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THYROID
MODULE
- Madhavankutty Jayanthi ANJANA
(20-1289-143)
Block 6, group 3
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ANATOMY OF THYROID GLAND The thyroid lobes are located
adjacent to the thyroid cartilage
• The thyroid gland arises as an outpouching of the and connected in the midline by
primitive foregut around the third week of an isthmus that is located just
gestation. It originates at the base of the tongue at
inferior to the cricoid cartilage.
the foramen cecum.
• Thyroid follicles are initially apparent by 8 weeks,
and colloid formation begins by the eleventh week
of gestation.
• The adult thyroid gland is brown in color and firm
in consistency and is located posterior to the strap
muscles. The normal thyroid gland weighs
approximately 20 g, but gland weight varies with
body weight and iodine intake.
• It lies between C5 and T1. It lies behind the
sternohyoid and sternothyroid muscles, wrapping
around the cricoid cartilage and superior tracheal 2
rings. It is inferior to the thyroid cartilage of the
larynx.
Arterial and Venous Supply to
Thyroid Gland
1) The superior thyroid artery is the first branch of the external carotid artery. After
arising, the artery descends toward the thyroid gland. As a generalization, it
supplies the superior and anterior portions of the gland.
2) The inferior thyroid artery arises from the thyrocervical trunk (which in turn is a
branch of the subclavian artery). The artery travels superomedially to reach the
inferior pole of the thyroid. It tends to supply the posteroinferior aspect of the
gland.
3) In a small proportion of people (around 10%), there is an additional artery
present; the thyroid ima artery. It comes from the brachiocephalic trunk of the arch
of aorta, supplying the anterior surface and isthmus.
4)Venous drainage is carried out by the superior, middle and inferior thyroid veins,
which form a venous plexus. The superior and middle veins drain into the internal
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jugular veins, whereas the inferior drains into the brachiocephalic vein
NERVE SUPPLY OF THYROID
GLAND
The right RLN arises from the vagus at its
crossing with the right subclavian artery. The left RLN arises from the
The nerve usually passes posterior to the vagus nerve where it crosses
artery before ascending in the neck, its
the aortic arch, loops around
course being more oblique than the left
the ligamentum arteriosum, and
RLN. Along their course in the neck, the
RLNs may branch, and pass anterior, ascends medially in the neck
posterior, or interdigitate with branches of within the tracheoesophageal
the inferior thyroid artery groove
LYMPHATIC DRAINAGE
• The lymphatic drainage of the thyroid is
multidirectional and extensive.
• It drains initially into peri-thyroid nodes

PRE-LARYNGEAL NODES
Laterally, the gland drains
into
SUPERIOR DEEP
CERVICAL
PRETRACHEAL NODES
NODES

INFERIOR DEEP
CERVICAL NODES
PARA TRACHEAL NODES

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Physiology of the Thyroid Gland

