2. Thyroid – throat (latin)
Largest endocrine gland, 15-30 g in adults
Butterfly/H shape
Extent – middle of thyroid cartilage to 4th to
6th tracheal rings (C5,C6,C7,T1)
Deep to cervical strap muscles covering
cricoid cartilage and upper tracheal rings
2 lateral lobes (right and left) – conical in
shape (vertical limbs)
Connected by isthmus (horizontal limb) –
connects lower part of 2 lobes, overlies 2nd
and 3rd tracheal rings
3. Each lobe measures 5 cm length, 3 cm
breadth and 2 cm AP diameter
Pyramidal lobe – 3rd lobe in 50% cases,
extends from isthmus near left lobe towards
the hyoid bone
4.
5. Capsule
True capsule
Surrounds the gland
Formed by peripheral condensation of
connective tissue of the gland
Deep to it lies dense capillary plexus
Remove the gland along with true capsule
False capsule
Derived from pretracheal layer of deep cervical
fascia
On inner surface of glands it forms a ligament on
each side – Posterior suspensory ligament of
Berry
6. Berry ligament – attaches thyroid lobe to cricoid
cartilage and 1st and 2nd tracheal rings
Leads to thyroid swelling moving up with
swallowing
RLN passes deep, lateral or above the berry
ligament
Branch of Inferior thyroid artery also passes deep
to this ligament. This can bleed during surgery
So clamping of the artery can damage RLN
Ligament also contains small amount of thyroid
tissue – if left behind during thyroid surgery
leads to incomplete removal
7.
8. Blood Supply
Superior Thyroid artery
Inferior Thyroid artery
STA
Upper 1/3rd of lobe and upper 1/3rd of isthmus
1st ant br of ECA just below the greater horn of
hyoid bone
Divides at upper pole into anterior and posterior
branches
Ant branch anastomise with opp side ant branch
Post branch anastomise with ascending branch of
ITA
Related to external laryngeal nerve
9. ITA
Lower 2/3rd of each lobe and lower 2/3rd of isthmus
Branch of thyrocervical trunk (br of subclavian
artery)
Also supplies upper ½ of trachea
Related to RLN behind the gland
Divides into 4 or 5 branches
One ascending br anastomise with post br of STA and
supplies parathyroid gland
Thyroidea ima artery
Lowest thyroid artery – 10%, at inferior border of
isthmus
Arises from aortic arch/innominate artery/lower CCA
10.
11. Venous Drainage
Sup thyroid vein
At upper pole, accompanies STA
Terminates into IJV/ common facial vein
Middle thyroid vein
Middle of lobe, no corresponding artery
Terminates into IJV
Inferior thyroid vein
Lower border of isthmus, multiple
Terminates into left or right brachiocephalic vein
Kocher’s vein
V rare, between middle thyroid vein and inferior
thyroid vein
Drains into IJV
12.
13. Nerve supply
Autonomic Nervous System
Middle cervical ganglion (partially from superior and
inf cervical ganglion)
Parasympathetic division from vagus nerve
RLN
Lies in Beahr’s RLN triangle or RLN triangle of lore
Lat – carotid sheath, strap muscles
Med – trachea, oesophagus
Sup – lower pole of thyroid gland
Rt RLN more prone for injury during thyroid surgery
as it lies more ant and lateral at inf pole of thyroid
gland
14. Non recurrent laryngel n
0.3-0.8%
Rt side – mc
Anomalous, dont hook around vessels
SLN
Related to STA and vein
Divides into larger internal and smaller external
laryngeal nerve (cricothyroid muscle)
Located in the sternothyrolaryngeal triangle or
triangle of joll
Boundaries – sup –sternothyroid muscle, roof –
strap muscles, floor – cricothyroid muscle,
medially – cervical midline, laterally – upper pole
of thyroid gland and sup thyroid vessels
15. Lymphatic drainage
II,III,IV,V,VI,VII
Upper part of lat lobe and sup border
isthmus – prelaryngeal ln, upper deep
cervical ln
Lower part of lobe and lower isthmus –
pretracheal, paratracheal ln, lower deep
cervical ln
16. Parathyroid glands
On posterior aspect of each lobe
Sup parathyroid
Above inf thyroid artery
Post to RLN
Upper 1/3rd of lobe
Close to cricoid cartilage
Inf parathyroid
Below inf thyroid artery
Ant to RLN
Near lower pole
But can be located anywhere between hyoid bone to
sup mediastinum as they descend along with thymus
gland
17.
