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120 Cards in this Set
- Front
- Back
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What are the typical measurements of a thyroid lobe?
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Each thyroid lobe measures approximately 4cm high, 1.5cm wide, and 2cm deep.
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The ventral diverticlum (which will eventually become the thyroid), forms at __ weeks gestation, and descends from the base of tongue to its adult pretracheal position , assuming its final adult position by __ weeks gestation.
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4 weeks
7 weeks |
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The parafollicular C cells arise from which other cells?
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neural crest cells
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What is the lymphatic drainage of the thyroid gland?
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Isthmus and medial thyroid lobes --> delphian, pretracheal and superior mediastinal nodes
Lateral thyroid --> internal jugular chain Inferior pole --> paratracheal perirecurrent laryngeal nerve nodes |
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Which cervical fascial layer envelops the thyroid gland?
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The middle layer (visceral layer) of the deep cervical fascia
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What structures allows the thyroid gland to elevate with the larynx and trachea with deglutition?
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Anterior and posterior suspensory ligaments, attach the thyroid to the laryngotracheal complex
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Where does the anterior suspensory ligament of the thyroid attach?
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arises from the anterior aspect of the first several tracheal rings and inserts on the undersurface of the thyroid isthmus
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Where does the posterior suspensory ligament of the thyroid attach? What is its other name?
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Anterior suspensory ligament of the thyroid = Berry ligament
- it's a condensation of the thyroid capsule - well vascularized, deriving a branch of the inferior thyroid artery - the RLN can penetrate the thyroid gland WITHIN the ligament of Berry in a significant percentage of pts |
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The Superior Laryngeal Nerve (SLN) has which branches?
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Internal branch - supplies sensation to the larynx
External branch - motor innervation to cricothyroid muscle and inferior constrictor |
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The right nonrecurrent RLN occurs in approximately _____% of cases.
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0.5-1%
In this case, the nonrecurrent laryngeal nerve branches off the vagus nerve around the level of the cricoid cartilage. |
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The right RLN enters the neck base at the thoracic inlet more ________ (medially/laterally) than does the left recurrent.
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more laterally than the left recurrent (the left RLN is more paratracheal and ascends in the tracheoesophageal groove)
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The right RLN crosses which artery as it ascends the neck and travels lateral to medial?
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inferior thyroid artery
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In approximately how many cases will the RLN branch prior to its laryngeal entry point?
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1/3 cases (seen in the above image)
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How far above the superior pole of the thyroid does the SLN split into internal and external branches?
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About 2-3 cm above
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Where in proximity to the thyroid does the external branch of the SLN lie?
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- The external branch of SLN innervates the crycothyroid and inferior constrictor muscles (as seen in the image on the left).
- It descends to the region of the superior pole and extends medially along the inferior constrictor muscle to enter the cricothyroid muscle. As the external branch slopes downward on the inferior constrictor musculature, it has a close association with the superior pole pedicle. |
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In what percent of cases is the external branch closely associated with the superior thyroid vascular pedicle, placing it at risk during ligation of the superior pole vessels.
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20% of cases
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Describe the typical arterial supply to the thyroid gland.
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- Superior thyroid artery (from ECA)
- Inferior thyroid artery (from thyrocervical trunk) - Thyroid ima artery (may arise from innominate artery, carotid artery or aortic arch directly; present in 1.5-12% of cases (may be encountered on tracheotomy) |
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Describe the typical venous drainage to the thyroid gland.
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Superior thyroid vein (branch of IJV and travels with the superior thyroid artery in the superior pole vascular pedicle)
Middle thyroid vein (drains into the IJV, and travels without arterial complement) Inferior thyroid vein (drains into the IJV and brachiocephalic vein, and also travels without arterial complement) |
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What percentage of T3 is produced by the thyroid gland?
How about in the periphery? |
10% in thyroid gland
80% in periphery (from conversion of T4 to T3) |
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What is the half-life of T3 and when should you recheck TFT after exogenous T3 dose change?
