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22 Thyroid Flashcards

1
Q

Embryological origin of thyroid

A

1st and 2nd pharyngeal arches

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2
Q

Origin of superior thyroid artery

A

First branch off external carotid

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3
Q

Origin of inferior thyroid artery

A

Of thryocervical trunk

Supplies both the inferior and superior parathryoids

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4
Q

Ima artery

A

From innominant or aorta
Supplies the thyroid isthmus
1% of patients

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5
Q

Superior and middle thyroid veins drain to:

A

Internal jugular vein

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6
Q

Inferior thyroid vein drains to:

A

Innominante vein

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7
Q

Superior laryngeal nerve

A

Motor to cricothyroid muscle
Runs lateral to thyroid lobes
Runs close to superior thyroid artery
Injury - loss of projection and easy voice fatigability

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8
Q

Recurrent laryngeal nerve

A

Motor - all of larynx except cricothyroid muscle
Runs posterior to thryoid lobe in tracheoesophageal groove
Can run with inferior thyroid adrtery
Left RLN - around aorta; Left LLN - around innominate artery
Injury - hoarseness; bilateral injury can obstruct airway

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9
Q

Liagment of berry

A

Posterior medial suspensory ligament close to RLNs

Needs careful dissection

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10
Q

Peroxidases

A

Link iodine and tyrosine together

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11
Q

Deiodinases

A

Separates iodine from tyrosine

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12
Q

Most sensitive indicator of thyroid gland function?

A

TSH

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13
Q

Tubercules of Zuckerland

A

Most lateral, posterior extension of thyroid tissue
Rotate medially to find RLNs
Leave behind in a subtotal thyroidectomy

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14
Q

Post-thyroidectomy stridor

A 
Incisional hematoma (open neck and remove emergent)
Bilateral RLN injury (emergent tracheostomy)
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15
Q

Thyroid storm

A

Sx: Tachycardia, fever, numbness, irritability, vomiting, diarrhea, HOCF
Undiagnosed Graves’ disease
Precipitants - anxiety, excessive gland palpation, adrenergic stimulants
Tx: B-blockers, PTU, Lugol’s solution, cooling blankets, oxygen, glucose

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16
Q

Wolff-Chaikoff effect

A

High doses of iodine (Lugol’s solution, potassium iodide) - inhibits TSH action on thyroid and inhibits organic coupling of iodide.
Results in less T3 and T4 release.
Transitory effect.

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17
Q

Best initial test for asymptomatic thryoid nodule?

A

FNA

Thyroid function tests

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18
Q

Thyroid FNA shows: Follicular cells

A

Lobectomy (10% CA risk)

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19
Q

Thyroid FNA shows: THyroid cancer

A

Thyroidectomy or lobectomy

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20
Q

Thyroid FNA shows: Cyst fluid

A

Drain fluid

If recurs or is bloody - lobectomy

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21
Q

Thyroid FNA shows: collid tissue

A

Most likely to be a colloid goiter - low chance of malignancy (<1%)
Tx: thyroxine, lobectomy if it enlarges

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22
Q

Thyroid FNA shows: normal thyroid tissue and TFTs are elevated

A

Solitary toxic nodule
Tx:
- Asymptomatic can monitor
- Symptomatic - PTU and 131I

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23
Q

Thyroid FNA shows: Indeterminant

A

Get radionuclide study

  • Hot nodule - PTU and 131I if symptomatic
  • Cold nodule - lobectomy
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24
Q

Goiter

A

Any abnormal enlargemetn
MCC - iodine deficiency
Operate if airway compression or suspicious nodule
Tx: subtotal or total thyroidectomy

