Surgery Marrow Pg 81-90 (Endocrine)
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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.

    <p>Romovac suction drain</p> Signup and view all the answers

    Match the following MIVAT approaches with their descriptions:

    <p>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</p> Signup and view all the answers

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

    <p>Total thyroidectomy</p> Signup and view all the answers

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

    <p>True</p> Signup and view all the answers

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

    <p>To reduce venous congestion and create a bloodless field.</p> Signup and view all the answers

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

    <p>4-8</p> Signup and view all the answers

    Match the following types of thyroid surgery with their features:

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

    What is a common complication associated with the endocrine system?

    <p>Hypothyroidism</p> Signup and view all the answers

    All complications of the endocrine system are related to diabetes.

    <p>False</p> Signup and view all the answers

    Name one hormone produced by the endocrine system.

    <p>Insulin</p> Signup and view all the answers

    The _____ system regulates hormones in the body.

    <p>endocrine</p> Signup and view all the answers

    Match the endocrine glands with their functions:

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

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

    <p>20%</p> Signup and view all the answers

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

    <p>False</p> Signup and view all the answers

    What is the primary characteristic of a toxic adenoma?

    <p>A benign tumor that produces excessive thyroid hormone.</p> Signup and view all the answers

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

    <p>retrosternal goiter</p> Signup and view all the answers

    Match the following thyroid conditions with their descriptions:

    <p>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</p> Signup and view all the answers

    Which of the following is NOT an indication for thyroidectomy?

    <p>Graves' Disease</p> Signup and view all the answers

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

    <p>False</p> Signup and view all the answers

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

    <p>Differentiated Thyroid Cancer (DTC)</p> Signup and view all the answers

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

    <p>RET</p> 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.

    <p>True</p> Signup and view all the answers

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

    <p>Cowden Syndrome</p> Signup and view all the answers

    Follicular thyroid cancer is associated with the ______ gene.

    <p>AP</p> Signup and view all the answers

    Match the following thyroid cancer types with their associated syndromes:

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

    What is the most common cause of hypoparathyroidism?

    <p>Vascular insult to parathyroid glands</p> Signup and view all the answers

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

    <p>True</p> Signup and view all the answers

    What are the earliest symptoms of hypoparathyroidism?

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

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

    <p>1</p> Signup and view all the answers

    Match the following treatments with their indications:

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

    What does a TIRADS score of TR 5 indicate?

    <p>Highly Suspicious</p> Signup and view all the answers

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

    <p>False</p> Signup and view all the answers

    What is the primary purpose of a thyroid scan?

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

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

    <p>mildly</p> Signup and view all the answers

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

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

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

    <p>Crile's method</p> Signup and view all the answers

    A normal thyroid gland is both visible and palpable.

    <p>False</p> Signup and view all the answers

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

    <p>T3, T4, or TSH</p> Signup and view all the answers

    In thyroid examinations, a __________ vascularity indicates benign nodules.

    <p>Peripheral</p> Signup and view all the answers

    Match the thyroid nodule features with their classification:

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

    Which of the following is a physiological cause of gynecomastia?

    <p>Newborn</p> Signup and view all the answers

    Polymastia refers to the absence of breast tissue.

    <p>False</p> Signup and view all the answers

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

    <p>Axilla</p> Signup and view all the answers

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

    <p>pathological</p> Signup and view all the answers

    Match the following conditions with their descriptions:

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

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

    <p>External Laryngeal Nerve</p> Signup and view all the answers

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

    <p>False</p> Signup and view all the answers

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

    <p>Berry's Ligament</p> Signup and view all the answers

    The thyroid gland is shaped like a ______.

    <p>butterfly</p> Signup and view all the answers

    Match the following arteries with their roles in thyroid anatomy:

    <p>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</p> Signup and view all the answers

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

    <p>Thyrocervical Trunk</p> Signup and view all the answers

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

    <p>False</p> Signup and view all the answers

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

    <p>Berry's Ligament</p> 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.

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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.

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