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Atlas of Thyroid Disorders & Thyroid Surgery
Amit Agarwal
SECTION 1:
Examination of Thyroid
CLINICAL EXAMINATION OF THYROID: LAHEY'S METHOD
CRILE'S METHOD
GENERAL EXAMINATION SPECIFIC TO THYROID DISEASES
Primary toxic features
Features of distant metastasis
EXAMINATION OF THYROID: PALPATION
Surface
Smooth
Bosselated
CONSISTENCY
PALPATION
Consistency
CAREFUL! A CYSTIC SWELLING OF THYROID MAY FEEL FIRM
CAREFUL! HARD NODULE IS NOT ALWAYS MALIGNANT
MOBILITY
PALPATION OF TRACHEA
RETROSTERNAL EXTENSION
PERCUSSION OF MANUBRIUM
PEMBERTON'S SIGN
BERRY'S SIGN
KOCHER'S TEST
HORNER'S SYNDROME
THRILL
THYROID OPHTHALMOPATHY
VON GRAEFE'S SIGN
DALRYMPLE'S SIGN
CONJUNCTIVAL EDEMA
EXOPHTHALMOMETRY
GOFFROY'S SIGN
GRIFFITH'S SIGN
MöBIUS’ SIGN
NAFZIGER'S TEST
SECTION 2:
Benign Thyroid Diseases
LINGUAL THYROID
Evaluation
MANAGEMENT
THYROGLOSSAL CYST: CLINICAL FEATURES
ETIOLOGY
THYROGLOSSAL FISTULA
EVALUATION
SISTRUNK'S OPERATION
CONGENITAL HYPOTHYROIDISM: CAUSES
MANAGEMENT
GRAVES’ DISEASE: DIAGNOSIS
ANCILLARY TEST
INDICATIONS OF SURGERY
ADOLESCENT GRAVES’ DISEASE
TREATMENT
NODULAR TOXIC GOITER
DIAGNOSIS
MANAGEMENT
TOXIC NODULE
Clinical presentation
MANAGEMENT
SOLITARY THYROID NODULE
FNAC
THYROID FUNCTION TEST
ULTRASONOGRAPHY (USG)
USG CHARACTERISTICS
LARGE THYROID NODULES
USG MICROCALCIFICATION: PAPILLARY CARCINOMA
LATERAL LYMPH NODE
ULTRASONOGRAPHY
PAPILLARY CARCINOMA
THYROID SCAN
X-RAY NECK: TO LOOK FOR TRACHEAL DEVIATION/COMPRESSION
X-RAY NECK
MANAGEMENT
THYROIDITIS
Painful Thyroid
Causes
SUB-ACUTE THYROIDITIS (SAT)
HASHIMOTO'S THYROIDITIS
HISTOPATHOLOGY
EUTHYROID MULTINODULAR GOITER
PATHOLOGY
CLINICAL FINDINGS
EVALUATION
POTENTIAL COMPLICATIONS/INDICATION FOR SURGERY: 5 CS
TREATMENT ISSUES
DOES POSTOPERATIVE TSH SUPPRESSION REDUCE RECURRENCE RATE?
SECTION 3:
Retrosternal Goiter
RETROSTERNAL GOITER: DEFINITION
CLASSIFICATION
CLINICAL PRESENTATION
EVALUATION: PLAIN X-RAY
CONTRAST-ENHANCED COMPUTED TOMOGRAPHY (CECT)
LUNG FUNCTION STUDIES
TREATMENT OPTIONS
SURGICAL TECHNIQUE
SECTION 4:
Surgical Anatomy
BLOOD SUPPLY: VENOUS DRAINAGE
EXTERNAL BRANCH OF SLN
RECURRENT LARYNGEAL NERVE (RLN): TOOTHPASTE SIGN
POSITION IN THE NECK
VARIATION IN SIZE
RELATIONSHIP WITH INFERIOR THYROID ARTERY
VARIATION—RLN MAY CROSS THE ITA ANTERIORLY!!