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T3 half life is 1 day, so reassess TFT after change of exogenous T3 in 1-2 weeks
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What is the half-life of T4 and when should you recheck TFT after exogenous T4 dose change?
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T4 half life is 6-7 days, so reassess TFT after change of exogenous T3 in 5-6 weeks
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What do pregnancy and use of birth control pills do to thyroid-binding globulin? What does this cause T3 uptake to do?
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Increases TBG
T3 resin uptake is low |
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What do androgen and anabolic sterois do to thyroid-binding globulin? What does this cause T3 uptake to do?
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Decreases TBG
T3 resin uptake is high |
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Myxedema refers to which thyroid state?
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Nonpitting edema secondary to increased glycosaminoglycans in tissue in severe hypothyroidism
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What is the pathogenesis of Grave's dz?
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Autoimmune dz resulting from immunoglobulin, autoantibody binding to the TSH receptor, which results in TSH-like activity
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A patient with Grave's dz develops this. What is it called?
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Thyroid Acropachy - characterized by digital clubbing and edema of the hands and feet
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What lab tests other than T3/T4/TSH can confirm Grave's disease?
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Presence of Thyroid Stimulating Immunoglobulins (TSI)
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What is the typical progression of disease in toxic multinodular goiter?
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Preexisting nontoxic nodular goiter --> progressive nodule formation and hyperfunctional regions resulting in TSH suppression, and adjascent normal gland becoming less active on I(123) scans, and hyperfunctional areas being hot --> suppressed TSH but normal T4/T3 is called subclinical hyperthyroidism --> autonomous TH secreting hyperfunctional regions despite TSH supression
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What is Jod-Basedown phenomenon?
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Development of overt hyperthyroidism in such patients with exogenous iodine (ie. iodine CT contrast) .
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How long are PTU and methimazole typically administered before the patient is rendered euthyroid?
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6-8wks
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Describe the Wolff-Chaikoff effect. When does it happen?
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Potassiun iodide and Lugol's solution are given to inhibit organification and prevent TH release; done preoperatively to decrease thyroid gland vascularity. This is termed the Wolff Chaikoff effect.
The Wolff–Chaikoff effect lasts several days (around 10 days), after which it is followed by an "escape phenomenon", which is described by resumption of normal organification of iodine and normal thyroid peroxidase function. "Escape phenomenon" is believed to occur because of decreased inorganic iodine concentration secondary to down-regulation of sodium-iodide symporter (NIS) on the basolateral membrane of the thyroid follicular cell. |
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Which adverse effect of PTU now caused methimazole to be the first line initial tx for hyperthyroidism?
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Liver failure
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How long must conception be delayed in a female who received radioactive iodine ablation?
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6 months
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What is the disadvantage of radioactive iodine ablation?
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80% of Graves Dz and 50% of those with toxic nodules will become hypothyroid
Also possibility of long-term malignancies secondary to radiation |
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How soon does radioactive ablation normalize TH levels compared to surgery?
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Usually radiation takes longer, up to 6-8 weeks
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What are the indications of surgery for Graves?
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1) Failure or significant side effects after medical treatment
2) Need for rapid return to euthyroidism 3) Massive goiter 4) Wish to avoid radioactive iodine |
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What is the most common single thyroid disease?
What is the most common form of thyroiditis? |
Hashimoto's thyroiditis for both
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What is the histologic appearance of Hashimoto's thyroiditis?
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lymphocytic infiltration with germinal center formation
follicular acinar atrophy, Hurthle cell metaplasia Fibrosis |
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What serological lab study will be seen in Hashimoto's thyroiditis?
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Increased thyroid peroxidase antibodies
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What will the thyroid feel like on palpation in a pt with Hashimoto's thyroiditis?
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Painless, firm, symmetric goiter, although regional pain has been reported.
Typically both sides are enlarged. |
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Does pt with Hashimoto's thyroiditis typically have hyperthyroidism or hypothyroidism?
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Usually pts are euthyroid at presentation, but hypothyroid sx may occur.
Hypothyroidism may develop with time and results from progressive loss of follicular cells |
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What is a rare complication of Hashimoto's that causes a rapidly enlarging mass?
