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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
Q

Enroth’s sign

A

edema of eyelid and conjunctiva

26
Q

Causes of pulsatile exophthalmos

A 
Cavernous sinus thrombosis 
Carotid cavernous sinus AV fistula
Ophthalmic artery aneurysm
Orbital hemangioma
Orbital vascular tumor
27
Q

Anti thyroid drugs

A

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
Q

Subclinical hyperthyroidism

A

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
Q

Thyrotoxicosis factitia

A

Intake of excessive L-thyroixine in the absence of indications to loose weight .

30
Q

Jod - Basedow disease

A

Due to excessive intake of iodides in Patients with hyperplastic endemic goitre - Large intake of iodides by the gland - Temporary hyperthyroidism

31
Q

Symptoms of thyrotoxicosis

A

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
Q

Cardiac Signs of Thyrotoxicosis

A

Crile’s Grading

33
Q

Dermopathy in Graves’ Disease

A

Pretibial myxedema , Pruritis ,Palmar erythema Duputryen’s Contracture

34
Q

Signs in Graves’ Disease

A

1) Eye Signs
2)Cardiac Signs
3) Dermopathy
4)Thyroid Acropachy
Others

35
Q

Complications of anti thyroid drugs

A 
Allergic reactions
Agranulocytosis - Sore throat (1st sign)
Hepatotoxicity
Polyarthritis
Lupus vasculitis
36
Q

Types of Follicular Adenoma (Benign)

A

Colloidal - No potential for microinvasion ; Commonest
Fetal - Microfollicular; Potential for micro invasion
Embryonic - Atypical ; Potential for microinvasion
Hurtle/ Oxyphillic -
Hyalinising trabecular type

37
Q

Malignant Thyroid Types

A

1) Differentiated - Papillary .Follicular , Papillofollicular and Hurtle cell type
2) Undifferentiated - Anaplastic
3) Medullary Ca.
4) Malignant lymphoma
5) Secondaries in thyroid

38
Q

Etiology of Thyroid Cancers

A

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
Q

Classification of Papillary Ca.

A

Woolner’s Classification -

1) Occult Primary < 1.5 cms
2) Intrathyroidal
3) Extrathyroidal

40
Q

Lindsay tumour

A

Encapsulated papillary variant with follicular Ca . together called papillofollicular ca. is called Lindsay tumour acting as papillary Ca.

41
Q

Microscopic Changes in Papillary Ca.

A

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
Q

Psamomma bodies seen in

A

Papillary ca of thyroid
Meningioma
Serous cystadenoma of ovary

43
Q

Berry in thyroid

A

Berry’s ligament
Berry picking
Berry’s sign

44
Q

Treatment of Papillary Ca.

A

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
Q

Thyroid paradox

A

Cellular tumors are soft and cystic tumors are hard or cystic

46
Q

Symptoms of Papillary Ca.

A

1) Swelling in the neck - Firm/hard/cystic
2) Compression symptoms are unlikely
3) Lymph node enlargement

47
Q

Types of Follicular Ca

A

Invasive and Non invasive types as spread is mostly through blood

48
Q

Clinical features of Follicular Ca.

A

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
Q

Investigations for Follicular Ca.

A

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
Q

Treatment of follicular Ca

A

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
Q

Central Node compartment Dissection

A

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
Q

Completion thyroidectomy

A

When Frozen section biopsy results are inconclusive then hemithyroidectomy . When it confirms the diagnosis of Differentiated tumour Completion thyroidectomy

53
Q

Anaplastic Ca. Clinical features

A

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
Q

Medullary Ca - Types

A

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
Q

Position of the patient in thyroidectomy

A

Rose’s position - neck is hyperextended with head tilt of 15 degrees

56
Q

Incision of thyroidectomy

A

Kocher’s incision - Horizontal incision 2 finger breath above the sternal notch from the post. border of one SCM to other

57
Q

Anaplastic Ca - Management

A

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
Q

Medullary Ca. - Treatment

A

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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