neck diseases（留学生）

8/14/2019 neck diseases

http://slidepdf.com/reader/full/neck-diseases 1/61

Neck Diseases

Affiliated Hospital of Jining Medical Colledge

Dep.Mammary and Thyroid Surgery

Zhu KunBing

朱坤兵



The Thyroid Gland



Shape and position H-shape Left and right lobes: lie on either

side of inferior part of larynx andsuperior part of trachea, extendfrom middle of thyroid cartilage tolevel of sixth trachea cartilage

Isthmus: overlies 2nd to 4thtracheal cartilage

Pyramidal lobe: some times arisesfrom isthmus

Fibrous capsule:

A sheath of pretracheal fascia whichis attached to arch of cricoid andthyroid cartilages, hence, thethyroid gland moves with larynxduring swallowing and oscillatesduring speaking

The Thyroid Gland



Relations

Anteriorlly－ skin , superficial fascia,

investing fascia, infrahyoid muscles

and pretracheal layer Posteromedialy－ larynx and trachea,

pharynx and esophagus, recurrent

laryngeal n.

Posterolateraly－ carotid sheath and

cervical part of sympathetic trunk



Inferior thyroid artery/vein

Superior thyroid artery/vein

Arteria thyroidea ima

Lateral lobe

Pyramidal lobe

Isthmus

external carotid



Superior laryngealn.

Recurrent laryngeal n.

Trachea

Esophagus

parathyroid gland

http://image.baidu.com/i?ct=503316480&z=0&tn=baiduimagedetail&word=%BC%D7%D7%B4%CF%D9&in=19471&cl=2&cm=1&sc=0&lm=-1&pn=396&rn=1&di=2205669608&ln=2000



Arteries of thyroid gland and nerves of larynx

Superior thyroid a. Branch of external carotid a. Runs superficial and parallel

to the external branch of superior laryngeal n. to reach

the upper pole of thyroidgland Gives off superior laryngeal

a. in company with internalbranch of superior laryngealn.



Superior laryngeal nerve

Internal branch which

pierces thyroid membraneto innervates mucous

membrane of larynx above

fissure of glottis

External branch is fine n.,which descends in company

with the superior thyroid a.

and supplies cricothyroid



Inferior thyroid artery Branch of thyrocervical trunk off subclavian a.

Turns medially and downward, reaches the posterior

border of the thyroid gland and is closely related to therecurrent laryngeal n.

Supplies inferior pole of thyroid gland

Recurrent laryngeal nerves Ascend in tracheo-esophageal groove

Pass deep to the lobe of the thyroid gland and come into

close relationship with the inferior thyroid a.

Cross either in front of or behind the artery of may pass

between its branches

Nerves enter larynx posterior to cricothyroid joint, the

nerve is now called inferior laryngeal nerve

Innervations: laryngeal mucosa below fissure of glottis ,

all laryngeal laryngeal muscles except cricothyroid



Arteria thyroid ima May arise (4%) from the brachiocephalic a. or aortic arch

Venous drainage Superior and middle thyroid veins into internal jugular vein

Inferior thyroid veins to left brachiocephalic vein



Parathyroid gland

Yellowish-brown, ovoid bodies

Position

Two superior parathyroid

glands: lie at junction of superior

and middle third of posterior

border of thyroid gland

Two inferior parathyroid glands:

lie near the inferior thyroid

artery, close to the inferior poles

of thyroid gland

Function: regulate calcium andphosphate balance and is therefore

essential for life



Cervical part of trachea Begins at lower end of larynx－ level of

C6 vertebra Consists of a series of incomplete cartilage

rings

Extends into thorax

Relations in the neck Anteriorly

The skin , superficial fascia, investing

fascia, suprasternal space and jugular

arch, infrahyoid muscles and pretracheal

fascia, isthmus of thyroid gland ( in frontof the 2nd to 4th tracheal cartilage),

inferior thyroid v. and unpaired thyroid

venous plexus, arteria thyroid ima ( if

present), and left brachiocephalic v. in

child



Laterally

The lobes of the thyroid gland ( down as far as the sixth ring) and the

carotid sheath

Posteriorly

The right and left recurrent laryngeal nerves, the esophagus



Thyroid Function

Synthesize、 Store&Secrete

triidothyronine(T3 )

thyroxine (T4 )



Physiology Control

Hypothalamus:TRF

Pituitary:Thyrotropin(TSH)

adenylyl cyclase activity

Thyroid: T3、 T4



Thyroid Hormones Function

Accelerate cellular oxygenization rate;

boost body's metabolism overall. Promote protein,carbohydrate &fat

disintegrate

Promote body's growth and development

,histodifferentiation。



Evaluation of the Thyroid History-taking

Systematic mathod of palpating thyroid

size, contour, consistency, nodularity

fixation, displacement of trachea,

cervical lymph nodes.

The serum level of T3、 T4

Radioactive iodine uptake(RAI)



Goiter



Etiology

Material iodine deficiency

Thyroid hormones requirement increase synthesis&secretary disorder



Pathology Follicle distend,filled with a lot of colloid;

Follicular parietal cell become thin and flat.



