thyroid gland

Post operative complications

1- Hemorrhage: A reactionary bleeding

may occur in the first 24 hours. Its due
to slipping ligature or from remnant of
thyroid tissue. The patient suffer from
suffocation, dyspnea and restlessness,
with or with out neck mass.
Treatment is by rapid and adequate evacuation of the hematoma and controlling the bleeding.
2- Respiratory obstruction: due to laryngeal edema caused by excessive manipulation, intubation injury or tracheomalecia. The patient suffer from suffocation after removal of the endotracheal tube. Treatment by reinsertion the tube with steroid, rarely trachiostomy

Post operative complications

3-Recurrent laryngeal nerve injury:

its technical fault, its either transient or permanent, unilateral or bilateral.
Transient unilateral type due to traction
or compression on the nerve, recovery is suspected in 3 months.
Permanent unilateral injury is due to division of the nerve which causes horsiness of the voice.
Bilateral injury causes sever dyspnea and suffocation that necessitate immediate tracheostomy.
4- External branch of superior laryngeal nerve injury: leads to inability to tense the ipsilateral vocal cord and hence difficulty in "hitting high notes," projecting the voice, and voice fatigue during prolonged speech.

4- parathyroid insufficiency:

Its either temporarily due to ischemia
of or permanent due to infarction or inadvertent removal.
Early manifestation (temporary) is tetany which is presented as cercum oral numbness, carpopedial spasm and strider due to spasm of laryngeal muscle (laryngesmus striduolus)
Treatment: IV infusion of 10% calcium gluconate which can be repeated each 8 hours
Late type (permanent) presented as repeated carpopedial spasm, trousseas and schvostic signs.
Needs long term vit D and calcium.
Post operative complications

Post operative complications

4- Thyroid insufficiency:
20% of thyroidectomized patients may suffer from hypothyroidism after 2 to 5 years which needs replacement therapy.
5-Recurrent of thyrotoxicosis:
Occur in 5 to 10% due to less adequate removal of tissue.
Treatment by antithyroid or RAI.
6-Thyroid storm Life-threatening exacerbation of thyrotoxicosis with mortality of 50%
Precipitating factors: Thyroid surgery in unprepared patient. Radioiodine. Withdrawal of antithyroid drugs. Acute illness (e.g. stroke, infection, trauma)
Clinical features: Severe thyrotoxicosis, Fever, delirium ,seizure, coma and acute heart failure.

Post operative complications`

7- wound complication:
like infection or keloid formation or granuloma formation.
Post operative follow up
1- fibro-optic laryngoscope before leaving the hospital.
2-Serum calcium after 6 weeks.
3- Six months follow up to determine thyroid function for 1 year then yearly for long time.

• :Treatment

• IVF, cooling the patient with ice packs, oxygen, diuretics for cardiac failure, digoxin for atrial fibrillation, sedation and IV hydrocortisone. Specific treatment is by carbimazole 10–20 mg 6-hourly, Lugol’s iodine 10 drops 8-hourly by mouth or sodium iodide 1 g i.v. Propranolol intravenously (1–2 mg) or orally 40 mg 6-hourly) to block -adrenergic effects.

Thyroiditis

Its inflammation of thyroid tissue, its either acute sub-acute or chronic form
:Acute form could be
Supurative more common in children followed URTI. Streptococcus and anaerobes account for 70% of infection.
MO reach the gland via: a-hematogenous or lymphatic route, direct spread , penetrating trauma .
clinically: sudden painful enlargement of the gland with fever, chills, dysphonia and odynophagia.
Treatment: Paranteral antibiotic, drainage if abscess is formed.
Non supurative infection may result from bacterial or viral infection.
subacute thyroiditis: dequrvain disease
Chronic form: hashimotos, or riedels thyroiditis

Sub-acute thyroiditis - dequarvain disease

Self-limited disease may be due to viral infection.
Its more common in female around 40 years.
Pathology: There is infiltration of the gland by monocyte, lymphocyte and epetheloid cells.
Clinical picture: The condition may pass into 4 stages:
1- Acute toxic stage characterized by sudden painful goiter with hyperthyroidism for 2 to3 months.
2-Euthyroid stage there is only goiter
3-Hypothyroid stage remain for 2 to 4 months.
4-Recovary stage within 1 to 6 months.
Investigation: High ESR, absent thyroid antibodies,
RAI-131- uptake is low, H level depending on the stage of the disease, FNA is diagnostic.
Treatment : NSAI, prednesolone 40 mg for 1 month tapered in 2 months. replacement therapy in hypothyroid stage.


