2. Theodor Kocher（1841~1917）

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

4. Thyroid anatomy

5. Superficial veins and cutaneous nerves of neck

6. Recurrent Laryngeal Nerve

7. 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

8. 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.

9. 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

10. 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.

11. Blood supply

12. 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

13. Benign Thyroid Disease
Endemic Goiter
Thyroiditis
Hyperthyroidism

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

15. Endemic Goiter
diffuse goiter
nodular goiter

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

17. 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

18. Hyperthyroidism Graves’ disease toxic nodular goiter
toxic thyroid adenoma

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

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

21. Extrathyroid Presentation
vitiligo
pretibial myxoedema
digital hippocratisme
ophtalmopathy

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

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

24. Traitement
Radioiodine ablation
Surgery
Antithyroid medication

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

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

27. Nontoxic goiter
Multinodular Goiter
Substernal Goiter

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

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

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

31. 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

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

33. Thyroid nodules
Ultrasound
Scintigraphy CT
L’MRI
FNA

34. Scintigraphy

35. Cold nodule

36. Hot nodule

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

38. 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

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

40. Treatment
The main treatment : surgical ablation.

41. 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

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

43. 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

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

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

47. 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

48. 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

49. 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

50. Minimally invasive surgery

51. Thank you