PSGS Review 2015

+

PSGS Review 2014 Surgery Head and Neck Ida Marie Tabangay Lim,MD FPCS,FPSGS,FPAHNSI

+

THYROID GLAND DISASS

+ ANATOMY N

adult thyroid gland light brown in color ; firm , weighs 15 to 20 g.

 formed

by two lateral lobes connected centrally by an isthmus.

 the

lobes are 4 cm long, 2 cm wide, and 2 to 4 mm thic!, with the isthmus 2 to " mm thic!.

+ ANATOMY  #yramidal

lobe $ 80 percent of indi%iduals; usually &ust to the left of the midline, e'tending u(ward from the isthmus along the anterior surface of the thyroid cartilage. )t is a remnant of the thyroglossal duct

+ ANATOMY

+

-*((d #u..*y / '(ur )a(r ar$erie#

thyroid arteries! "r#$ %ranc& external carotid artery

 superior



inferior arteries! ari#e 'r()thyroid $&e thyrocervical trunk (' $&e #u%c*avian ar$erie#



Occa#i(na**y a fth artery the thyroidea ima+ (rigina$ing direc$*y 'r() $&e aortic arch or the innominate artery,

+ NOS DRAINAG/  Superior

thyroid vein and middle thyroid vein$ internal jugular vein

 The

inferior thyroid veins *usually forming a (le'us that drains into the brachiocephalic vein.

+ Ner%e +u((ly 

)nner%ation of the gland is by sym(athetic fibers from the su(erior and middle cer%ical sym(athetic ganglia. The fibers enter with the blood %essels and are %asomotor in action.



#arasym(athetic fibers are deri%ed from the %agus ner%e and reach the gland %ia branches of the laryngeal ner%es

+ Regu*a$i(n (' T&yr(id Ac$ivi$y Hy.($&a*a)ic!.i$ui$ary!$&yr(id a3i# H5P5O6! $&e .rinci.a* &()e(#$a$ic c(n$r(* (' $&yr(id &(r)(ne #ecre$i(n , elease of T 4 and T- is stimulated by thyrotro(in or thyroid- stimulating hormone (TSH) from the ant. pituitary Secretion of TSH is directly suppressed by T 4 and T3 (a negative feedback loop). TSH release also is stimulated by the hypothalamic hormone thyrotropin-releasing hormone (TH).

+ T&yr(id &(r)(ne %i(#yn$&e#i#

+ +ynthesis of Thyroid hormone 

S$e.# in $&e #yn$&e#i# (' $&yr(id &(r)(ne are/ 



16 ac$ive $ra..ing and c(ncen$ra$i(n (' i(dide in $&e '(**icu*ar ce**7

26 ra.id (3ida$i(n (' i(dide $( i(dine7 86 *inkage (' i(dine wi$& $yr(#ine re#idue# in $&yr(g*(%u*in7  46 c(u.*ing (' $&e#e i(d($yr(#ine# )(n(i(d(! and dii(d($yr(#ine6 $( '(r) $&e ac$ive $&yr(id &(r)(ne# T 4 and T8, 

+ T&e $&yr(id &(r)(ne#

+ T&e $&yr(id &(r)(ne#

+

-NIGN THYROID DISORDRS

+

)eni*n Thyroid Gland "isorders

THYROGLO!L "#$T !%O&!L'(

HYPRTHYROIDIS9 %O"#L!R GO'T(R OL'T!RY THYRO'" %O"#L( THYRO'"'T'

+ (&)RYOLOGY O TH( THYRO'" GL!%" ,

Ori*inates from the ase of the ton*ue

,

$audal mi*ration to the neck

,

Thyroid tissue may e found from the ase of the ton*ue to the mediastinum

+ Thyroid !nomalies 

.yramidal loe



Lin*ual thyroid



u-sternal/ mediastinal thyroid



Thyro*lossal duct cyst

+ T&yr(g*(##a* duc$ cy#$ &id-line mass w&ic& )(ve# wi$& ton*ue protrusion

9ay re#u*$ $(/ 1, econdary infection 01 :().re##i(n 8, ;i#$u*a 4, 9a*ignancy ! 1< 2=< wi$& '(cu# in $&e $&yr(id g*and6 T>/

istrunk

+ HYPRTHYROIDIS9 

?$&yr($(3ic(#i# ? ! c*inica* #yndr()e cau#ed %y ina..r(.ria$e*y &ig& $&yr(id &(r)(ne ac$i(n in $i##ue# genera**y due $( e3ce##ive *eve*# (' ac$ive $&yr(id &(r)(ne #ecre$ed in$( $&e circu*a$i(n



