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THYROID GLAND 
Al-Qadisiya Collage Of Medicine 
6th Stage
THYROID GLAND 
Index :- 
1- Historical Background 
2- Embryology 
3- Anatomy 
4- physiology 
5- Evaluation of Patient with thyroid diseases 
6- THYROIDITIS 
-------------------------------------------------------------- 
Hypo-Hyper-thyroidism &Thyroid neoplasm 
Will be discussed in the next week
Historical Background 
 The term thyroid gland 
(Greek thyreoeides, 
shield-shaped) 
 however, attributed to 
Thomas Wharton in his 
Adenographia at 1656 
In 1776, the thyroid was classified as a ductless gland 
by Albrecht von Haller and was thought to have numerous 
functions 
ranging from lubrication of the larynx to acting as a reservoir 
for blood to provide continuous flow to the brain, and to 
beautifying women’s necks.
Embryology 
The thyroid gland arises as 
an out pouching of the 
primitive 
foregut around the third 
week of gestation. It 
originates at the 
base of the tongue at the 
foramen cecum. 
The developing thyroid lobes arising in the fourth pharyngeal 
pouch , while the isthmus arise from Third pharyngeal pouch
Embryology 
 With further development, the thyroid 
descends into the neck anterior to the hyoid 
bone and laryngeal cartilages. 
 Certain congenital anomalies such as ectopic 
thyroid tissue or thyroglossal duct cysts are 
directly related to this embryologic descent. 
 The parafollicular cells, or C cells, are derived 
from the neural crest, migrate to the thyroid, 
and produce calcitonin.
Embryology 
The descent of theThyroid , 
showing possible sites of 
ectopic thyroid tissue or 
thyroglossal 
cysts, and also the course of a 
thyroglossal fistula. 
The arrow shows 
the further descent of the 
thyroid that 
may take place retrosternally 
into the 
superior mediastinum.
Thyroid Anatomy 
The normal thyroid gland weighs 
20–25 g. The functioning unit is 
the lobule supplied by a single 
arteriole and consisting of 24–40 
follicles lined with cuboidal 
epithelium 
Formed of 2 lobes (Rt & Lt), that are connected by band of 
tissue called “isthmus”.
The blood supply to the thyroid arises from two pairs of main 
arteries: the superior thyroid artery (branch of the 
external carotid) and the inferior thyroid artery (branch of the 
thyro-cervical trunk). A thyroidea ima artery arises directly from 
the aorta or innominate in 1% to 4% of individuals to enter the 
isthmus 
Venous return :- 
The superior thyroid 
veins & The middle vein . 
The superior and middle 
veins drain directly into 
the internal jugular veins. 
The inferior veins often 
form a plexus, which 
drains into the 
brachiocephalic veins
The recurrent laryngeal nerve (RLN) 
usually courses 1 cm anterior or 
posterior to the inferior thyroid artery. 
Careful dissection around this artery is 
necessary to avoid injury to the RLN. 
Lymphatic Drainage 
1- direct to deep cervical L.N 
2- sub capsular plexuses :- 
A- juxtathyroid node ( Delphian ) 
centrally located 
B- pretracheal L.N 
C- L.N along the veins 
3- The drain to deep cervical and 
mediastainal L.N
Thyroid physiology 
The thyroid gland is concerned with the synthesis of the iodine 
- containing hormones thyroxine (tetra - iodothyronine, T4) 
and tri – iodothyronine (T3) , which control the metabolic rate 
of the body; 
T3 is the active hormone, and T4 is converted to 
T3 in the periphery. 
The thyroid gland also secretes calcitonin from the 
parafollicular C cells, which reduces the level of serum calcium 
and is therefore antagonistic to parathormone.
Physiological control of secretion 
The immediate control of synthesis and 
liberation of T3 and T4 is by 
thyroid - stimulating hormone 
(TSH) produced by the anterior pituitary. 
TSH is secreted in response to the level of 
thyroid hormones in the blood by 
a negative feedback mechanism. 
