Post operative complications 1- Hemorrhage: A reactionary bleeding may occur in the first 24 hours. Its due to slipping ligature or from remnant of thyroid.

Post operative complicationsPost operative complications11 - -Hemorrhage:Hemorrhage: A reactionary bleeding A reactionary bleeding

may occur in the first 24 hours. Its duemay occur in the first 24 hours. Its due to slipping ligature or from remnant ofto slipping ligature or from remnant ofthyroid tissue. The patient suffer fromthyroid tissue. The patient suffer fromsuffocation, dyspnea and restlessnesssuffocation, dyspnea and restlessness,,with or with out neck masswith or with out neck mass..

TreatmentTreatment is by rapid and adequate evacuation is by rapid and adequate evacuation of the hematoma and controlling the bleedingof the hematoma and controlling the bleeding..

22 - -Respiratory obstruction:Respiratory obstruction: due to laryngeal due to laryngeal edema caused by excessive manipulation, edema caused by excessive manipulation, intubation injury or tracheomalecia. The patient intubation injury or tracheomalecia. The patient suffer from suffocation after removal of the suffer from suffocation after removal of the endotracheal tube. Treatment by reinsertion endotracheal tube. Treatment by reinsertion the tube with steroid, rarely trachiostomythe tube with steroid, rarely trachiostomy

Post operative complicationsPost operative complications33--Recurrent laryngeal nerve injuryRecurrent laryngeal nerve injury::

its technical fault, its either transient or its technical fault, its either transient or permanent, unilateral or bilateralpermanent, unilateral or bilateral..Transient unilateral type due to tractionTransient unilateral type due to traction or compression on the nerve, recovery is or compression on the nerve, recovery is suspected in 3 monthssuspected in 3 months..

Permanent unilateral injury is due to division Permanent unilateral injury is due to division of the nerve which causes horsiness of the of the nerve which causes horsiness of the voicevoice..Bilateral injury causes sever dyspnea and Bilateral injury causes sever dyspnea and suffocation that necessitate immediate suffocation that necessitate immediate tracheostomytracheostomy..

44 - -External branch of superior laryngeal nerve External branch of superior laryngeal nerve injury: injury: leads to inability to tense the leads to inability to tense the ipsilateral vocal cord and hence difficulty in ipsilateral vocal cord and hence difficulty in "hitting high notes," projecting the voice, "hitting high notes," projecting the voice, and voice fatigue during prolonged speechand voice fatigue during prolonged speech..

44 - -parathyroid insufficiencyparathyroid insufficiency::Its either temporarily due to ischemiaIts either temporarily due to ischemiaof or permanent due to infarction or of or permanent due to infarction or inadvertent removalinadvertent removal . .

Early manifestation (temporary) is tetany which Early manifestation (temporary) is tetany which is presented as cercum oral numbness, is presented as cercum oral numbness, carpopedial spasm and strider due to spasm carpopedial spasm and strider due to spasm of laryngeal muscle (laryngesmus striduolus)of laryngeal muscle (laryngesmus striduolus)Treatment:Treatment: IV infusion of 10% calcium IV infusion of 10% calcium gluconate which can be repeated each 8 gluconate which can be repeated each 8 hourshours

Late type (permanent) presented as repeated Late type (permanent) presented as repeated carpopedial spasm, trousseas and schvostic carpopedial spasm, trousseas and schvostic signssigns . .

Needs long term vit D and calciumNeeds long term vit D and calcium..

Post operative complicationsPost operative complications

Post operative complicationsPost operative complications44-- Thyroid insufficiencyThyroid insufficiency::

20%20% of thyroidectomized patients may suffer of thyroidectomized patients may suffer from hypothyroidism after 2 to 5 years from hypothyroidism after 2 to 5 years which needs replacement therapywhich needs replacement therapy..

55--Recurrent of thyrotoxicosisRecurrent of thyrotoxicosis:: Occur in 5 to 10% due to less adequate Occur in 5 to 10% due to less adequate

removal of tissueremoval of tissue.. TreatmentTreatment by antithyroid or RAI by antithyroid or RAI..

