Comprehensive search for thyroid gland

thyroid gland will say all thing in this artical about it let we put all of point During the following lines

ANATOMY OF THE THYROID GLANDULA

It is surrounded by the thyroid capsule, which is a dependence of the middle cervical aponeurosis, also supported by 3 ligaments, a medium one that extends from the larynx to the middle part of the thyroid and 2 lateral ones, ranging from the lobes to the trachea and the cricoids, also supported by the thyroid vessels and their conjunctive sheaths.
Of pink gray color of 6 to 7cm. wide by 3 high by 15 to 20 mm. thick, weighs 25 to 30 gs.
H-shaped posterior concavity, is divided into isthmus and lateral lobes.

Isthmus
Its posterior face embraces the cricoid and the first 2 tracheal rings, from its upper edge comes the pyramid of Lalouette, the rest of the thyroglossal duct.

Lateral lobes
They have a triangular pyramid shape. Base 2 cm above the sternum; vertex, on the posterior border of the thyroid cartilage, 1/3 medium.
Internal face: embraces the larynx, trachea, pharynx and esophagus;
external face: covered by the musc. infrahyoids.
Posterior aspect: in relation to the vasculonervioso package of the neck. By its posterointerno border it is in relation to the recurrent nerve
Arteries come from the 2 superior thyroid arteries, branches of the external carotid, from the inferior thyroid, branches of the subclavian, sometimes from the middle thyroid or Neubauer, which is born from the aorta or brachiocephalic trunk.
The veins form a thyroid plexus, they are divided into: superior thyroid veins, which flow into the internal jugular or the tirolinguofacial trunk; inferior thyroid veins, which go to the internal jugular veins and the brachiocephalic trunk and the middle thyroid veins that drain into the internal jugular
Lymphatics: ascending, descending and lateral
Nerves: cervical sympathetic, upper and recurrent laryngeal

PARATHYROIDS
In nº of 4, they are located behind the lobes of the thyroid, 2 superior and 2 inferior.

SIDE REGION OF THE NECK

SUPERFICIAL
MUSCLES Cutaneous muscle of the
wide and thin neck , above the superficial cervical aponeurosis, is inserted from below into the SCT of the subclavicular region, above the lower border of the maxillary
innervation: cervico-facial branch of the facial

Esternocleidomastoideo
is inserted into the manubrium of the sternum, clavicle and mastoid
Relations
external, superficial, covered by the skin, the external jugular vein and branches of the superficial cervical plexus
The inner side is in relation to the nervous nerve bundle of the neck
Innervation : spinal and cervical plexus.

MUSCLE infrahyoid
Esternocleidohioideo
From the inner end of the clavicle and the breastbone tohyoid.

Omohyoid
Digastric muscle, which goes from the hyoid bone to the shoulder blade

Sternothyroid
Located below the sternocleidohyoid, it is inserted below in the posterior aspect of the sternum and first costal cartilage and above in the thyroid cartilage
The 3 anterior muscles are innervated by the hypoglossal loop

Tirohioideo
Short muscle, located below the sternocleidohyoid, goes from the thyroid to the hyoid tubercles; innervated by a hypoglossus bouquet.

 

THYROID PATHOLOGY ANOMALIES 

LATERAL
REMAINS OF ABERRANT THYROIDS
The true lateral aberrant thyroid tissue is rare, since the lateral primordia are usually incorporated into the lateral lobes.
Currently, it is considered that this anomaly almost always represents a papillofollicular carcinoma, a metastasis of a thyroid cancer.