The secretion of TSH is also under 
The influence of the 
hypothalamic -thyrotrophin - 
releasing hormone ( TRH )
Evaluation of thyroid disorders 
1- History ( discuss in each topic ) 
2- examination 
3- Biochemical tests 
4- Radiological tests 
5- FNAC 
6- Core Biopsy 
7- laryngoscope
Biochemical Evaluation of thyroid disorders 
1- Measurement of TSH (0.3 to 5 mIU/L) is the most useful 
biochemical test in the diagnosis of thyroid illness. In most 
patients without pituitary disease, increased TSH signifies 
hypothyroidism, suppressed TSH suggests hyperthyroidism, 
and normal TSH reflects a euthyroid state 
2- Assessment of free T 4 (4.5 to 11.2 μg/dL) concentration 
supports identified abnormalities in TSH and provides an index 
of severity of illness .
Biochemical Evaluation of thyroid disorders 
3- Measurement of T 3 (80 to 200 ng/dL) is unreliable as a test 
for hypothyroidism. This test is useful in the occasional patient 
with suspected hyperthyroidism, suppressed TSH, and normal 
T4 (T3 thyrotoxicosis). 
4- Anti-thyroid antibodies are found in the serum of patients 
with autoimmune thyroiditis (Hashimoto thyroiditis). 
5- Anti-TSH receptor antibodies, which stimulate the TSH 
receptor, are detectable in more than 90% of patients with 
autoimmune hyperthyroidism (Graves' disease).
Biochemical Evaluation of thyroid disorders
Radiological Evaluation of thyroid disorders 
1- Chest X-ray 2- Ultrasound 3- CT & MRI 4- Isotope scan 
5- PET scan 
Chest and thoracic inlet radiograph 
Simple radiographs of the chest and thoracic inlet will rapidly 
and economically confirm the presence of significant 
retrosternal goitre and clinically important degrees of tracheal 
deviation and compression. Pulmonary metastases may also 
be detected
Thyroid Gland - part 1
Radiological Evaluation of thyroid disorders 
1- Chest X-ray 2- Ultrasound 3- CT & MRI 4- Isotope scan 
5- PET scan 
Ultrasound scanning 
High-frequency ultrasound scanning gives good anatomical 
images of the thyroid and surrounding structures but, 
unfortunately , reveals more thyroid swellings than are 
clinically relevant. After a period of years the ultrasound is 
enjoying a revival as a means of reducing the number of 
unsatisfactory aspiration cytology samples; it permits more 
targeted sampling, allowing the identification of parathyroid 
adenomas and nodes involved in thyroid cancer.
Transverse scan of normal thyroid. 
R, right lobe; L, left lobe; T, trachea
Radiological Evaluation of thyroid disorders 
1- Chest X-ray 2- Ultrasound 3- CT & MRI 4- Isotope scan 
5- PET scan 
Computerised tomography & magnetic resonance imaging 
These are not indicated for thyroid swellings and are reserved 
for the assessment of known malignancy and to assess the 
extent of retro-sternal and, occasionally, recurrent goitres. The 
appearance of a retro-sternal goitre on CT can give a 
misleading impression of the operative difficulty in delivery 
through a neck incision
Computerised tomography scan of the chest showing a retrosternal 
goitre with tracheal displacement (arrowed)
Sagital CT section showing goitre filling posterior 
mediastinum.
