Endocrine surgery

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20 Endocrine surgery

Thyroid gland

Surgical anatomy and development

The thyroid gland develops from the thyroglossal duct, which grows downwards from the pharynx through the developing hyoid bone. On the front of the trachea, the duct bifurcates and fuses with elements from the fourth branchial arch, from which the parafollicular (C) cells are derived.

The duct is normally obliterated in early fetal life but can persist in part to produce a thyroglossal cyst. The upper end of the duct is identified in adults as the foramen caecum at the junction of the anterior two-thirds and the posterior third of the tongue. Arrest of descent of the duct may result in an ectopic thyroid (e.g. lingual thyroid).

There are two pairs of parathyroid glands. The upper glands arise from the fourth branchial arch and are usually found at the back of the thyroid above the inferior thyroid artery. The lower glands arise from the third arch (in association with the thymus) and are less constant in position. They are usually found posterior to the lower pole of the thyroid lobes but can lie within the gland, some distance below it, in the upper mediastinum or within the thymus.

The lobes of the thyroid lie on the front and sides of the trachea and larynx at the level of the 5–7th cervical vertebrae (Fig. 20.1). They are connected by a narrow isthmus, which overlies the second and third tracheal rings. The thyroid normally weighs 15–30 g and is invested by the pre-tracheal fascia, which binds it to the larynx, cricoid cartilage and trachea (Fig. 20.2). The strap muscles (sternohyoid and sternothyroid) lie in front of the pretracheal fascia and must be separated to gain access to the gland. It is difficult to feel the normal thyroid gland except at puberty and during pregnancy, when physiological enlargement occurs.

The superior thyroid artery runs down to the upper pole of the gland as a branch of the external carotid artery, whereas the inferior thyroid artery runs across to the lower pole from the thyrocervical trunk (a branch of the subclavian artery). As it nears the gland, the inferior thyroid artery usually passes in front of the recurrent laryngeal nerve, but may branch around it. Blood drains through superior, middle and inferior thyroid veins into the internal jugular and innominate veins. Lymphatics pass laterally to the deep cervical chain and downwards to pretracheal and mediastinal nodes. The recurrent laryngeal nerve, a branch of the vagus, passes upwards in the groove between the oesophagus and trachea to enter the larynx and supply all of its intrinsic muscles except the cricothyroid. The superior laryngeal nerve (also a branch of the vagus) runs with the superior thyroid vessels and supplies the cricothyroid muscles (external branch), which tense the vocal cords. The recurrent nerve also supplies sensation to the larynx below the vocal cords. The internal branch of the superior laryngeal nerve provides sensation above the cords. Normal sensory and motor function within the larynx is necessary for speech and coughing. Both nerves are at risk of damage during thyroid surgery and the consequences, if permanent, can be disabling.

Enlargement of the thyroid gland (goitre)

Clinical features

Goitre is a visible or palpable enlargement of the thyroid (Fig. 20.4). The swelling appears in the lower part of the neck and retains the shape of the normal gland (thyreos – Greek for shield). The swelling characteristically moves upwards on swallowing because of the gland’s attachment to the trachea. Patients may have a dry mouth, and when asking them to swallow, water should be provided.

Non-toxic nodular goitre

Investigations

In the case of retrosternal goitre, plain films of the thoracic inlet may reveal tracheal deviation (Fig. 20.5A) and CT may show tracheal compression (Fig. 20.5B) The presence of stridor indicates compromise of the tracheal lumen. T3, T4 and TSH are usually normal and that being the case isotope scans are not indicated.

Thyroiditis

Solitary thyroid nodules

Slow-growing and painless clinically ‘solitary’ nodules are common, although 50% of them are really part of a multinodular goitre. Of the true solitary nodules, half are benign adenomas and the rest are cysts or differentiated cancers. The pivotal diagnostic test is fine-needle aspiration cytology, complemented by ultrasonography, isotope scans and thyroid function tests (Fig. 20.6). Cysts can be aspirated and, provided that they do not refill and that the cytology is negative for neoplastic cells, they need not be removed. Very rarely, a cyst contains a carcinoma (often papillary) within its wall, and blood-stained aspirate or a residual swelling after aspiration should raise this possibility. A cytopathologist cannot distinguish between a follicular adenoma and follicular carcinoma; this can only be achieved on definitive histopathology by looking for capsular or vascular invasion. Diagnostic surgery is needed if aspiration reveals a follicular neoplasm. Intraoperative frozen section does not always provide a definitive diagnosis, but the demonstration of carcinoma by whatever means indicates that more extensive surgery may be needed (e.g. complete total thyroidectomy).

Hyperthyroidism

Thyrotoxicosis results from the overproduction of T3 and T4 and, because of the feedback mechanism, serum TSH levels are reduced or undetectable. The three conditions that may produce thyrotoxicosis are primary thyrotoxicosis (Graves’ disease), toxic multinodular goitre and toxic adenoma.

Primary thyrotoxicosis (Graves’ disease)

Clinical features

The patient is usually a young female (male:female ratio 1:8) and the condition can be familial. The thyroid is usually moderately and diffusely enlarged and soft, and because of its vascularity a bruit may be audible. High circulating levels of T3 and T4 increase the basal metabolic rate and potentiate the actions of the sympathetic nervous system.

Other features

Exophthalmos is usual but not invariable (Fig. 20.7). Ophthalmoplegia, pretibial myxoedema, proximal muscle myopathy and finger clubbing are sometimes present. Menstrual irregularity and infertility can occur.

image

Fig. 20.7 Thyroid-associated ophthalmopathy.

(Courtesy of Prof Michael Sheppard, University of Birmingham Medical School.)

Management

Malignant tumours of the thyroid

Thyroid cancer accounts for less than 1% of all forms of malignancy. As with all thyroid disease, females are more often affected (male:female ratio 1:3). The two main types of thyroid carcinoma are papillary (50%) and follicular (30%), with the remainder comprising medullary carcinoma, anaplastic carcinoma and lymphoma (EBM 20.1). The incidence of thyroid cancer is increased by exposure to ionizing radiation: for example, following the Chernobyl disaster.

20.1 Relevant websites and publications for the management of thyroid cancer are:

www.aace.com/pub/guidelines/index.php American Association of Endocrine Surgeons, thyroid_carcinoma guidelines.

www.baets.org.uk/Pages/guidelines/.php British Association of Endocrine and Thyroid Surgeons.

www.british-thyroid-association.org National thyroid cancer guidelines group of the British Thyroid Association.

Northern Cancer Network. Guidelines for management of thyroid cancer. Clinical Oncology 2000; 12:373–391.

Thyroidectomy

Technique

The gland is exposed through a transverse skin-crease incision placed 2–3 cm above the sternal notch. The deep cervical fascia is divided longitudinally in the midline and the strap muscles are separated. Each lobe is mobilized by dividing the vessels supplying the superior pole, the middle and inferior thyroid veins, and the inferior thyroid artery. It is quick, easy and safe to do this using for example the harmonic scalpel in place of liagatures or clips. The recurrent laryngeal nerves should be identified, so that they can be protected from injury. Generally nothing less than a total lobectomy should be performed, to avoid the need for reoperation on that side. Care is taken to preserve the parathyroid glands. Haemostasis must be meticulous and drains are rarely necessary. The layers of the neck are reconstituted with continuous absorbable sutures and the skin with a subcuticular suture. Minimally invasive thyroidectomy is being explored in the minority of very small goiters.