66--Thyroid stormThyroid storm Life-threatening exacerbation Life-threatening exacerbation of thyrotoxicosis with mortality of 50%of thyrotoxicosis with mortality of 50%

Precipitating factors: Precipitating factors: Thyroid surgery in Thyroid surgery in unprepared patient. Radioiodine. Withdrawal unprepared patient. Radioiodine. Withdrawal of antithyroid drugs. Acute illness (e.g. of antithyroid drugs. Acute illness (e.g. stroke, infection, trauma)stroke, infection, trauma) Clinical features: Clinical features: Severe thyrotoxicosis, Fever, Severe thyrotoxicosis, Fever, delirium ,seizure, coma and acute heart delirium ,seizure, coma and acute heart failurefailure..

Post operative complicationsPost operative complications`̀

77 - -wound complicationwound complication:: like infection or keloid formation or granuloma formationlike infection or keloid formation or granuloma formation..

Post operative follow upPost operative follow up11 - -fibro-optic laryngoscope before leaving the hospitalfibro-optic laryngoscope before leaving the hospital..

22--Serum calcium after 6 weeksSerum calcium after 6 weeks..33 - -Six months follow up to determine thyroid function for 1 Six months follow up to determine thyroid function for 1 year year

then yearly for long timethen yearly for long time..

::TreatmentTreatmentIVF, cooling the patient with ice packs, oxygen, IVF, cooling the patient with ice packs, oxygen, diuretics for cardiac failure, digoxin for atrial diuretics for cardiac failure, digoxin for atrial fibrillation, sedation and IV hydrocortisone. fibrillation, sedation and IV hydrocortisone. Specific treatment is by carbimazole 10–20 mg Specific treatment is by carbimazole 10–20 mg 6-hourly, Lugol’s iodine 10 drops 8-hourly by 6-hourly, Lugol’s iodine 10 drops 8-hourly by mouth or sodium iodide 1 g i.v. Propranolol mouth or sodium iodide 1 g i.v. Propranolol intravenously (1–2 mg) or orally 40 mg 6-intravenously (1–2 mg) or orally 40 mg 6-

hourly) to block -adrenergic effectshourly) to block -adrenergic effects . .

ThyroiditisThyroiditisIts inflammation of thyroid tissue, its either acute Its inflammation of thyroid tissue, its either acute sub-acute or chronic formsub-acute or chronic form

::AcuteAcute form could be form could be SupurativeSupurative more common in children followed URTI. more common in children followed URTI.

Streptococcus and anaerobes account for 70% of Streptococcus and anaerobes account for 70% of infectioninfection..MO reach the gland via: a-hematogenous or MO reach the gland via: a-hematogenous or lymphatic route, direct spread , penetrating traumalymphatic route, direct spread , penetrating trauma ..clinically:clinically: sudden painful enlargement of the gland sudden painful enlargement of the gland with fever, chills, dysphonia and odynophagiawith fever, chills, dysphonia and odynophagia..

Treatment:Treatment: Paranteral antibiotic, drainage if abscess Paranteral antibiotic, drainage if abscess is formedis formed..Non supurative Non supurative infection may result from bacterial or infection may result from bacterial or viral infectionviral infection..subacutesubacute thyroiditis: thyroiditis: dequrvain diseasedequrvain diseaseChronic form: Chronic form: hashimotos, or riedels thyroiditishashimotos, or riedels thyroiditis

Sub-acute thyroiditis - dequarvain diseaseSub-acute thyroiditis - dequarvain diseaseSelf-limited disease may be due to viral infectionSelf-limited disease may be due to viral infection . .Its more common in female around 40 yearsIts more common in female around 40 years..

Pathology:Pathology: There is infiltration of the gland by There is infiltration of the gland by monocyte, lymphocyte and epetheloid cellsmonocyte, lymphocyte and epetheloid cells..

Clinical picture: Clinical picture: The condition may pass into 4 The condition may pass into 4 stagesstages::

11 - -Acute toxic stage characterized by sudden painful Acute toxic stage characterized by sudden painful goiter with hyperthyroidism for 2 to3 monthsgoiter with hyperthyroidism for 2 to3 months..

22--Euthyroid stage there is only goiterEuthyroid stage there is only goiter33--Hypothyroid stage remain for 2 to 4 monthsHypothyroid stage remain for 2 to 4 months..

44--Recovary stage within 1 to 6 monthsRecovary stage within 1 to 6 months.. Investigation: Investigation: High ESR, absent thyroid antibodiesHigh ESR, absent thyroid antibodies , ,

RAI-131- uptake is low, H level depending on the RAI-131- uptake is low, H level depending on the stage of the disease, FNA is diagnosticstage of the disease, FNA is diagnostic..