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thyroid lymphoma - do FNA or Bx
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What's another name for subacute granulomatous thyroiditis?
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DeQervain's thyroiditis
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Subacute granulomatous thyroiditis is the most common cause of ______ thyroiditis
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painful
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What is the typical thyroid state progression in subacute granulomatous thyroiditis?
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Hyperthyroid --> euthyroid --> hypothyroid --> euthyroid (50%) or permanent hypothyroid (5%)
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What's the tx for subacute granulomatous thyroiditis?
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Self-limiting dz, tx with NSAID's and rarely steroids.
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What's another name for silent, painless or postpartum thyroiditis?
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lymphocytic thyroiditis - typically painless, symmetric thyroid enlargement and reversible hyperthyroidism
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What is the tx for lymphocytic thyroiditis?
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No tx, self-limiting
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Describe acute suppurative thyroitis
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Rare thyroid infection with abscess formation
- most often bacterial (commonly due to Staph, Strep, or Enterobacter) but can be fungal or even parasitic - Typically presents in setting of an URI - Tx = I&D and IV Abx - Children may demonstrate left pyriform sinus fistulae, so after acute tx, evaluate for this condition is reasonable, including barium swallow, CT or endoscopy |
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What is Riedel's Struma?
What is the hallmark histological presentation? |
aka Riedel's Thyroiditis - rare inflammatory process of unknown etiology that causes diffuse thyroid fibrosis; thyroid equivalent to sclerosing cholangitis or retroperitoneal fibrosis
Histological hallmark is extrathyroidal extension of fibrosis into surrounding neck structures |
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How does Riedel's Struma present?
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Large, nontender goiter with a woody consistency (same way that Ludwig's angina feels) fixed to surrounding structures
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When should a pt with a goiter be offered surgery?
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All pts who are symptomatic
All pts with significant radiographic evidence of airway obstruction All pts with substernal goiter Significant cosmetic issue |
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What is Pemberton's sign?
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Development of venous engorgement or subjective respiratory discomfort with the arms extended over the head can suggest obstruction of the thoracic inlet from a large or substernal goiter
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What is the incidence of carcinoma in multinodular goiters?
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About 7.5% (typically small intrathyroid papillary carcinomas)
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What percentage of adult population have thyroid nodules?
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4-7%
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List the risk factors which increase concern for thyroid malignancies
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<20yo or >60yo
Hx of exposure to ionizing radiation Males Rapid growth, pain Family Hx of thyroid cancer Hard, fixed lesion Lymphadenopthy Vocal cord paralysis Size >4cm Aerodigestive tract compromise (stridor, dysphagia) |
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What is the initial screening lab test in a workup of a thyroid nodule?
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TSH is the very first test
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Are thyrogloblin levels used in the workup of thyroid nodules?
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Not useful due to an extensive overlap in levels between benign and malignant conditions
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Are calcitonin levels used in the workup of thyroid nodules?
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Because of the rarity of medullary carcinoma of the thyroid, calcitonin levels is not a routine SCREENING test in a workup of a nodule.
HOWEVER, once medullary carcinoma is suspected on FNA, calcitonin immunohistochemistry can confirm the FNA diagnosis |
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What role does radionucleotide scanning play in thyroid nodule screening?
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Can define nodules as cold or hot
Cannot specify benign vs malignant |
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In a thyroid nodule workup, a pt is found to have low TSH. What is the next step?
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If low TSH (hyperfunctioning gland), then get I123 or Tc99 scanning to evaluate if the whole gland is hyperactive (ie. Graves dz) or a hyperactive nodule.
If "hot" nodule or uniform uptake in the gland, then tx for hyperthyroidism. If "cold" nodule, then proceed to FNA. |
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In a thyroid nodule workup, a pt is found to have normal or high TSH. What is the next step?
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If TSH is normal or high (underfunctioning thyroid), then proceed to US-guided FNA
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What is your plan for the following FNA results?
