Thyroid gland

Embryology:

The thyroid gland arises from 2 origins.

1. Thyroglossal duct:
It begins as a diverticulum at the dorsum of the tongue that elongates, and
descends in front of hyoid and thyroid cartilages where it ends by dividing
into 2 parts that forms the 2 lobes of the gland.

2. Ultimobranchial body:

It is an out pocket of the fourth pharyngeal pouch.

It gives rise to parafollicular (C) cells which secrete calcitonin.

Congenital anomalies of the thyroid gland:

1. Agenesis: failure of formation.
2. Lingual thyroid: failure of descend.
3. Retrosternal goiter: over descend.
4. Thyroglossal cyst: persistence of part of thyroglossal duct.
5. Ectopic thyroid tissue is located in an area other than the normal
position anterior to the laryngeal cartilage.
6. Pyramidal lobe.
1
 Course of descend of thyroglossal duct

Congenital anomalies of the thyroid gland

2
Lingual thyroid may be the only functioning thyroid tissue in the body

Thyroglossal cyst

3
A thyroglossal cyst forms as an embryological remnant of thyroglossal duct.

Clinical criteria:

1. Cystic swelling in or near the midline of the neck.

2. It moves on swallowing because of its attachment to the larynx by the
pretracheal fascia.
3. It moves upwards when the patient protrudes his tongue because of
its attachment to the tract of thyroid gland.

Complications:

1. Infection that may turn into abscess formation.

2. The cyst may rupture and forms a fistula.

Investigations:

Ultrasound scan:

To determine whether the mass is cystic or solid, and to document

the presence of a normal thyroid gland in the lower neck.
A solid neck mass with no distal thyroid gland raises concern of a
so-called “ectopic thyroid” in which the neck mass represents the
entire child’s thyroid tissue.

CT or MRI may be required.

Treatment: Sistrunk operation, which involves removal of the cyst

and the thyroglossal duct track.

4
 Sistrunk operation

The track runs in close proximity to the hyoid bone therefore the central
part of the hyoid bone is excised.

Dissection is continued up to the foramen caecum of the tongue.

5
 Thyroglossal fistula

A thyroglossal fistula is an acquired condition that occurs due to:

1. Infection and spontaneous rupture of thyroglossal cyst.

2. Drainage of infected thyroglossal cyst.
3. Inadequate excision of thyroglossal cyst.

Clinical picture:

It is usually found in between the area of thyroid gland and foramen

cecum of tongue base.

The hood sign is a characteristic finding in thyroglossal fistula;

where the opening of fistula is indrawn and been overlaid by a fold
of skin as hood.

6
 Investigations:

Ultrasounds scan.

Fistulogram.

Treatment: Sistrunk operation.

Surgical anatomy of thyroid gland

- The thyroid gland is a single, bilobed butterfly shaped gland that lies on
the front of the neck below Adam’s apple, it is the largest of all
endocrine glands.

- It is brownish-red in colour.

- It weighs about 25-30g (larger in women).

- It is surrounded by a thin, fibrous capsule of connective tissue and

external to this capsule there is a false capsule formed by pretracheal
fascia, which is responsible for its movement during swallowing.

7
- It is formed of right and left lobes which are 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.

- The functional units are thyroid follicles which are responsible for
synthesis and secretion of T3 and T4, and occasional scattered Para
follicular cells called “C cells” produce calcitonin hormone.

Arterial Supply

The arterial supply to the thyroid gland is via two main arteries:

• Superior thyroid artery: arises as the first branch of the external

carotid artery.
• It lies in close proximity to the external branch of the superior
laryngeal nerve (innervates the larynx).
• The artery is ligated during thyroidectomy as near to the superior pole
of the thyroid as possible to avoid injury to the external laryngeal
nerve.

8
 • Inferior thyroid artery: arises from the thyrocervical trunk (a branch
of the subclavian artery).
• It lies in close proximity to the recurrent laryngeal nerve (innervates
the larynx).
• The artery is ligated during thyroidectomy away from the gland to
avoid injury to recurrent laryngeal nerve.
• In a small proportion of people (around 10%) there is an additional
artery, the thyroid ima artery, which arises from the brachiocephalic
trunk.

Venous drainage:

1. The superior and middle thyroid veins drain into the internal jugular vein.

2. The inferior thyroid veins drain into the innominate vein.

Lymphatic drainage:

There is an extensive lymphatic network within and around the gland:

1. Some lymph channels pass directly to the deep cervical nodes.

2. The subcapsular plexus drains principally to the juxtathyroid lymph

nodes, prelaryngeal , and paratracheal nodes and nodes on the superior
and inferior thyroid veins, and from there to the deep cervical and
mediastinal groups of nodes.