Radiological Evaluation of thyroid disorders 
1- Chest X-ray 2- Ultrasound 3- CT & MRI 4- Isotope scan 
5- PET scan 
Isotope scanning 
The uptake by the thyroid of a low dose of either radiolabelled 
iodine (123I) or the cheaper technetium (99mTc) will demonstrate 
the distribution of activity in the whole gland. Routine isotope 
scanning is unnecessary and inappropriate for distinguishing 
benign from malignant lesions because the majority (80%) of ‘cold’ 
swellings are benign and some (5%) functioning or ‘warm’ swellings 
will be malignant. Its principal value is in the toxic patient with a 
nodule or nodularity of the thyroid. Localisation of overactivity in 
the gland will differentiate between a toxic nodule with suppression 
of the remainder of the gland and toxic multinodular goitre
Technetium thyroid scan showing a ‘cold’ nodule that 
does not take up isotope expanding the left thyroid lobe
Technetium thyroid scan showing appearance of a 1-cm
Radiological Evaluation of thyroid disorders 
1- Chest X-ray 2- Ultrasound 3- CT & MRI 4- Isotope scan 
5- PET scan 
PET scan may be useful, particularly in localising disease which 
does not take up radioiodine.
Fine-needle aspiration cytology (FNAC) 
is the investigation of choice for 
discrete thyroid swellings. FNAC has 
excellent patient compliance, is simple 
and quick to perform in the out-patient 
department and is readily 
repeated. FNAC results should be 
reported using standard terminology. 
There is a trend to use ultrasound to 
guide the needle to achieve more 
accurate sampling and reduce the rate 
of unsatisfactory aspirates
Fine-needle aspiration cytology (FNAC) 
Classification of fine-needle aspiration cytology 
reports 
Thy1 = Non-diagnostic 
Thy2 = Non-neoplastic 
Thy3 = Follicular 
Thy4 = Suspicious of cancer 
Thy5 = Malignant
Core biopsy 
Core biopsy gives a strip of tissue for histological rather than 
cytological assessment. It has a high diagnostic accuracy but 
requires local anaesthesia, and may be associated with 
complications 
such as :- pain, bleeding, tracheal and recurrent laryngeal 
nerve damage.
Laryngoscope 
Flexible laryngosopy is widely used preoperatively to 
determine the mobility of the vocal cords, although usually for 
medicolegal rather than clinical reasons. 
Nevertheless, the presence of a unilateral cord palsy coexisting 
with a swelling suggestive of malignancy is usually diagnostic.
Laryngoscope
THYROIDITIS 
Thyroiditis is a group of autoimmune and 
inflammatory disorders characterized by 
infiltration of the thyroid with inflammatory cells and 
subsequent fibrosis of the gland..
THYROIDITIS 
Autoimmune thyroiditis 
is a chronic autoimmune disorder characterized by destructive 
lymphocytic infiltration of the thyroid. 
The disease is 15 times more common in women, and more 
than 90% of patients have circulating antibodies directed 
against 
thyroid microsomes and thyroglobulin.
THYROIDITIS 
Autoimmune thyroiditis 
Although patients initially are euthyroid, 
hyperthyroidism and hypothyroidism may occur later. 
Thyroid hormone is given to hypothyroid patients both as 
replacement therapy and to suppress TSH. 
Thyroidectomy is indicated for :- 
1- compressive symptoms, 
2- a dominant nodule 
3- suspicious for malignancy, 
4- or cosmetic preference.
THYROIDITIS 
Acute suppurative thyroiditis 
is rare and caused by pyogenic infection with 
Streptococcus or Staphylococcus species. Treatment 
consists of appropriate antibiotic therapy and surgical 
drainage of abscesses. Long-term effects on thyroid 
function are uncommon.
THYROIDITIS 
Subacute (de Quervain) thyroiditis 
is a rare condition that occurs in young women, 
often after a viral upper respiratory tract infection. 
Symptoms include fatigue, weakness, and painful 
thyroid enlargement radiating to 
the patient's jaw or ear
THYROIDITIS 
Subacute (de Quervain) thyroiditis 
Fine needle aspiration (FNA) can be diagnostic with 
the identification of giant cells. 
Treatment with non steroidal anti-inflammatory drugs 
or steroids can alleviate symptoms. 
The condition almost always remits spontaneously 
within a few weeks.