Grea$ )a(ri$y @B@AA cGy

rate is dose dependent  @ m$i - EAB  =A m$i - >EB  =@ m$i - F:B

+

R!' Treatment 

Hypothyroidism   

=@B ;ithin = year 7B every year thereafter .ermanent



&ay a**ravate exophthalmos - 77B



(xacerate thyrotoxicosis/thyroid storm



$rosses placenta - no pre*nancy for = year



&ay cause infertility in ;omen



&ay increase risk of cancer in children



$ontraindicated in pre*nant D reast feedin* patients



.re*nancy test in all ;omen of childearin* !G

+

R!' Treatment 

(ase of treatment



Hi*hly e6ective esp1 in di6use



*oiters %o moridity related to sur*ery



Treatment of choice for failed sur*ical mana*ement



The e6ect is seen in =1@ to 8 months

+

#RG(RY 

$omplete and permanent control of toxicity



Rapid control of symptoms



Removal of mass



Treatment of choice for hu*e *oiters



%eeds pre-operative preparation



Overall moridity - =-0B

+ Grave#/ di#ea#e ! Surgica* care T&yr(idec$()y/ 1, I' i$ i# $&e c&(ice (' $&e .a$ien$ 2, 8,

4,

Sec(nd $ri)e#$er (' .regnancy ;ai*ure re#i#$ance (r in$(*erance6 (' drug $&era.y P((r c().*iance $( drug $&era.y

+ Trea$)en$ '(r Grave#K Di#ea#e

+ :(n$raindica$i(n# $( .ar$icu*ar T3

+&OR)'"'TY R(L!T(" TO #RG(RY 

Inury $( $&e recurren$ and #u.eri(r *aryngea* nerve#



Hy.($&yr(idi#)



Hy.(.ara$&yr(idi#)



He)a$()a+ #er()a



Ane#$&e$ic and )edica* c().*ica$i(n

+ %O"#L!R %O%-TO'$ GO'T(R



n*arge)en$ (' $&e $&yr(id



N( $(3ici$y



N( cancer

+

$!#( !&'L'!L G O'T(R

(%"(&'$ G O'T(R .OR!"'$ GO'T(R

In&eri$ed eny)a$ic de'ec$

I(dine de"ciency in %o denite cause can e die$ estalished

I).aired i(dine )e$a%(*i#) #ua**y a##(cia$ed wi$& &y.($&yr(idi#)

9(un$ain(u# regi(n#

+ '%"'$!T'O% OR

#RG(RY 

 

Huge g(i$er w&ic& i# c(#)e$ica**y unacce.$a%*e :().re##i(n #y).$()# Su#.ici(n (' )a*ignancy

+ "O&'%!%T OR OL'T!RY THYRO'" %O"#L( 

&ost are eni*n - colloid *oiter or adenoma



@-=@B are mali*nant2 0-7 fold increase if nodule is solid



8AB incidence in the presence risk factors - lo; dose neck irradiationC 4+5 family history



%!) - most accurate dia*nostic tool

+ S(*i$ary $&yr(id n(du*e

+ ;ac$(r# #ugge#$ing increa#ed ri#k (' )a*ignan$ .($en$ia* 

Hi#$(ry (' &ead and neck irradia$i(n



;a)i*y &i#$(ry (' )edu**ary $&yr(id carcin()a 9T:6 (r )u*$i.*e end(crine ne(.*a#ia $y.e 2 9N26

 

Age M20 (r @0 year#! =0< M20 y(6 9a*e #e3!80< ST6



Gr(wing n(du*e



Hard c(n#i#$ency! 40< incidence P!PGH6



:ervica* aden(.a$&y



;i3ed n(du*e



Per#i#$en$ &(ar#ene##+ dy#.&(nia+ dy#.&agia+ (r dy#.nea

+ Laoratory (valuation 

Seru) TSH #&(u*d %e $e#$ed "r#$+ wi$& a $&ird!genera$i(n a##ay



I' TSH *eve* i# *(w M0,= )icr(!I)L6+





)ea#ure 'ree T4 and $rii(d($&yr(nine T867 i' TSH *eve* i# &ig& @=,0 )icr(!I)L6+ )ea#ure 'ree T4 and $&yr(id .er(3ida#e an$i%(dy TPOA%6 Seru) ca*ci$(nin #&(u*d %e )ea#ured i' ;NA (r 'a)i*y &i#$(ry #ugge#$# )edu**ary $&yr(id carcin()a

+Radionuclide cannin*



Per'(r) $&yr(id #cin$igra.&y '(r a $&yr(id n(du*e (r 9NG i' $&e TSH *eve* i# %e*(w $&e *(wer *i)i$ (' $&e range g(i$er (r i' ec$(.ic $&yr(id $i##ue (r an(r)a* re$r(#$erna* i# #u#.ec$ed



In i(dine!de"cien$ area#+ .er'(r) $&yr(id #cin$igra.&y '(r a $&yr(id n(du*e (r 9NG even i' $&e TSH *eve* i# in $&e *(w!n(r)a* range