Treatment :Treatment : NSAI, prednesolone 40 mg for 1 month NSAI, prednesolone 40 mg for 1 month tapered in 2 months. replacement therapy in tapered in 2 months. replacement therapy in hypothyroid stagehypothyroid stage..

Chronic thyroiditis -hashimotosChronic thyroiditis -hashimotos-- Its autoimmune disease with inherited Its autoimmune disease with inherited

predisposition, an antibody formed against predisposition, an antibody formed against thyroid gland, like antimicrosomal thyroid gland, like antimicrosomal (antiperoxidase) and antithyroglobulin antibody(antiperoxidase) and antithyroglobulin antibody..

Pathology:Pathology: excessive lymphoid tissue infiltration excessive lymphoid tissue infiltration with degeneration of the follicleswith degeneration of the follicles..

Clinical picture: Clinical picture: female at 50 years, may female at 50 years, may associated with other autoimmune disease like associated with other autoimmune disease like DM,SLE,RADM,SLE,RA..There is painless and firm goiter which is defuse There is painless and firm goiter which is defuse or nodular with pressure symptoms, later there or nodular with pressure symptoms, later there is picture of hypothyroidism. Thyroid lymphoma is picture of hypothyroidism. Thyroid lymphoma is a rare but well-recognized, ominous is a rare but well-recognized, ominous complicationcomplication . .

Investigation:Investigation: low T3,T4,elevated TSH. low RAIU. low T3,T4,elevated TSH. low RAIU. High AB titer. FNA is diagnosticHigh AB titer. FNA is diagnostic..

Treatment: Treatment: Replacement therapy by thyroxin. Replacement therapy by thyroxin. Surgery indicated in large goiter, or suspicion of Surgery indicated in large goiter, or suspicion of malignancymalignancy..

Chronic thyroiditis – Riedels diseaseChronic thyroiditis – Riedels diseaseExtensive infiltration of thyroid gland by fibrous tissue Extensive infiltration of thyroid gland by fibrous tissue extend to trachea and surrounding structures,extend to trachea and surrounding structures, may may associated with other focal sclerosing syndromes like associated with other focal sclerosing syndromes like mediastinal and mediastinal and retroperitoneal fibrosis or sclerosing retroperitoneal fibrosis or sclerosing

cholangitischolangitis . . Clinically:Clinically: painless, hard mass, which progresses over painless, hard mass, which progresses over

weeks to years to produce pressure symptoms and weeks to years to produce pressure symptoms and hoarseness. Patients may present with hypothyroidism hoarseness. Patients may present with hypothyroidism

and hypoparathyroidism due to replacement of the glands and hypoparathyroidism due to replacement of the glands by by fibrous tissuefibrous tissue . .

Physical examination Physical examination hard, "woody" thyroid gland with hard, "woody" thyroid gland with fixation to surrounding tissuesfixation to surrounding tissues . .

Investigation: Investigation: low H level, low RAIU, AB may be positive, low H level, low RAIU, AB may be positive, FNA is diagnostic but open biopsy may neededFNA is diagnostic but open biopsy may needed..Treatment:Treatment: replacement therapy replacement therapy . .

Surgery indicated in pressure symptoms (esthmusectomy) Surgery indicated in pressure symptoms (esthmusectomy) to release the trachea or if malignancy cannot ruled out.to release the trachea or if malignancy cannot ruled out. reported experience show dramatic improvement with reported experience show dramatic improvement with corticosteroids and tamoxifencorticosteroids and tamoxifen..

Thyroid tumorThyroid tumor thyroid tumorthyroid tumor

Follicular adenoma

Primary secondary

Carcinoma lymphoma modularly

Differentiated undifferentiated

Benign malignant

Papillary ca Follicular ca

Thyroid carcenomaThyroid carcenomaType of caType of caPapillary caPapillary caFollicular caFollicular caAnaplastic Anaplastic

cacaAgeAge 30-4030-40 40-5040-50 60-8060-80

Sex ratio Sex ratio (f:m)(f:m)

3:13:1 3:13:1 1:1.31:1.3

PercentagePercentage 6060%% 20%20% 10%10%SpreadSpread lymphaticlymphatic bloodblood bothboth

Predisposing Predisposing FF

neck neck radiationradiation

long long standing standing

goitergoiter

Not Not knownknown

Multi focal Multi focal lesionlesion

positivepositive negativenegativenegativenegative

H H dependencydependency

TSHTSH TSHTSH nonnon

PrognosesPrognoses goodgood fairfair poorpoor

Clinical pictureClinical pictureThyroid cancer accounts for <1% of allThyroid cancer accounts for <1% of all malignancies (2% of women and 0.5% of malignancies (2% of women and 0.5% of men) its usually presented asmen) its usually presented as::

11 - -Painless rapid growing mass (painful mass Painless rapid growing mass (painful mass radiate to ear in case of local invasion)radiate to ear in case of local invasion)..