THYROIDITIS 
Riedel's thyroiditis 
is a rare, progressive inflammatory condition of the 
entire thyroid gland, strap muscles, and other neck 
structures. Its cause is unknown, and it can be 
associated with other fibrotic processes, including 
retroperitoneal fibrosis, sclerosing cholangitis, and 
fibrosing mediastinitis
THYROIDITIS 
Riedel's thyroiditis 
Riedel's thyroiditis may require surgical excision to 
exclude malignancy or relieve compressive symptoms 
on the trachea or esophagus.
Thyroid Gland - part 1

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Thyroid Gland - part 1

  • 1. THYROID GLAND Al-Qadisiya Collage Of Medicine 6th Stage
  • 2. THYROID GLAND Index :- 1- Historical Background 2- Embryology 3- Anatomy 4- physiology 5- Evaluation of Patient with thyroid diseases 6- THYROIDITIS -------------------------------------------------------------- Hypo-Hyper-thyroidism &Thyroid neoplasm Will be discussed in the next week
  • 3. Historical Background  The term thyroid gland (Greek thyreoeides, shield-shaped)  however, attributed to Thomas Wharton in his Adenographia at 1656 In 1776, the thyroid was classified as a ductless gland by Albrecht von Haller and was thought to have numerous functions ranging from lubrication of the larynx to acting as a reservoir for blood to provide continuous flow to the brain, and to beautifying women’s necks.
  • 4. Embryology The thyroid gland arises as an out pouching of the primitive foregut around the third week of gestation. It originates at the base of the tongue at the foramen cecum. The developing thyroid lobes arising in the fourth pharyngeal pouch , while the isthmus arise from Third pharyngeal pouch
  • 5. Embryology  With further development, the thyroid descends into the neck anterior to the hyoid bone and laryngeal cartilages.  Certain congenital anomalies such as ectopic thyroid tissue or thyroglossal duct cysts are directly related to this embryologic descent.  The parafollicular cells, or C cells, are derived from the neural crest, migrate to the thyroid, and produce calcitonin.
  • 6. Embryology The descent of theThyroid , showing possible sites of ectopic thyroid tissue or thyroglossal cysts, and also the course of a thyroglossal fistula. The arrow shows the further descent of the thyroid that may take place retrosternally into the superior mediastinum.
  • 7. Thyroid Anatomy The normal thyroid gland weighs 20–25 g. The functioning unit is the lobule supplied by a single arteriole and consisting of 24–40 follicles lined with cuboidal epithelium Formed of 2 lobes (Rt & Lt), that are connected by band of tissue called “isthmus”.
  • 8. The blood supply to the thyroid arises from two pairs of main arteries: the superior thyroid artery (branch of the external carotid) and the inferior thyroid artery (branch of the thyro-cervical trunk). A thyroidea ima artery arises directly from the aorta or innominate in 1% to 4% of individuals to enter the isthmus Venous return :- The superior thyroid veins & The middle vein . The superior and middle veins drain directly into the internal jugular veins. The inferior veins often form a plexus, which drains into the brachiocephalic veins
  • 9. The recurrent laryngeal nerve (RLN) usually courses 1 cm anterior or posterior to the inferior thyroid artery. Careful dissection around this artery is necessary to avoid injury to the RLN. Lymphatic Drainage 1- direct to deep cervical L.N 2- sub capsular plexuses :- A- juxtathyroid node ( Delphian ) centrally located B- pretracheal L.N C- L.N along the veins 3- The drain to deep cervical and mediastainal L.N
  • 10. Thyroid physiology The thyroid gland is concerned with the synthesis of the iodine - containing hormones thyroxine (tetra - iodothyronine, T4) and tri – iodothyronine (T3) , which control the metabolic rate of the body; T3 is the active hormone, and T4 is converted to T3 in the periphery. The thyroid gland also secretes calcitonin from the parafollicular C cells, which reduces the level of serum calcium and is therefore antagonistic to parathormone.
