عرض بوربوينت ل thyroid disease
-
Upload
roger961 -
Category
Health & Medicine
-
view
1.618 -
download
7
Transcript of عرض بوربوينت ل thyroid disease
![Page 1: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/1.jpg)
Thyroid Thyroid diseasesdiseases
![Page 2: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/2.jpg)
EmbryologyEmbryology• 1st of the body’s endocrine glands to
develop (28th day of gestation)• Originates as a proliferation of
endodermal epithelial cells
![Page 3: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/3.jpg)
• As the thyroid start to descent it is still connected to the tongue via thyroglossal duct
• This tubular duct later solidifies & obliterates entirely (7-10 wk of gestation)
• Some• While the gland descent it passes
anterior to hyoid bone & then laryngeal cartilages, forming its mature shape & median isthmus
• Completes its descent 7th wk…immediately anterior to trachea
![Page 4: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/4.jpg)
• An ectopic thyroid gland • Failure of thyroid to descend→
lingual thyroid• Incomplete descent result in
resting point of gland high in the neck or just below the hyoid bone
• Imp. Differentiate between ectopic & thyroglossal cyst → total thyroidectomy
• Hyoid bone • Sistrunk procedure
![Page 5: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/5.jpg)
• If thyroglossal duct does not atrophy → remnant can manifest clinically as thyroglossal cyst, midline mass track anywhere from the thyroid cartilage to base of tongue (rupture)
• Pyramidal lobe of thyroid 50%.• Represents a persistence of
inferior end of thyroglossal duct that has failed to obliterate
![Page 6: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/6.jpg)
• Parafollicular ( C cells), special subset of cells within thyroid gland→ secrete calcitonin
• Arise from the ultimobranchial body, which is infiltrated by neural crest cells→ last structure derived from pharyngeal pouches
![Page 7: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/7.jpg)
AnatomyAnatomy• Under middle layer of deep cervical fascia,
thyroid has an inner true capsule → thin & adheres closely to gland
• Extension of the capsule →lobes & lobules. Lobules are composed of follicles (structural units of gland) → consist of a layer of simple epithelium enclosing a colloid- filled cavity, which contain iodothyroglobulin (precursor of thyroid hormone)
• Epithelial cells: 1) principal (follicular) cells →formation of colloid
2) parafollicular (C) cells →cacitonin
![Page 8: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/8.jpg)
• Anterior suspensory ligament extends from superior-medial aspect of each thyroid lobe to cricoid & thyroid cartilage
• Posteromedial aspect of gland is attached to side of cricoid cartilage, 1st & 2nd tracheal ring by posterior suspensory (Berry) ligament
• This firm attachment to the laryngoskeleton is responsible for its movement during swallowing
![Page 9: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/9.jpg)
• Lateral surface of the gland is covered by sternothyroid m.
• Sternohyoid & sternothyroid ms. are joined in the midline by avascular fascia that must be incised to retract the muscles laterally to access the gland during thyroidectomy
• Should…high in neck cus motor N. supply from ansa cervicalis enters these ms. inferiorly
![Page 10: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/10.jpg)
Arterial spplyArterial spply• Superior & inferior thyroid as. & occasionally thyroid ima a. • Thyroid ima is a single artery which enter the gland from
inferior border of isthmus (imp. to consider in tracheostomy→ potential source of bleeding
• Superior thyroid a. →1st anterior branch of external carotid a.