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25
Substernal goiter
Usually secondary - vessels originate from superior and inferior thyroid arteries Primary - rare, vessles originate from innominate artery
26
Mediastinal thyroid tissue
Inferior extension of normally placed gland
27
Lingual thyroid
Thyroid tissue that persists at foramen cecum Sx: dysphgia, dyspnea, dysphonia 2% malignancy risk Tx: thryoxine suppression, abolish with I131
28
Thyroglossal duct cyst
Moves upward with swallowing Risk for infection and malignancy Tx: Sistrunk procedure (remove midportion of hyoid bone with thyroglossal duct cyst)
29
Treatment for young patients, small goiters and mild T3/T4 elevations?
Propylthiouracil | Methimazole
30
Treatment for pregnant patients?
PTU
31
PTU (thioamide)
Inhibits peroxidases, inhibits peripheral conversion | AE: aplastic anemia, agranulocytosis
32
Methimazole
Inhibits peroxidases | AE: creatinism, aplastic anemia, agranulocytosis
33
Radioactive iodine (131I)
Poor surgical risk or unresponsive to PTU | CI - children, pregnancy
34
Graves disease
Exophthalmos, pretibial edema, afib, heat intolerance, thirst, increase appetite, weight loss, sweating, palpitations IgGG antibodies to TSH receptor Dx: decreased TSH, increased T3/T4; increased 123I uptake, diffusely Tx: Thioamides, 131I, thyroidectomy
35
Operating on graves disease?
Indication - suspicious nodule, non-compliant patient, recurrence after medical therapy, children, pregnancy (not controlled with PTU) Preop prep - PTU until euthyroid, B-blocker, Lugol's solution (decrease friability and vascularity) Op - bilateral subtotal or total thyroidectomy
36
Toxic multinodular goiter
Women, >50yo Sx: tachycardia, wt loss, insomnia, airway compromise (can be precipitated by contrast dye) Hyperplasia secondary to chornic low-grade TSH stimulation Tx: Surgery (subtotal or total thyroidectomy), 131I if elderly and frail
37
Single toxic nodule
Women, younger, usually >3cm if symptomatic, functions autonomously Dx: Thyroid scan (hot nodule) Tx: Thioamides and 131I, lobectomy if medical tx infeffective
38
Hashimoto's
Hyopthyroidism Enlarge gland, painless, chronic thyroiditis History of childhood XRT Humeral and cell-mediated autoimmune disease (microsomal and thyroglobulin antibodies) Tx: Thyroxine, partial thyroidectomy if continues to grow, nodules appear or compression symptoms
39
Bacterial thyroiditis
Contiguous spread from URI normal thyroid function test, fever, dysphagia, tenderness Tx: - ABX - Lobectomy (R/O cancer for unilateral swelling) - Total thyroidectomy (persistent inflammation)
40
DeQuervain's Thyroiditis
Hyperthyroid > hypothyroid Viral URI precursor Elevated ESR Tx: Steroids, ASA - Lobectomy (R/O cancer for unilateral swelling) - Total thyroidectomy (persistent inflammation)
41
Riedel's fibrous stomra
``` Woody, fibrous compartment - invasive Need biopsy to R/O CA/lymphoma Compression symptoms Tx: - Steroids, thyroxine - Isthmectomy or trachesotyom for airway symptoms - RLNs at great risk if resected ```
42
Thyroid nodule - worrisome for malignancy
``` Solid Solitary Cold Slow growing Hard Male Age >50yo PRevious neck XRT MEN IIa or IIb ```
43
Follicular adenoma
Colloid, embryonal, fetal No increased cancer risk Lobectomy to prove it is an adenoma
44
Papillary thyroid carcinoma
Best prognosis Childhood XRT Lymphatic spread first - but prognosis based on local invasion Pathology - psammoma bodies, oprhan annie nuclei
45
Treatment of papillary thyroid carcinoma - minimal/incidental (<1cm)
Lobectomy
46
Treatment of papillary thyroid carcinoma - Bilateral lesion, multicentricity, history of XRT, positive margins or tumors >1cm
Total thyroidectomy
47
Treatment of papillary thyroid carcinoma - clinically positive cervical ndoes
Ipsilateral MRND
48
Treatment of papillary thyroid carcinoma - extrathyroidal tissue involvement
Ipsilateral MRND
49
Treatment of papillary thyroid carcinoma - metastatic disease, residual local disease, positive LN or capsular invasion
131I | 4-6 weeks after surgery
50
When do you use XRT in treatment of papillary thyroid carcinoma?
Unresectable disease not responsive to 131I
51
Enlarged lateral neck lymph node with normal-appearing thyroid tissue?
Papillary thyroid CA with lymphatic spread Total thyroidectomy and MRND 131I 4-6 weeks after surgery
52
Follicular thyroid carcinoma
Hematogenous spread - bone FNA shows follicular cells Tx: Lobectomy - Adenoma/folliclar cell hyperplasia - done - Follicular CA - total thyroidectomy and 131I (if >1cm or extrathyroidal)
53
Medullary thyroid carcinoma
``` MEN IIa or IIb Parafollicular C cells Path - amyloid deposition Screen for hyperPTH and Pheo Lymphatic spread Tx: total thyroidectomy with central neck node dissection ```
54
What is the first manifestation of MEN IIa or IIb?
Diarrhea
55
Where does medullary thyroid cancer spread to?
Lung, liver, bones
56
Prophylaxtic thyroidectomy and central node dissection for MEN - when?
MEN IIa - 6yo | MEN IIb - 2yo
57
Hurthle cell carcinoma
Most benign Bone and lung mets Tx: Total thyroidectomy and MRND for clinically positive nodes
58
Anaplastic thyroid cancer
Most aggressive | Tx: total thyroidectom, palliative thyroidectomy or chemo-XRT
59
XRT effective for:
Papillary, follicular, medullary and Hurthle cell thyroid CA
60
131I effective for:
Papillary and follicular thyroid CA only
61
Indications for 131I
Recurrent CA Primary inoperable tumors due to invasion Tumars >1cm or extrathyroidal disease (extra-capsular invasion, nodal spread or mets)
62
I131 AE
``` Sialoadenitis GI symptoms Infertility BM suppression Parathyroid dysfunction Leukemia ```
63
Gene Mutations: Papillary Thyroid Carcinoma
BRAF
64
Gene Mutations: Medullary Thyroid Carcinoma
RET-1
65
Gene Mutations: Anaplastic Thyroid Carcinoma
p53
66
Gene Mutations: Follicular thyroid carcinoma
PAX8/PPAR-gamma

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