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Surgery > Chapter 17 > Flashcards

Chapter 17 Flashcards

1
Q

How is the thyroid encapsulated?

A

By a fibrous capsule, which is in turn invested by a false capsular layer arising from the deep cervical fascia (pretracheal fascia)
-The fascial attachment between the gland and the upper two or three tracheal rings is also known as the ligament of Berry

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2
Q

Where do the strep muscles reside?

A

The strep muscles are the sternothyroid and sternohyoid

They reside anterior to the lobes of the gland are innervated by the ansa cervicalis

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3
Q

What define the posteromedial borders of the thyroid gland?

A

The trachea and the esophagus

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4
Q

What lies lateral to each lobe of the thyroid?

A

Common carotid artery

Internal jugular vein

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5
Q

What lies medial to each thyroid lobe?

A

Vagus, in the cleft between the trachea and esophagus, and beneath or embedded in the ligament of Berry

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6
Q

Blood supply of the thyroid- general

A

Predominantly from the paired superior and inferior thyroid arteries

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7
Q

Superior thyroid artery

A

The first branch off the external carotid artery and descends toward the superior pole of the thyroid lobe, where it divides into anterior and posterior branches

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8
Q

Inferior thyroid artery

A

A branch of the thyrocervical trunk and travels posterior to the carotid sheath before it reaches the posterior surface of the mid-portion of the gland
-Also provides the principal blood supply to all 4 parathyroid glands in ~80%

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9
Q

Thyroid ima arteries

A

Present in 5-10% of the population
Arise from the brachiocephalic trunk or directly from the aortic arch and can provide additional blood supply to the thyroid

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10
Q

What veins drain the superior poles and lateral aspects of the thyroid, respectively?

A

Superior and middle veins

Drain into the internal jugular veins

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11
Q

What arise from the inferior poles of the thyroid and course anterior to the trachea?

A

Inferior thyroid veins

Drain into the brachiocephalic veins

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12
Q

Lymphatics of the thyroid

A

Interlobular lymphatics communicate with intrascapular lymphatics
Pretracheal lymph nodes, paratracheal lymph nodes, and the tracheoesophageal lymph nodes along the recurrent laryngeal chain
The supraisthmic pretracheal lymph nodes that run alongside the pyramidal lobe are also known as the delphian nodes
The regional nodal basins are a frequent site of metastatic thyroid cancer?

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13
Q

How is the thyroid innervated?

A

By postganglionic fibers that originate from the cervical sympathetic ganglia

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14
Q

RLN

A

Comprised of all intrinsic laryngeal muscles except for the cricothyroid muscle
Injury leads to hoarseness and difficulty in phonation secondary to paralysis of the ipsilateral vocal cord

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15
Q

What does bilateral RLN injury result in?

A

Abduction of both vocal cords with complete airway obstruction necessitating emergent intubation or tracheostomy

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16
Q

Branching of the RLN

A

Branches from the vagus nerve and loops around the origin of the right subclavian artery to ascend in the tracheoesophageal groove

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17
Q

Branching of the left RLN

A

Branches from the vagus nerve and loops around the aortic arch near the ligamentum arteriosum

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18
Q

Nonrecurrent laryngeal nerve on the right side

A

Present in ~1% of the population and is often associated with an aberrant subclavian artery
A left is much less common and may be associated with a right-sided aortic arch

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19
Q

What innervates the cricothyroid muscle?

What can an injury to this nerve result in?

A

External branch of the superior laryngeal nerve

Loss of vocal projection and volume, particularly at higher pitches

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20
Q

Hormones involved in the thyroid

A

Thyroid hormones

Calcitonin

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21
Q

Thyroid function tests

A

Unlike T4 or T3 levels, which vary depending on the plasma level of TBG, albumin, and prealbumin, serum TSH levels are independent of the concentrations of carrier proteins in the circulation

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22
Q

What should be done following adjustment of an oral T4 dosage?

A

Serum TSH measurement should be delayed for at least 4-8 wks

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23
Q

When are TSH levels not reliable indicators of thyroid dysfunction?

A

In pts who have neuropsychiatric disorders or diseases of the pituitary gland (pituitary adenoma)

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24
Q

TRH stimulation test

A

Check baseline TSH level, administer synthetic TRH, measure TSH level again after 30-60 mins

  • Normally, a rise in TSH from baseline is observed after TRH administration
  • Pts with hypothyroidism have a blunted response or no rise in TSH
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25
Q

Thyroid imaging

A

US is noninvasive and inexpensive (solid vs cystic)
FNA
Radionuclide imaging- functional assessment of the thyroid gland
-Allows for localization of thyroid tissue, detection of functional metastatic lesions from thyroid cancer, and an estimation of the size of the thyroid gland

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26
Q

What can detect areas of calcification in the thyroid?

Identify regions of increased vascularity?

A

High-resolution u/s

Ultrasonography with Doppler

27
Q

What are three hyperthyroid causes that more commonly require surgical intervention

A

Graves dz (toxic diffuse goiter)
Toxic nodular goiter
Solitary toxic nodule

28
Q

Possible accompanying sx of hyperthyroid diseases?