• Superior to the superior pole the external branch of superior laryngeal N runs with superior thyroid a
• High ligation of this artery places the nerve at risk of injury
→dysphonia
![Page 11: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/11.jpg)
• Inferior thyroid a. → arises from thyrocervical trunk
• Closely associated with recurrent laryngeal N, relationship is highly variable
![Page 12: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/12.jpg)
• Follicular cells synthesize & secrete 2 major hormones (T3 & T4) →collectively referred to as thyroid hormone
• Thyroid hormone affect all cells within the body except those in brain, spleen, testes & uterus
• Regulated through a feedback loop hypothalamus (TRH)
↓Anterior part of pituitary (TSH)
↓Thyroid gland (T3 & T4)
90% T4 & 10% T3..in body tissues T4 →T3 greatest metabolic effect
![Page 13: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/13.jpg)
Investigations & Investigations & TreatmentTreatment
![Page 14: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/14.jpg)
Blood testsBlood tests• Thyroid Function Test mesure serum TSH free T4 & free T3
• Thyroid Autoantibody estimation . Antithyroid Abthyroid microsomal Ab (TMAb) 95% of
patients with Hashimoto.D
Thyroglobulin Ab (TGAb) 60% of patients with Hashimoto.D
Ab against thyroid TSH receptors (TRAbs) seen in patients with Graves . D
• Serum thyrogloublin …used in follow up of metastatic thyroid carcinoma after tyhyroidectomy
![Page 15: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/15.jpg)
X- raysX- rays• Plain radiograph chest & thoracic inlet ….to detect retrosternal thyroid extension ,thyroid calcification
,bony or mediastinal LN & lung metastases
• CT scan……For detecting regional &distant metasasis from thyroid cancr
• MRI….diagnosis of cervical LN metastasis
![Page 16: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/16.jpg)
AP CXR with large retrosternal
Goitere
CT scan
![Page 17: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/17.jpg)
UltrasoundUltrasound• Used to establish the size & shape of
the gland .• May indicate if nodules are single or
multiple.• It will distinguish between cystic &
solid lesions. (intrathyroid lesion)
![Page 18: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/18.jpg)
Radioisotpe scanRadioisotpe scan• Single or multiple nodules .• Over functioning (hot nodules) or
non-functioning (cold nodules) • 20% of cold nodules are malignant• Hot nodules ….rarely malignant
Hot nCold n
![Page 19: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/19.jpg)
HowHow????• An injected or inhaled or ingested compound
labelled with a suitable radionuclide is concentrated in the organ under review .
• The emitted radiation is detected by the gamma camera.
• Examples of radionuclides… Technetium 99m (99mTc) iodine 131(131I) Krypton (81mKr) Gallium67
(67Ga)
![Page 20: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/20.jpg)
FNAFNA• Should be performed in the investigation
of all thyroid nodules.
• Distinguish between a solid lesion & a cyst • If the lesion is solid….cells are sent for
cytological examination• If the lesion is a cyst ….then the fluid can
be removed
![Page 21: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/21.jpg)
HowHow????• A 21 G needle attached to a syringe ,flushed with
saline.
• is passed several times through the nodule while suction is maintained on the syringe.
• The aspirated cells are then smeared onto slide & wet &/or dry fixed.
• Results of cytology show benign cells, suspicious cells , malignant cells or the specimen is inadequate & consists of red cells only.
![Page 22: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/22.jpg)
![Page 23: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/23.jpg)
Thyroid DisordersThyroid Disorders
![Page 24: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/24.jpg)
HypothyroidismHypothyroidism• Usually due to autoimmune disorder
(Hashimoto thyroiditis).
• Investigations.. TSH
free T4 &/or T3 Ab : TPO (thyroid peroxidase
enzyme)
antithyroglobulin
![Page 25: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/25.jpg)
• Treatment… thyroxine to render the patient euthyroid normal dose 75-150 ug TSH cheacked every 12-18 months liothyronine(T3) is an alternative
elderly patient with ischemic heart disease
starting at 25ug & dose every fortnight (to avoid tachyarrhythmias & cardiac
failure)
![Page 26: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/26.jpg)
HyperthyroidismHyperthyroidism• It may be caused by … Grave’s disease (autoimmune
thyrotoxicosis)
Toxic multinodular goiter
solitary toxic adenoma
![Page 27: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/27.jpg)
Graves’ DiseaseGraves’ Disease• Investigations… TSH free T4 &/or T3 90% of patients will have arised
TRAb 70% of patients will have arised TPO
![Page 28: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/28.jpg)
• Treatment… Initial treatment.. thyroid uptake blocking drugs eg…carbimazole & propylthyouracil SE…neutropenia (sore throat) profuse diarrhea hepatocellular failure
B-blockers (propanolol) if the patient is symptomatic with sweating ,termor
or tachycardia • Note.. Control of thyrotoxicosis usually takes 6 weeks. But maintenance is required for 18 months
![Page 29: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/29.jpg)
• Defenitive treatment.. Radioactive iodine SE: long-term hypothyroidism
if inappropriate (young children at home) surgery
Sugery previously…subtotal thyroidectomy
but…10% recurrent thyrotoxicosis 70% hypothyroidism in long term
current surgical tratment of choice….. total thyroidectomy & long term thyroxine
postoperatively
![Page 30: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/30.jpg)
Multinodular goitreMultinodular goitre • Two types..