18. Development
Midline thyoid diverticulum
In floor of foregut and then migrate to adult
position
Thyroglossal duct – connects thyroid diverticulum
to foregut (foramen caecum)
If it persists lead to cyst or fistula
Ectopic thyroid
Lingual thyroid – if improper descent
Ultimo branchial bodies
Contribute 10% of thyroid
Contribute to formation of parafollicular
calcitonin producing C cells
19. Endocrine gland
Cells 2 types
Follicular cells
Produce a glycoprotein called thyroglobulin
(Tg) – present as colloid in lumen of follicular
cells
Role in formation of T3 and T4
Parafollicular cells – C cells
Secretes calcitonin – lowers calcium, role in
calcium metabolism
20. Synthesis of thyroid hormones
Hypothalamus – secretes TRH (Thyrotropin releasing
hormone), acts on pituitary
Pituitary – releases TSH (Thyroid stimulating
hormone) or thyrotropin, acts on follicular cells of
thyroid gland
Thyroid follicular cells – synthesis and release of T3,
T4 – inhibitory effect
Action in follicular cells
Enzyme Iodide peroxidase
Uptaken iodide -> iodine
Coupling of iodine and tyrosine -> iodotyrosine
2 molecules of diiodotyrosine -> T4
1 molecule of diiodotyrosine and 1 molecule of
monoiodotyrosine -> T3
21. Secretion
Enzyme Diiodotyrosine deiodinase
Causes deiodination of MIT, DIT which
liberates iodine and recycled
If enzyme absent – iodine lost in urine –
iodine deficiency
T3
Produced 20% in thyroid gland
Remaining 80% in peripheral tissues due to
deiodination of T4
3 times more potent than T4
22. History taking
AGE
since birth – thyroglossal cyst
Near puberty/pregnancy/teenage girls – simple
goitre, physiological goitre
Young females – MNG, STN
Malignancy - < 20 yrs, > 60 yrs
Papillary ca, follicular ca, medullary ca – younger
age, anaplastic ca – older age
Thyrotoxicosis – younger and middle age group
SEX
Females more common
In males affected – more chances of turning
malignant
23. OCCUPATION
Stress – thyrotoxicosis
RESIDENCE
Endemic goitre – low iodine content areas – himalyas,
southern hills
Areas of high calcium content- producing chalk or
limestone (calcium – goitrogenic)
CHIEF COMPLAINTS
Swelling
Mc asymptomatic STN
Onset/rate of growth
Sudden increase in size with pain – haemorrhage
Slow growth – simple/colloid/MNG/SNG, Papillary
ca/follicular ca
Fast rapid growth – anaplastic ca/lymphoma
24. Pain
Inflammatory – painful
Malignant – painless, later painful
Hemoptysis – tracheal erosion
Stridor/dyspnoea – tracheal pressure or
infiltration
Dysphagia – oesophageal pressure or infiltration
Hoarseness – RLN pressure or infiltration (mc –
anaplastic ca)
Primary thyrotoxicosis – less enlargement, loss of
weight despite..... good appetite, cold climate
prefernce, intolerance to heat, excessive
sweating, irritability, tremors of hands and
tongue, loose stools, amenorrhoea
25. Secondary thyrotoxicosis
In a long standing STN/MNG/colloid goitre
Palpitation, dyspnoea on exertion, chest pain on
exertion, dysarrythmia
Hypothyroidism
Increase in weight despite.....poor appetite, fat
at back of neck and shoulders, intolerance to
cold weather, prefers warm climate, minimal
swelling, dull appearance, loss of hair, lethargy,
constipation, menstrual disturbances
Pulmonary metastasis – chest pain, cough,
dyspnoea
Bone metastasis – bone pain, pathological
fracture
26. PAST HISTORY
Any drug intake
Radiotherapy – papillary ca
HTN/DM/CAD
PERSONAL HISTORY
Diet
Less iodine – follicular ca
Excess iodine – papillary ca
Brassica family veg like cabbage, brocali –
goitrogenic
FAMILY HISTORY
Medullary ca – runs in families
27. EXAMINATION
GENERAL PHYSICAL EXAMINATION
Build and nutrition
Thin and underweight – thyrotoxicosis
Obese and overweight – hypothyroidism
Anaemia, cachexia – malignancy
FACIES
Thyrotoxicosis – excitement, anxiety, tension,
agitated look....., nervousness
Eye – protruding eye ball (exophthalmos), lid
retraction, widening of palpebral fissure, oedema of
eye lids (upper eye lid)
Hypothyroidism – puffy face without expression, dull,
low intelligence
28. PULSE RATE
Rapid and irregular in thyrotoxicosis
(tachycardia)