LINGUAL THYROID
The lingual thyroid is thyroid tissue at the base of the tongue, it is relatively rare, 1 in 3,000 cases of thyroid disease.
It is associated with cervical atireosis in 70% of cases and is more frequent in women.
Clinical Manifestations
Posterior lingual mass in asymptomatic patient.
It can increase in size, produce dysphagia, dysphonia, dyspnea, suffocation. Hypothyroidism is common, but hyperthyroidism rarely occurs, it is rarely malignant.
It is confirmed by scintigraphy with 123 I or 99 Tc.
Treatment
Surgery
131 I to reduce the size.
Thyroid hormone restitutive to suppress the lingual thyroid and reduce its size.
The indications for surgery are: Difficulty swallowing, speech or breathing.
Hemorrhage.
Uncontrolled hyperthyroidism.
Suspicion of malignancy

THYROID SEMIOLOGY
Reason for consultation: may be nervousness, agitation, weight loss, dyspnea, arrhythmia, palpitations, dysphagia, dyspnea, laryngeal stridor, tremor, hyperdefecation or diarrhea.
It is visualized if it increases in size, with the head in hyperextension. It ascends with swallowing, the goiter can be regular, irregular, of multiple nodules or unique, elastic, even stony.
Palpation from the back of the patient.
Palp. from Lahey from the front, moving with the hand on the opposite side to the one touched by the thyroid.
Crile Method: From the front, with the fingers behind and the thumbs feel.
In large goiters can cause stridor by compression of the lateral lobes of the thyroid (Kocher)
If positive, the patient has a saber trachea (Rx)

TOXIC BOCIO
In the case of Graves Basedow, diffuse exophthalmic goiter.
SIGNS
Exophthalmia
S. Stellwag: retraction of the upper eyelid, rarity rare.
S. de Von Graffe: rigidity of the upper eyelid, when directing the downward gaze, lack of correlative movement of the upper eyelid remains white zone between cornea and eyelid.
S. de Moebius: difficulty in the convergence
S. de Joffroy Absence of wrinkles on the forehead when the pte. Tilt your head forward and look up.
S. de Jellinek: pigmentation of the eyelids and the lower half of the eye.
S. de Dallrymple: Enlargement of the palpebral fissure.
S. de Rosembach: trembling of the closed eyelids.
S. de Gatalá: the sick sleep with their eyes half open.
S. de Lian: Hyperesthesia in the thyroid area
S. of Marañón: Vasomotor line in the thyroid area
Pretibial myxoedema
Osteoporosis
In the auscultation of the neck, murmurs are perceived, arrhythmias and murmurs are perceived upon cardiac auscultation.
A palpation of the neck can be felt a thrill.
Submerged goiter: Engrossed veins and dyspnea when lateralizing the neck and head.

TIROTOXICOSIS
It refers to a range of clinical manifestations that are related to an excessive primary secretion of active thyroid hormone.
It includes: Graves disease (diffuse toxic goiter), toxic multinodular goiter and simple toxic adenoma.
Graves’ disease
Etiology and pathological anatomy
The cause is unknown, it is considered a systemic autoimmune disorder in which hyperthyroidism, exophthalmos and a dermopathy called pretibial myxedema, are three parts of the same process.
Hyperthyroidism is due to antibodies against TSH hormone receptors, which bind to the receptor region and thereby stimulate thyroid function.
In many individuals suffering from this process can be detected immunoglobulins ETAP (long-acting thyroid stimulators) and EIT (thyroid stimulating immunoglobulins). Among the factors that contribute to the condition are inheritance, sex and emotional disorders.
It tends to occur in members of the same family, also in this is greater the frequency of other thyroid disorders, such as Hashimoto’s thyroiditis.
More frequent in women, ratio 6: 1 to 7: 1.
Psychosomatic aspects are highlighted.
v The thyroid has a diffuse growth and its surface is smooth or slightly micronodular, microscopically the gland looks hyperplastic, very vascularized, with little colloid and lymphoid accumulations.

Toxic multinodular goiter
It usually overlaps a multinodular nontoxic and chronic goiter. It presents multiple nodules, many of which contain irregularly large aggregates of cells, these zones can function independently of TSH stimulation; that is, they are autonomous nodes.

Toxic
adenoma The toxic toxic adenoma is a follicular tumor, like the multinodular toxic adenoma, it can function independently of the TSH, and the exogenous administration of thyroid, does not suppress the secretion of T 3 and T 4 .