Nondiagnostic/inadequate: Bening: Malignant: Indeterminate: |
Nondiagnostic/inadequate: repeat US-guided FNA in 3 months, if inadequate again then surgery or close f/u
Benign: follow clinically at 6-18mo intervals if easily palpable; if not easily palpable, do FNA at same intervals; surgery possible Malignant: surgery Indeterminate: |
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If a pt has a thyroid cyst, what is the tx? (based on size..)
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If cyst is <4cm - aspirate & potentially suppressed
If cyst >4cm - resected |
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Which thyroid malignancy can have a variable histology and cytology on testing?
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Medullary carcinoma
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What is the name of the new system for reporting thyroid cytopathology?
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The Bethesda System - uses six classifications, rather then the old four
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"The main difficulty with FNA in the identification of malignancy is the differentiation of _______ adenoma from ________ carcinoma. Why is it difficult?
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Follicular adenoma vs carcinoma
- to diagnose follicular carcinoma, histological evidence of capsular invasion is needed. Thus, you must evaluate the entire capsule to make an accurate distinction; this goal cannot be attained with FNA. |
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A thyroid FNA result demonstrate Hurthle cell-predominant aspirate. What is the tx?
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Hurthle cells are large polygonal follicular cells with granular cytoplasm; may indicate underlying Hurthle cell adenoma or Hurthle cell carcinoma. Hurthle cells may also be present as metaplastic cells in a variety of thyroid disorders, such as multinodular goiter and Hashimoto's thyroiditis.
Tx - surgical resection due to risk of carcinoma |
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What is the range of false-negative FNA readings?
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1-6%
- false-negative readings occur with greater frequency in small lesions <1cm, large lesions >3cm or cystic lesions |
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What percentage of thyroid nodules are cysts?
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About 20%
- the risk carcinoma in a cyst that has persisted after aspiration attempts ranges from 10-30% (papillary carcinomas can present with cystic mets) |
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What is ultrasound elastography?
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A newly developed US technique which determines the stiffness of an abnormal growth by testing how it compresses.
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What unique cells are found in papillary carcinoma of the thyroid?
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Cells with Orphan Annie eyes nuclei
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Does papillary carcinoma spread easily?
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Papillary carcinoma is strongly lymphotrophic, with early spread through intrathyroidal lymphatics as well as to regional cervical lymphatic beds.
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What percentage of pts with papillary thyroid carcinoma will have nodal disease?
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30% adults and up to 60% kids
(3% mets) |
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Which pathway is know play a role in papillary thyroid carcinoma?
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Alteration in the mitogen-activated protein kinase (MAPK) pathway is central to malignant transformation
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What is a strong prognostic factor in follicular carcinoma of the thyroid?
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degree of pericapsular invasion
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What is the rate of nodal spread and distant mets with follicular carcinoma compared to papillary carcinoma
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Follicular ca is LESS likely to present with nodal mets than papillary ca, but MORE likely to present with distant mets (16% vs 3%).
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What subtype of follicular carcinoma follows a more aggressive course than follicular carcinoma?
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Hurthle cell carcinoma, aka follicular carcinoma, oxyphilic type
- overall mortality rate is 30-70% |
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What are the key prognostic factors for well-differentiated thyroid carcinoma?
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Age (males <40 and females <50 have improved prognosis)
Degree of invasiveness/extrathyroidal extension Mets Sex (males have worse prognosis) Size (lesions <1.5cm have better prognosis) |
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What are the preoperative staging recommendations for well-differentiated thyroid carcinomas?
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Pts with malignant cytologic findings on FNA, being tx with thyroidectomy, undergo preoperatiev neck ultrasound for eval of contralateral lobe and cervical lymph nodes. CT scanning of the neck can be considered.
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When is lobectomy alone a sufficiency surgical tx for thyroid cancer?
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Only for small, low-risk (age, sex, invasion, mets, size), isolated, intrathyroidal papillary carcinomas without cervical nodal disease
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What meds/treatments can be given to the patient postoperatively s/p thyroidectomy?
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Thyroid hormone (usually T4) is given to suppress TSH to 0.1 to 0.3 in high-risk pts.