non-toxic
toxic (plummer’s disease)
Investigations… TSH (if toxic MNG)
FNA…of the dominant nodule if present Ultrasound…may confirm multiple nodules X-ray of thoracic inlet & CT… extent of retrosternal extension & the
degree of tracheal deviation & compression .
![Page 31: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/31.jpg)
• Treatment… non-toxic goitre ….total
thyoidoectomy if there is …rterosternal extension tracheal compression cosmetically
unacceptable
toxic MNG.. initially…carbimazole then ….total thyroidectomy or radioiodine
![Page 32: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/32.jpg)
Solitary toxic adenomaSolitary toxic adenoma• Investigations… TSH 99mTcO4 thyroid isotope solitary hot
nodule
• Treatment.. initially…carbimazole then……thyroid lobectomy or
radioactive iodine
![Page 33: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/33.jpg)
Solitary toxic noduleSolitary toxic nodule• Investigations… exclude solitary toxic adenoma (TSH) FNA…..to exclude malignancy
other investigations (not routinely required for the majority of STNs)
ultrasound …discriminate between solid & cysts 99mTcO4 thyroid isotope scan….function of nodule
![Page 34: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/34.jpg)
• Treatment…
FNA
benign
ObserveRepeat FNAAfter 6-12months
suspicious
surgery
malignant
surgery
inadequate
Repeat FNAThyroid lobectomy
![Page 35: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/35.jpg)
Mangement of thyroid malignancyMangement of thyroid malignancy
• Differentiated thyroid carcinoma… which include…
papillary thyroid carcinoma follicular thyroid carcinoma
• Treatment….according to the Grading system
Good prognosis
Poor prognosis
![Page 36: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/36.jpg)
• Good prognosis
• Female < 45yrs old• Male < 40 yrs old• Tumor < 5cm• Minimally invasive follicular
carcinoma
Treatment• Thyroid lobectomy with subsequent
TSH suppression
![Page 37: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/37.jpg)
• Poor prognosis
•Female > 45 yrs old•Male > 40 yrs old•Tumor >5 cm•Any patient with distant metastsis•Extrathyroidal invasion
Treatment•Total thyroidectomy •subsequent radioiodine (131I)•& TSH suppression with thyroxine
![Page 38: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/38.jpg)
• Undifferentiated thyroid carcinoma (anaplastic)
Treatment…• Surgery …limited role …… (releive airway
obstruction)
• External beam radiotherapy &/or chemotherapy (mostly palliative)
the vast majority of patients die within 12 months
![Page 39: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/39.jpg)
Medullary thyroid carcinomaMedullary thyroid carcinoma
Treatment• Total thyroidectomy with central lymph
node clearance
• Postoperatively …thyroxine replacement (but not TSH suppression)
• Postoperative calcitonin measurement is auseful tumor cell marker (follow up)
![Page 40: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/40.jpg)
Thyroid lymphomaThyroid lymphoma
• Diagnosed by FNA or trucut biopsy• Should be staged with a bone marrow
aspirate & CT scan of chest & abdomenTreatment• If confined to the thyroid alone… thyroid lobectomy with subsequent adjuvant
radiotherapy & chemotherapy• Otherwise ….chemoradiation alone
![Page 41: عرض بوربوينت ل thyroid disease](https://reader031.fdocuments.us/reader031/viewer/2022012400/556bd2a7d8b42ab2138b4683/html5/thumbnails/41.jpg)
Complication of thyroid Complication of thyroid surgerysurgery
• Damage to recurrent laryngeal nerve ….. leading to palsy & causing hoarseness.
• Damage to external branch of superior laryngeal nerve … leading to palsy & hoarseness
• Hypocalcaemia …caused by damage to parathyroids
• Haemorrhage…causing laryngeal oedema & respiratory compromise.