  • 11. Physiological control of secretion The immediate control of synthesis and liberation of T3 and T4 is by thyroid - stimulating hormone (TSH) produced by the anterior pituitary. TSH is secreted in response to the level of thyroid hormones in the blood by a negative feedback mechanism. The secretion of TSH is also under The influence of the hypothalamic -thyrotrophin - releasing hormone ( TRH )
  • 12. Evaluation of thyroid disorders 1- History ( discuss in each topic ) 2- examination 3- Biochemical tests 4- Radiological tests 5- FNAC 6- Core Biopsy 7- laryngoscope
  • 13. Biochemical Evaluation of thyroid disorders 1- Measurement of TSH (0.3 to 5 mIU/L) is the most useful biochemical test in the diagnosis of thyroid illness. In most patients without pituitary disease, increased TSH signifies hypothyroidism, suppressed TSH suggests hyperthyroidism, and normal TSH reflects a euthyroid state 2- Assessment of free T 4 (4.5 to 11.2 μg/dL) concentration supports identified abnormalities in TSH and provides an index of severity of illness .
  • 14. Biochemical Evaluation of thyroid disorders 3- Measurement of T 3 (80 to 200 ng/dL) is unreliable as a test for hypothyroidism. This test is useful in the occasional patient with suspected hyperthyroidism, suppressed TSH, and normal T4 (T3 thyrotoxicosis). 4- Anti-thyroid antibodies are found in the serum of patients with autoimmune thyroiditis (Hashimoto thyroiditis). 5- Anti-TSH receptor antibodies, which stimulate the TSH receptor, are detectable in more than 90% of patients with autoimmune hyperthyroidism (Graves' disease).
  • 15. Biochemical Evaluation of thyroid disorders
  • 16. Radiological Evaluation of thyroid disorders 1- Chest X-ray 2- Ultrasound 3- CT & MRI 4- Isotope scan 5- PET scan Chest and thoracic inlet radiograph Simple radiographs of the chest and thoracic inlet will rapidly and economically confirm the presence of significant retrosternal goitre and clinically important degrees of tracheal deviation and compression. Pulmonary metastases may also be detected
  • 18. Radiological Evaluation of thyroid disorders 1- Chest X-ray 2- Ultrasound 3- CT & MRI 4- Isotope scan 5- PET scan Ultrasound scanning High-frequency ultrasound scanning gives good anatomical images of the thyroid and surrounding structures but, unfortunately , reveals more thyroid swellings than are clinically relevant. After a period of years the ultrasound is enjoying a revival as a means of reducing the number of unsatisfactory aspiration cytology samples; it permits more targeted sampling, allowing the identification of parathyroid adenomas and nodes involved in thyroid cancer.
  • 19. Transverse scan of normal thyroid. R, right lobe; L, left lobe; T, trachea
  • 20. Radiological Evaluation of thyroid disorders 1- Chest X-ray 2- Ultrasound 3- CT & MRI 4- Isotope scan 5- PET scan Computerised tomography & magnetic resonance imaging These are not indicated for thyroid swellings and are reserved for the assessment of known malignancy and to assess the extent of retro-sternal and, occasionally, recurrent goitres. The appearance of a retro-sternal goitre on CT can give a misleading impression of the operative difficulty in delivery through a neck incision
  • 21. Computerised tomography scan of the chest showing a retrosternal goitre with tracheal displacement (arrowed)
  • 22. Sagital CT section showing goitre filling posterior mediastinum.
  • 23. Radiological Evaluation of thyroid disorders 1- Chest X-ray 2- Ultrasound 3- CT & MRI 4- Isotope scan 5- PET scan Isotope scanning The uptake by the thyroid of a low dose of either radiolabelled iodine (123I) or the cheaper technetium (99mTc) will demonstrate the distribution of activity in the whole gland. Routine isotope scanning is unnecessary and inappropriate for distinguishing benign from malignant lesions because the majority (80%) of ‘cold’ swellings are benign and some (5%) functioning or ‘warm’ swellings will be malignant. Its principal value is in the toxic patient with a nodule or nodularity of the thyroid. Localisation of overactivity in the gland will differentiate between a toxic nodule with suppression of the remainder of the gland and toxic multinodular goitre
  • 24. Technetium thyroid scan showing a ‘cold’ nodule that does not take up isotope expanding the left thyroid lobe
  • 25. Technetium thyroid scan showing appearance of a 1-cm
  • 26. Radiological Evaluation of thyroid disorders 1- Chest X-ray 2- Ultrasound 3- CT & MRI 4- Isotope scan 5- PET scan PET scan may be useful, particularly in localising disease which does not take up radioiodine.