I131 is given in ablative doses in pts who have undergone less than total thyroidectomy , which should complete the thyroid ablation and render the pt hypothyroid External beam radiation has been employed to palliate extensive central neck disease, prolong local control, and improve quality of life in inoperable cases or where gross dz persists postoperatively. |
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Thyroglobulin is usually elevated or decreased after total thyroid ablation in pts with known metastatic disease?
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Usually elevated in pts with metastatic disease, even after thyroid ablation.
- Along with whole body scanning, it can be used to assess the status of metastatic disease. - If thyroglobulin is low or unmeasureable after total thyroid ablation and whole body scanning is negative, pts rarely harbor clinically significant metastatic disease - If thyroglobulin is high, may perform a PET/CT scan |
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How often do you need to follow patients postoperative for well-differentiated thyroid cancer?
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Cervical US performed at 6 and 12 months, and then annually for 3-5 years to eval the thyroid bed and central and lateral cervical nodal compartments.
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Medullary carcinoma of the thyroid arises from which cells?
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Parafollicular C cells (NOT thyroid follicular cells)
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Which oncogene point missense germ-line mutation has been identified in patients with inherited medullary carcinoma of the thyroid?
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RET
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What is the tx for medullar carcinoma of the thyroid?
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Total thyroidectomy with central neck dissection (level VI; include the pre- and paratracheal, pre-cricoid (Delphian) and perithyroidal.)
- Also, if pts have palpable medullary carcinoma of the thyroid, should also receive ipisilateral level II-V neck dissections with consideration for bilateral dissection. |
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Medullary thyroid carcinoma can present which which syndromes?
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MEN 2a and 2b (multiple endocrine neoplasia)
FMTC (familial nonmultiple endocrine neiplasia medullary carcinoma) |
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Primary thyroid lymphomas are typically of Hodgkin's or non-Hodgkin's type?
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non-Hodgkin's type (1* thyroid Hodgin's dz is extremely rare)
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What is the mainstay of tx for thyroid lymphomas?
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radiation therapy and chemotherapy (surgery is mainly restricted to biopsy)
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The incidence of primary thyroid lymphomas in pts with ____________________ is markedly increased
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Hashimoto's thyroiditis
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What is anaplastic carcinoma though to derive from?
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Believed to occur from a terminal dedifferentiation of previously undetected long-standing differentiated thyroid carcinoma.
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About 25% of undifferentiated thyroid cancers have _______ mutations.
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BRAF
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What is the average survival length of a pt with anaplastic thyroid carcinoma?
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It is one of the most lethal human malignancies, with an average survival of about 6 months.
- Tx is mainly with external beam radiation and chemotherapy; surgery for debulking is also performed. |
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Where is the approximate location of the inferior parathyroid on the thyroid gland?
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Located within 1cm inferior or posterior to the thyroids inferior pole
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What is the Tubercle of Zuckerkandl and what is its importance?
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It is a pyramidal extension of the thyroid gland, present at the most posterior side of each lobe. Emil Zuckerkandl described it in 1902 as the processus posterior glandulae thyreoideae.
The structure is important in thyroid surgery as it is closely related to the recurrent laryngeal nerve, the inferior thyroid artery, Berry's ligament and the parathyroid glands. |
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What portion of the RLN brach above the crossing point of the RLN and inferior thyroid artery?
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1/3rd
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Why must you always take the inferior and superior thyroid arteries as close to the thyroid as possible?
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to optimize parathyroid preservation
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What will the pts voice sound like with bilateral RLN paralysis?
How about with SLN external branch paralysis? |
RNL paralysis bilaterally may result in a nearly normal voice, but also respiratory insufficiency with postop stidor.
SLN external branch paralysis (0.4 - 3% cases) results in reduction of cricothyroid vocal cord tensing with loos of high vocal registers. The affected cord will be lower and bowed, with laryngeal rotation. |
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What are S&Sx of hypoparathyroidism after thyroidectomy?
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Initially pt may have perioral and digital paresthesias.