Nerve supply of the intrinsic muscles of the larynx:

All the intrinsic muscles of the larynx which play a vital rule in breathing and
phonation are supplied by the recurrent laryngeal nerve, except the
cricothyroid, “singer’s muscle”, which is supplied by the external laryngeal
nerve.

What is meant by goiter?

The normal thyroid gland is impalpable. Any swelling of the thyroid gland is
termed a goiter regardless of the cause, and this term came from Latin
word gutter which means swollen throat.

9
What is the differential diagnosis of thyroid enlargement?

Simple goiter: has a normal hormone level.

1. Physiological: during puberty, pregnancy and lactation.

2. Colloid (endemic).

3. Simple multinodular goiter.

Toxic goiter: has an increased thyroid hormone level.

1. Diffuse: (Graves’ disease).

2. Multinodular: (Plummer’s disease).

3. Toxic adenoma.

Neoplastic goiter:

1. Benign.

2. Malignant.

Inflammatory goiter:

1. Autoimmune: Chronic lymphocytic thyroiditis (Hashimoto’s

disease).

2. Granulomatous: De Quervain thyroiditis

3. Fibrosing: Riedel’s thyroiditis

4. Infective: acute (bacterial & viral), chronic.

10
Simple goiter:

This term is applied to thyroid enlargement with no disturbance in thyroid

function. It is not due to neoplasia, or inflammation; it may be diffuse or
nodular.

What is the etiology of simple goiter?

It results from iodine deficiency which results in decreased synthesis of T3,

T4, and consequently increased TSH production causes increased growth
of thyroid gland.

Decreased thyroid hormone synthesis occurs due to:

1. Iodine deficiency: absolute in endemic areas, and relative during

puberty, pregnancy and lactation.

2. Deficiency of enzyme which convert inorganic iodine to organic iodine.

3. Goitrogenic substances which interfere with iodine uptake by the thyroid

gland, e.g. thyocianates in cabbages, some drugs like paramino salicylic
acid.

Types of simple goiter:

1. Physiological goiter (diffuse): during puberty, pregnancy and lactation.

2. Colloid goiter (endemic): the follicles are distended and full of colloid
material.
3. Simple multinodular goiter (the commonest type).

11
Clinical picture:

Neck swelling that moves with swallowing, it can be soft or firm, with
smooth or nodular surface.

Investigations: normal thyroid hormone levels.

Complications of simple nodular goiter:

1. Tracheal obstruction.

2. Secondary thyrotoxicosis.

3. Malignancy.

4. Cyst formation.

5. Hemorrhage.

6. Calcification.

7. Retrosternal extension.

What is the treatment of simple goiter?

1. Prophylactic: dietary supplementation with iodine in iodine deficient

areas.

2. Medical treatment: thyroxin 0 .1 to 0.2mg for diffuse goiter.

3. Surgical treatment: subtotal thyroidectomy.

a. For large goiters with obstructive symptoms (e.g. dyspnea , dysphagia).

b. For cosmetic reasons.

12
Postoperative suppressive doses o L thyroxin 0.1- 0.2mg are given to avoid
recurrence in the remainder o the gland.

Retrosternal goiter:

A retrosternal goiter, also known as a substernal goiter, is an enlarged

thyroid gland that grows inferiorly and passes through the thoracic inlet into
the thoracic cavity.

Types of retrosternal goiter:

1. Plunging goiter: it rises with deglutition, and then descends through

the thoracic inlet.
2. Mediastinal goiter: it lies wholly in the chest and is connected to
thyroid gland and supplied by thyroid blood vessels.
3. Intrathoracic goiter: it lies wholly in the chest and is completely
separated from the thyroid gland and supplied by mediastinal blood
vessels.

Clinical picture:

History:

It is more common in short necked men.

It may be symptomless.

The main complaint is dyspnea which becomes worse at night and is

often spasmodic.
Dyspnea is aggravated by any position that reduces the thoracic inlet
such as lying down or flexion of the neck.

13
Examination:

Inspection:
The lower border of the thyroid cannot be seen.
Dilated veins are seen at the upper part of the chest.

Pemberton’s sign: bilateral arm elevation causes facial plethora.

It is attributed to a "cork effect" resulting from the thyroid obstructing

the thoracic inlet, thereby increasing pressure on the venous system.

Percussion o the neck may reveal retrosternal dullness.

Investigations:
1. Chest x-ray:

Reveals a shadow in the superior mediastinum.

Scabbard trachea.

2. CT of the chest.
3. Technetium-99 scan.
Treatment: thyroidectomy.
Pemberton’s sign

14
 5 Ts of widened mediastinum

Thyroid,Thoracic aorta ,Thymus,Teratoma,Terrible lymphoma

Scabbard trachea

Scabbard is the sheath used for covering swords, knives or other large
blades.

