Surgery Marrow Pg 81-90 (Endocrine)

Podcast Beta

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is the first step in the MIVAT procedure?

Collar Incision (correct)

Closure and Drainage

Ligation of Vessels

Removal of Thyroid Gland

The parathyroid glands are typically located above the thyroid gland.

False

What must be avoided when splitting the strap muscles during surgery?

Injury to the ansa cervicalis

The _________ is placed after the incision is closed during the MIVAT procedure.

Romovac suction drain Signup and view all the answers

Match the following MIVAT approaches with their descriptions:

Trans-axillary = Most common approach Trans-oral robotic surgery (TORS) = Robotic surgery through the oral cavity Retro-auricular = Approach behind the ear Nipple = Surgical approach through the nipple Signup and view all the answers

Which type of thyroid surgery involves the removal of both lobes plus the isthmus?

Total thyroidectomy Signup and view all the answers

The incidence of complications is the same across all types of thyroidectomy.

True Signup and view all the answers

What is the purpose of the Rose/Barking Dog position during thyroid surgery?

To reduce venous congestion and create a bloodless field. Signup and view all the answers

In subtotal thyroidectomy, __________ grams of gland are left on both sides.

4-8 Signup and view all the answers

Match the following types of thyroid surgery with their features:

Hemithyroidectomy = ↓ Risk of recurrence Total thyroidectomy = Both lobes + isthmus removed Subtotal thyroidectomy = 4-8g of gland left Near total thyroidectomy = Lobectomy + subtotal lobectomy Signup and view all the answers

What is a common complication associated with the endocrine system?

Hypothyroidism Signup and view all the answers

All complications of the endocrine system are related to diabetes.

False Signup and view all the answers

Name one hormone produced by the endocrine system.

Insulin Signup and view all the answers

The _____ system regulates hormones in the body.

endocrine Signup and view all the answers

Match the endocrine glands with their functions:

Pancreas = Regulates blood sugar levels Thyroid = Regulates metabolism Adrenal glands = Responds to stress Pituitary gland = Controls other endocrine glands Signup and view all the answers

What is the chance of malignancy in a non-functioning/cold nodule?

20% Signup and view all the answers

Graves' Disease is caused by an underproduction of thyroid hormones.

False Signup and view all the answers

What is the primary characteristic of a toxic adenoma?

A benign tumor that produces excessive thyroid hormone. Signup and view all the answers

A __________ is characterized by enlargement of the thyroid gland behind the breastbone.

retrosternal goiter Signup and view all the answers

Match the following thyroid conditions with their descriptions:

Graves' Disease = Overproduction of thyroid hormones due to autoimmune disease Toxic Nodular Goiter = Enlargement due to nodules producing excessive hormone Non-Functioning Nodule = 20% chance of being malignant Thyroiditis = Inflammation of the thyroid gland Signup and view all the answers

Which of the following is NOT an indication for thyroidectomy?

Graves' Disease Signup and view all the answers

Hyperfunctioning/hot nodules have a higher chance of being malignant compared to non-functioning/cold nodules.

False Signup and view all the answers

Name a condition that can cause a large malignant goiter in the neck.

Differentiated Thyroid Cancer (DTC) Signup and view all the answers

What is the gene associated with Medullary thyroid cancer and MEN2 syndrome?

RET Signup and view all the answers

A tumor classified as T2 in TNM staging indicates it is larger than 2 cm but less than or equal to 4 cm.

True Signup and view all the answers

Which syndrome is associated with an increased risk of breast and thyroid cancer?

Cowden Syndrome Signup and view all the answers

Follicular thyroid cancer is associated with the ______ gene.

AP Signup and view all the answers

Match the following thyroid cancer types with their associated syndromes:

Medullary = MEN2 Follicular = Carney complex Papillary = Familial papillary thyroid carcinoma Any type = Cowden Syndrome Signup and view all the answers

What is the most common cause of hypoparathyroidism?

Vascular insult to parathyroid glands Signup and view all the answers

Chvostek sign is characterized by the twitching of facial muscles when the facial nerve is tapped.

True Signup and view all the answers

What are the earliest symptoms of hypoparathyroidism?

Perioral numbness, tingling/paresthesia Signup and view all the answers

Permanent hypoparathyroidism can occur in _____% of cases after the removal of parathyroid glands.