Clinical manifestations
Graves’ disease is very frequent in young patients, although it occurs at all ages after breastfeeding, it is rare before 10 years of age and in the elderly patient. More frequent in women than in men
Thyrotoxicosis in multinodular goiter, usually occurs after age 50; the toxic adenoma appears from 30 to 40.
The patient feels warmer and develops intolerance to heat, has more sweating and thirst.
Weight loss and increased appetite
Cardiovascular manifestations Tachycardia, atrial fibrillation, congestive heart failure.
The patient experiences palpitations, there is cutaneous and peripheral vasodilation. The pulse is called celer or jumpy.
Patients are very excited, restless, hyperkinetic, with emotional instability and insomnia.
They can develop psychosis; wasting, muscle weakness and fatigue are common manifestations.
Myopathy can occur more frequently in men.
The physical examination shows tremor in the extended fingers and hyperactive tendon reflexes.
Wet and warm skin, facial flushing and perspiration.
fragility in the nails, fine hair, which falls when combed.
Pretibial myxedema in 3 to 5% of patients.
There may be gynecomastia in men and increase in breast size in women.
Menstrual periods are usually scarce or do not occur, sometimes the libido increases, fertility is reduced, the abortion rate is high.
There is diarrhea or hyperdefecation, there may be hypercalcemia.
In toxic multinodular goiter, symptoms related to obstruction of the trachea and esophagus are more common.
In the toxic adenoma a solitary tumor that grows inside the thyroid associated with these signs is palpated; There may not be exophthalmos
LABORATORY
Cholesterol and lipids go down in hyperthyroidism and rise in hypothyroidism.
In Graves’ disease 1% of patients have pernicious-type anemia and 30% have been reported to have antibodies against gastric parietal cells in circulation
Metabolism of creatinine and creatine rise in hyperthyroidism, 3 days of diet without meat or chocolate, is determined in urine creatinine and should not exceed 50 mg, an increase may be present in hyperthyroidism.

Total plasma I: 6 to 10 micrograms x 100 ml.
I proteic: PBI 4 to 8 micrograms%
I extractable with butanol: BEI 2 to 6 micrograms%
It is normal that the difference between the GDP and the BEI is less than 0.6%, if not that the thyroid secretes iodine proteins abnormal as in enf. de Hashimoto
131 uptake and elimination tests
2-20 microcuries are administered, usually gl. it captures 15 to 45% in 24 hours, 5-10% in hypothyroidism, 45 to 90% in hyperthyroidism.
The amount eliminated by urine in 24 hours is 35 to 65% of the ingested, less than 30% in the hyperthyroid and more than 80% in the hypothyroid
PBI 131 : VN at 48 hs. 0.02 to 0.20%

Calculated at 24 hs. of administered the I 131 , usually oscillate between 15 to 40%
Uptake test : It is also found to this test in the new books with the name CYRA, with values ​​lower than 22%

ASSESSMENT OF THE ANATOMY OF THE THYROID
CENTROLOGRAM THYROID OR GAMMAGRAFIA It
allows to visualize the shape of the gland as well as variations in the capacity of this to capture the I 131 , 123 I or 99 Tc. The latter two confer a much lower dose of thyroid radiation.
Thyroid nodules can be classified as: Hot, hyperfunctional; warm, functional and cold, hypofunctional nodules, which concentrate less radioactivity than the rest of the thyroid.

DIRECT MEASUREMENTS OF THE CONTRIBUTION OF T 3 , T 4 AND TSH
The exact amount of circulating thyroid hormones is currently dosed in the large centers, using Radio-immunoassay (RIA)
techniques. TIA RIA doses
: 12.5 micrograms% ml
T3: Up to 170 micrograms% ml.
TSH: up to 4.5 micro units / 100 ml.