22--Horsiness of the voiceHorsiness of the voice . .33--Hard and irregular on palpationHard and irregular on palpation..

44--may not move with swallowingmay not move with swallowing..55--Carotid pulsation may be absent (Berry Carotid pulsation may be absent (Berry

sign)sign)66--Horner syndrome due to local invasion of Horner syndrome due to local invasion of

sympathetic nervesympathetic nerve . .77--There may be hard lymph node in neckThere may be hard lymph node in neck..

88--pressure manifestation may existpressure manifestation may exist.. InvestigationInvestigation::

11 - -Normal thyroid HNormal thyroid H22 - -Cold mass by RAIUCold mass by RAIU

33 - -Positive ABPositive AB44 - -FNA is diagnostic in most condition except FNA is diagnostic in most condition except

for follicular typefor follicular type

Prognostic factors in Deferential thyroid Prognostic factors in Deferential thyroid cancercancer

age, sex, size, capsular invasion and histopathology of age, sex, size, capsular invasion and histopathology of the tumor play in important rule in prognosisthe tumor play in important rule in prognosis..

11 - -Low risk groupLow risk group represent 80% of the condition with represent 80% of the condition with 98% 25 year survival rate. It include98% 25 year survival rate. It includeA- Male less than 40, or female less than 50 years A- Male less than 40, or female less than 50 years without distal metastasiswithout distal metastasis..

B- Older age with intra thyroid papillary Ca, or B- Older age with intra thyroid papillary Ca, or follicular Ca less than 5 Cm without capsular follicular Ca less than 5 Cm without capsular invasion, no distal metastasisinvasion, no distal metastasis..

22 - -High risk group High risk group represent 20% of the condition with represent 20% of the condition with 46% 25 year survival rate. It include46% 25 year survival rate. It includeA- All patients with distal metastasisA- All patients with distal metastasis..B- Extra thyroid papillary CaB- Extra thyroid papillary Ca..

C- Follicular Ca more than 5 Cm or with capsular C- Follicular Ca more than 5 Cm or with capsular invasioninvasion

Lymphatic involvement not associated with bad Lymphatic involvement not associated with bad prognosisprognosis..

Surgical management of differentiated thyroid CAThe surgical strategy of patients with low-risk cancers remains controversial. A- Total thyroidectomy B- LobectomyThe benefit of total thyroidectomy are

1 -Enables the use of RAI to detect and treat residual thyroid tumor or metastatic disease. 2- Makes serum Thymoglobulin level a more sensitive marker for recurrent or persistent disease. 3- Eliminates contra lateral occult cancers as sites of recurrence. 4- 33 to 50% of patients who develop a recurrence die from their disease5- Reduces the need for re-operative surgery with its attendant risk of increased complication rates .

The benefit of lobectomy are :1-Total thyroidectomy is associated with a

higher complication rate like hypothyroidism, RLN injury and hypoparathyroidism (10-30%)

2-Recurrence in the remaining thyroid tissue is unusual (5%) and most are curable by surgery .

3-Tumor multicentricity seems to have little prognostic significance, and its rare in contra lateral lobe .

4-Patients who have undergone lobectomy still have an excellent prognosis.

5-In case of recurrence, or suspicious secondaries, the remaining thyroid can be ablated by high dose of RAI High-risk group or bilateral tumor should undergo total thyroidectomy.Presence of LN necessitate modified radical neck dissection.

Follow up1 -It is standard practice to prescribe

thyroxine in a dose of 0.1–0.2 mg daily, to suppress endogenous TSH production, for all patients after operation for differentiated thyroid carcinoma on the basis that most tumors are TSH dependent.

2 -The measurement of serum thyroglobulin is invaluable in the follow up and detection of metastatic disease in patients who have undergone surgery for differentiated thyroid cancer.