+ *$ra#(und )eni*n features

&ali*nant features

Hy.erec&(ic n(du*e Regu*ar )argin# (r &a*( T&in wa** cy#$ gg#&e** (r a)(r.&(u# ca*ci"ca$i(n wi$& #&ad(wing P(*aried c(**(idc()e$ (r ca$K# eye6 9u*$in(du*ari$y wi$&(u$ a d()inan$ n(du*e Perin(du*ar va#cu*aria$i(n (n D(..*er Decrea#ing #ie (ver $i)e

Hy.(ec&(ic n(du*e -*urred (r irregu*ar )argin Inva#i(n (' )u#c*e (r #urr(unding #$ruc$ure# n*arged cervica* n(de# 9icr(ca*ci"ca$i(n# wi$&(u$ #&ad(wingrea* $i)e6 In$ran(du*ar va#cu*aria$i(n (n D(..*er 9(re $a** $&an wide )icr(n(du*e# M 1,= c)6 Increa#ing #ie (n TSH #u..re##i(n

+ %! !c(#$ eFec$ive diagn(#$ic $((* $( diFeren$ia$e w&e$e&r n(du*e i# %enign (r )a*ignan$

:y$(*(gic diagn(#e# #&(u*d %e (rganied in$( 4 ca$eg(rie# 1, inadeJua$e )a$eria* 2, %enign 8, #u#.ici(u# 4, )a*ignan$ $u)(r#

+ %!$ "# %enign o llow up 1year ! epea t " #

# t yp ical o r S u sp ici o u s Symptoms

$obectomy

$obectomy

'alignant &hyroidectomy

+ummary of Recommendations for &ana*ement and Treatment of Thyroid %odules 



:*inica* )anage)en$ (' $&yr(id n(du*e# #&(u*d %e guided %y $&e re#u*$# (' S eva*ua$i(n and ;NA %i(.#y %!-.ositive Thyroid %odule  ;(r a $&yr(id n(du*e wi$& .(#i$ive )a*ignan$6 ;NA re#u*$#+ #urgica* $rea$)en$ i# rec())ended

+ %!-%e*ative Thyroid %odule 

#e (' #u..re##ive $&era.y wi$& *ev($&yr(3ine LT46 )ay %e c(n#idered in $&e '(**(wing/    



Pa$ien$# 'r() ge(gra.&ic area# wi$& i(dine de"ciency Y(ung .a$ien$# wi$& #)a** $&yr(id n(du*e# N(du*ar g(i$er# wi$& n( evidence (' 'unc$i(na* au$(n()y c()%ined wi$& a#.ira$i(n i' n(du*e i# cy#$ic

#e (' LT4 $&era.y #&(u*d %e av(ided in )(#$ ca#e# and e#.ecia**y in $&e '(**(wing/ 



 

Large $&yr(id n(du*e# and g(i$er#+ .ar$icu*ar*y in $&e .re#ence (' #y).$()# (r #ign# (' 'unc$i(na* au$(n()y :*inica**y #u#.ici(u# *e#i(n# (r *e#i(n# wi$& an inadeJua$e cy$(*(gic #a).*e P(#$)en(.au#a* w()en and )en (*der $&an 0 year# Pa$ien$# wi$& cardi(va#cu*ar di#ea#e

+;ac$# $( re)e)%er wi$& #u..re##ive $&era.y 

LT4 $rea$)en$ induce# a c*inica**y #igni"can$ reduc$i(n (' $&yr(id n(du*e v(*u)e in (n*y a )in(ri$y (' .a$ien$# 20!=0< #ucce## ra$e6



L(ng!$er) TSH #u..re##i(n )ay %e a##(cia$ed wi$& %(ne *(## and arr&y$&)ia in e*der*y .a$ien$# and )en(.au#a* w()en



LT4 $rea$)en$ #&(u*d never %e 'u**y #u..re##ive e3(gen(u# $&yr(3ine $( )ain$ain TSH *eve* a$ 0,8!8 u)*,6



N(du*e regr(w$& i# u#ua**y (%#erved a'$er ce##a$i(n (' LT4 $&era.y



I' n(du*e #ie decrea#e#+ LT4 $&era.y #&(u*d %e c(n$inued *(ng $er)



I' $&yr(id n(du*e gr(w# during LT4 $rea$)en$+ rea#.ira$i(n and .(##i%*y #urgica* $rea$)en$ #&(u*d %e c(n#idered

+ ur*ical Treatment A##(cia$ed *(ca* #y).$()# e,g,, c().re##i(n

1,

2,

Hy.er$&yr(idi#) 'r() a *arge $(3ic n(du*e+ (r &y.er$&yr(idi#) and c(nc()i$an$ 9NG Gr(w$& (' $&e n(du*e

