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Thyroid - Surgery > Thyroid > Flashcards

Thyroid Flashcards

1
Q

Thyroglossal cyst - Clinical Features and Operation name

A

C/Fs - Tugging sign
Transilluminant and Fluctuant
Operation name - Sistrunk operattion

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2
Q

Thyroglossal fistula - 2 Signs

A

Hood’s sign

Crescentric sign

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3
Q

Pendred syndrome

A

Dyshormogenesis and deafness

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4
Q

Levels of T3,T4 And TSH

A

T3 - 2.1- 3.1nmol/lt
T4 - 55-105nmol/lt
TSH - 0- 5 IU/ml of plasma

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5
Q

Types of simple non toxic goitre

A

Types 1)Diffuse hyperplastic - physiological , primary or secondary iodine deficiency.

2) Colloidal goitre
3) Multinodular goitre
4) Simple nontoxic nodule
5) Recurrent Nontoxic nodule
6) Wolf - Chaikoff goitre
7) Hakkaido goitre

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6
Q

Types of Toxic Goitre

A

1)Diffuse (primary) - Graves disease
2)Multinodular (secondary ) - PLummer’s Disease.
3) Toxic Nodule (Tertiary)
Recurrent toxicosis

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7
Q

Who grading of Goitre

A

Grade 0 - NOt visible and Not palapable
Grade 1 - Palpable but not visible in normal neck position
Grade 3 - Visible even in normal neck position

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8
Q

Stages of multinodular goitre formation

A

1) Hypertrophy and hyperplasia - Due to increased TSH
2) Fluctuation in TSH levels- Both active and inactive lobules
3) Formation of nodules( only internodular tissue is active)

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9
Q

Kocher’s test is Positive in

A

Multinodular goitre and Carcinoma of thyroid

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10
Q

Complications of Multinodular Goitre

A

1) Secondary thyrotoxicosis
2) Malignancy - Follicular ca.
3) Hemorrhage and necrosis
4) Compression on trachea
5) Cosmetic reasons

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11
Q

Treatment of MNG`

A

Surgery - because its an irreversible state and chances of complications is more
Total or subtotal thyroidectomy or Hartley Dunhill operation.

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12
Q

Solitary Thyroid nodule and Dominant nodule

A

If the nodule is palpable and the rest of the gland is not palpable - Solitary nodule
If the nodule is palpable and the rest of the gland is also palpable - Dominant thyroid nodule
Solitary nodule has 4 times more chances of becoming malignant than dominant nodule

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13
Q

Solitary nodule - Treatment (Based on FNAC results - Benign solitary nodule)

A

1) Non - toxic nodule - Observation by clinical palpation and FNAC yearly - 20% increase in size or >2mm increase in size warrants a repeat FNAC and if signs of tracheal compression and cosmesis is present then hemithyroidectomy
2) Toxic nodule - Start on Anti thyroid drugs and then Radioactive iodine and if needed hemithyroidectomy
3) Colloidal - Observation or Hemithyroidectomy
4) FLUS - Total thyroidectomy

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14
Q

Solitary Nodule -Treatment (Based on FNAC results - Malignant solitary nodule)

A

1) Papillary Ca. - Total or near total thyroidectomy, if FNAC shows extracapsular involvement - Radioactive iodine treatment and post op L-thyrosine therapy
2) Foliicular Ca. - Total thyroidectomy
3) Medullary Ca. - Total thyroidectomy and Neck nodal dissection including central part.
4) In Isthmus - Isthmectomy

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15
Q

Retrosternal Goitre

A

When >50% of goitre is behind the suprasternal notch ie.below the thoracic inlet. OR
When mediatinal extension requires mediastinal dissection OR
Extension into anterior mediastinum is >2cms OR
Extension reaches T4 vertebrae level

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16
Q

Findings in Retrosternal Goitre

A

INSPECTION - Dilated and engorged neck and chest veins.
PALPATION - Lowe border is not felt and Pemberton test is positive
PERCUSSION - Dull note over sternum

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17
Q

Reason for Pemberton Test

A

Compression of retrosternal goitre on compressable stuructures like SVC and TRACHEA - Therefore dilated veins on chest and lower neck and Dyspnea

