Theodor Kocher （ 1841~1917 ）

Embryology

Amygdal

thyeo-glosse tube

Corps ultimo-branchialLateral thyroid

Esophage

Conduit auditif extermeTympan

Parathyroide III

Parathyroide IV

Thymus

Thyroidien lobe

Langue

Thyroid anatomy

Superficial veins and cutaneous nerves of neck

Recurrent Laryngeal Nerve

Recurrent laryngeal nerve

• On either side of the trachea

• Lateral to the ligament of Berry

• Entering the larynx• Right side: separating from the vagus when cr

ossing the subclavian artery

• Left side: separating from the vagus when traversing over the arch of the aorta

Recurrent Nerve

Anomalous variations in the course of the right recurrent laryngeal nerve.A, A nonrecurrent laryngeal nerve arises from the vagus.B, The normal course of the recurrent laryngeal nerve arises from the vagus after it passes beneath the subclavian artery. C, The unusual nonrecurrent nerve and recurrent laryngeal nerve join to form a common distal nerve.

Superior Laryngeal Nerve

• separated from the vagus nerve• two branches: The larger internal branch -sensory function and it innervates the larynx. The smaller external branch -the cricothyroid muscle

Blood supply

• Four main arteries, two superior and two inferior :

The superior thyroid artery

The inferior thyroid artery

• Three pairs of venous systems drain the thyroid.

Blood supply

Parathyroid Glands

superiorparathyroid gland

inferiorparathyroid glandRecurrent nerve

inferior thyroid artery

superior thyroid artery

Superior Laryngeal Nerve external branch

Common carotid

Internal jugular

Benign Thyroid Disease

• Endemic Goiter

• Thyroiditis

• Hyperthyroidism

Endemic Goiter

• Etiology

1/3 of the world’s population, specifically in underdeveloped countries.

• Cause

Iodine deficiency

Endemic Goiter

• diffuse goiter

• nodular goiter

Thyroiditis

• Acute Suppurative Thyroiditis

• Subacute Thyroiditis

De Quervain’ s thyroiditis)

• Chronic thyroiditis

Hashimoto’s thyroiditis

Riedel’s thyroiditis (struma)

Hashimoto’s thyroiditis

• A cause of hypothyroidism in adult

• Immune complex and complement

• An exacerbation of immune response.

• An infiltration of lymphocytes

• TSH-blocking antibodies.

• A hypothyroid clinical state

Hyperthyroidism

• Graves’ disease

• toxic nodular goiter

• toxic thyroid adenoma

Grave’s disease

• Most hyperthyroid states are caused by Graves’ disease (diffuse toxic goiter).

Clinical Presentation of Hyperthyroidism

• Physical examination• Increased hyper metabolic state• Cardiovascular stress• Gastrointestinal sign• Psychiatric signs• Genital disorders• Hematopoietical modification• Extrathyroid Presentation

Extrathyroid Presentation

• vitiligo

• pretibial myxoedema

• digital hippocratisme

• ophtalmopathy

Biology

• T3L↑, T4L↑, TSH↓

• Anti-thyroglobuline antibody ↑

• Anti-microsomal antibody ↑

• Anti-TSH-recepter immunoglobuline

Diagnosis

• An extensive history

• Physical examination

• Signs and symptoms of thyrotoxicosis

• Thyroid function tests

Traitement

• Radioiodine ablation

• Surgery

• Antithyroid medication

Toxic nodular goiter-toxic adenoma (Plummer’s disease )

• Autonomous function. • Independent of TSH control.• Symptoms : mild, peripheral • Thyroid hormone ↑, TSH ↓ Antithyroid antibody ↓

• Diagnosis confirmed after:

clinical suspicion

131 I radionuclide scan

• Treatment

lobectomy or near-total thyroidectomy

antithyroid medication

radioiodine therapy is not effective

Nontoxic goiter

• Multinodular Goiter

• Substernal Goiter

The work-up of a solitary thyroid nodule

FNA, fine-needle aspiration; Rx, therapy.

Preoperative preparation

• ORL exam and general exam

• Antithyroid medication

• The lugos

• The beta-blockage

Operation Complications

• Bleeding

• Recurrent laryngeal nerve injury

• Superior laryngeal nerve injury

• Hypoparathyroidisme

• Thyrotoxic storm

• Infection

• Hypothyroidism

Thyroid malignancie

• Less than 1% of all malignancies in the U.S.

• 40/1,000,000 occur per year.

• 6/1,000,000 die per year

• Thyroid oncogenesis

Histo-pathology

• Papillary

• Follicular

• Hürthle cell carcinomas

• Medullary thyroid cancer (MCT)

• Anaplastic carcinoma

Thyroid nodules

• Ultrasound

• Scintigraphy

• CT

• L’MRI

• FNA

Scintigraphy

Cold nodule

Hot nodule

Papillary Carcinoma

• Epidemic

the most common of the thyroid neoplasms and usually associated with an excellent prognosis

Prognostic Risk Classification for Patients with Well-Differentiated Thyroid Cancer (AMES or AGES * )

Low risk High risk

Age <40 years >40 years

Sex Female Male

Extent No local extension, intrathyroidal, no capsular invasion

Capsular invasion, extrathyroidal extension

Metastasis None Regional or distant

Size <2 cm >4 cm

Grade Well differentiated Poorly differentiated

Clinical Presentation

• Solitary painless masses

• Dysphagia

• Cervical tenderness,

• Painful neck mass,

• Superior vena cava syndrome (extremely rare)

Treatment

• The main treatment : surgical ablation.

Follicular Carcinoma

• Second category of well-differentiated thyroid cancers

• Follicular, and mixed papillaryfollicular

cancers (90% of all thyroid cancers)

• A malignant neoplasm of the thyroid epithelium

Clinical presentation

• Solitary painless mass

• The coexistence of lymph node involvement (extremely rare)

• Cervical adenopathy (rare)

Treatment

• Primarily surgical.

Thyroid lobectomy and Isthmectomy

<2cm,well contained within one thyroid lobe

Total thyroidectomy >2 cm, (>4 cm, the risk for cancer >50%)

• Lymph node dissection

• Radioiodine treatment

Hürthle Cell Carcinoma

• A subtype of follicular carcinoma

• Presents in much the same fashion as follicular cell neoplasms.

• Preoperative FNA

• Principal treatment is surgical

Medullary Carcinoma

• 5% to 10% of thyroid malignancies

• A biological marker, Calcitonin

• Presentation: a palpable mass

an elevated calcitonin level

• Single and unilateral

Diagnosis

• MCT :

a mass and an elevated calcitonin level

• Detailed and in-depth family history

• Signs and symptoms

• Screening for pheochromocytoma with 24-hour urinary catecholamines

Anaplastic Thyroid Cancer

• Less than 1% of all thyroid malignancies

• Most aggressive form of thyroid cancer

• Typical presentations : dysphagia

cervical tenderness

painful neck mass

superior vena cava syndrome

Treatment

• Most reports with resection are not optimistic .

• less than one third of them are resectable• chemotherapy adds little to the overall prog

nosis • Prognosis is bad

Minimally invasive surgery

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