RELATIONSHIP WITH INFERIOR CONSTRICTOR AT LARYNGEAL ENTRY POINT
EXTRALARYNGEAL BRANCHING
RELATION WITH SUPERIOR PARATHYROID
RELATION WITH INFERIOR PARATHYROID
RELATIONSHIP WITH BERRY'S LIGAMENT
RELATIONSHIP WITH TUBERCLE OF ZUCKERKANDL
NON-RECURRENT LARYNGEAL NERVE
PARATHYROID
BLOOD SUPPLY OF SUPERIOR PARATHYROID GLANDS
PARATHYROID CHANGES COLOR
PYRAMIDAL LOBE
RECURRENCE IN PYRAMIDAL LOBE AFTER TOTAL THYROIDECTOMY
DETACHED THYROID NODULE
NECK DISSECTION: CONTENTS OF CAROTID SHEATH
SECTION 5:
Technique of Thyroidectomy
SKIN MARKING
RAISING FLAPS BY CUTTING PLATYSMA
RAISING THE FLAPS
LIGATION IN CONTINUITY OF THE ANTERIOR JUGULAR VEINS
FINDING AND DISSECTING THE MIDLINE
FINDING AND DISSECTING THE MIDLINE
SEPARATING THE STRAP MUSCLES
CUTTING THE STRAP MUSCLES
SURGICAL TECHNIQUE
LIGATING THE MIDDLE THYROID VEIN(S)
MULTIPLE MIDDLE THYROID VEINS
DELIVERING THE THYROID LOBE
SUPERIOR POLE: CREATING MEDIAL SPACE
ATTEMPTING TO IDENTIFY THE EBSLN
NEUROMONITORING OF EBSLN
LIGATION OF SUPERIOR PEDICLE
SUTURELESS THYROIDECTOMY
IDENTIFYING THE SUPERIOR PARATHYROID GLAND
DISSECTING THE SUPERIOR PARATHYROID GLAND
IDENTIFYING THE SUPERIOR PARATHYROID GLAND
SURGICAL TECHNIQUE: PRESERVING THE BLOOD SUPPLY OF PARATHYROID GLAND
SAVING THE SUPERIOR PARATHYROID GLAND
FINDING THE RECURRENT LARYNGEAL NERVE (RLN)
PALPATING FOR THE RLN NEAR THE INFERIOR POLE OF THYROID
FINDING THE RLN: LATERAL APPROACH
FINDING THE RLN: SUPERIOR APPROACH
FINDING THE RLN: INFERIOR APPROACH
RECURRENT LARYNGEAL NERVE (RLN): EXPOSURE AND DISSECTION
DISSECTION
BLUNT DISSECTION STARTED
FINDING THE RECURRENT LARYNGEAL NERVE (RLN)
BLUNT DISSECTION
MORE DISSECTION
BERRY'S LIGAMENT IS NOT ALWAYS AVASCULAR!
RECURRENT LARYNGEAL NERVE (RLN)
IDENTIFYING THE INFERIOR PARATHYROID GLAND
DISSECTING THE INFERIOR PARATHYROID GLAND
SAVING THE INFERIOR PARATHYROID GLAND
DISSECTING THE INFERIOR PARATHYROID GLAND
SAVING THE INFERIOR PARATHYROID GLAND
IDENTIFYING THE TUBERCLE OF ZUCKERKANDL, IF PRESENT
IMPORTANCE OF TZ
TYING THE BERRY'S LIGAMENT…
LIGATING THE INFERIOR THYROID VEIN
SEPARATING THE THYROID LOBE FROM THE TRACHEA
SUTURING THE STRAP MUSCLES LEAVING A GAP IN THE INFERIORMOST PORTION
SKIN CLOSURE: SUBCUTICULAR STITCH
GLUE
SUBCUTICULAR STITCH
SECTION 6:
Special Situations
COMPLETE THYROIDECTOMY: WORK-UP
TECHNIQUE OF RE-DO SURGERY
CARCINOMA THYROID WITH EXTRATHYROIDAL EXTENSION TO STRAP MUSCLES
Large Thyroid Mass Compressing the IJV
LARGE GOITERS
RECURRENT GOITERS
SMALL INCISION THYROIDECTOMY
DISSECTING AND SAVING RLN APPARENTLY INVADED BY METASTATIC LN IN MTC
SECTION 7:
Complications of Thyroidectomy
CHYLOUS FISTULA AFTER LEFT NECK DISSECTION
TRACHEOMALACIA
HYPOCALCEMIA
RLN INJURY: COMMON SITES OF DAMAGE
OVERSTRETCHING!!