HISTORICAL TESTS FOR EVALUATION OF THYROID FUNCTION
Basal Metabolism

MEASUREMENTS OF THYROID RESPONSE CAPACITY AND HYPOPHYSIS
Test of stimulation with thyrotropin
Test of Dear. 
It is used to distinguish hypophyseal mixedems from primitives. The capacity of the thyroid uptake is determined, before and 24 hours. after the injection of 4 U of TSH. I 131 is administered as a marker.
In the primary, the uptake hardly increases and in the pituitary cause it rises 20% or more.

Test of inhibition of TSH with Triiodothyronine 
Werner test
25 to 50 gammas of triiodothyronine c / 8 hs are administered. orally, for 7 days, causes inhibition of TSH increase, with which the uptake of I 131 decreases to lower values ​​by more than 50% This is not achieved in hypertroidism type Basedow, or autonomic hyperfunctioning adenomas Plummer type; but in the pituitary-dependent hot nodules.

TEST OF STIMULATION WITH HLT It
allows measuring the responsiveness of the pituitary gland to the EV administration of HLT, the hypothalamic stimulator of TSH release. In euthyroid individuals who have normal pituitary function, an immediate increase in TSH is observed.
TSH peak: 10 to 30 micro U / ml at 30 minutes.

Indirect tests assessing the occupation of plasma hormone receptors
HAMOLSKY test
In vitro capture of radioactive T3 by human hematis. VN: 11 to 19% increased in hyperthyroidism and decreased in hypothyroidism
T3 uptake by Resin , Varies from 20 to 30%

STUDY OF ANTITIROID ANTIBODIES
Anti thyroglobulins, Anti colloid,
Anti microsomal fraction
Long-acting thyroid stimulator: ETAP or LATS
Thyroid stimulating immunoglobulin: EIT, these two globulins are most frequently found in Graves’ disease.

HISTOLOGICAL ASSESSMENT OF THYROIDES
Central biopsy with needle or aspiration biopsy with cytological study.
TREATMENT

ANTITIROIDAL MEDICATIONS They
interfere with the organic fixation of thyroid iodine and inhibit the coupling of iodotyrosines
They have no effect on the fundamental cause of the disease, although there is recent evidence that treatment with propylthiouracil decreases thyroid stimulating immunoglobulins.
The treatment is followed with clinical data such as pulse and weight of patients, hormone concentrations are useful, as well as the free thyroxine index (TL 4 ), to assess the treatment.
With the treatment no significant lasting remissions are achieved, less than 40% of the patients remit with antithyroid treatment.
Methylmercaptoimidazole has a potency ten times higher than OCT. 100 to 300 mg of OCT for 6 to 8 hours is equivalent to 10 to 40 mg of methimazole for 12 hours.
Side effects such as fever, rash, neuritis and polyarteritis, occur in 3 to 12% of cases, while serious complications such as agranulocytosis or aplastic anemia, only occur in 1% of cases, if reduction is detected of the leukocyte count, the medication is suspended.
Radioactive iodine
It has been used in large series treatment, it does not have the potential risk of recurrent injury surgery, or of hypoparathyroidism, but it can lead to permanent myxedema, it sometimes requires the repetition of the treatment and it is related to leukemia and bone cancer, in addition to genetic disorders in the progeny of the treated subject.
Preparation for the operation
Methimazole to euthyroidism, iodine (Lugol) for approx. 10 days to reduce the vascularization of the gland, sometimes it is associated with propanolol to reduce the frequency of the pulse.
The preparation with propanolol alone, can be associated with thyroid storm in the postoperative period and to prevent it, it should be continued for several weeks in the postoperative period, as the patients continue thyrotoxic.

Results of the operation The mortality rate due to thyroidectomy is less than 1%
Permanent paralysis of the recurrent laryngeal nerve in 0 to 3% of cases.
Injury of the parathyroid gland, with consecutive tetany in 1 to 3% of the patients submitted to thyroidectomy for thyrotoxicosis.
In 10 to 30% of them, permanent hypothyroidism developed, while in 2 to 12% of patients, of the world series consulted, there was recurrence of hyperthyroidism.
The main advantages of surgical treatment are: immediate control of the disease and a lower frequency of myxedema, compared to treatment with radioactive iodine.
Thyroidectomy also allows the simultaneous removal of any incidental papillary carcinoma.