8,

Su#.ici(u# (r )a*ignan$ ;NA re#u*$#

4,  

=,

Pa$ien$ %e*(ng# $( &ig& ri#k gr(u. N(du*e i# #(*id

;ai*ure (' $&yr(id #u..re##i(n

+ Radi(i(dine Indica$i(n#/ 1, ;(r #)a** g(i$er# v(*u)e M100 )L6 2, In $&(#e wi$&(u$ #u#.ec$ed )a*ignan$ .($en$ia* 8, In .a$ien$# wi$& a &i#$(ry (' .revi(u# $&yr(idec$()y 4, In $&(#e a$ ri#k '(r #urgica* in$erven$i(n

+ RAI N($ $&e "r#$!*ine $&era.y 1, I' c().re##ive #y).$()# are .re#en$ 2, I' .a$ien$# &ave *arge n(du*e# $&a$ reJuire &ig& a)(un$# (' radi(i(dine and )ay %e re#i#$an$ $( $rea$)en$ 8, I' i))edia$e re#(*u$i(n (' $&yr($(3ic(#i# i# de#ired

+ THYROIDITIS

+

THYRO'"'T'



Ha#&i)($(/#



De Quervain/#



Riede*/#



Acu$e Su..ura$ive

+ Ha#&i)($(/# Di#ea#e ! 9(#$ c())(n '(r) (' $&yr(idi$i# ! :&r(nic *y).&(cy$ic $&yr(idi$i# !

Au$(i))une $&yr(idi$i#

!

T&yr(id au$(an$i%(die# 1, an$i!$&yr(id .er(3ida#e 2, an$i$&yr(g*(%u*in au$(an$i%(die#

! Gene$ic .redi#.(#i$i(n ! 9ay c(!e3i#$ w .a.i**ary :A

+ HASHI9OTO/S DISAS ! :*inica* 9ani'e#$a$i(n#/ / AFec$# w()en c())(n*y / 9(#$ 'reJuen$ c().*ain$ ! en*arge)en$ (' $&e neck w .ain  $enderne## in $&e regi(n (' $&e neck / )(#$ individua*# are ini$ia**y &y.er$&yr(id and #u%#eJuen$*y %ec()e# eu$&yr(id (r &y.($&yr(id

! diFu#e  #y))e$ric en*arge)en$ B0ntreated micrometastases are e'(ected to (roliferate gradually and be detected sooner or later as o%ert metastases.

+#robable +olution to the 9ilemma



+electi%e nec! dissection was utili8ed as a com(romise between obser%ation alone and formal nec! dissection

+ationale for +electi%e Nec! 9issection

 There

are defined first echelon nodes at highest ris! of nodal metastases from different (rimary sites

 Therefore,

selecti%e nec! dissection is indicated in (atients with high ris! of occult metastases.

 +ome

of these (atients de%elo( ino(erable nec! metastases and conse@uent distant metastases des(ite close follow u(. +haha, 22

*urrent 4hilosophy in the 'anagement of *ervical $ymph "ode 'etastases "=

 !adical nec6 dissection for " @ disease and other select circumstances  '!", >?+ for " 2 and "1 disease  Selective nec6 dissection for limited " 1 disease

"0

 Supraomohyoid nec6 dissection for oral cavity primaries  7ugular node dissection for pharyngolaryngeal primaries

4..!.&.  'ultiple positive nodes  )-tranodal spread  ther ominous features

+ndications for 'ultidisciplinary &reatment of SAuamous *ell *ancers of the :ead and "ec6

&

 :igher & stage +++ +9  4ositive margins  minous pathologic features

"

 :igh ris6 of micromets in "0 nec6  'ultiple nodal metastases "2b  'assive nodal metastases "@  )-tra nodal spread  minous pathologic features

'

 :igh ris6 of distant metastases B&@ or B"1  ,istant metastases

+ ;

,iagnosis and 'anagement of 4arotid (land &umors

+Ma&or sali%ary glands

#arotid gland +ublingual gland

+ubmandibular gland

+

alivary Gland Tumors 6ocation

L Mali gnant Malignant

L :eni gn :enign

#arotid

2 L

5 $L

+ubmandibular

4 L

" L

+ublingualJMinor

" L

4 L

+ #arotid gland

+#arotid gland

+u(erficial lobeE







lateral to the facial ner%e Ma!es u( L of the glandB #resents as a (re auricular mass; may also be infra$ or (ost auricular

9ee( lobeE 

medial to the facial ner%e



Ma!es u( the remaining 2L



retromandibular or (ara(haryngeal masses, with dis(lacement of the tonsil or soft (alate a((reciated in the throat.

+

ndifferentiated

carcinoma

 Adenos@uamous

carcinoma