World Surgery Forum: Thyroid

Thyroid Case

Name:

Age/Sex:

Occupation:

Residence:

Presenting Complaints

Swelling in front of Neck Duration

History of Presenting Illness

H/O Swelling

Site
Duration
Onset
Progress of the swelling:
Associated

H/O Pain

Site
Duration
Onset
Character: Usually dull-aching
Radiation
Relieving factors
Aggravating factors

R/O Pressure Symptoms

H/O Difficulty in Swallowing: Solid or liquid
H/O Difficulty in breathing
H/O Hoarseness of Voice
H/O Drooping of the upper eyelid (ptosis), Absence of sweating of the face (anhidrosis)

R/O Hyperthyroidism

Primary Hyperthyroidism (Mainly CNS Symptoms)

H/O Tremors
H/O Irritability on slight provocation
H/O Insomnia
H/O Muscle Weakness

Primary Hyperthyroidism (Eye Symptoms)

H/O Bulging of eyes

Duration
Progress
History of redness of eye and watering
History of double vision
Loss of vision

Secondary Hyperthyroidism (Mainly Cardiovascular Symptoms)

H/O Palpitations
H/O Ectopic Beats
H/O Chest pain
H/O Breathlessness on exertion

Hyperthyroidism (Sympathetic Hyperstimulation)

H/O Increased sweating
H/O Heat intolerance

Hyperthyroidism (Increased BMI)

H/O Increased Appetite
H/O Weight Loss

Hyperthyroidism (GI)

H/O Increased frequency of passing stools

6/02/2017 02:11:00 AM

62 year old Man from a remote village had come with complaints of swellings in neck from past 1 year. The swellings were painless.
He had a history of hoarseness of voice, loss of appetite and significant loss of weight.
There was an irregular mass in the midline which moves on swallowing.
Multiple large fixed nodes were palpable (Left Side - Mid jugular, lower jugular large nodes and Right Side - Multiple small nodes, middle and lower jugular group)
On palpation of left side of neck, Berry's sign was positive (Berry’s sign is the absence of carotid pulsation on palpation)
FNAC revealed Papillary Thyroid Carcinoma.

Left Side of Neck

Right Side of Neck

1/22/2017 01:36:00 PM

What are the manifestations in Eye in cases of Thyrotoxicosis due to Graves Disease?

The condition is otherwise called Graves opthalmopathy. It is an autoimmune inflammatory disorder affecting the orbit around the eye, characterized by upper eyelid retraction, lid lag, swelling (edema), redness (erythema), conjunctivitis, and bulging eyes (proptosis).

What are various signs seen in Graves opthalmopathy?

Rosenbach's sign
Stellwag's sign
Dalrymple's sign
Von Graef's Sign
Joffroy's sign
Moebius' Sign

What is the cause of development of Graves Opthalmopathy?

The autoantibodies target the fibroblasts in the eye muscles, and those fibroblasts can also differentiate into fat cells (adipocytes). Fat cells and muscles expand and become inflamed causing buldging of eyes. Veins become compressed, and are unable to drain fluid, causing edema.

What percentage of Graves disease patients are affected?

Graves opthalmopathy affects between 25-50% of patients with Graves' disease.

How is Graves opthalmopathy treated?

Various management options include:

Topical Lubrication
Corticosteroids
Thyroidectomy
Tarsorraphy
Treatment with selenium is effective in mild cases (Ref)
Orbital Radiotherapy

Related Links:

Thyroidectomy Steps

Thyroid Study Material

6/18/2016 05:58:00 PM

GA, head ring, shoulder bolster to extend the neck
Transverse incision 2 cm above sternal notch
Skin, subcutaneous fat and platysma are incised transversely
Investing fascia and connective tissue between the sternohyoid and sternothyroid muscles are incised vertically.
Usually the strap muscles are not divided, but this may be necessary in case of large got results.
If they do need to be divided this should be done as high as possible (ie above the point of entry of the ansa cervicalis nerve branches) to prevent denervation and muscle wasting
Pretracheal fascia around the thyroid is incised
Thyroid lobe is mobilised
RLN is identified
Traditionally, the superior thyroid artery is tied off close to the thyroid gland (to protect the ELN) and the inferior thyroid artery is tied off laterally away from the thyroid (to protect the RLN). However, many surgeons now divide the branches of the inferior thyroid artery individually on the gland to protect the blood supply to the parathyroids
If a parathyroid is excised, it can be cut up and implanted in the sternomastoid. The majority of these continue to function normally
Thyroid gland is excised
Haemostasis, suction drain, closure in layers (approximate strap muscles and platysma), skin closure