clinical anatomy of the thyroid gland - الجامعة المستنصرية11_08_34... · clinical...
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![Page 1: Clinical Anatomy of the Thyroid Gland - الجامعة المستنصرية11_08_34... · Clinical Anatomy of the Thyroid Gland Lawrence M. Witmer, PhD Professor of Anatomy Department](https://reader034.vdocuments.site/reader034/viewer/2022052609/5a701b797f8b9ac0538bac3c/html5/thumbnails/1.jpg)
Clinical Anatomy of the Thyroid Gland
Lawrence M. Witmer, PhD Professor of Anatomy
Department of Biomedical Sciences Heritage College of Osteopathic Medicine
Ohio University, Athens, Ohio 45701 [email protected]
Handout download: http://www.oucom.ohiou.edu/dbms-witmer/gs-rpac.htm
25 October 2011
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Anatomical Overview • Right & left lobes connected
by an isthmus • Occasional pyramidal lobe • Levator glandulae thyroideae • Slightly larger in women; may
enlarge during menstruation & pregnancy • Extends from oblique line on
thyroid cartilage down to 4th or 5th tracheal ring • Attaches to cricoid cartilage
via suspensory ligament
thyroid cartilage
common carotid a.
cricoid cartilage
isthmus
thyroid lobes pleural cupola
From Netter’s Atlas
variation (from
Hollinshead 1968)
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Case Presentation
A 32-year-old woman presents with a swelling on the anterior part of her neck. She also reports that her breathing is sometimes affected by the swelling. On examination, a single, firm, rounded mass can be felt on the left side of the laryngotracheal region. It moves up and down with swallowing. Ultrasound reveals a solid nodule in the left lobe of her thyroid gland. A needle biopsy subsequently indicates that malignant changes have taken place in the cells.
Preliminary Diagnosis: Tumor of the left lobe of the thyroid
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1. Why does the mass move up and down on swallowing?
2. What can explain the difficulty breathing? 3. What structures would be endangered by subtotal or total
thyroidectomy? 4. Why is the nature of the patient’s voice of interest
postoperatively?
Questions
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Fascia & Spaces
Skandalakis’ Surgical Anatomy 2004
Moore et al. 2010
superficial fascia
skin
fat
platysma
veins (ant. & ext. jug.) and cutaneous nn.
deep fascia (investing layer) platysma
C7
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Fascia & Spaces
sternocleido- mastoid
Deep Fascia
3. prevertebral fascia 4. carotid sheath
1. investing fascia 2. pretracheal fascia
C7
Moore et al. 2010
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Fascia & Spaces
Deep Fascia
3. prevertebral fascia 4. carotid sheath
1. investing fascia 2. pretracheal fascia
a. muscular layer b. visceral layer thyroid gland
trachea & larynx
esophagus
C7
Moore et al. 2010
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Fascia & Spaces
Skandalakis’ Surgical Anatomy 2004
thyroid cartilage
cricoid cartilage
suspensory ligament of Berry
visceral layer of pretracheal fascia (false capsule)
true capsule
thyroid gland
pretracheal fascia
Moore et al. 2010
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Fascia & Spaces
Deep Fascia
3. prevertebral fascia 4. carotid sheath
1. investing fascia 2. pretracheal fascia
common carotid a. (and sympathetic plexus)
internal jugular v.
vagus n. (and carotid
sinus n.)
deep cervical lymph nodes
C7
Moore et al. 2010
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pretracheal fascia
prevertebral fascia
trachea
Skandalakis’ Surgical Anatomy 2004
Fascia & Spaces pretracheal fascia
retropharyngeal (retrovisceral)
space
visceral space
of Stiles carotid sheath
not discussed today: • suprasternal space of Burns • ―Danger space‖ of Grodinsky & Holyoke
Moore et al. 2010
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Strap Muscles
sternohyoid sternothyroid
thyroid
sternocleidomastoid (cut)
From Netter’s Atlas
thyrohyoid
omohyoid
internal jugular v. cricothyroid
hyoid bone
thyroid cartilage
Attachment of sternothyroid to oblique line on thyroid cartilage prevents superior expansion of thyroid
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1. Why does the mass move up and down on swallowing?
2. What can explain the difficulty breathing? 3. What structures would be endangered by subtotal or total
thyroidectomy? 4. Why is the nature of the patient’s voice of interest
postoperatively?
Questions
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Thyroid CT C7
sternocleidomastoid
trachea
C7
strap muscles
Thyroid ( )
esophagus
From Ellis et al. 1991
internal jugular v.
common carotid a.
From web reference 1
displaced trachea thyroid tumor
Compression and displacement of trachea by thyroid tumor
normal
normal
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1. Why does the mass move up and down on swallowing?
2. What can explain the difficulty breathing? 3. What structures would be endangered by subtotal or
total thyroidectomy? 4. Why is the nature of the patient’s voice of interest
postoperatively?
Questions
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superior thyroid a.
thyroid
From Netter’s Atlas
inferior thyroid a.
middle thyroid v.
inferior thyroid v.
internal jugular v.
common carotid a.
cricothyroid m.
external laryngeal n.
superior thyroid v.
recurrent laryngeal n.
pretracheal lymph node
pyramidal lobe
Vascular Supply & Relations
Anterior View
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Vascular Supply & Relations
superior thyroid a.
thyroid
From Netter’s Atlas
inferior thyroid a. parathyroids
common carotid a.
inferior constrictor m.
external laryngeal n.
esophagus recurrent laryngeal n.
recurrent laryngeal n.