Chronic thyroiditis -hashimotos-
Its autoimmune disease with inherited predisposition, an antibody formed against thyroid gland, like antimicrosomal (antiperoxidase) and antithyroglobulin antibody.
Pathology: excessive lymphoid tissue infiltration with degeneration of the follicles.
Clinical picture: female at 50 years, may associated with other autoimmune disease like DM,SLE,RA.
There is painless and firm goiter which is defuse or nodular with pressure symptoms, later there is picture of hypothyroidism. Thyroid lymphoma is a rare but well-recognized, ominous complication.
Investigation: low T3,T4,elevated TSH. low RAIU. High AB titer. FNA is diagnostic.
Treatment: Replacement therapy by thyroxin. Surgery indicated in large goiter, or suspicion of malignancy.

Chronic thyroiditis – Riedels disease

Extensive infiltration of thyroid gland by fibrous tissue extend to trachea and surrounding structures, may associated with other focal sclerosing syndromes like mediastinal and retroperitoneal fibrosis or sclerosing cholangitis.
Clinically: painless, hard mass, which progresses over weeks to years to produce pressure symptoms and hoarseness. Patients may present with hypothyroidism and hypoparathyroidism due to replacement of the glands by fibrous tissue.
Physical examination hard, "woody" thyroid gland with fixation to surrounding tissues.
Investigation: low H level, low RAIU, AB may be positive, FNA is diagnostic but open biopsy may needed.
Treatment: replacement therapy.
Surgery indicated in pressure symptoms (esthmusectomy) to release the trachea or if malignancy cannot ruled out. reported experience show dramatic improvement with corticosteroids and tamoxifen.

Thyroid tumor

thyroid tumor

Follicular adenoma

Primary secondary

Carcinoma lymphoma modularly

Differentiated undifferentiated
Benign malignant
Papillary ca Follicular ca

Thyroid carcenoma

• Type of ca
• Papillary ca
• Follicular ca
• Anaplastic ca
• Age
• 30-40
• 40-50
• 60-80
• Sex ratio (f:m)
• 3:1
• 3:1
• 1:1.3
• Percentage
• 60%
• 20%
• 10%
• Spread
• lymphatic
• blood
• both
• Predisposing F
• neck radiation
• long standing goiter
• Not known
• Multi focal lesion
• positive
• negative
• negative
• H dependency
• TSH
• TSH
• non
• Prognoses
• good
• fair
• poor


Clinical picture
Thyroid cancer accounts for <1% of all
malignancies (2% of women and 0.5% of men) its usually presented as:
1- Painless rapid growing mass (painful mass radiate to ear in case of local invasion).
2-Horsiness of the voice.
3-Hard and irregular on palpation.
4-may not move with swallowing.
5-Carotid pulsation may be absent (Berry sign)
6-Horner syndrome due to local invasion of sympathetic nerve.
7-There may be hard lymph node in neck.
8-pressure manifestation may exist.
Investigation:
1- Normal thyroid H
2- Cold mass by RAIU
3- Positive AB
4- FNA is diagnostic in most condition except for follicular type

Prognostic factors in Deferential thyroid cancer

age, sex, size, capsular invasion and histopathology of the tumor play in important rule in prognosis.
1- Low risk group represent 80% of the condition with 98% 25 year survival rate. It include
A- Male less than 40, or female less than 50 years without distal metastasis.
B- Older age with intra thyroid papillary Ca, or follicular Ca less than 5 Cm without capsular invasion, no distal metastasis.
2- High risk group represent 20% of the condition with 46% 25 year survival rate. It include
A- All patients with distal metastasis.
B- Extra thyroid papillary Ca.
C- Follicular Ca more than 5 Cm or with capsular invasion
Lymphatic involvement not associated with bad prognosis.

Surgical management of differentiated thyroid CAThe surgical strategy of patients with low-risk cancers remains controversial. A- Total thyroidectomy
B- Lobectomy
The benefit of total thyroidectomy are
1- Enables the use of RAI to detect and treat residual thyroid tumor or metastatic disease. 2- Makes serum Thymoglobulin level a more sensitive marker for recurrent or persistent disease. 3- Eliminates contra lateral occult cancers as sites of recurrence. 4- 33 to 50% of patients who develop a recurrence die from their disease5- Reduces the need for re-operative surgery with its attendant risk of increased complication rates.