1)Two types of hormones are produced, which are the iodine

containing hormones; tri-iodothyronine(T3) and thyroxine (T4).
Thyroid hormones regulate the basal metabolic rate and are
important in the regulation of growth of tissues, particularly nervous
tissue. Release stimulated by TSH from the pituitary. The second
type of hormone produced from the thyroid gland is calcitonin, which
regulates blood calcium levels along with parathyroid hormone and
acts to reduce blood calcium by inhibiting its removal from bone.
2)The thyroid is the storage site of >90% of the body’s iodine content
and accounts for one third of the plasma iodine loss. The remaining
plasma iodine is cleared via renal excretion.
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EVALUATION OF PATIENTS WITH THYROID
DISEASE
▪TSH TESTS : The best way to initially test thyroid function is to measure the TSH level in a blood sample. Changes in
TSH can serve as an “early warning system” – often occurring before the actual level of thyroid hormones in the body
becomes too high or too low.
▪T4 TESTS : T4 is the main form of thyroid hormone circulating in the blood. A Total T4 measures the bound and free
hormone and can change when binding proteins differ. A Free T4 measures what is not bound and able to enter and
affect the body tissues.
▪T3 TESTS
T3 tests are often useful to diagnosis hyperthyroidism or to determine the severity of the hyperthyroidism. Patients who
are hyperthyroid will have an elevated T3 level.
▪THYROID ANTIBODY TESTS The immune system of the body normally protects us from foreign invaders such as
bacteria and viruses by destroying these invaders with substances called antibodies produced by blood cells known as
lymphocytes. In many patients with hypothyroidism or hyperthyroidism, lymphocytes react against the thyroid (thyroid
autoimmunity) and make antibodies against thyroid cell proteins. Two common antibodies are thyroid peroxidase
antibody and thyroglobulin antibody. 7
▪THYROGLOBULIN : Thyroglobulin (Tg) is a protein produced by normal thyroid cells and thyroid cancer
cells. It is not a measure of thyroid function and it does not diagnose thyroid cancer when the thyroid gland is
still present. It is used most often in patients who have had surgery for thyroid cancer in order to monitor
them after treatment.
▪RADIOACTIVE IODINE UPTAKE
Because T4 contains iodine, the thyroid gland must pull a large amount of iodine from the bloodstream in order to
make an appropriate amount of T4. The thyroid has developed a very active mechanism for doing this. Therefore, this
activity can be measured by having an individual swallow a small amount of iodine, which is radioactive. The
radioactivity allows the doctor to track where the iodine goes.
• Ultrasound : Ultrasound is an excellent noninvasive and portable imaging study of the thyroid gland with the added
advantage of no radiation exposure. It is helpful in the evaluation of thyroid nodules, distinguishing solid from cystic
ones, and providing information about size and multicentricity.
• Computed Tomography/Magnetic Resonance Imaging Scan : CT and magnetic resonance imaging (MRI) studies
provide excellent imaging of the thyroid gland and adjacent nodes and are particularly useful in evaluating the extent of
large, fixed, or substernal goiters (which cannot be evaluated by ultrasound) and their relationship to the airway and
vascular structures.
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BENIGN THYROID
DISORDERS
A) Hyperthyroidism
Graves’ Disease
1)Graves’ disease is an autoimmune disorder. Autoantibodies are
produced and are directed against TSH receptors of follicular cells.
The antibody is Long-Acting Thyroid Stimulating (LATS) antibody.
2)Diffuse goiter is present here and the patient will develop
thyrotoxicosis. LATS attack the extra orbital connective tissue which
leads to proptosis. This disease is more common among females of
child bearing age.
3)Undue connective tissue deposition with water on the lateral
malleolus leads to pretibial myxedema. 9

4)Thyroid function tests reveal increased T3, T4, LATS and

decreased TRH,TSH.
Three treatment options are available for people with Graves’ disease

anti-thyroid drugs (propylthiouracil or

radioactive iodine (RAI) therapy
thyroid Surgery
methimazole)

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Toxic multinodular Goiter
1)Usually occur in older individuals, who often have a prior
history of a nontoxic multinodular goiter.
2)Over several years, enough thyroid nodules become
autonomous to cause hyperthyroidism.
3)suppressed TSH level and elevated free T4 or T3 levels.
RAI uptake also is increased, showing multiple nodules with
increased uptake and suppression of the remaining gland.
4)Surgery is performed via near-total or total
thyroidectomy and it is recommended to avoid recurrence
and the consequent increased complication rates with
repeat surgery. Care must be taken in identifying the RLN,
which may be found laterally on the thyroid (rather than
posterior) or stretched anteriorly over a nodule. RAI
therapy is reserved for elderly patients who represent very 1
poor operative risks, provided there is no airway 1

compression from the goiter and thyroid cancer is not a

concern.
Toxic Adenoma
1)This is a benign neoplasia.
2)In some people, one of the follicular cells undergoes neoplasia
which leads to adenoma formation. This adenoma is autonomous and
produces thyroid hormones independent of TSH.
3)Physical examination usually reveals a solitary thyroid nodule
without palpable thyroid tissue on the contralateral side.
4)The adenoma is hypertrophied whereas the remaining gland
undergoes atrophy.
5)There is increased T3,T4 and decreased TSH.
6)RAI scanning shows a “hot” nodule with suppression of the rest of
the thyroid gland.
Smaller nodules may be managed with antithyroid medications and
RAI. Larger nodules can require higher doses, which can lead to
hypothyroidism. Surgery (lobectomy and isthmusectomy) is preferred
to treat young patients and those with larger nodules

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Thyroid Storm

1) Thyroid storm refers to the abrupt onset of severe hyperthyroidism. This

condition occurs most commonly in patients with underlying Graves disease
and probably results from an acute elevation in catecholamine levels, as
might be encountered during infection, surgery, cessation of antithyroid
medication, or any form of stress.

2)Patients are often febrile and present with tachycardia out of proportion to
the fever. Thyroid storm is a medical emergency. A significant number of
untreated patients die of cardiac arrhythmias.