Slow in hypothyroidism (bradycardia)
Sleeping pulse rate – 4 am to 5 am.........during
deep sleep
TREMORS OF HAND – primary thyrotoxicosis
Tremors of tongue
Skin
Moist and warm feet and hands – thyrotoxicosis
Dry and cold skin - hypothyroidism
29. LOCAL EXAMINATION
INSPECTION
Seen only if enlarged
Pizzillo’s method – hands behind head and
patient asked to push his head against them
Uniform enlargement – simple goitre, colloid
Nodular
Swallowing – swelling moves up (D/D – level
VI LN, thyroglossal cyst, sub hyoid bursa)
Protrusion of tongue – no movement (diff
from thyroglossal cyst)
30. PALPATION
With neck slightly flexed
From behind and front
Lahey’s method
Stand in front. Push the thyroid to the side being
examined and palpate
Smooth – colloid goitre
Hard – malignancy
Bosselated – MNG
Size of nodule > 1.5 cm – malignancy
Mobility both horizontal and vertical directions –
fixed in malignancy
31. Fixity to skin
Consistency – hard in malignancy
Extent
Shape
Position
Lower border examination – for retrosternal
goitre
Berry’s sign – absence of carotid pulsations if
carotid sheath involved
Kocher’s test – press the lateral lobe – if leads to
stridor indicate tracheal pressing, infiltration
32. Lymph node examination
Level II,III,IV,V,VI
Papillary ca – common, early ln metastasis
Non tender, discrete, firm ln
Position, size, site, number, consistency,
tenderness
Measurements
Circumference of neck over swelling – to find
out the change in size of swelling
PERCUSSION – for retrosternal goitre..... Not
much role
33. AUSCULTATION
Guttman’s sign – thyroid bruit present –
systolic bruit over goitre, seen in primary
thyrotoxicosis
Laryngoscopy
Fixed vc- if RLN infiltrated.....
Ankle examination – oedema – seen in
secondary thyrotoxicosis
34. Thyroid Function Tests
T3, T4, TSH
T3, T4 -> Mostly bound to serum proteins, small
amount is unbound or free -> responsible for
metabolic activity
Free T3, T4
TSH – secreted from pituitary, depend on T3, T4
levels (negative feedback), also regulated by
thyrotropin releasing hormone (TRH) from
hypothalamus
Normal values (euthyroid)
Free T3 3.5-7-5 mmol/l, Free T4 10-30nmol/l,
TSH – 0.3-3.3 mU/l
35. Thyrotoxicosis T3,T4 increased, TSH
decreased
Hypothyroidism T3, T4 decreased, TSH
increased
T3 toxicity T3 increased, T4 normal, TSH
decreased
Developing hypothyroidism T3,T4 normal but
lower limits, TSH increased
Thyroid auto antibodies – high in
autoimmune disorders, formed against
thyroid peroxidase, thyroglobulin (anti
thyroglobulin)
36. FNAC/FNAB
Fine needle aspiration cytology/biopsy
Simple, quick, economical OPD procedure
21 G needle and 5ml syringe
Gold standard/ investigation of choice
Accuracy 92-95%
Results – malignant, benign, non neoplastic,
suspicious, insufficient
USG guided FNAC – more accurate
Complications – pain, haematoma, entry into
trachea, transient vc paralysis
37. USG Neck
To determine number, dimensions and
physical character of swelling
Measures size of gland
Detect small nodules 2-4 mm which cant be
palpated clinically
Differentiate cystic from solid swellings
Detect malignancy
Detect cervical lymphadenopathy
USG guided FNAC
38. X Ray Neck, Chest and thoracic inlet
Position and compression of trachea
Tracheal deviation, displacement
Retrosternal goitre
Calcifications – help to determine type of ca
– stippled polymorph calcifications (papillary
ca), dense polymorph (medullary ca)
39. CT/MRI/PET
Detect regional metastasis, cervical
lymphadenopathy
Detect local recurrence
Detect invasion of larynx, pharynx, trachea,
oesophagus and invasion of thyroid cartilage
Detect extent of disease and degree of
calcification
Detect retrosternal goitre
Detect pulmonary metastasis
40. Thyroid scan/ Scintigraphy/ Isotope scan
Technetium 99m, Thallium 201, Iodine 123,
Iodine 131
To rule out area of overactivity in thyroid
gland
To rule out malignancy, metastasis
To differentiate between cold (non
functional) and hot (functional) nodule of > 5
mm, 80% cold, cold 10-20% chance of
malignancy, hot 1% chance of malignancy
I 131 scan obtained at 24 hrs, Technetium
99m scan at half an hour................