A scabbard trachea is called so because of its resemblance of shape

caused by lateral compression usually by thyroid enlargement.

15
 Solitary thyroid nodule

A solitary thyroid nodule is defined clinically as a localized thyroid

enlargement with an apparently normal adjacent gland.

What is the differential diagnosis of solitary thyroid nodule?

1. Dominant nodule in SMNG.

2. Colloid nodule.

3. Thyroid cyst.

4. Adenoma.

4. Toxic nodule.

5. Carcinoma.

16
 What are the findings that raise suspicion of malignancy in solitary
thyroid nodule?

History:

1. History of previous irradiation.

2. Elderly patient.

3. Recent onset of rapid increase in size.

4. Pain.

Examination:

1. Nodule is hard, irregular, with limited mobility.

2. Metastasis, (lymph or blood borne).

Management:

Thyroid function tests:

Hyperthyroid: isotope scan….toxic nodule…….surgery.

Euthyroid:

Ultrasound: Cyst……….aspirate.

Solid…….fine needle aspiration cytology (FNAC).

Fine needle aspiration cytology:

Benign: observe.

Suspicious: e.g. follicular adenoma…..lobectomy.

Malignant: total thyroidectomy.

17
Types of thyroidectomy

1. Total thyroidectomy: 2 × total lobectomy + isthmusectomy.

2. Subtotal thyroidectomy: 2 subtotal lobectomy + isthmusectomy.
3. Near-total thyroidectomy: total lobectomy + isthmusectomy +
subtotal lobectomy (Dunhill procedure).
4. Lobectomy: total lobectomy + isthmusectomy.

Thyroidectomy incision

18
Steps of thyroidectomy:

Anesthesia.

Skin incision.

Exposing the gland.

Devascularization of the gland.

Excision of the gland with due care to avoid injury to recurrent laryngeal
nerves, and parathyroid glands.

Hemostasis and wound closure in layers.

Complications of thyroidectomy:

1. Wound hematoma:

Subcutaneous.

Deep tension hematoma.

2. Respiratory obstruction.

Laryngeal edema, due to trauma by endotracheal tube.

Deep neck hematoma, (remove sutures and evacuate hematoma at

bedside).

Bilateral recurrent laryngeal nerve injury.

Collapse of trachea due to tracheomalacia.

3. laryngeal nerve injury:

a. External laryngeal nerve: loss of high pitched voice due to

paralysis of the cricothyroid muscle.

19
 b. Recurrent laryngeal nerve:

Unilateral: hoarseness of voice, and dyspnea on exertion.

Bilateral: aphonia and suffocation (needs tracheostomy).

4. Hypoparathyroidism.

5. Hypothyroidism.

6. Thyroid storm.

7. Hypertrophic and keloid scars.

Alternatives of traditional surgery:

1. Endoscopic transoral thyroidectomy (scarless thyroidectomy), it was first

described and developed in Asia where due to sociocultural reasons neck
scars are considered a stigma.

2. Robotic thyroidectomy.

20
References

Bailey & Love's Short Practice of Surgery, 28th Edition.

Ellis and Calne's Lecture Notes in General Surgery, 14th Edition.

Kaser Aliny introduction to surgery, 10th Edition, 2024.

Applied Anatomy for Students and Junior Doctors 11th Edition, - by

Harold Ellis.

21
 Quiz

Select the single best answer:

1. What is a thyroglossal cyst?
a. It is a retention cyst.
b. It is a parasitic cyst.
c. It is a congenital cyst.
d. It is an acquired cyst.
2. The superior thyroid artery is ligated near the superior pole of the thyroid
gland to avoid injury of:
a. Superior laryngeal nerve.
b. Inferior laryngeal nerve.
c. Internal laryngeal nerve.
d. External laryngeal nerve.
3. The inferior thyroid artery is ligated away from the thyroid gland to avoid injury
of:
a. The vagus nerve.
b. The sympathetic trunk.
c. The recurrent laryngeal nerve.
d. The external laryngeal nerve.
4. The thyroid gland moves with deglutition because:
a. It is enclosed within the investing fascia.
b. It is enclosed within the pretracheal fascia.
c. It is enclosed within the prevertebral fascia.
d. It is enclosed within the paravertebral fascia.
5. A25-year-old- female singer was submitted to subtotal thyroidectomy on
account of having a large simple multinodular goiter. She became unable to
produce high pitched voice after the operation, what could be the reason?
a. Injury to internal laryngeal nerve.
b. Injury to external laryngeal nerve.
c. Injury to Inferior laryngeal nerve.
d. Injury to recurrent laryngeal nerve.

Answer the following questions:

What are the types of simple goiter?

Mention 4 complications of simple multinodular goiter.

What are the types of retrosternal goiter?

Mention 4 complications of thyroidectomy.

22