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18
Q

Dalrymple’s sign

A

Upper eye lid retraction - upper sclera is seen

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19
Q

Von-Graefe’s sign

A

Lid lag

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20
Q

Stellwag’s sign

A

Absence of blinking

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21
Q

Joffrey’s sign

A

Absence of wrinkling of forehead on upward gaze

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22
Q

Mobius sign

A

Loss of convergence

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23
Q

Naffzieger’s sign

A

When pt is sitting with neck extended , protruded eye balls are seen when the examiner stands behind the patient

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24
Q

Jellinek’ sign

A

pigmentation of upper eyelid

25
Enroth's sign
edema of eyelid and conjunctiva
26
Causes of pulsatile exophthalmos
``` Cavernous sinus thrombosis Carotid cavernous sinus AV fistula Ophthalmic artery aneurysm Orbital hemangioma Orbital vascular tumor ```
27
Anti thyroid drugs
1) Prevent thyroid hormone synthesis - Propylthiouracil, Methimazole and Carbimazole 2) Prevent Iodine Uptake - Perchlorates, Nitrates 3) Prevent release of hormones - Iodides, Lugol's iodine 4) Thyroid Ablation - Radioactive iodine 123
28
Subclinical hyperthyroidism
When T3 , T4 levels are normal and TSH levels are low and no presence of clinical signs and symptoms . One of the causes of infertility both Subclinical hyper/hypothyroidism
29
Thyrotoxicosis factitia
Intake of excessive L-thyroixine in the absence of indications to loose weight .
30
Jod - Basedow disease
Due to excessive intake of iodides in Patients with hyperplastic endemic goitre - Large intake of iodides by the gland - Temporary hyperthyroidism
31
Symptoms of thyrotoxicosis
1) Cadiovascular - Palpitations, Dyspnea , Cardiac arrhythmias , Cardiac Failure 2) GI - Weight loss in spite of increased appetite, Diarrhoea. 3) Neuromuscular - Weakness of muscles and tremors 4) Skeletal - Increase in the linear growth 5) Genito - urinary - Ameno / Oligorrhea , Occasional urinary infrequency 6) Psychological - Nervousness, irritability insomnia 7) Sympathetic - palpitations , sweating , Cold intolerance
32
Cardiac Signs of Thyrotoxicosis
Crile's Grading
33
Dermopathy in Graves' Disease
Pretibial myxedema , Pruritis ,Palmar erythema Duputryen's Contracture
34
Signs in Graves' Disease
1) Eye Signs 2)Cardiac Signs 3) Dermopathy 4)Thyroid Acropachy Others
35
Complications of anti thyroid drugs
``` Allergic reactions Agranulocytosis - Sore throat (1st sign) Hepatotoxicity Polyarthritis Lupus vasculitis ```
36
Types of Follicular Adenoma (Benign)
Colloidal - No potential for microinvasion ; Commonest Fetal - Microfollicular; Potential for micro invasion Embryonic - Atypical ; Potential for microinvasion Hurtle/ Oxyphillic - Hyalinising trabecular type
37
Malignant Thyroid Types
1) Differentiated - Papillary .Follicular , Papillofollicular and Hurtle cell type 2) Undifferentiated - Anaplastic 3) Medullary Ca. 4) Malignant lymphoma 5) Secondaries in thyroid
38
Etiology of Thyroid Cancers
1) Radiation both external and as Radioactive iodine therapy 2) Multinodular Goitre - to Follicular Ca. 3) Medullary Ca is Familial 4) Familial 5) Cowden syndrome - Mutation in PTEN gene - Ca Breast , Ca Thyroid And Multiple hamartomas 6) Raised TSH levels - to Papillary Ca. 7) Hashimoto's thyroiditis
39
Classification of Papillary Ca.
Woolner's Classification - 1) Occult Primary < 1.5 cms 2) Intrathyroidal 3) Extrathyroidal
40
Lindsay tumour
Encapsulated papillary variant with follicular Ca . together called papillofollicular ca. is called Lindsay tumour acting as papillary Ca.
41
Microscopic Changes in Papillary Ca.
p1) Papillary projections in cystic spaces 2) Tumor cells - Show ground glass appearance with ORPHAN - ANNIE EYE Appearance of nuclei Tall cell type of papillary Ca. is aggressive and worse prognosis 3) Presence of Psammoma bodies found only on histopath and not in FNAC
42
Psamomma bodies seen in