1 Signup and view all the answers

Match the following treatments with their indications:

IV Calcium gluconate = Major symptoms or Serum Calcium < 8mg/dl Oral Calcium and Vitamin D3 = Minor symptoms and Serum Calcium > 8mg/dl Monitor symptoms and Serum Calcium = Routine management Serum PTH monitoring = Determine hormonal status Signup and view all the answers

What does a TIRADS score of TR 5 indicate?

Highly Suspicious Signup and view all the answers

Fine needle aspiration cytology (FNAC) can effectively differentiate between follicular adenoma and carcinoma.

False Signup and view all the answers

What is the primary purpose of a thyroid scan?

To assess thyroid function and detect abnormalities such as hyperthyroidism. Signup and view all the answers

A TIRADS score of TR 3 is classified as __________ suspicious.

mildly Signup and view all the answers

Match the Royal College of Pathologist classification categories with their respective actions:

Thy 1 = No further action required Thy 4 = Hemithyroidectomy Thy 3 = Follow up Thy 5 = Surgery indicated Signup and view all the answers

What is the ideal method to look for nodularity in the thyroid gland?

Crile's method Signup and view all the answers

A normal thyroid gland is both visible and palpable.

False Signup and view all the answers

Name one key component of the Thyroid Function Tests (TFT).

T3, T4, or TSH Signup and view all the answers

In thyroid examinations, a __________ vascularity indicates benign nodules.

Peripheral Signup and view all the answers

Match the thyroid nodule features with their classification:

Echogenicity: Iso- or hyperechoic = Benign Calcifications: Microcalcifications = Malignant Shape: Taller > Wider = Malignant Margins: No infiltrative margins = Benign Signup and view all the answers

Which of the following is a physiological cause of gynecomastia?

Newborn Signup and view all the answers

Polymastia refers to the absence of breast tissue.

False Signup and view all the answers

What is the most common site for accessory breast tissue in polymastia?

Axilla Signup and view all the answers

Gynecomastia can be aggravated by _____ induced factors, including drugs like steroids and oestrogen.

pathological Signup and view all the answers

Match the following conditions with their descriptions:

Gynecomastia = Enlargement of male breast Polymastia = Accessory breast tissue Amastia = Absence of breast tissue Klinefelter Syndrome = Genetic disorder associated with male breast cancer risk Signup and view all the answers

Which nerve is located near the superior pole of the thyroid gland?

External Laryngeal Nerve Signup and view all the answers

The left recurrent laryngeal nerve has a shorter course than the right recurrent laryngeal nerve.

False Signup and view all the answers

What is the most common site of injury to the recurrent laryngeal nerve during surgery?

Berry's Ligament Signup and view all the answers

The thyroid gland is shaped like a ______.

butterfly Signup and view all the answers

Match the following arteries with their roles in thyroid anatomy:

Superior Thyroid Artery = Drains into the external carotid artery Inferior Thyroid Artery = Supplies parathyroid glands Thyrocervical Trunk = Branch of the subclavian artery Arteria thyroidea ima = Direct branch of the aortic arch Signup and view all the answers

What is the primary blood supply origin for the inferior thyroid artery?

Thyrocervical Trunk Signup and view all the answers

The middle thyroid vein is typically found in 60% of individuals.

False Signup and view all the answers

Name the ligament that attaches the thyroid gland to the trachea.

Berry's Ligament Signup and view all the answers

Study Notes

Thyroid Abnormalities

Solitary Toxic Nodule: Single, functioning nodule in the thyroid gland.
Non-Functioning/Cold Nodule: Nodule that does not function, does not take up iodine. Has a 20% chance of being malignant.
Hyperfunctioning/Hot Nodule: Nodule in the thyroid that functions and takes up iodine. Has a 4% chance of being malignant.
Graves' Disease: Autoimmune disease affecting the thyroid gland, leading to overproduction of thyroid hormones.
Toxic Nodular Goiter (Plummer's Disease): Thyroid gland enlargement due to nodules producing excessive thyroid hormone.
Toxic Adenoma: Benign tumor in the thyroid gland producing excessive thyroid hormone.
Thyroiditis: Inflammation of the thyroid gland.

CECT Neck & Thorax Indications

Retrosternal goiter: Enlargement of the thyroid gland behind the breastbone.
Large malignant goiter: A large, cancerous goiter in the neck

Whole Body Iodine Scan Indications

Differentiated Thyroid Cancer (DTC) after total thyroidectomy to check for residual recurrent disease.