3)Propanolol to blockthe sympathetic activity, PTU to prevent peripheral

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conversion of T4 to T3, Glucocorticoids 3
B) HYPOTHYROIDISM

1)Hypothyroidism is a condition caused by a structural or functional derangement that interferes with the
production of thyroid hormone.
2) Congenital absence of thyroid gland is cretinism, which if not treated will lead to hypothyroidism.
3) In adults, symptoms in general are nonspecific, including tiredness, weight gain, cold intolerance,
constipation, and menorrhagia.
4)Hypothyroidism is characterized by low circulating levels of T4 and T3. Raised TSH levels are found in
primary thyroid failure, whereas secondary hypothyroidism is characterized by low TSH levels that do not
increase following TRH stimulation.
5)T4 is the treatment of choice and is administered in dosages varying from 50 to 200 μg per day, depending
on the patient’s size and condition.
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C) Thyroiditis
Thyroiditis, or inflammation of the thyroid
gland, encompasses a diverse group of
Hashimoto’s Thyroiditis (Chronic Lymphocytic Thyroiditis)
disorders characterized by some form of
1)AI disorder associated with PTPN 22 and CTLA 4 gene. There is
thyroid inflammation cell mediated damage to the thyroid gland.
2)Anti-TPO, anti-microsomal, anti-thyroglobulin antibodies are
present.
3)It usually occurs in middle aged females.
4)Initially there is thyrotoxicosis and later there is hypothyroidism.
5)An elevated TSH and the presence of thyroid autoantibodies
usually confirm the diagnosis.
6)Thyroid hormone replacement therapy is indicated in overtly
hypothyroid patients, with a goal of maintaining normal
TSH levels.

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Acute (Suppurative)
Thyroiditis
1)Arises due to bacterial infection
2)The most common bacteria involved is S. Risk Factors in Developing Thyroid
aureus. Malignancy
• Gender
3)There is fever, tender thyroid gland,
• Age
enlargement of cervical lymph node.
• Genetics
4)The diagnosis is established by • Radiation exposure
leukocytosis on blood tests and FNAB for • Diet low in iodine
Gram’s stain, culture, and cytology. • Race
5)Antibiotics can be used for treatment. 1
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MANAGEMENT OF SOLID THYROID NODULES

⮚Nodules that cause hyperthyroidism are treated using –

Radioactive iodine, anti-thyroid medications, surgery

⮚Nodules that can cause cancer are treated using –

Surgery, Ablation

⮚Nodules that cause hypothyroidism are treated using –

Surgery, thyroid hormone therapy

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THYROID MALIGNANCY

⮚Papillary Thyroid Cancer

1)Most common cancer of thyroid. Associated with RET

PTC gene mutation.
2)Seen usually in younger patients. Causes metastases via
lymphatics. There is also cervical lymph node enlargement.
3)The risk factors include Hahimoto’s, previous radiation
exposure, thyroglossal cyst.
4)Orphan Annie eye nuclei and Psamomma bodies are
seen on microscopy.
5)In general, patients with PTC have an excellent prognosis
with a >95% 10-year survival rate. 1
6)Total or near-total thyroidectomy is the treatment of 9

choice.
Follicular Thyroid
Cancer
1)Associated with RAS PI3K gene mutation. Occurs usually in
middle aged women.

2)The metastasis here can be seen in the form of capsular invasion

or vascular invasion and this is the most confirmatory way to
diagnose this cancer.
The serum thyroglobulin is increased. Poor long term prognosis if
age >50y.

3)Total thyroidectomy is recommended by some surgeons in older

patients with follicular lesions >4 cm because of the higher risk of
cancer in this setting (50%) and certainly should be performed in
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patients with atypia on FNA, a family history of thyroid cancer. 0
Medullary Thyroid Cancer

1) Only thyroid cancer which arises from parafollicular

cells.
2) Best tumor marker is calcitonin , often deposits
within the tumor as Amyloid
3) Associated with MEN 2A,B.
4) Prophylactic thyroidectomy is indicated as
treatment.
5) Can be diagnosed via FNAC.
6) Associated with RET gene mutation.
7) If calcitonin is absent, carcino embryonic antigen
(CEA) can be used as tumor marker.
8) The 10-year survival rate is approximately 80% but 2

decreases to 45% in patients with lymph node 1

involvement
Anaplastic Thyroid
Cancer
1)Thyroid gland is firm, non tender.

2)Occurs in elderly females.

3)Poor prognosis.

4)Positive cytokeratin is used as a

marker for this cancer.

5)Chemotherapy (cyclophosphamide, 2
2
doxorubicin, vincristine, and
prednisone) is the treatment
TNM CLASSIFICATION
OF THYROID TUMORS

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Complications of Thyroid Surgery

⮚Bleeding in the neck

⮚Hoarseness/Voice Change (recurrent
laryngeal nerve injury)
⮚Hypocalcemia (Hypoparathyroidism)
⮚Infection
⮚Thyroid storm
⮚Hypothyroidism

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THANK
YOU 3
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