A 
Tachycardia
Wt loss
Tremors
Increased anxiety
Sleep disturbances
29
Q

Graves dz

A

An autoimmune disorder characterized by the presence of antibodies against the TSH receptor on the follicular cell

30
Q

Graves dz is _____ more common in ____ than ____

A

6-7x
Women
Men

31
Q

Clinical manifestations of Graves dz

A 
Fatigue
Heat intolerance
Wt loss
Diarrhea
Hair loss
Irritability
Tremor
Arrhythmias
HTN
Osteoporosis
Amenorrhea
Sweating
32
Q

Exam of Graves dz

A

Thyroid gland is typically diffusely enlarged, symmetric, and smooth

33
Q

Tx options for Graves

A

Medical
Radioactive iodine thyroid ablation
Surgical thyroid ablation

34
Q

Medical therapy for Graves

A

Aimed at reducing thyroid hormone levels and is the first-line therapy for most pts
Thionamide therapy must be continued for a prolonged period to control thyroid levels and allow for spontaneous remission
Beta blocking agents such as propranolol may be used as adjuvants

35
Q

Radioactive iodine therapy for Graves

A

Induces long-standing remission in most pts, with relatively few side effects, and is the definitive tx used for most adult pts with Graves dz in the US

36
Q

Advantages and disadvantages for radioactive iodine therapy for Graves

A

Primary advantage- Does not require an invasive procedure

Disadvantage- high incidence of hypothyroidism

37
Q

Who are not considered candidates for radioactive iodine therapy in Graves disease?

A

Pregnant women
Pts with concomitant thyroid nodules
Those with very large glands
Generally avoided in children

38
Q

When is operative intervention indicated for Graves?

A

Pts who are noncompliant with, or intolerant to, antithyroid drug therapy
Those who are refractory to medical therapy
Those with contraindications to radioactive therapy
Those with large glands (greater than or equal 80 g)
Symptomatic compression
Those with concern for malignancy
Pts who are younger than 20 yrs with large goiters

39
Q

What should be done preoperatively for Graves?

A

Achieve a euthyroid state with administration of pTU in combo with propranolol typically initiated 4-8 wks before operation and continued during and after the operation
Lugol solution can be given to pts to decrease the vascularity of the gland and make it firmer and easier to resect

40
Q

Autonomously functioning thyroid nodules

A

Function and grow independent of TSH
Appear hot on radionuclide studies
Majority of these nodules enlarge, develop central necrosis, and become nonfunctional

41
Q

Solitary toxic nodules

A

Have a peak incidence during the fifth decade of life and are much more common in women

42
Q

Toxic multinodular goiter

A

Accounts for approximately 20% of pts with hyperthyroidism and is most common in women older than 50 yrs

43
Q

Tx of solitary functional nodules

A

Influenced by size and degree of function, as well as by the pt’s age and overall health

44
Q

When to treat toxic nodules surgically

A

Ones that exceed 3 cm in diameter

45
Q

What is the standard tx for toxic multinodular goiter?

A

Antithyroid drug therapy, followed by thyroidectomy

46
Q

Presentation of hypothyroid

A 
Fatigue
Wt gain
Brittle nails
Coarse hair
Constipation
Neurocognitive disturbances, such as depression, irritability or impaired memory
47
Q

What is the MC inflammatory condition of the thyroid and the most frequent cause of spontaneous hypothyroidism?

A

Hashimoto thyroiditis

48
Q

What can occur during the acute phase of Hashimoto thyroiditis?

A

Transient hyperthyroidism

49
Q

Findings on palpation in Hashimoto thyroiditis

A

Gland is usually firm and rubbery with a lobulated surface

50
Q

What is usually sufficient to make the dx of Hashimoto thyroiditis?

A

Elevated antimicrosomal antibody titer, along with a suggestive clinial exam

51
Q

When is thyroidectomy indicated in Hashimoto thyroiditis?

A

When the gland continues to grow despite thyroid suppression therapy

52
Q

When should a Hashimoto thyroiditis pt be evaluated for lymphoma?

A

A rapid enlargement of the thyroid gland

53
Q

Acute thyroiditis

A

An infectious disorder, which is more common in women

54
Q

Organisms of acute thyroiditis

A

S. pyogenes
S. aureus
P. pneumoniae
Usually spread via the lymphatics from local infectious sources

55
Q

Presentation of acute thyroiditis

A

Acute onset of neck pain and fever

Pts typically euthyroid

56
Q

Tx of acute thyroiditis

A

Appropriate IV abx

Surgical drainage if abscess present

57
Q

Subacute thyroiditis

A

A dz that typically occurs in middle-aged women within wks of an upper respiratory or other viral infection

58
Q

Sx of subacute thyroiditis

A 
Weakness
Depression
Easy fatiguability
Anterior neck pain
Referred pain to the ear or angle of the jaw
59
Q

Exam of subacute thyroidits

A

Pt usually afebrile
Thyroid firm and extremely TTP
Thyroid may be swollen unilaterally, and the overlying skin is occasionally erythematous

60
Q

Tx of subacute thyroiditis

A

Typically self-limited and usually resolves within a few mos
Salicylates
NSAIDs
Corticosteroids

61
Q

Riedel struma

A

A very rare chronic inflammatory proliferative d/o in which the thyroid tissue and frequently the adjacent strap muscles and carotid sheaths are replaced by dense fibrous tissue

62
Q

Presentation of Riedel struma

A

Pts are most often euthyroid, although hypothyroidism may be seen in up to 30% of pts

63
Q

Workup for Riedel struma

A

Open bx to r/o thyroid carcinoma or lymphoma

64
Q

Tx of Riedel struma

A

Often self-limiting
Steroids or tamoxifen is sometimes beneficial
If airway compromise present, surgical therapy with isthmusectomy

Surgery (30 decks)

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