BEWARE!! IT MAY BE PULLED UP WITH THE THYROID NODULE
SECTION 8:
Malignant Lesions of Thyroid
Papillary Carcinoma
CLINICAL PRESENTATION
INITIAL INVESTIGATIONS
ULTRASONOGRAPHY
ANCILLARY INVESTIGATIONS
RISK STRATIFICATION
MANAGEMENT
EXTENT OF THYROIDECTOMY
EXTENT OF LYMPH NODE DISSECTION
HISTOPATHOLOGY
POSTOPERATIVE RAI REMNANT ABLATION
DOSE OF 131I ABLATION
SUPPRESSIVE THERAPY WITH THYROXINE
LOCALLY INVASIVE TO THYROID CARTILAGE
LOCALLY ADVANCED PAPILLARY CARCINOMA: STRAP MUSCLE INVASION
ESOPHAGEAL INVASION
MANAGEMENT OF LOCALLY INVASIVE PTC
LN IN PTC
PTC
PAPILLARY MICROCARCINOMA
MULTIFOCAL PAPILLARY MICROCARCINOMA THYROID
MANAGEMENT
VARIANTS OF PTC
FOLLICULAR VARIANT OF PTC (FVPTC)
TALL CELL VARIANT
FOLLICULAR NEOPLASM/CARCINOMA
FINE NEEDLE ASPIRATION CYTOLOGY (FNAC)
PRESENTATION
FOLLICULAR NEOPLASM: MANAGEMENT
CLINICAL PRESENTATION
FTC: SKELETAL METASTASES
SKULL METASTASES
PLAIN X-RAY AND CT SHOWING DESTRUCTION OF SKULL BONES
RAI UPTAKE IN SKELETAL METASTASES
METASTATIC FOLLICULAR CARCINOMA: DETECTION
MANAGEMENT
MANAGEMENT OF PARAPARESIS/PARAPLEGIA
LONG-TERM PROGNOSIS
HURTHLE CELL NEOPLASM/CARCINOMA
CLINICAL AND HISTOLOGICAL CHARACTERISTICS
STN WITH A FNAC DIAGNOSIS OF HURTHLE CELL NEOPLASM: SURGICAL MANAGEMENT
HISTOPATHOLOGY
POSTOPERATIVE MANAGEMENT
DIFFERENCES FROM FTC
Medullary Thyroid Cancer (MTC)
CLINICAL PRESENTATION
SOME FEATURES OF THYROID NODULE MAY PROMPT SUSPICION OF MTC
SIGNS AND SYMPTOMS OF LOCALLY INVASIVE TUMOR SHOULD BE LOOKED FOR
MEDULLARY THYROID CANCER (MTC): FAMILY SCREENING
SCREEN FOR INVOLVEMENT OF OTHER ENDOCRINE GLANDS
MULTIPLE ENDOCRINE NEOPLASIA (MEN) IIA
FNAC
SERUM CALCITONIN
EVALUATION TO RULE OUT MEN II
USG AND CT
ANCILLARY INVESTIGATIONS: CECT
METASTATIC WORK-UP
GENETIC SCREENING
CLINICOPATHOLOGICAL CORRELATION
PATTERN OF LOCOREGIONAL AND METASTATIC SPREAD
CENTRAL COMPARTMENT NODES DISSECTION (CCND)
PATTERN OF METASTATIC SPREAD
Distant Metastases
BEHAVIOR
EXTENT OF SURGERY
HISTOPATHOLOGY
SPECIAL STAINS
IMMUNOHISTOCHEMISTRY
SURGICAL APPROACH
POSTOPERATIVE PROTOCOL
PROGNOSIS
PROGNOSTIC FACTORS
PERSISTENT HYPERCALCITONINEMIA
EVALUATION
MANAGEMENT APPROACHES
CAN PRESENT IN TWO DIFFERENT WAYS?
ANAPLASTIC TRANSFORMATION
ANAPLASTIC CARCINOMA
FNAC
TRU-CUT BIOPSY: ROLE
MANAGEMENT OF ATC: TOTAL THYROIDECTOMY
ROLE OF HYPERFRACTIONATED RADIOTHERAPY AND CHEMOTHERAPY
INDEX
TOC
Index
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