Podcast
Questions and Answers
What is the first step in the MIVAT procedure?
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.
The parathyroid glands are typically located above the thyroid gland.
False (B)
What must be avoided when splitting the strap muscles during surgery?
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.
The _________ is placed after the incision is closed during the MIVAT procedure.
Match the following MIVAT approaches with their descriptions:
Match the following MIVAT approaches with their descriptions:
Which type of thyroid surgery involves the removal of both lobes plus the isthmus?
Which type of thyroid surgery involves the removal of both lobes plus the isthmus?
The incidence of complications is the same across all types of thyroidectomy.
The incidence of complications is the same across all types of thyroidectomy.
What is the purpose of the Rose/Barking Dog position during thyroid surgery?
What is the purpose of the Rose/Barking Dog position during thyroid surgery?
In subtotal thyroidectomy, __________ grams of gland are left on both sides.
In subtotal thyroidectomy, __________ grams of gland are left on both sides.
Match the following types of thyroid surgery with their features:
Match the following types of thyroid surgery with their features:
What is a common complication associated with the endocrine system?
What is a common complication associated with the endocrine system?
All complications of the endocrine system are related to diabetes.
All complications of the endocrine system are related to diabetes.
Name one hormone produced by the endocrine system.
Name one hormone produced by the endocrine system.
The _____ system regulates hormones in the body.
The _____ system regulates hormones in the body.
Match the endocrine glands with their functions:
Match the endocrine glands with their functions:
What is the chance of malignancy in a non-functioning/cold nodule?
What is the chance of malignancy in a non-functioning/cold nodule?
Graves' Disease is caused by an underproduction of thyroid hormones.
Graves' Disease is caused by an underproduction of thyroid hormones.
What is the primary characteristic of a toxic adenoma?
What is the primary characteristic of a toxic adenoma?
A __________ is characterized by enlargement of the thyroid gland behind the breastbone.
A __________ is characterized by enlargement of the thyroid gland behind the breastbone.
Match the following thyroid conditions with their descriptions:
Match the following thyroid conditions with their descriptions:
Which of the following is NOT an indication for thyroidectomy?
Which of the following is NOT an indication for thyroidectomy?
Hyperfunctioning/hot nodules have a higher chance of being malignant compared to non-functioning/cold nodules.
Hyperfunctioning/hot nodules have a higher chance of being malignant compared to non-functioning/cold nodules.
Name a condition that can cause a large malignant goiter in the neck.
Name a condition that can cause a large malignant goiter in the neck.
What is the gene associated with Medullary thyroid cancer and MEN2 syndrome?
What is the gene associated with Medullary thyroid cancer and MEN2 syndrome?
A tumor classified as T2 in TNM staging indicates it is larger than 2 cm but less than or equal to 4 cm.
A tumor classified as T2 in TNM staging indicates it is larger than 2 cm but less than or equal to 4 cm.
Which syndrome is associated with an increased risk of breast and thyroid cancer?
Which syndrome is associated with an increased risk of breast and thyroid cancer?
Follicular thyroid cancer is associated with the ______ gene.
Follicular thyroid cancer is associated with the ______ gene.
Match the following thyroid cancer types with their associated syndromes:
Match the following thyroid cancer types with their associated syndromes:
What is the most common cause of hypoparathyroidism?
What is the most common cause of hypoparathyroidism?
Chvostek sign is characterized by the twitching of facial muscles when the facial nerve is tapped.
Chvostek sign is characterized by the twitching of facial muscles when the facial nerve is tapped.
What are the earliest symptoms of hypoparathyroidism?
What are the earliest symptoms of hypoparathyroidism?
Permanent hypoparathyroidism can occur in _____% of cases after the removal of parathyroid glands.
Permanent hypoparathyroidism can occur in _____% of cases after the removal of parathyroid glands.
Match the following treatments with their indications:
Match the following treatments with their indications:
What does a TIRADS score of TR 5 indicate?
What does a TIRADS score of TR 5 indicate?
Fine needle aspiration cytology (FNAC) can effectively differentiate between follicular adenoma and carcinoma.
Fine needle aspiration cytology (FNAC) can effectively differentiate between follicular adenoma and carcinoma.
What is the primary purpose of a thyroid scan?
What is the primary purpose of a thyroid scan?
A TIRADS score of TR 3 is classified as __________ suspicious.
A TIRADS score of TR 3 is classified as __________ suspicious.
Match the Royal College of Pathologist classification categories with their respective actions:
Match the Royal College of Pathologist classification categories with their respective actions:
What is the ideal method to look for nodularity in the thyroid gland?
What is the ideal method to look for nodularity in the thyroid gland?
A normal thyroid gland is both visible and palpable.
A normal thyroid gland is both visible and palpable.
Name one key component of the Thyroid Function Tests (TFT).
Name one key component of the Thyroid Function Tests (TFT).
In thyroid examinations, a __________ vascularity indicates benign nodules.
In thyroid examinations, a __________ vascularity indicates benign nodules.
Match the thyroid nodule features with their classification:
Match the thyroid nodule features with their classification:
Which of the following is a physiological cause of gynecomastia?
Which of the following is a physiological cause of gynecomastia?
Polymastia refers to the absence of breast tissue.
Polymastia refers to the absence of breast tissue.
What is the most common site for accessory breast tissue in polymastia?
What is the most common site for accessory breast tissue in polymastia?
Gynecomastia can be aggravated by _____ induced factors, including drugs like steroids and oestrogen.
Gynecomastia can be aggravated by _____ induced factors, including drugs like steroids and oestrogen.
Match the following conditions with their descriptions:
Match the following conditions with their descriptions:
Which nerve is located near the superior pole of the thyroid gland?
Which nerve is located near the superior pole of the thyroid gland?
The left recurrent laryngeal nerve has a shorter course than the right recurrent laryngeal nerve.
The left recurrent laryngeal nerve has a shorter course than the right recurrent laryngeal nerve.
What is the most common site of injury to the recurrent laryngeal nerve during surgery?
What is the most common site of injury to the recurrent laryngeal nerve during surgery?
The thyroid gland is shaped like a ______.
The thyroid gland is shaped like a ______.
Match the following arteries with their roles in thyroid anatomy:
Match the following arteries with their roles in thyroid anatomy:
What is the primary blood supply origin for the inferior thyroid artery?
What is the primary blood supply origin for the inferior thyroid artery?
The middle thyroid vein is typically found in 60% of individuals.
The middle thyroid vein is typically found in 60% of individuals.
Name the ligament that attaches the thyroid gland to the trachea.
Name the ligament that attaches the thyroid gland to the trachea.
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.
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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.