41. Serum calcium
Normal – 8.5-10.5 mg/dl
Screening test for medullary ca
For post op thyroidectomy management
Carcino embryonic antigen (CEA) –
screening test for medullary carcinoma
Excision biopsy – lobectomy, excision of
isthmus
Bone scan – bone metastasis
IDL – vc paralysis
Barium swallow – obstruction in oesophagus
43. Goitre – ..... Any generalised enlargement of
thyroid gland irresepective of its pathology
NON TOXIC
Simple goitre
Physiological goitre (puberty, pregnancy,
lactation, menopause)
Diffuse parenchymal goitre
Colloid goitre
Solitary nodular goitre
Multinodular goitre
Retrosternal goitre
44. Endemic areas
Younger age gp
Etiology
Iodine def
Goitrogens
Anti thyroid drugs
Genetic
Pregnancy
Colloid goitre –whole gland enlarged, soft
and elastic, age 20-30 yrs
45. Solitary nodular goitre
Clinically palpable swelling when rest of the gland
not palpable
Commonest site – at junction of isthmus and one
lateral lobe
Middle aged females
Due to hyperplasia of certain regions of thyroid
C/F – dyspnoea, hoarseness of voice, secondary
thyrotoxicosis, dysphagia, stridor
Cyst, benign (adenoma), malignant
MNG
Age gp 20-40 yrs, F:M 6:1
Malignancy 8%
Treatment – partial thyroidectomy
46. Cold nodules – 20% malignancy
Cold nodules + semi solid/ solid – 50%
malignancy
Nodule
Filled with brown/green/black watery fluid
or jelly like material
Cholesterol crystals
Fibrous tissue
Cystic, can undergo calcification
47. Retrosternal goitre
Congenital/acquired (mainly)
Types
Substernal – behind the sternum
Intra thoracic – within thorax
Plunging – intra thoracic but forced into neck by
raised intra thoracic pressure (on coughing)
Dyspnoea on lying down on one side only
Engorged veins over upper part of chest
X Ray – soft tissue shadow in superior
mediatinum or calcification
Deviation/compression of trachea
I 131 scan
48. Developmental anomaly
1:10000
Females
Only thyroid tissue/additional thyroid tissue
C/F
Mass in base of tongue
If large can cause airway obstruction, difficulty
in swallowing
Diagnosis – USG, TFT
D/D – Base of tongue lesions like lymphoma, scc,
lingual tonsil, minor salivary gland tumour,
thyroglossal cyst
49. Treatment – surgical removal followed by
long term thyroid hormones
(suprahyoid/transpharyngeal)
Radioactive iodine to ablate the thyroid
58. NEONATAL HYPOTHYROIDISM/CRETINISM
1:5000
Manifests after several weeks of intra uterine life
Etiology
Maternal or foetal deficiency of iodine due to inadequate
iodine in mother’s diet
Anti thyroid drugs to mother
Radio active iodine to mother
Agenesis of thyroid in infant
C/F
Lethargy
Stunted growth
Mental retardation
Hearing loss
Myxoedema coma – severe hypothyroidism
59. CHRONIC LYMPHOCYTIC THYROIDITIS
MC – Women at menopause (50 yrs)
Etiology
Auto immune disease
Genetic
C/F
Enlarged thyroid, soft, rubbery, firm on palpation
Pain and tenderness
Hypothyroidism
Pressure symptoms on oesophagus
Coughing
Associated with other conditions like RA, myasthenia
60. Diagnosis
FNAC
T3, T4 decreased, TSH increased
High titre of antibodies – anti thyroglobulin,
anti thyro peroxidase, anti TSH receptor
Treatment
Thyroid supplements
61. BACTERIAL THYROIDITIS
Staphylococcus/streptococcus
Swelling, pain during swallowing, redness
over skin, fever
Antibiotics, anti inflammatory
VIRAL THYROIDITIS
Sub acute thyroiditis/ de quervain thyroiditis
Endemic goitre areas
Females
Middle age (40 yrs)
62. C/F
Pain
Low grade fever
Thyroid swelling
Sore throat
Diagnosis
ESR raised (>40)
Increased T3, T4
Low or normal TSH
Treatment – oral prednisolone 1mg/kg body
weight tapered later over 4 weeks.....
