cancer cells after surgery
•All macroscopic thyroid tissue must be
removed surgically before giving it
•Radioiodine treatment is also used in cases of
recurrence

70. Undifferentiated (anaplastic) carcinoma
•Most aggressive of all malignancies in humans
but are rare
•May develop de novo or as dedi
ff
erentiation of a
papillary or poorly di
ff
erentiated carcinoma
•It is characterised by rapid growth, visceral
invasion and distant metastases
•Can be confused clinically with thyroid
lymphoma so core biopsy is a must
•Almost all patients die within 6 months

71. Undifferentiated (anaplastic) carcinoma
•Radio and chemotherapy does not improve
survival
•Patients with disease limited to neck and
detected early do slightly better with aggressive
surgery, radio and chemotherapy
•Majority of patients will not be considered for
curative treatment due to lack of evidence
•Patients with airway obstruction may require
tracheostomy as palliation

72. Medullary carcinoma
•Tumours of the parafollicular (C cells)
•The cells are similar to carcinoid tumours
•High levels of serum calcitonin and carcinoembryonic
antigen are produced by many medullary tumours
•Calcitonin levels fall after resection and rise again with
recurrence - Tumour marker
•30% of cases have diahrrea
•Medullary carcinoma may occur in combination with
adrenal phaeochromocytoma and hyperparathyroidism

73. Medullary carcinoma
•The syndrome known as multiple endocrine
neoplasia type 2A (MEN-2A)
•Familial form of the disease frequently a
ff
ects
children and young adults
•When associated with prominent mucosal
neuromas involving the lips, tongue and inner
aspect of the eyelids, with a Marfanoid habitus,
the syndrome is referred to as MEN type 2B

74. Medullary carcinoma
•Lymph node involvement occurs in 50–60% cases
•Blood-borne metastases are common
•Not TSH dependent so no take up of radioactive iodine
•Nodal involvement virtually eliminates the prospect of
cure
•Small tumours con
fi
ned to the thyroid gland may have
spread by the time of diagnosis
•Progression of disease may be very slow and there is
long survival even if it is not cured

75. Medullary carcinoma - Treatment
•Staging of the neck and chest is done
•Disease con
fi
ned to the thyroid - total
thyroidectomy with elective dissection of the
central neck nodes
•If there is evidence of nodal metastases, cure is
unlikely, but gross disease should be excised
• Patients are highly likely to recur

76. Malignant lymphoma
•Was previously confused and mis-diagnosed as
anaplastic carcinoma
•Radiation gives dramatic response
•Radical surgery is unnecessary
•In patients with tracheal compression, isthmusectomy
•Prognosis is good, if there is no involvement of
cervical lymph nodes
•If it is part of widespread malignant lymphoma
disease the prognosis is worse

77. THYROIDITIS
•Chronic lymphocytic (autoimmune) thyroiditis
•Common condition associated with raised titres of
thyroid antibodies
•Presents as a goitre, which may be di
ff
use or nodular
or with established or subclinical thyroid failure -
diagnosis is by biopsy
•Granulomatous thyroiditis (subacute thyroiditis, de
Quervain’s thyroiditis)
•Symptoms are pain in the neck, fever, malaise and a
fi
rm, irregular enlargement of one or both thyroid lobes

78. THYROIDITIS
•In
fl
ammatory markers are raised, thyroid antibodies are
absent, serum T4 is high normal or slightly raised, and the
123I uptake is low
•It is self-limiting
•In 10% of cases the onset is acute, the goitre very painful
and tender and there may be symptoms of hyperthyroidism
•Diagnosis is con
fi
rmed by FNAC, radioactive iodine uptake
and by a rapid symptomatic response to prednisone
•Speci
fi
c treatment is prednisone l0–20mg daily for 7 days,
and the dose is then tapered

79. THYROIDITIS
•Riedel’s thyroiditis
•Very rare, accounting for 0.5% of goitres
•Thyroid tissue is replaced by
fi
brous tissue in
fi
ltrating into
muscles and adjacent structures, including parathyroids,
recurrent nerves and carotid sheath
•Most probably a collagen disease
•Goitre may be unilateral or bilateral and is very hard and
fi
xed
•Diagnosis is by biopsy to di
ff
erentiate from anaplastic
carcinoma
•Treatment is with high-dose steroid, tamoxifen and thyroxine
replacement.