Pathology

Simple

Nodosity



Nodular GoiterCystic degeneration

Secondary hyperthyroidism

Canceration



Evaluation of Thyroid Nodules

and Goiters

(2)Percutaneous fine-needle biospy

(1)Sensitive TSH

Cancer

99%

Indeterminate

or suspicious

20%

Benign

<5%

Inadequate

specimen%Cancer

OperateUsually

operate

TSH-

suppressive

treat and

observe

Repeat



Operation Indication Symptoms of pressure

Substernal extension

Cosmetic deformity Secondary hyperthyroidism

Suspicion of cancer



Nodular Goiter



Specimen



Afteroperatoin



Goiter of Substernal extension







operating



Hyperthyroidism



Definition

Systematic hypermetabolism

Disorders

Feedback control mechanism of

the secretion of thyroid hormoneout of work

The level of thyroid hormone

of blood circulation



Types

Primarily hyperthyroidism（ Graves'disease）

Secondary

hyperthyroidism（ Pulmmer'disease）

Hyperactive adenoma

Iodine

Thyroiditis



Primary Hperthyroidism

Manifestation:Diffuse thyromegaly

Hypermetabolism

Cause: Autoimmune disease

Long-acting thyroid stimulator (LATS)Thyroid-stimulating immunoglobulinsTSI



Secondary Hperthyroidism

Usually due to nodular goiter



Hyperactive Thyroid Adenoma

Solitary autonomic hyperfunctional nodule

Tissues around nodule become atrophia。 Usually not with ophthalmoptosis



Diagnosis

Clinical manifestation

Special examination



Clinical Manifestation Nervousness,weight loss with increased appetite,heat

intolerance,increasing sweating,muscular weakness andfatigue,increased bowel frequency,polyuria,menstrual

irregularities,infertility . Goiter,tachycardia,aterial fibrillation,warm mosit

skin,thyroid thrill and bruit,cardiac flowmurmur,gynecomastia.

Eyes signs:stare,lid lag,exophthalmos. TSH low or absent;TSI,iodine upake,T3 and T4

increased;T3 suppression test abnormal.



Special Examination Basal metabolic rate

BMR ＝ (PR+PP)－ 111

131I uptake ratio: 2h>25% 24h>50%

T3 、 T4



Treament

Drugs treatment： PTU,Tapazol 50％

Radioiodine therapy： 131I 90％

Operation



Operation Indicatio Secondary hyperthyroidism&hyperactive adenoma； Primary hyperthyroidism of midrange or above； Thyromegaly with symptoms of pressure

Recidivist after ATD or 131I post-treatment ; Can not persist on medication



Surgical Contraindication

Teenagers

Lower symptom Elderly patient or can not suffer operation。



Preoperative preparation General preoperative preparation

Drugs:ATD ,lugol's iondine solution,Propranolol



Operation opportunity Symptom get baisc controll（ moodstable,good sleep,

weight gain）

PR<90/min， BMR<＋ 20％ ;T3,T

4in

normal level.

Thyroid become small, stiff;vascular murmur

decrease.



Operation

Anesthesia: general anaesthesia；

cervical plexus regional analgesia

Operation



Postoperative Complications

Dyspneic respiration&choke

Recurrent laryngeal nerve (RLN) injure

superior laryngeal nerve（ SLN） injure Rheumatic contraction

Thyroid crisis



Rheumatic Contraction



Thyroid Neoplasm



Benign Tumor:adenoma

Secondary hyperthyroidism（ 20％）

Canceration（ 10％）

Fast freezing pathological section



Thyroid Carcinoma



Pathology Papillary adenocarcinoma： 60-80％ ;age:30～

45 years female; 80％ :multinodular。

Follicular adenocarcinoma： 10-20％， age:50years

Undifferentiated carcinoma： 1％， age:70

years。

Medullary carcinoma： 7％



Papillary adenocarcinoma

Papillary adenocarcinoma： 60-80％ ;

age:30～ 45 years female; 80％ :multinodular 。



Follicular adenocarcinoma

Follicular adenocarcinoma： 10-20％， age:50years



Undifferentiated carcinoma

Undifferentiated carcinoma： 1％， age:70 years。



Clinical Manifestation early stage： hard nodule

Advanced stage： Symptoms of

pressure

Local metastasis： palpable lymph

nodes。

Metastasis： to lungs or bone



Therapy

Differentiated thyroid carcinoma

Undifferentiated thyroid carcinoma



Operation

Total lobectomy with isthmectomy

Neartotal thyroidectomy

Total thyroidectomy Peripheral lymph node disscetion

No

Central lymph nodes disscetion

Modified radical neck disscetion

Radical neck dissection。



Modified radical neck disscetion



Thyroid operation by endoscope

http://f/endoscope%20thyroid%20operation.wmv

http://f/endoscope%20thyroid%20operation.wmv



Documents

neck diseases（留学生）