The benefit of lobectomy are:

1-Total thyroidectomy is associated with a higher complication rate like hypothyroidism, RLN injury and hypoparathyroidism (10-30%)
2-Recurrence in the remaining thyroid tissue is unusual (5%) and most are curable by surgery.
3-Tumor multicentricity seems to have little prognostic significance, and its rare in contra lateral lobe.
4-Patients who have undergone lobectomy still have an excellent prognosis.
5-In case of recurrence, or suspicious secondaries, the remaining thyroid can be ablated by high dose of RAI
High-risk group or bilateral tumor should undergo total thyroidectomy.
Presence of LN necessitate modified radical neck dissection.


Follow up
1- It is standard practice to prescribe thyroxine in a dose of 0.1–0.2 mg daily, to suppress endogenous TSH production, for all patients after operation for differentiated thyroid carcinoma on the basis that most tumors are TSH dependent.

2- The measurement of serum thyroglobulin is invaluable in the follow up and detection of metastatic disease in patients who have undergone surgery for differentiated thyroid cancer.


Indications for post operative RAI study1- All patients with high risk group. 2- Incomplete removal of tumor 3- Recurrence of tumor 4- Suspicion of secondaries.5- High level of thymoglobulin post operatively.
.
External Beam Radiotherapy
EBR indicated in:
1- Unrespectable tumor.
2- Locally invasive or recurrent disease .
3- Bone metastases to decrease the risk of fractures.
4-Controlling pain from bony metastases.

Chemotherapy has been used with little success in disseminated thyroid cancer, and there is no role for chemotherapy.

Thyroid lymphoma

Accounts for 1% of thyroid malignancies.
Often arises with Hashimoto's thyroiditis
or non-Hodgkin's B-cell lymphoma
presents as a painless and rapid enlarging goiter with pressure effects.
Diagnosis made by FNAC
Chemo and Radiotherapy is treatment of choice
Prognosis is good - often more than 50% 5 year survival








Medullary Carcenoma :Arise from parafolliculer cells.There is high level of calcitonen and 5HT, which may cause diarrhea.Represent 5% of thyroid tumor.It may be sporadic ( 80% )or familial which is occur in children and young age, its more invasive, multifocal and may associated with(MEN-2- A) as parathyroid hyperplasia medullary carcinoma, Phiochromcytoma , or with (MEN-2-B) as parathyroid hyperplasia or tumor, Phiochromcytoma with skin pigmentation, multiple neuromas in the tongue and mucous membrane and marfanoid habits. It metastasize by lymph and blood. Prognoses is good without metastases. FNA is diagnostic.Surgery is the treatment of choice.Family screen in case of familial type.

Anaplastic Carcinoma

Accounts for approximately 1% of all thyroid malignancies.
Male and female equally affected Most age involved at seventh and eighth decade of life.
Clinically: Rapidly enlarging mass and may be painful.
The tumor is large and may be fixed to surrounding structures or may be ulcerated.
Associated symptoms: dysphonia, dysphagia, and dyspnea
Lymph nodes usually are palpable at presentation.
Evidence of metastatic spread also may be present.
Diagnosis is confirmed by FNAB
Treatment :The tumor is the most aggressive thyroid malignancies, with few patients surviving 6 months beyond diagnosis.
All forms of treatment have been disappointing.
In respectable mass, thyroidectomy may lead to a small
improvement in survival, especially in younger individuals. Combined radiation and chemotherapy may be used as palliative management..


1- Enables the use of RAI to detect and treat residual thyroid tumor or metastatic disease. 2- Makes serum Thymoglobulin level a more sensitive marker of recurrent or persistent disease. 3- Eliminates contralateral occult cancers as sites of recurrence. 4- 33 to 50% of patients who develop a recurrence die from their disease5- Reduces the need for reoperative surgery with its attendant risk of increased complication rates. 6- Follow-up studies suggest that recurrence rates are lowered and that survival is improved in patients undergoing total or near-total thyroidectomy
Surgical management of differentiated thyroid CAThe surgical strategy of patients with low-risk cancers remains controversial. Proponents of total thyroidectomy argue that :