Progressive neuromuscular irritability results in spontaneous carpopedal spasms, abd cramps, laryngeal stridor, mental status changes, QT prolongation on EKG, and ultimately tetanic contractions. |
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Treatment of hypocalcemia is usually begin when the calcium level falls below ____ mg/dL
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7.5 mg/dL, or in a symptomatic patient
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What is the frequency of temporary and permanent hypoparathyroidism after total thyroidectomy?
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Temporary (less than 6 mo) - 17-40%
Permanent (>6mo) - 10% |
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Total serum calcium levels fall by ___ mg/dL for every 1g/dL fall in albumin
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0.8
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List causes for primary hyperparathyroidism (HPT)
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Spontaneous
Familial Associated with MEN syndromes (males - 1:2000; females - 1:500) |
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Which MEN syndromes have associated parathyroid involvement?
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MEN 1 (Werner)
MEN 2a (Sipple) |
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What is the frequency of parathyroid carcinoma in those with primary hyperparathyroidism (HPT)?
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About 1% (expect very high serum PTH and calcium levels)
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What is the difference between secondary and tertiary hyperparathyroidism?
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Secondary HPT - a hyperplastic response of parathyroid tissue (all 4), typically secondary to renal failure
Tertiary HPT - when this parathyroid response becomes autonomous, persisting after correction of the primary metabolic derangement (typically renal transplant) with increased PTH levels despite normalization of calcium. |
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What is the cause of benign familial hypocalciuric hypercalcemia (BFHH)?
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Autosomal dominant inherited disease characterized by excess renal calcium reabsorption = high serum Ca and low urine Ca
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Which pts with hypercalcemia are offered surgery?
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Symptomatic hypercalemia
Elevated calcium levels greater than 1 mg/dL above the upper limit of normal Young pts under 50yo (due to potential for development of sx) All pts who desire it or have had a previous episode of life-threatening hypercalcemia Older pts who are assx = controversial. If pt has osteoporosis, decreased CrCl or high calciuria, then consider surgery. |
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What is the best initial imaging modality for preoperative parathyroid localization?
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Sestamibi scan (using technetium-99m)
- The Tc99 is initially taken up by BOTH thyroid and parathyroid glands. The thyroid uptake is, over time, washed out, yet sestamibi is retained by adenomatous parathyroid glands. (imagine showing L anterior parathyroid enhancement 2 hours after administration of sestamibi) |
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What is the sensitivity of sestamibi scans and what role does SPECT scanning play in parathyroid adenoma's?
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Sestamibi sensitivity in the literature is 70-100%.
Single proton emission computerized tomography (SPECT) scanning for primary hyperparathyroidism increases the accurace of routine sestamibi scanning by about 2-3% by providing a three-dimensional picture rather than a planar (PA) view. |
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What is Hybrid SPECT/CT?
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Combines the 3rd functional information of SPECT with the anatomic information of CT, further improving preoperative localization
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What is the half-life of PTH?
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Very short, about 10 minutes, so intra-operative PTH may be measured.
PTH should fall to within normal limits intraoperatively following resection of an adenoma |
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What do parathyroid glands look like compared to fat?
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Flat-bean or leaf-like shaped yellow-tan, caramel or mahogany in color (compared to brighter, less distinct yellow fat)
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What percent of humans will have more than four parathyroid glands?
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about 5%
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The superior parathyroid glands are derived from which branchial pouch?
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4th
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The inferior parathyroid glands are derived from which branchial pouch?
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3rd
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How can you find the superior parathyroids during surgery?
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Typically occur at the level of the cricothyroid articulation of the larynx, approximately 1cm above the intersection of the RLN and inferior thyroid artery.
Closely related to the posterolateral aspect of the superior thyroid pole. Located at a plane deep (dorsal) to the plane of the RLN in the neck. |
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Where do the inferior parathyroids lie in relation to the RLN?
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Anterior/superficial (ventral) to the RLN
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Where are the most common ectopic locations for parathyroid adenomas?
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Retroesophageal
Retrotracheal Anterior mediastinal Intrathyroidal Carotid sheath Hyoid/angle of mandible |
