Theodor Kocher（1841~1917）

Embryology Langue Conduit auditif exterme Tympan Amygdal thyeo-glosse tube Parathyroide III Parathyroide IV Corps ultimo-branchial Thymus Lateral thyroid Thyroidien lobe Esophage

Thyroid anatomy

Superficial veins and cutaneous nerves of neck

Recurrent Laryngeal Nerve

Recurrent laryngeal nerve On either side of the trachea Lateral to the ligament of Berry Entering the larynx Right side: separating from the vagus when crossing the subclavian artery Left side: separating from the vagus when traversing over the arch of the aorta

Recurrent Nerve Anomalous variations in the course of the right recurrent laryngeal nerve. A, A nonrecurrent laryngeal nerve arises from the vagus. B, The normal course of the recurrent laryngeal nerve arises from the vagus after it passes beneath the subclavian artery. C, The unusual nonrecurrent nerve and recurrent laryngeal nerve join to form a common distal nerve.

Superior Laryngeal Nerve separated from the vagus nerve two branches: The larger internal branch -sensory function and it innervates the larynx. The smaller external branch -the cricothyroid muscle

Blood supply Four main arteries, two superior and two inferior : The superior thyroid artery The inferior thyroid artery Three pairs of venous systems drain the thyroid.

Blood supply

Parathyroid Glands superior thyroid artery Superior Laryngeal Nerve external branch superior parathyroid gland Common carotid Internal jugular inferior thyroid artery inferior parathyroid gland Recurrent nerve

Benign Thyroid Disease Endemic Goiter Thyroiditis Hyperthyroidism

Endemic Goiter Etiology Cause 1/3 of the world’s population, specifically in underdeveloped countries. Cause Iodine deficiency

Endemic Goiter diffuse goiter nodular goiter

Thyroiditis Acute Suppurative Thyroiditis Subacute Thyroiditis De Quervain’ s thyroiditis) Chronic thyroiditis Hashimoto’s thyroiditis Riedel’s thyroiditis (struma)

Hashimoto’s thyroiditis A cause of hypothyroidism in adult Immune complex and complement An exacerbation of immune response. An infiltration of lymphocytes TSH-blocking antibodies. A hypothyroid clinical state

Hyperthyroidism Graves’ disease toxic nodular goiter toxic thyroid adenoma

Grave’s disease Most hyperthyroid states are caused by Graves’ disease (diffuse toxic goiter).

Clinical Presentation of Hyperthyroidism Physical examination Increased hyper metabolic state Cardiovascular stress Gastrointestinal sign Psychiatric signs Genital disorders Hematopoietical modification Extrathyroid Presentation

Extrathyroid Presentation vitiligo pretibial myxoedema digital hippocratisme ophtalmopathy

Biology T3L↑, T4L↑, TSH↓ Anti-thyroglobuline antibody ↑ Anti-microsomal antibody ↑ Anti-TSH-recepter immunoglobuline

Diagnosis An extensive history Physical examination Signs and symptoms of thyrotoxicosis Thyroid function tests

Traitement Radioiodine ablation Surgery Antithyroid medication

Toxic nodular goiter-toxic adenoma (Plummer’s disease ) Autonomous function. Independent of TSH control. Symptoms : mild, peripheral Thyroid hormone ↑, TSH ↓ Antithyroid antibody ↓

Diagnosis confirmed after: clinical suspicion 131 I radionuclide scan Treatment lobectomy or near-total thyroidectomy antithyroid medication radioiodine therapy is not effective

Nontoxic goiter Multinodular Goiter Substernal Goiter

The work-up of a solitary thyroid nodule FNA, fine-needle aspiration; Rx, therapy.

Preoperative preparation ORL exam and general exam Antithyroid medication The lugos The beta-blockage

Operation Complications Bleeding Recurrent laryngeal nerve injury Superior laryngeal nerve injury Hypoparathyroidisme Thyrotoxic storm Infection Hypothyroidism

Thyroid malignancie Less than 1% of all malignancies in the U.S. 40/1,000,000 occur per year. 6/1,000,000 die per year Thyroid oncogenesis

Histo-pathology Papillary Follicular Hürthle cell carcinomas Medullary thyroid cancer (MCT) Anaplastic carcinoma

Thyroid nodules Ultrasound Scintigraphy CT L’MRI FNA

Scintigraphy

Cold nodule

Hot nodule

Papillary Carcinoma Epidemic the most common of the thyroid neoplasms and usually associated with an excellent prognosis

No local extension, intrathyroidal, no capsular invasion Prognostic Risk Classification for Patients with Well-Differentiated Thyroid Cancer (AMES or AGES * ) Low risk High risk Age <40 years >40 years Sex Female Male Extent No local extension, intrathyroidal, no capsular invasion Capsular invasion, extrathyroidal extension Metastasis None Regional or distant Size <2 cm >4 cm Grade Well differentiated Poorly differentiated

Clinical Presentation Solitary painless masses Dysphagia Cervical tenderness, Painful neck mass, Superior vena cava syndrome (extremely rare)

Treatment The main treatment : surgical ablation.

Follicular Carcinoma Second category of well-differentiated thyroid cancers Follicular, and mixed papillaryfollicular cancers (90% of all thyroid cancers) A malignant neoplasm of the thyroid epithelium

Clinical presentation Solitary painless mass The coexistence of lymph node involvement (extremely rare) Cervical adenopathy (rare)

Treatment Primarily surgical. Thyroid lobectomy and Isthmectomy <2cm,well contained within one thyroid lobe Total thyroidectomy >2 cm, (>4 cm, the risk for cancer >50%) Lymph node dissection Radioiodine treatment

Hürthle Cell Carcinoma A subtype of follicular carcinoma Presents in much the same fashion as follicular cell neoplasms. Preoperative FNA Principal treatment is surgical

Medullary Carcinoma 5% to 10% of thyroid malignancies A biological marker, Calcitonin Presentation: a palpable mass an elevated calcitonin level Single and unilateral

Diagnosis MCT : a mass and an elevated calcitonin level Detailed and in-depth family history Signs and symptoms Screening for pheochromocytoma with 24-hour urinary catecholamines

Anaplastic Thyroid Cancer Less than 1% of all thyroid malignancies Most aggressive form of thyroid cancer Typical presentations : dysphagia cervical tenderness painful neck mass superior vena cava syndrome

Treatment Most reports with resection are not optimistic . less than one third of them are resectable chemotherapy adds little to the overall prognosis Prognosis is bad

Minimally invasive surgery

Thank you