Treatment of exophthalmos
The effects of the treatment on the ocular signs are variable, in general it responds to all the therapeutic options.
It is important to treat hypothyroidism when it occurs, as it seems to aggravate ophthalmopathy.
The signs and symptoms of malignant or severe exophthalmos are: increased lacrimation, venous congestion and conjunctival edema or chemosis.
The treatment is basically symptomatic, the eyes should be protected from the wind and the sun. Patients should sleep in a semi-sitting position to reduce venous congestion.
In severe chemosis, tarsorraphy is indicated to face the eyelids and prevent ulceration of the cornea.
Corticosteroid eye drops or their systemic administration are of some benefit.
External radiation from retroorbital tissues is useful, but forms cataracts. If intra-orbital pressure puts vision at risk, surgical decompression of the orbit or its contents should be resorted to.

HYPOTHYROIDISM
ETIOLOGY
Spontaneous hypothyroidism, or myxedema, is due to thyroid aplasia, or replacement of the gland by non-functional goiter, adenoma, or thyroiditis.
It is rarely secondary to hypopituitarism.
It can also originate in thyroidectomy or radioactive treatment.
Clinical manifestations
Thyroid insufficiency in the newborn is called cretinism, it does not manifest initially due to the passage of hormones through the placenta, it manifests during breastfeeding, it leads to a mental retardation, often irreversible.
Children have a poor growth pattern and should be differentiated from mongolism and dwarfism.
In childhood and adolescence is known as juvenile hypothyroidism, the child is smaller and his intellect is deficient, abdominal distension, umbilical hernias and prolapse of rectum are common in children.
In the adult it is a frequent manifestation of lymphocytic thyroiditis.
80% of cases occur in the female sex
In mild cases there is fatigue and weight gain, in the severe there is fatigue and apathy, slow in the mental and physical processes, language alteration, there is headache and dementia develops.
It increases in weight, the skin dries up, thickens and becomes bloated.
The hair becomes dry and fragile.
There is macroglossia and the voice is hoarse.
There are muscle cramps.
Decreased cardiac output, with hemodynamic alterations that resemble congestive heart failure.
There is widening of cardiac dullness due to dilatation of the heart or pericardial effusion.
Distant heart sounds, bradycardic pulse, sometimes there is hypertension. As the disease progresses, dyspnea and pulmonary effusions occur.
There is constipation, abdominal distension due to gas or ascites.
There is achlorhydria and pernicious anemia in 12% of patients.
In women there is a decrease in libido, alteration of ovulation and menorrhagia, in men impotence and oligospermia.
Microcytic anemia is frequent, ECG reveals bradycardia and decreased voltage.
The EEG shows slow activity of alpha waves and loss of amplitude.
There is a decrease in serum concentrations of T 3 and T 4 and ITL, serum TSH levels are elevated and serum cholesterol often exceeds 300 mg / 100 ml.
Treatment
Supplemental hormone doses are used, frequently L-thyroxine, and the therapeutic efficacy is corroborated by the determination of T 4 , ITL and TSH.

THYROIDITIS Acute non-suppurative thyroiditis , usually of viral origin and co-occurring with flu-like symptoms, produces fever, great asthenia, pain and transient hypothyroidism, and is treated with rest and aspirin.
Acute suppurative thyroiditis
It is the rarest, is accompanied by abscess formation.
It occurs after acute infection of the upper respiratory tract.
Severe pain in the anterior part of the neck of sudden onset, dysphagia, fever and chills.
It is usually unilateral, the treatment consists of drainage.

HASHIMOTO DISEASE (LYMPHADENOID BOCIOUS)
Chronic lymphocytic thyroiditis, is the most common chronic form
It is an autoimmune process in which the subject is sensitized to its own thyroglobulin and cellular components
There is a familial predisposition.
There is data of a statistically significant relationship with papillary carcinoma.
PATHOLOGICAL ANATOMY
The thyroid is symmetrical, pale, firm; the tissue is infiltrated by lymphocytes and there is destruction of epithelial cells and the basement membrane of the follicles, as the disease progresses, fibrosis progresses.