IIndications for post operative RAI ndications for post operative RAI studystudy1- All patients with high risk group. 1- All patients with high risk group. 2- Incomplete removal of tumor 2- Incomplete removal of tumor 3- Recurrence of tumor 3- Recurrence of tumor 4- Suspicion of secondaries.4- Suspicion of secondaries.5- High level of thymoglobulin post 5- High level of thymoglobulin post operativelyoperatively..

.

External Beam RadiotherapyEBR indicated in:

1 -Unrespectable tumor.2 -Locally invasive or recurrent disease.

3 -Bone metastases to decrease the risk of fractures.

4-Controlling pain from bony metastases .Chemotherapy has been used with little success in disseminated thyroid cancer, and there is no role for chemotherapy.

Thyroid lymphoma Accounts for 1% of thyroid malignancies .

Often arises with Hashimoto's thyroiditis or non-Hodgkin's B-cell lymphoma presents as a painless and rapid enlarging goiter with pressure effects.Diagnosis made by FNACChemo and Radiotherapy is treatment of choice

Prognosis is good - often  more than 50% 5 year survival

Medullary Carcenoma :Medullary Carcenoma :Arise from parafolliculer cells.Arise from parafolliculer cells.There is high level of calcitonen There is high level of calcitonen and 5HT, which may cause and 5HT, which may cause diarrhea.diarrhea.Represent 5% of thyroid tumor.Represent 5% of thyroid tumor.It may be sporadic ( 80% )or It may be sporadic ( 80% )or familial which is occur in children familial which is occur in children and young age, its more invasive, and young age, its more invasive, multifocal and may associated multifocal and may associated with(MEN-2- A) as parathyroid with(MEN-2- A) as parathyroid hyperplasia medullary carcinoma, hyperplasia medullary carcinoma, Phiochromcytoma , or with (MEN-Phiochromcytoma , or with (MEN-2-B) as parathyroid hyperplasia 2-B) as parathyroid hyperplasia or tumor, Phiochromcytoma with or tumor, Phiochromcytoma with skin pigmentation, multiple skin pigmentation, multiple neuromas in the tongue and neuromas in the tongue and mucous membrane and marfanoid mucous membrane and marfanoid habits.habits. It metastasize by lymph and It metastasize by lymph and blood.blood. Prognoses is good without Prognoses is good without metastases. metastases. FNA is diagnostic.FNA is diagnostic.Surgery is the treatment of Surgery is the treatment of choice.choice.Family screen in case of familial Family screen in case of familial

typetype . .

Anaplastic CarcinomaAccounts for approximately 1% of all thyroid malignancies.Male and female equally affected Most age involved

at seventh and eighth decade of life .Clinically: Rapidly enlarging mass and may be painful .

The tumor is large and may be fixed to surrounding structures or may be ulcerated.Associated symptoms: dysphonia, dysphagia, and dyspnea Lymph nodes usually are palpable at presentation .Evidence of metastatic spread also may be present.Diagnosis is confirmed by FNAB

Treatment :The tumor is the most aggressive thyroid malignancies, with few patients surviving 6 months beyond diagnosis.

All forms of treatment have been disappointing .In respectable mass, thyroidectomy may lead to a smallimprovement in survival, especially in younger individuals. Combined radiation and chemotherapy may be used as palliative management..

11 - -Enables the use of RAI to detect and treat residual Enables the use of RAI to detect and treat residual thyroid tumor or metastatic disease. thyroid tumor or metastatic disease. 2- Makes serum Thymoglobulin level a more 2- Makes serum Thymoglobulin level a more sensitive marker of recurrent or persistent disease. sensitive marker of recurrent or persistent disease. 3- Eliminates contralateral occult cancers as sites of 3- Eliminates contralateral occult cancers as sites of recurrence. recurrence. 4- 33 to 50% of patients who develop a recurrence 4- 33 to 50% of patients who develop a recurrence die from their diseasedie from their disease5- Reduces the need for reoperative surgery with its 5- Reduces the need for reoperative surgery with its attendant risk of increased complication rates. attendant risk of increased complication rates. 6- Follow-up studies suggest that recurrence rates 6- Follow-up studies suggest that recurrence rates are lowered and that survival is improved in patients are lowered and that survival is improved in patients undergoing total or near-total thyroidectomyundergoing total or near-total thyroidectomy

Surgical management of differentiated thyroid CAThe surgical strategy of patients with low-risk cancers remains controversial. Proponents of total thyroidectomy argue that: