Theodor Kocher （ 1841~1917 ）

2. Theodor Kocher（1841~1917）

3. Embryology Langue Conduit auditif exterme Tympan Amygdal thyeo-glosse tube Parathyroide III Parathyroide IV Corps ultimo-branchial Thymus Lateral thyroid Thyroidien lobe Esophage

4. Thyroid anatomy

5. Superficial veins and cutaneous nerves of neck

6. Recurrent Laryngeal Nerve

7. Recurrent laryngeal nerve • On either side of the trachea • Lateral to the ligament of Berry • Entering the larynx • Right side: separating from the vagus when crossing the subclavian artery • Left side: separating from the vagus when traversing over the arch of the aorta

8. Recurrent Nerve Anomalous variations in the course of the right recurrent laryngeal nerve. A, A nonrecurrent laryngeal nerve arises from the vagus. B, The normal course of the recurrent laryngeal nerve arises from the vagus after it passes beneath the subclavian artery. C, The unusual nonrecurrent nerve and recurrent laryngeal nerve join to form a common distal nerve.

9. Superior Laryngeal Nerve • separated from the vagus nerve • two branches: The larger internal branch -sensory function and it innervates the larynx. The smaller external branch -the cricothyroid muscle

10. Blood supply • Four main arteries, two superior and two inferior : The superior thyroid artery The inferior thyroid artery • Three pairs of venous systems drain the thyroid.

11. Blood supply

12. Parathyroid Glands superior thyroid artery Superior Laryngeal Nerve external branch superior parathyroid gland Common carotid Internal jugular inferior thyroid artery inferior parathyroid gland Recurrent nerve

13. Benign Thyroid Disease • Endemic Goiter • Thyroiditis • Hyperthyroidism

14. Endemic Goiter • Etiology 1/3 of the world’s population, specifically in underdeveloped countries. • Cause Iodine deficiency

15. Endemic Goiter • diffuse goiter • nodular goiter

16. Thyroiditis • Acute Suppurative Thyroiditis • Subacute Thyroiditis De Quervain’ s thyroiditis) • Chronic thyroiditis Hashimoto’s thyroiditis Riedel’s thyroiditis (struma)

17. Hashimoto’s thyroiditis • A cause of hypothyroidism in adult • Immune complex and complement • An exacerbation of immune response. • An infiltration of lymphocytes • TSH-blocking antibodies. • A hypothyroid clinical state

18. Hyperthyroidism • Graves’ disease • toxic nodular goiter • toxic thyroid adenoma

19. Grave’s disease • Most hyperthyroid states are caused by Graves’ disease (diffuse toxic goiter).

20. Clinical Presentation of Hyperthyroidism • Physical examination • Increased hyper metabolic state • Cardiovascular stress • Gastrointestinal sign • Psychiatric signs • Genital disorders • Hematopoietical modification • Extrathyroid Presentation

21. Extrathyroid Presentation • vitiligo • pretibial myxoedema • digital hippocratisme • ophtalmopathy

22. Biology • T3L↑, T4L↑, TSH↓ • Anti-thyroglobuline antibody ↑ • Anti-microsomal antibody ↑ • Anti-TSH-recepter immunoglobuline

23. Diagnosis • An extensive history • Physical examination • Signs and symptoms of thyrotoxicosis • Thyroid function tests

24. Traitement • Radioiodine ablation • Surgery • Antithyroid medication

25. Toxic nodular goiter-toxic adenoma (Plummer’s disease ) • Autonomous function. • Independent of TSH control. • Symptoms : mild, peripheral • Thyroid hormone ↑, TSH ↓ Antithyroid antibody ↓

26. Diagnosis confirmed after: clinical suspicion 131 I radionuclide scan • Treatment lobectomy or near-total thyroidectomy antithyroid medication radioiodine therapy is not effective

27. Nontoxic goiter • Multinodular Goiter • Substernal Goiter

28. The work-up of a solitary thyroid nodule FNA, fine-needle aspiration; Rx, therapy.

29. Preoperative preparation • ORL exam and general exam • Antithyroid medication • The lugos • The beta-blockage

30. Operation Complications • Bleeding • Recurrent laryngeal nerve injury • Superior laryngeal nerve injury • Hypoparathyroidisme • Thyrotoxic storm • Infection • Hypothyroidism

31. Thyroid malignancie • Less than 1% of all malignancies in the U.S. • 40/1,000,000 occur per year. • 6/1,000,000 die per year • Thyroid oncogenesis

32. Histo-pathology • Papillary • Follicular • Hürthle cell carcinomas • Medullary thyroid cancer (MCT) • Anaplastic carcinoma

33. Thyroid nodules • Ultrasound • Scintigraphy • CT • L’MRI • FNA

34. Scintigraphy

35. Cold nodule

36. Hot nodule

37. Papillary Carcinoma • Epidemic the most common of the thyroid neoplasms and usually associated with an excellent prognosis

39. Clinical Presentation • Solitary painless masses • Dysphagia • Cervical tenderness, • Painful neck mass, • Superior vena cava syndrome (extremely rare)

40. Treatment • The main treatment : surgical ablation.

41. Follicular Carcinoma • Second category of well-differentiated thyroid cancers • Follicular, and mixed papillaryfollicular cancers (90% of all thyroid cancers) • A malignant neoplasm of the thyroid epithelium

42. Clinical presentation • Solitary painless mass • The coexistence of lymph node involvement (extremely rare) • Cervical adenopathy (rare)

43. Treatment • Primarily surgical. Thyroid lobectomy and Isthmectomy <2cm,well contained within one thyroid lobe Total thyroidectomy >2 cm, (>4 cm, the risk for cancer >50%) • Lymph node dissection • Radioiodine treatment

45. Hürthle Cell Carcinoma • A subtype of follicular carcinoma • Presents in much the same fashion as follicular cell neoplasms. • Preoperative FNA • Principal treatment is surgical

46. Medullary Carcinoma • 5% to 10% of thyroid malignancies • A biological marker, Calcitonin • Presentation: a palpable mass an elevated calcitonin level • Single and unilateral

47. Diagnosis • MCT : a mass and an elevated calcitonin level • Detailed and in-depth family history • Signs and symptoms • Screening for pheochromocytoma with 24-hour urinary catecholamines

48. Anaplastic Thyroid Cancer • Less than 1% of all thyroid malignancies • Most aggressive form of thyroid cancer • Typical presentations : dysphagia cervical tenderness painful neck mass superior vena cava syndrome

49. Treatment • Most reports with resection are not optimistic . • less than one third of them are resectable • chemotherapy adds little to the overall prognosis • Prognosis is bad

50. Minimally invasive surgery