Surgery: Thyroid, Parathyroid, Adrenal

Front 1

Look at thyroid anatomy

Back 1

Superior thyroid arteries from external carotid
Inferior thyroid arteries from thyrocervical trunk
Thyroid IMA from Aorta
Veins drain into internal jugular
RLN relations and functions

Front 2

What is foramen cecum

Back 2

Point of attachment of the thyroglossal duct and is formed during embryological descent of thyroid gland.

Thyroglossal duct cysts can form anywhere along this descent.

Front 3

What does the Recurrent Laryngeal Nerve do?

Back 3

It is off of the vagus.

Provides motor and sensory to the larynx.

Front 4

Function of the Thyroid?

Back 4

Produces T3 and T4 in response to TSH.

It is the thermostat.

More T4, but activity is in T3.
Peripheral conversion of T4--> T3

Front 5

What is hypothyroid?
Treatment?

Back 5

Low T3, T4,
High TSH

Tx: Synthroid, Iodine.
No role for surgery!

Front 6

MC hyperthyroid disease? Description?

Back 6

Graves.

Goiter, exothalmos (from fat buildup behind eyes), wt loss, heat intolerance.
Diffuse I131 uptake.

Often self limiting, but can take up to 5 yrs.

Front 7

Treatment for hyperthyroid?

Back 7

I131,
Beta blockers,
Anti-thyroids (PTU),
Subtotal or total surgery.

Front 8

What is toxic goiter?

Back 8

2nd mcc hyperthyroid
Diffuse I131 uptake

Front 9

Treatment for toxic goiter?

Back 9

I131,
Beta blockers,
anti-thyroid meds,
Surgery

Front 10

A few other causes of need for surgery due to hyperthyroidism?

Back 10

Solitary Toxic Nodule: "hot" on I131 imaging.

Thyroiditis: Hashimotos, DeQuervain, Riedel's Struma

All need partial or subtotal thyroidectomy

Front 11

Work up of a solitary nodule found on exam?

Back 11

US - cyst or solid, fine needle aspiration.
I131 scan: hot or cold nodule? (hot-dark, prob ok. cold -ligther, usually bad, maybe cancer)
T4, TSH
Exploration w/ lobectomy AT LEAST.

Front 12

Treatment for thyroid storm?

Back 12

Beta blockers and PTU PREOP!!

Front 13

MCC thyroid cancer?

Back 13

Papillary carcinoma. 70% thyroid ca.
W>M. 30-40 age group.
Predominant type in kids w/ thyroid cancer and in pts w/ previous radiation to head and neck.
Relatively slow growing, not usually primary ca that kills, usually mets do.

Front 14

Treatment of Papillary Carcinoma of thyroid?

Back 14

Lobectomy is usually sufficient UNLESS;
Extremes age,
Tumor >2 cm
In those cases do complete thyroidectomy!

I131 ablation postop

Front 15

Follicular Carcinoma of Thyroid

Back 15

10% thyroid cancers.
Angioinvasive, spreads widely via circulatory system, as opposed to lymphatics.
CV much faster spread than lymph!

Front 16

Treatment for follicular carcinoma of thyroid?

Back 16

Total thyroidectomy.

I131 ablation postop

Front 17

Medullary cancer of thyroid?

Back 17

7%.
May be hereditary, MEN IIa: neural crest
Parafollicular C cells which make calcitonin (decreases calcium level). Not really thyroid, so NO I131 ablation!

Front 18

Treatment for medullary cancer of thyroid?

Back 18

Total thyroidectomy.
No chemo.
Check rest of family! If they have high calcitonin, possible they have the same cancer. Can also check Ret proto-oncogene.

Front 19

What is Anaplastic Thyroid Cancer?

Back 19

Aggressive cancer. Often invades surrounding areas like the trachea, so often end up doing tracheostomy.

Median survival is 4 months.

Front 20

Look at parathyroid anatomy

Slide 16 shows embryologic origination of glands.

Back 20

2 pairs, upper and lower.
Upper from 4th pharyngeal pouch,
Lower form 3rd pharyngeal pouch (longer descent, more variable location).

All arteries from inferior thyroid artery.
All veins drain into internal jugular.

Front 21

Function of parathyroid glands

Back 21

Produce PTh to regulate calcium and phos.
In response to LOW calc, PTh:
- releases calc from bones,
- increases calc absorption and phos excretion from kidneys.
- increases calc uptake from gut.
PTh is opposed by calcitonin.

Front 22

Signs/Sx of HypERcalcemia

Back 22

Moans,
Stones,
Groans: GI cramping, diarrhea, etc.
Psychic overtones.

Front 23

Differential dx of hypercalcemia.
Use pneumonic.

Back 23

MISHAP
Malignancy (PThr & mets),
Idiopathic,
Sarcoid,
Hyperpara, hyperthyroid,
Addisons, vit A intox,
Pagets, Parathyroid hyperplasia.

All should have LOW PTh except hyperparathyroidism.

Front 24

Workup of hyperparathyroidism?

Back 24

Suspicion,
Blood work: Ca elevated, Cl:Ph >33 suggestive. Should "dump" CaCl.
Elevated PTh - diagnostic.
US, CT?
Surgery: single gland adenoma or 4 gland hyperplasia.

Front 25

What should you do if in surgery you find a single gland enlargement (adenoma)?
(80%)

Back 25

Remove enlarged gland.