63. CLASSIFICATION
BENIGN – ADENOMAS
MALIGNANT
PRIMARY
ARISING FROM FOLLICULAR CELLS
WELL DIFF – PAPILLARY CA (60-70%), FOLLICULAR CA
(10-20%)
UNDIFF – ANAPLASTIC CA (5-10%)
ARISING FROM PARAFOLLICULAR CELLS – MEDULLARY
CA (5%)
ARISING FROM LYMPHOID CELLS – LYMPHOMA
SECONDARY
METASTASIS - DISTANT
DIRECT SPREAD FROM LARYNX, POST CRICOID REGION
64. Iodine deficiency – Follicular Ca due to dietary
deficiency
Ionizing radiation – Papillary Ca
Solitary thyroid nodule – 10-20%
Familial/genetic – Medullary Ca
Autoimmune disorders – Lymphoma
Poor prognostic factors
Age > 45 yrs
Male gender
LN, distant metastasis
Size of tumour > 4 cm
Poorly differentiated tumours
65. MC benign thyroid neoplasms
Types
Follicular
Microfollicular
Hurthle cell
C/F
Present as solitary nodule or dominant
nodule in MNG in middle aged females
Encapsulated, well demarcated tumour
Rarely toxic
Not a premalignant condition
66. Etiology
Exposure to ionizing radiation
Can even occur in adequate iodine intake
60-80%, MC
Younger age gp 3rd and 4th decade
Children
M:F 1:3
Well diff ca
C/F
Firm, non capsulated, hard, non tender slow
growing thyroid nodule/lump in neck for more
than one year involving both thyroid lobes
67. Types
Minimal/micro/occult ca - < 1.5 cm, common,
incidental finding on USG
Intra thyroid ca – within thyroid but > 1.5 cm
Extra thyroid ca – outside thyroid capsule
Spread
Locally to strap muscles, trachea, oesophagus,
RLN
LN – high incidence level III – VI 40-50%
Less incidence of distant metastasis (mainly
pulmonary)
Prognosis – 10 yr survival rate > 90% for
intrathyroid and 60% for extra thyroid
68. Pathology
“ orphan annie eyed “ large nuclei
Laminated calcified “ psammoma bodies” (40-
50%)
Treatment
Minimal invasive/ age < 45 yrs – lobectomy/
isthmusectomy with 1 cm margin
Age > 45 yrs – total thyroidectomy
Nodal metastasis – selective neck dissection
Post op radio iodine ablation of residual thyroid
tissue
Thyroxine supplements to suppress TSH
Post op RT if doubtful clearance or extensive LN
69. Etiology
Low iodine intake
Middle age 5th – 6th decade
M:F 1:3
10-20%
Well diff ca
C/F
New solitary thyroid nodule
Malignant changes in thyroid swelling of
many years duration
Capsular invasion
70. Types
Minimally invasive
Widely invasive with distant metastasis
mainly to bone and lungs
Diagnosis – lobectomy ( to diff from follicular
adenoma)
71. ONCOCYTIC CARCINOMA
Sub type of follicular ca
Age gp – older 6th decade
M:F 1:2
Mainly benign
If malignant – highly aggressive
More incidence of LN and distant metastasis
Reduced 10 yr survival rate
Dont take up radioactive iodine
Technetium scan for follow up
72. UNDIFFERENTIATED CA
Etiology
Long standing goitre
< 5%
M:F 2:3
Older age gp 60-80 yrs
h/o pre existing MNG
h/o previous treated well diff ca
C/F
Painful rapid growing, hard, irregular mass fixed
to surrounding structures associated with
referred otalgia, hoarseness of voice, cervical
lymphadenopathy, dysphagia and dyspnoea
73. Spread
Local spread to larynx, pharynx, oesophagus,
trachea and neck
High incidence of LN and distant metastasis
Poor prognosis – death within few months or 1 yr
Treatment
Palliative
Tracheostomy with division of isthmus if stridor
RT and CT – limited role only for regression of
tumour but recurrence common
74. Arise from calcitonin producing parafollicular
cells
5%
Located in upper and middle part of gland
Types
Familial/hereditary/multifocal
Less common 20-25%
Younger age gp
Females
Associated with MEN (multiple endocrine
neoplasia) syndrome
Diarrhoea – 30%, pain, dyspnoea, dysphagia and
hoarseness
75. MEN II A (sipple’s syndrome)
Autosomal dominant inheritance associated with
phaeochromocytoma, hyperparathyroidism and
hirschprung disease
MEN II B
Rare condition associated with
phaeochromocytoma, hyperparathyroidism,
marafanoid habitus and mucosal neuroma
involving tongue and lips
Sporadic
MC 75-80%
4th decade
Both sexes equally involved
76. Tumour markers
S Calcitonin
CEA
RET Protooncogene
Pathology
Solid, well circumscribed, non capsulated
Consists of eosinophil cells
Spread
LN metastasis – 50-75%, more in sporadic
Distant metastasis – lungs, liver, bones, adrenal
glands
Prognosis – 10 yr survival rate 80%
77. Treatment
Total thyroidectomy
Level VI LN clearance even in N0 neck
If LN metastasis – II – VI LN clearance
If inoperable – RT
Radio active iodine – not much role except
for recurrence.....