Clinical manifestations
More frequent in women, average age, 50 years.
There is neck growth, pain and hypersensitivity in the thyroid region.
There may be difficulty breathing and swallowing due to compression.
Dyspnea, weight gain and fatigue due to hypothyroidism.
Most individuals are euthyroid or hypothyroid, but a transient thyrotoxicosis was described.
A gland of diffuse growth and increased consistency is palpated.
It is often associated with autoimmune diseases.
It is sometimes part of an endocrine organic failure syndrome, which may include Addison’s disease, diabetes, and ovarian or testicular failure.

Diagnostic data
In the early stages there may be hyperfunction.
With the progress of the disease the values ​​of T 4 , T 3 and ITL decrease . Most tests can be euthyroid, the uptake may be low. Antithyroid antibodies are detected in the serum. Puncture and aspiration biopsy is indicated to rule out carcinoma.

Treatment
If the thyroid is symmetrical and does not produce compression, suppressive doses of thyroid hormone are used.
If there are signs of compression or associated papillary carcinoma is demonstrated, subtotal or total thyroidectomy is performed.
It should be continued in the postoperative period with suppressive treatment with thyroid hormone and later with supplementary treatment.

SUBAGUA THYROIDITIS
Granulomatous thyroiditis, giant cell, epidemic, de Quervain.
Age of onset: 3 to 70 years, average 40 years.
Increased frequency in women, from 60 to 100%, is not considered to have a viral or autoimmune origin.
The gland is usually attached to neighboring tissues, but unlike the Riedel struma, it can be released by dissection.
There is growth of the follicles, with infiltration by large mononuclear cells, lymphocytes and neutrophils. The giant cells of foreign body, epithelioid, which contain many nuclei, are characteristic of the lesion.
Volpé classified subacute thyroiditis in four stages:
Stage I – Acute toxicity with painful and swollen gland, thyrotoxic symptoms lasting one to two months.
Stage II – Transition or euthyroid stage, gl. increased in size, hard and not painful, normal MB, elevated erythrosedimentation.
Stage III – Phase of compensation or hypothyroid, occurs two to four months after the start.
Stage IV – Remission or recovery that may occur in one to six months.
Almost all patients show edema and pain of the thyroid that can radiate to the head, neck and anterior chest. Sudden onset, with fever, malaise, fatigue, weakness, menstrual irregularities and weight loss. The white count is usually normal, the erythrosedimentation elevated during the first month.
The uptake of 131 I is low in the acute stage.
Needle biopsy or needle aspiration help with diagnosis.
ACTH and corticosteroids relieve symptoms but do not alter the disease.
It is treated with prednisone, 40 mg daily, salicylates and thyroid hormone.

THYROIDITIS (STRESS) OF RIEDEL
It is a chronic and rare inflammatory process that affects one or both lobes of the thyroid, often spreading to the adjoining fascia, trachea, muscles, vessels and nerves. Some consider it a terminal stage of Hashimoto’s thyroiditis or granulomatous thyroiditis.
Microscopy
The follicles are small and not numerous and there is a dense fibrous tissue.
Scar tissue can cause constriction and narrowing of the trachea.
It may resemble carcinoma based on clinical data.
It is more frequent in women, average age of 50 years.
Symptoms are due to compression of trachea, esophagus and recurrent laryngeal nerve.
In advanced cases there is hypothyroidism and some patients have antithyroid antibodies, the titers are lower than in Hashimoto’s disease.
The treatment is the administration of thyroid hormone, surgery is indicated when there are signs of compression.
It may consist of a section of the isthmus, thyroidectomy or hemithyroidectomy.

BOCIO
FAMILIAR BOCIO
Produced by inherited enzymatic defects, usually associated with hypothyroidism, many remain euthyroid.
The congenital error of the metabolism is inherited as an autosomal recessive trait, sometimes as dominant.
The accumulation of iodine, storage by the gland and coupling of iodotyrosines is altered.