  • 27. Fine-needle aspiration cytology (FNAC) is the investigation of choice for discrete thyroid swellings. FNAC has excellent patient compliance, is simple and quick to perform in the out-patient department and is readily repeated. FNAC results should be reported using standard terminology. There is a trend to use ultrasound to guide the needle to achieve more accurate sampling and reduce the rate of unsatisfactory aspirates
  • 28. Fine-needle aspiration cytology (FNAC) Classification of fine-needle aspiration cytology reports Thy1 = Non-diagnostic Thy2 = Non-neoplastic Thy3 = Follicular Thy4 = Suspicious of cancer Thy5 = Malignant
  • 29. Core biopsy Core biopsy gives a strip of tissue for histological rather than cytological assessment. It has a high diagnostic accuracy but requires local anaesthesia, and may be associated with complications such as :- pain, bleeding, tracheal and recurrent laryngeal nerve damage.
  • 30. Laryngoscope Flexible laryngosopy is widely used preoperatively to determine the mobility of the vocal cords, although usually for medicolegal rather than clinical reasons. Nevertheless, the presence of a unilateral cord palsy coexisting with a swelling suggestive of malignancy is usually diagnostic.
  • 32. THYROIDITIS Thyroiditis is a group of autoimmune and inflammatory disorders characterized by infiltration of the thyroid with inflammatory cells and subsequent fibrosis of the gland..
  • 33. THYROIDITIS Autoimmune thyroiditis is a chronic autoimmune disorder characterized by destructive lymphocytic infiltration of the thyroid. The disease is 15 times more common in women, and more than 90% of patients have circulating antibodies directed against thyroid microsomes and thyroglobulin.
  • 34. THYROIDITIS Autoimmune thyroiditis Although patients initially are euthyroid, hyperthyroidism and hypothyroidism may occur later. Thyroid hormone is given to hypothyroid patients both as replacement therapy and to suppress TSH. Thyroidectomy is indicated for :- 1- compressive symptoms, 2- a dominant nodule 3- suspicious for malignancy, 4- or cosmetic preference.
  • 35. THYROIDITIS Acute suppurative thyroiditis is rare and caused by pyogenic infection with Streptococcus or Staphylococcus species. Treatment consists of appropriate antibiotic therapy and surgical drainage of abscesses. Long-term effects on thyroid function are uncommon.
  • 36. THYROIDITIS Subacute (de Quervain) thyroiditis is a rare condition that occurs in young women, often after a viral upper respiratory tract infection. Symptoms include fatigue, weakness, and painful thyroid enlargement radiating to the patient's jaw or ear
  • 37. THYROIDITIS Subacute (de Quervain) thyroiditis Fine needle aspiration (FNA) can be diagnostic with the identification of giant cells. Treatment with non steroidal anti-inflammatory drugs or steroids can alleviate symptoms. The condition almost always remits spontaneously within a few weeks.
  • 38. THYROIDITIS Riedel's thyroiditis is a rare, progressive inflammatory condition of the entire thyroid gland, strap muscles, and other neck structures. Its cause is unknown, and it can be associated with other fibrotic processes, including retroperitoneal fibrosis, sclerosing cholangitis, and fibrosing mediastinitis
  • 39. THYROIDITIS Riedel's thyroiditis Riedel's thyroiditis may require surgical excision to exclude malignancy or relieve compressive symptoms on the trachea or esophagus.