78. Etiology
Uncommon
In case of Hashimoto’s autoimmune thyroiditis
(80%)
Age gp 60-80 yrs
M:F 1:4
C/F
Rapidly enlarging non tender mass associated
with dysphagia, dyspnoea and hoarseness
More chances of extra thyroidal spread and
distant metastasis
Non Hodgkin B Cell Lymphoma
79. Treatment
Localised – surgery
RT – main treatment
CT + RT – advanced
Doxorubicin + Cisplatin for chemotherapy
80. 2-4%
Due to metastasis from
Kidney
Breasts
Lungs
Head and Neck
Malignant melanoma
81. I 131
For radio active ablation of residual thyroid
tissue after surgery
Complications
Radiation toxicity
Withdrawl of thyroxine for 6 weeks
Thyroxine supplements
T4
To suppress TSH post surgery
Complications
Cardiac arrythmias
Decrease bone density
82. External beam radiotherapy
Unresectable tumours
Recurrence
Lymphoma
Chemotherapy
Inoperable advanced tumours
If I 131 ablation not possible
lymphoma
83. Papillary carcinoma/medullary carcinoma
N0 – level VI clearance
Follicular carcinoma
N0 – no role
If neck nodes positive
Selective neck dissection or MRND – sparing
level I, IJV, SCM, and XI CN
Clearance of level II – VI LN
84. Indications
Carcinoma
Compressive symptoms on trachea, oesophagus, RLN
Cosmetic
Types
Lobectomy/hemithyroidectomy
Indication – benign tumour, intrathyroid ca
Complete resection of one thyroid lobe and isthmus
Sub total thyroidectomy
Indication – MNG
B/L resection of more than half of thyroid lobe on
each side (leaving 3 g on each side) and isthmus
85. Near total thyroidectomy
Indication - malignancy
Complete removal of one lobe, isthmus and more
than 90% of other lobe leaving only 1 g behind to
protect parathyroid and RLN
Total thyroidectomy
Indication – malignancy
Complete removal of both side lobe and isthmus
Isthmusectomy
Indication
Small tumour invoving only isthmus
Diagnostic biopsy
Complete removal of isthmus
86. Completion thyroidectomy
Indication – if HP report of lobectomy turns
out to be malignant with capsular/vascular
invasion
Conversion of lesser surgery into near total,
sub total or total thyroidectomy
87. Anaesthesia – GA with endotracheal intubation
Position – supine with extension of head and
neck by placing sandbag under shoulder and
head ring under head
Incision – horizontal 2 finger breadth above
clavicle from one ant border of SCM to other ant
border
Can be extended post sup to
Hockey stick incision – for U/L ND
Modified apron flap – for B/L ND
Sub platysmal flap elevation – till level of hyoid
bone above and suprasternal notch below
88. Division of strap muscles – midline vertical incision
dividing sternohyoid and sternothyroid muscles which
are then retracted or resected
At lower pole
Identification and ligation of middle thyroid vein
Identification of parathyroid – if uninvolved preserved
Identification of RLN in tracheo oesophageal groove
Identification of ITA – ligated
Identification of berry ligament – divided
At upper pole
Identification of SLN
Identification and ligation of STA and superior
thyroid vein
89. Isthmus
Separation of isthmus from trachea
Division of isthmus
Cut surface of isthmus ligated
Similar procedure on other side
Required dissection of LN
Specimen delivered
Irrigation of wound with saline
Closure of wound by approximation ofstrap
muscles and platysma with sutures
91. Hypocalcemia
Due to removal of parathyroid glands......
Seen 1-4 days post operatively
Serum calcium < 8 mg/dl
C/F –
Numbness and tingling of lips, hands and feet
Treatment
Calcium and vitamin D supplements orally or
IV