BOCIO ENDEMICO
Thyroid growth that affects a significant number of inhabitants of an area or region.
Among the extrinsic factors is iodine deficiency, in endemic areas its content in drinking water is very low.
Prophylactic administration of iodine added to table salt prevents the problem.
The excess of iodides administered to a patient with endemic goiter produces thyrotoxicosis, a disease known as Jodbasedow.

BOCIO ESPORADICO
Goiter whose definitive cause can not be established once thyroiditis, tumor and endemic goiter have been ruled out.
Hypersecretion of TSH stimulates the growth of the gland.

Pathological anatomy
The thyroid may have diffuse growth and smooth surface or have macroscopic nodules, may present cellular hyperplasia and after administration of iodine, large follicles filled with colloid are visualized
Clinical manifestations
Equal frequency in the sexes in endemic areas, the gland is hyperplasia still more during pregnancy.
In general, they are asymptomatic.
In hospitalized physical and psychological effects of patients with goiter manifest, there may be symptoms of compression, dyspnea, dysphagia; or distension of jugular veins. If patients perceive sudden pain in the neck associated with a rapid increase in size of the same, it can be due to hemorrhage into part of the goiter, cyst or degenerative lesion.
In the early stages of life, endemic cretinism occurs, with osteopathic goiter and mental retardation, associated with poor physical development.
Diagnostic data: Rx torax, to see the trachea, its displacements and compressions, Rx. barium of the esophagus.
T4, T3 and ITL may be normal.

TREATMENT
In goiters by enzymatic and sporadic defect, thyroxine is administered.
The endemic one requires iodides and sometimes thyroxine.
Goiter submerged in the newborn, with risk of tracheal obstruction, may require resection of the isthmus.
In the nodular goiter, hemithyroidectomy, nodulectomy if there are several, and replacement treatment may be indicated, it is advisable to rule out tumor.

Nodules
In the United States each year approximately 1200 people die of thyroid cancer.
Groups at high risk of thyroid cancer
1) Individuals who have been exposed to low dose radiation to the head and neck regions.
2) Those in which another member of the family has medullary carcinoma of the thyroid, since this can be transmitted as an autosomal dominant trait.
Diagnostic tests to differentiate benign and malignant lesions
On physical examination, almost all cancers are hard and irregular.
Nodule of fast and painless growth.
Lymph nodes enlarged.
Fixation of the gland.

Complementary Practices
Radioactive Gammagraphy
Allows you to visualize areas of cold uptake or cold nodules

B-mode ultrasound To
detect if the nodule is cystic, few carcinomas are cystic, with the exception of some papillary tumors.

Puncture biopsy or aspiration puncture.

Patients who have had exposure to radiation and have multiple or solitary nodules, should be operated anyway.

BENIGN TUMORS Benign
adenomas of the thyroid are classified as embryonic, fetal, follicular or microfolic, according to their predominant histological characteristics.
Macroscopy
Injuries wrapped in a defined capsule, surrounded by a thin area of ​​tissue. compressed thyroid
Microscopy:
Uniform architecture
Mitosis rare
No lymphatic invasion or blood vessels.
Clinical manifestations: Slow growth of a nodule.

Bleeding into the tumor can give sudden pain and rapid increase in size.
Gammagraphy indicates warm, warm or cold nodule.

Treatment
Biopsy by puncture or aspiration
Subtotal hemithyroidectomy
Supplementary treatment that reduces recurrences.

MALIGNANT TUMORS
CARCINOMA PAPILLAR
Along with the follicular are known with differentiated thyroid cancers.
Papillary is the most common, accounts for two thirds of thyroid cancers and three-quarters of children.
More than half of the cases manifest before the age of 40, with a maximum frequency in the 3rd and 4th decade of life. More frequent in the female sex 3: 1.