Papillary ca of thyroid Meningioma Serous cystadenoma of ovary
43
Berry in thyroid
Berry's ligament Berry picking Berry's sign
44
Treatment of Papillary Ca.
1) Total or near total thyroidectomy with central compartment dissection. 2) Suppresive dose of L- thyrosin daily 3) Lateral neck node dissection ( Level 2A , 3, 4 and 5B) or Modified neck node dissection ( Preervation of SCM, IJV and Spinal accessory nerve) 4) Radioactive iodine therapy - for multicentric tumour , >1cm size , extracapsular invasion , presence of nodes and high risk grading 5) Berry's picking - picking up of enlarged lymphnodes
45
Thyroid paradox
Cellular tumors are soft and cystic tumors are hard or cystic
46
Symptoms of Papillary Ca.
1) Swelling in the neck - Firm/hard/cystic 2) Compression symptoms are unlikely 3) Lymph node enlargement
47
Types of Follicular Ca
Invasive and Non invasive types as spread is mostly through blood
48
Clinical features of Follicular Ca.
1) Swelling in the neck 2) Compression symptoms are common - Stridor 3) Recurrent laryngeal nerve palsy - Horseness 4) Dyspnea , cough , hemoptysis - 2daries in lung 5) Berry's sign positive 6) Swelling in the skull - Hard non-mobile, Fluctuant and Pulsatile
49
Investigations for Follicular Ca.
1) FNAC cannot be done as the main point of identification of follicular adenoma and Ca is that Ca shows vascular and lymphatic invasion which cannot be identified in FNAC 2) Fresh Frozen Biopsy - but even this is inconclusive 3) USG abd, chest X-ray , Bone X- ray - for 2ndaries
50
Treatment of follicular Ca
1) Total or near total thyroidectomy with central compartment dissection. 2) Suppressive dose of L- thyrosin daily 3) Lateral neck node dissection ( Level 2A , 3, 4 and 5B) or Modified neck node dissection ( Preervation of SCM, IJV and Spinal accessory nerve) 4) Post - op Radioactive iodine therapy ; Keep the patient in isolation and proper disposal of urine and feces.
51
Central Node compartment Dissection
Removal of Level 6 (Pre-tracheal , Para-tracheal , Pre-laryngeal , Tracheo-esophageal) and thymus and throid enbloc extending from hyoid bone above to subclavian vein below and carotids on both sides
52
Completion thyroidectomy
When Frozen section biopsy results are inconclusive then hemithyroidectomy . When it confirms the diagnosis of Differentiated tumour Completion thyroidectomy
53
Anaplastic Ca. Clinical features
1) Swelling in the neck - hard with involvement of isthmus and lateral lobes 2) Compression symptoms - Stridor 3) Lymph node enlarged and fixed 4) Dysphagia 5) Berry's Sign - positive
54
Medullary Ca - Types
1) Sporadic - Unifocal ; occurs in Posterior part of thyroid - compression is common 2) Hereditary - Autosomal dominant 3) Familial: 3A) Familial MCT without MEN syndrome 3B) MCT wit MEN 2A - 95% MCT(Multifocal and Bilateral) - 50% pheochromocytoma (multifoacal and bilateral) - 35% Hyperparathyroidism 3B) MCT with MEN 2B - 100% MCT - 50 % Pheochromocytoma - no Hyperparathyroidism
55
Position of the patient in thyroidectomy
Rose's position - neck is hyperextended with head tilt of 15 degrees
56
Incision of thyroidectomy
Kocher's incision - Horizontal incision 2 finger breath above the sternal notch from the post. border of one SCM to other
57
Anaplastic Ca - Management
1) FNAC is diagnostic 2) T4a is intrathyoidal and surgically resectable T4b is extrathyroidal and surgically non- resectable Treatment : 1) Tracheostomy with istmectomy - to relieve symptoms 2) External radiotherapy as usually thyroidectomy is not possible 3)Chemotherapy - Adriamycin
58
Medullary Ca. - Treatment
1) Total thyroidectomy with B/L central neck node dissection with ipsilateral lateral neck node dissection if the tumour is >1cm or if nodes are positive 2) Opposite neck node dissection is US neck shows opposite neck node involvement 3) External beam Radiotherapy for residual therapy 4) Chemotherapy is Adriamycin 5) Suppressive L-thyroxine 6) If family members have high calcitonin levels - Prophylactic total thyroidectomy

Thyroid - Surgery (2 decks)

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