Posterior View
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1. Why does the mass move up and down on swallowing?
2. What can explain the difficulty breathing? 3. What structures would be endangered by subtotal or total
thyroidectomy? 4. Why is the nature of the patient’s voice of interest
postoperatively?
Questions
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Skandalakis’ Surgical Anatomy 2004
4% intrathyroid
42% paratracheal
48% tracheoesoph. groove
6% paraesophageal
4%
42%
48%
6% C7
variation in recurrent laryngeal
nerve position (n = 204)
Recurrent Laryngeal N. & Suspensory Lig. of Berry
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Recurrent Laryngeal N. & Suspensory Lig. of Berry
From Netter’s Atlas
Variation in relationship of recurrent laryngeal n. to inferior thyroid a.
thyroid
inferior thyroid a. & branches
common carotid a.
recurrent laryngeal n.
recurrent laryngeal n.
inferior thyroid a. & branches
(from Hollinshead 1968)
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Recurrent Laryngeal N. & Suspensory Lig. of Berry
From Netter’s Atlas
Variation in relationship of recurrent laryngeal n. to suspensory lig.
thyroid
inferior thyroid a. & branches
recurrent laryngeal n.
superior thyroid a. & v. (cut)
parathyroids
susp. lig.
(from Hollinshead 1968)
superficial to ligament
deep to ligament
splits around ligament
passes thru gland
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Recurrent Laryngeal N. & Suspensory Lig. of Berry
From Sasou et al. 1998
thyroid
inferior thyroid a. recurrent laryngeal n. trachea
suspensory ligament of Berry
Variation in relationship of recurrent laryngeal n. to suspensory lig.
susp. lig.
(from Hollinshead 1968)
superficial to ligament
deep to ligament
splits around ligament
passes thru gland
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Case Presentation
Preliminary Diagnosis:
Thyroglossal Cyst
A 43-year-old male presents with a swelling in the front of his neck. He first noticed it 9 months ago and it has steadily grown. The lump lies near the midline and moves on swallowing. On palpation, it is firm and lays anterior to the thyroid cartilage. The mass is smooth, non-pulsatile, and non-fluctuant. The dorsum of the tongue was inspected but no thyroid tissue was observed. Ultrasound showed the mass to be cystic and separate from the thyroid gland.
cyst
thyroid cartilage
From Moore & Persaud 2003
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1. What is the embryonic derivation of a thyroglossal cyst?
2. Why did the mass move upwards on swallowing? 3. Why did the surgeon look for thyroid tissue on the tongue?
Questions
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Thyroid Development
From Moore & Persaud 2003
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Thyroid Development
From Moore & Persaud 2003
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From Moore & Persaud 2003
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1. What is the embryonic derivation of a thyroglossal cyst?
2. Why did the mass move upwards on swallowing? 3. Why did the surgeon look for thyroid tissue on the tongue?
Questions
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Thyroid Development
From Moore & Persaud 2003
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1. What is the embryonic derivation of a thyroglossal cyst?
2. Why did the mass move upwards on swallowing? 3. Why did the surgeon look for thyroid tissue on the
tongue?
Questions
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Ectopic Thyroid Tissue
thyroid gland
thyroglossal duct
pyramidal lobe
cervical thyroid
thyroid cartilage
accessory thyroid tissue
hyoid bone
lingual thyroid
foramen cecum
tongue
Moore et al. 2010
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Possible Locations of Thyroglossal Duct Cysts
From Moore & Persaud 2003
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References
Print Ellis, H., B. Logan, and A. Dixon. 1993. Human Cross-Sectional Anatomy: Atlas of Body Sections and CT Images. Butterworth-Heinemann, London. Hollinshead, W. H. 1968. Anatomy for Surgeons: Volume 1. The Head and Neck, Second Edition. Harper & Row, New York. Moore, K. L., A. F. Dalley, and A M. R. Agur. 2010. Clinically Oriented Anatomy, 6th Ed. Lippincott, Williams & Wilkins, Baltimore. Moore, K. L. and T. V. N. Persaud. 2003. The Developing Human: Clinically Oriented Embryology. Saunders, Philadelphia. Netter, F. H. 1987. The CIBA Collection of Medical Illustrations, Volume 8: Musculoskeletal System. CIBA-Geigy, Summit. ———. 2011. Atlas of Human Anatomy, 5th. Ed. Saunders, Philadelphia. Sasou, S., S. Nakamurak, and H. Kurihara. 1998. Suspensory ligament of Berry: its relationship to recurrent laryngeal nerve and anatomic examination of 24 autopsies. Head & Neck 20:695–698. Skandalakis, J. E., G. L. Colborn, T. A. Weidman, R. S. Foster, A. N. Kingsnorth, L. J. Skandalakis, N. P. Skandalakis, P. Mirilas (Editors). 2004. Surgical Anatomy: The Embryologic And Anatomic Basis Of Modern Surgery. McGraw-Hill, New York. Younes, N. A., and D. H. Badran. 2002. The cricothyroid space: a guide for successful thyroidectomy. Asian Journal of Surgery 25(3):226–231. Web 1. Thyroid tumor: http://www.auntminnie.com/ScottWilliamsMD2/nucmed/Tumor/Thallium/Thallium.htm 2. Gray’s Anatomy of the Human Body: http://www.bartleby.com/107/