Thyroidectomy Indications

Neoplasia: In case of tumors (cancer).
FNAC+ve Thy 3-5: Positive results from Fine-Needle Aspiration Cytology (FNAC) showing Thyroid abnormalities.
Clinical Suspicion: Increased age, Male sex, Hard, fixed nodule.
RLN palsy: Recurrent laryngeal nerve palsy.
Lymphadenopathy: Swelling of the lymph nodes.
Recurrent cyst: Recurrent cyst in the neck area.
Toxic adenoma: Benign tumor in the thyroid gland that produces excess thyroid hormone.
Pressure symptoms: Symptoms caused by pressure from the enlarged thyroid gland.
Cosmetic purpose: Cosmetic reasons for surgery.

MIVAT Approaches

Trans-axillary (most common).
Trans-oral robotic surgery (TORS).
Retro-auricular.
Nipple.

Types of Thyroid Surgery

Hemithyroidectomy: Removal of 1 lobe + isthmus. Reduces risk of recurrence.
Total thyroidectomy: Removal of both lobes + isthmus.
Subtotal thyroidectomy: Removal of majority of both glands + isthmus (4-8g of gland left on both sides). Reduces risk of recurrence (not done anymore).
Near total thyroidectomy (Hartley Dunhill procedure): One side: Lobectomy + isthmus removal. Other side: Subtotal lobectomy. Incidence of hypothyroidism, RLN injury, and hypoparathyroidism is equal in all types of thyroidectomy.

Thyroid Cancers

IOC: FNAC.
Medullary Thyroid Cancer: Associated with MEN2 syndrome and RET gene. Also associated with Cowden Syndrome, Werner/Adult progeroid syndrome, and Familial adenomatous polyposis.
Follicular Thyroid Cancer: Associated with Carney complex/Batman's Syndrome, Familial non medullary thyroid cancer syndrome, Familial papillary thyroid carcinoma. Associated with the AP gene on Chromosome 5, PTEN, and PRKAR IA.
Papillary Thyroid Cancer: Not associated with any specific syndrome or gene.

TNM Staging

T:* Primary tumor
T0: No 1° tumor.
T1: Tumor ≤1cm.
T1a: Tumor ≤1cm.
T1b: Tumor >1cm but ≤2cm.
T2: Tumor >2cm but ≤4cm.
T3a: Tumor >4cm limited to thyroid.
T3b: Tumor of any size invading only strap muscles.
T4: Gross extrathyroidal extension into major neck structures.
N:* Regional Lymph Nodes (LN)
N0: No regional LN metastasis.
N1: metastasis to regional nodes.
Nx: Regional LN can't be assessed.
M:* Distant metastasis
M0: No distant metastasis.
M1: Distant metastasis (+).

Hypoparathyroidism

Late cause: 48-72 hrs after sx.
Other potential complications: Keloid, Recurrence.
Cause: Vascular insult to parathyroid glands, most commonly the inferior thyroid artery.

Clinical Features of Hypoparathyroidism

Symptoms*
Start 48-72 hrs after sx.
Earliest: Perioral numbness, tingling/paresthesia.
Tetany progressing to Respiratory distress (cause of death).
Signs*
Chvostek sign: Twitching of facial muscles on tapping over facial nerve.
Trousseau sign (Carpopedal spasm/Obstetrician's hand): Deformity: Spasm of hand when BP cuff is inflated above the systolic BP. Due to neuromuscular hyperexcitability. Seen in hypocalcemia and hypoparathyroidism.

Management of Hypoparathyroidism

Monitor symptoms, S.Calcium (ionized > total).
S.PTH (1/2 life: 7 minutes).
Major symptoms or S.Ca2+ < 8mg/dl → IV Calcium gluconate + oral Ca2+ + oral Vit D3.
Minor symptoms and S.Ca2+ > 8mg/dl → Oral Ca2+ + oral Vit D3.

Permanent Hypoparathyroidism

Due to removal of parathyroid glands.
1% of cases.
Symptoms lasting ≥1 year.
Requires ongoing monitoring and management.

TIRADS Score

TR 1: Benign. No FNAC required.
TR 2: Not Suspicious. No FNAC required.
TR 3: Mildly suspicious. FNAC required.
TR 4: Moderately suspicious. FNAC required.
TR 5: Highly suspicious. FNAC required.

Thyroid FNAC (Fine Needle Aspiration Cytology)

10C in Thyroid disorders. Cannot be used to differentiate between follicular adenoma and carcinoma.
Needle used: 23 - 30 gauge.
Criteria for adequacy: At least 6 groups of follicular cells, with each group having at least 10 cells on a single slide.