Front 26

What should you do if in surgery you find 4 gland hyperplasia?
MEN I
20% cases

Back 26

Remove 3 1/2
or
Remove all 4 and re-implant 1/2 of one.

Front 27

How does chronic renal failure PRE transplant cause hyperparathyroidism?

Back 27

Pt holds onto phos and loses calc.
Low calc --> elevated PTh levels.
Normal compensation.
Causes 4 gland hyperplasia.
Surgery only if severe or if it's causing probs w/ phos, etc

Front 28

How does chronic renal failure POST transplant cause hyperparathyroidism?

Back 28

Parathyroid fails to reset and continues to hypersecrete.
High calcium now (because not losing via kidney) AND high PTh.
4 gland hyperplasia.
Do 3 1/2 gland removal.

Front 29

Look at Adrenal Gland Vascular Anatomy and physical anatomy

Back 29

Arterial supply from renal and phrenic arteries.
Adrenal arteries off of renal arteries.
L ven empties into L renal vein.
R vein empties into IVC directly!

Right adrenal looks bigger on CT because it is being squished down by the liver.

Front 30

What hormones does the adrenal cortex secrete?

Back 30

Outer layer: Aldosterone,
Middle: Cortisol,
Inner: Estrogen or Testosteron

Front 31

What hormones does the adrenal medulla secrete?

Back 31

Epinephrine, Norepi

Front 32

Medical and surgical options for adrenal tumors?

Back 32

Medical: suppress substance.

Surgical: remove tumor.

Front 33

Symptoms of pheochromocytoma?

Back 33

Sustained HTN or episodic HTN, tachycardia, headaches.

Vanillyl mandelic acid (VMA) and metanephrine in urine.

10% bilat.

Front 34

What is a pheochromocytoma?

Back 34

Tumor that secretes high amts of catecholamines, usually norepi, sometimes epi.

MEN II

Front 35

Workup of pheochromocytoma?

Back 35

CT to localize.

24 hr urine to look for VMA and metanephrine.

Front 36

Treatment of pheochromocytoma?

Back 36

Pre-op alpha THEN beta blockade.
Alpha blocker opens up vessels before giving beta blockers so w/ a lower BP, the blood can get through w/out resistence.
Remove tumor and adrenal gland.

Front 37

ABCs of pheochromocytoma?

Back 37

Alpha block and Agua (fluid).

Beta block.

Cut.

Front 38

What is Conn's Syndrome?

Back 38

Hyperaldosteronism from aldosterone producing adenoma.
High aldo from tumor, low renin from feedback loop.
Sustained HTN, hypernatremia and hypokalemia.

Front 39

Workup and treatment of Conn's syndrome?

Back 39

CT to localize tumor.

Excise gland/ adenoma.

Front 40

What are the differences between Cushing's SYNDROME vs Disease 1 and Disease 2?

Back 40

Syndrome: from exogenous steroids.

Disease 1*: pituitary adenoma causing increased ACTH causing increased cortisol.

Disease 2*: Lung Ca or adrenal tumor.

Front 41

Signs/ symptoms of cushings syndrome and disease?

Back 41

HTN,
Central obesity,
Stria,
DM,
Osteoporosis,
Hirsutism

Front 42

What is the Dexamethasone Suppression Test?

Back 42

A cortisol analog is given.
Normal pts will decrease cortisol production when challeneged w/ dexamethasone.
in pts w/ adrenal tumors, cortisol production remains high despite dexamethasone.
Give a low dose and high dose.

Front 43

Treatment for Cushings?

Back 43

Decrease exogenous steroids if that is the cause.
CT head AND abdomen.
Remove pit tumor or adrenal tumor or bilat adrenalectomy (in this case, need replacement therapy)

Front 44

What is Addison's Disease?

Back 44

Adrenal insufficiency, MC iatrogenic.
Also, autoimmune, TB, histoplasmosis, trauma, sepsis, surgery.

Front 45

Presentation of Addisons?

Back 45

Hypotension, low Na, high K, low gluc.

Usually cortisol part of gland is affected. If aldosterone, other things control BP, estrogen or testost affected, there are other places in the body that make these hormones and would prob go unnoticed. But if cortisol affected, no other place that makes cortisol and pt will be really sick.

Front 46

Workup for Addisons?

Back 46

Check gluc, lytes, and look at cortisol.
Look at these things if a pt has been acutely sick, should be getting better, but isn't.
They could be in adrenal crisis.

Front 47

Treatment for Addisons?

Back 47

Replace gluc and mineralcorticoids.

GIVE STEROIDS IF LIFE THREATENING!

Front 48

What is an incidentaloma?

Back 48

Adrenal mass found on CT.

If symptomatic, remove it after workup.
If asx, remove if >5 cm bc risk of cancer. If not, follow w/ serial CTs.

Front 49

MEN: (Multiple Endocrine Neoplasia Syndromes) I:
3 ps

Back 49

Pituitary Adenoma,
Parathyroid hyperplasia,
Pancreatic Islet Cell tumors (glucagonoma, insulinoma)

Front 50

MEN IIa?

Back 50

Parathyroid hyperplasia,
Medullary Ca,
Pheochromocytoma

Front 51

Men IIb?

Back 51

Medullary Ca,
Pheo,
Mucosal neuromas