Royal College of Pathologist Classification

Category	Classification	mx	Further Action
Benign	Thy 1
	Thy Ic
	Thy 2
	Thy 3	Non-neoplastic	Follow up
	Thy 4	Follicular	Hemithyroidectomy
	Thy 5	Suspicious of malignancy	Sx
		Malignant	USG guided FNAC repeated
		Non-diagnostic
		Non-diagnostic, cystic

Normal Thyroid Scan

Tc uptake assessed.
I131 uptake & organification assessed.

Thyroid Examination

Normal thyroid gland: neither visible nor palpable.

Clinical Methods of Examination

Pizillo's method
Lahey's method
Crile's method: Ideal method to look for nodularity.

Investigations in Thyroid Disorders

Thyroid Function Tests (TFT): First investigation done. Components: T3 (active form), T4, TSH, Anti thyroid antibodies. TSH ↓: Hyperthyroidism. TSH ↑: Hypothyroidism.

USG: Neck

Feature	Benign	Malignant
Echogenicity	Iso- or hyperechoic	Hypoechoic
Calcifications	Macrocalcifications	Microcalcifications
Border	Regular border	Border irregularity
Shape	Wider > taller	Taller > Wider
Margins	No infiltrative margins	Infiltrative margins
Cervical Lymph Nodes	Normal cervical lymph nodes (kidney shaped)	Abnormal cervical lymph nodes (round shaped), Loss of fatty hilum
Vascularity	Peripheral vascular vascularity	Increased intranodular vascularity

TIRADS Score: Thyroid Imaging Reporting & Data Systems

Criteria:

Composition
Margin
Shape
Echogenicity
Echogenic foci

Surgical Anatomy of Thyroid Gland

Butterfly-shaped gland.

Blood and Nerve Supply

External Laryngeal Nerve: Located near the superior pole of the gland.
Inferior Thyroid Artery: Also supplies parathyroid glands. Only capsular branches are ligated to prevent devascularization of parathyroid glands, preventing hypocalcemia.
Thyrocervical Trunk
Subclavian Artery
Brachiocephalic Trunk

Venous Drainage

Branches into: External Carotid Artery (branches in the neck), Superior Thyroid Artery (ligated close to the gland), Thyroid Gland, Arteria thyroidea ima (Direct branch of the aortic arch).
Drains into: Superior Thyroid Vein, Internal Jugular Vein, Middle Thyroid Vein (seen in 30% - First vessel ligated during thyroid surgery), Inferior Thyroid Vein, Left Brachiocephalic Vein.

Recurrent Laryngeal Nerves

In 2% of individuals: Non-recurrent laryngeal nerves.
Right Recurrent Laryngeal Nerve: Winds around the subclavian vessels.
Left Recurrent Laryngeal Nerve: Winds around the aortic arch. Longer course.
Berry's Ligament: Most common site of injury to the recurrent laryngeal nerve (RLN).

Boundaries of the Thyroid Gland

Lower Pole of Thyroid Gland
Recurrent Laryngeal Nerve
Lower Central Triangle

Recurrent Laryngeal Nerve Triangle (Beahr's Triangle)

Helps to locate RLN during surgery.

Berry's Ligament

Condensation of pre-tracheal fascia.
Attaches thyroid gland to trachea.
Helps in movement of thyroid swelling on deglutition.

Gynecomastia

Enlargement of male breast.
Unilateral (U/L) or Bilateral (B/L).

Causes of Gynecomastia

Physiological*
Newborn
Puberty
Senile
Pathological*
Drug-induced: Mnemonic - DISCKO: Digoxin, Isoniazid, Steroids, Spironolactone, Cimetidine, Ketoconazole, Oestrogen.
Idiopathic
Klinefelter Syndrome
Liver disease
Paraneoplastic conditions in HCC, RCC, Testicular cancer
Lepromatous / mumps orchitis.

Diagnostic Imaging for Gynecomastia

10C: USG (Disc of breast tissue).

Management of Gynecomastia

mx: Liposuction + Gland excision.

Polymastia

Accessory breast tissue.
Site: Axilla (most common).
Prominent during puberty/pregnancy.
mx: If pain(+)/ cosmetic reasons → Excision.

Amastia

Seen in Poland syndrome.
P.major & S.breast tissue do not develop.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

Explore the various types of thyroid abnormalities including solitary toxic nodules, hyperfunctioning nodules, and Graves' Disease. This quiz also covers imaging indications such as CECT for neck and thorax, and whole body iodine scans in relation to thyroid cancer. Test your knowledge on the diagnosis and management of thyroid conditions.