Pathological anatomy
It consists of columnar thyroid epithelium arranged in papillary projections with vasacular connective stems.
It has localized deposits of calcium, concentric, bodies of psamoma.
They often have papillary elements such as follicles.
It is the one that grows more slowly and becomes more malignant with age.
There is evidence that the growth of this tumor is favored by TSH, it spreads to the gland and regional nodes.
In 80% of cases it is multicentric.
You can give Mtts. lungs and bones that accumulate radioactive iodine, especially for their follicular elements and favor their treatment, once the total thyroidectomy has been performed.
Thyroid hormone suppressor doses are indicated after surgery. It has a good prognosis, although it gets worse after 50 years.

FOLICULAR CARCINOMA
It is the predominant element in a quarter of the malignant tumors of the thyroid; the lesion tends to occur in groups of greater age, with a maximum frequency in the fifth decade. It is three times more common in women than in men.

PATHOLOGICAL ANATOMY
Macroscopically, the tumor appears encapsulated. In the histological examination the lesion has follicles, but the cells are crowded and are recognized as an adenocarcinoma. The light of the acini is devoid of colloid.
It presents capsular and vascular invasion.
Multicentricity is much less common than in the ca. papillary.
The malignant potential surpasses that of ca. papillary. Although there may be spread to regional lymph nodes in 15% of cases, hematogenous spread to distant sites such as bone, lung and liver predominates and often occurs early.

Clinical Manifestations
Antec. of goiter
Nodule
Cervical nodes, sometimes
Metastasis that capture iodine
Mtts. lungs and bones.

TREATMENT
subtotal or total thyroidectomy
Removal of committed ganglion chains.
Treatment with suppressive doses of L thyroxine to inhibit TSH.
Treatment with radioactive iodine in doses of 30 mC and if it has MTTS 150 mC.
External radiation therapy is useful when the cancer invades the trachea and esophagus, or for metastatic lesions that do not capture radioactive iodine.
Chemotherapy in cases of tumors with mtts. who no longer take radioactive iodine, doxorubicin is used.

TUMORS OF HURTLE CELLS
Contain sheets of cells with eosinophilic cytoplasm.
Some are evident carcinomas and present invasion of the capsule, metastases to ganglia and other organs.
There are benign lesions that can cause further metastasis.
Total thyroidectomy is recommended in patients with clear signs of carcinoma and in benign lesions, hemithyroidectomy and control.

MEDULAR CARCINOMA
It is a tumor of C cells (formerly called parafollicular), producing calcitonin, which is a hormone that when injected into experimental animals, reduces the serum concentration of calcium by inhibiting bone resorption, in some mammals it is a Functional hormone that prevents hypercalcemia, however in humans this function has never been demonstrated.
C cells are derived from the neural crest and are part of the APUD system.
Anatomia pathológica
Histology
Clusters of round or polyhedral cells, similar to carcinoid cells, or fusiform, similar to fibroblasts, separated by zones of collagen or amyloid are found. The finding of amyloid in the stroma of the tumor is diagnostic.
Tumors vary from a microscopic size to 10 cm. or more in diameter.
In familial cases, bilateral multicentricity always occurs, in sporadic cases it is unique nodules.
It spreads to ganglia and mediastinum, then gives Mtts. distance, lung, liver, adrenal, bone.
58% of the cases are women, 27% of the cases have been family, the tumor of this type is inherited as an autosomal dominant trait.
Symptoms
one or multiple nodules
Cervical
adenopathy Dysphonia or dysphagia
Diarrhea is a common symptom and occurs in 30% of patients.
From 2 to 4% have adrenocortical hyperplasia and Cushing’s syndrome, it has been shown that by ectopic production of ACTH.
Other patients have kidney stones and pheochromocytoma symptoms
This tumor in family cases participates in what is called multiple endocrine neoplasia type II (MEN II).
MEN II A, medullary carcinoma, pheochromocytoma, and hyperparathyroidism.
MEN II B, medullary carcinoma, pheochromocytoma, neuromas in the mucosa of the lips, tongue and conjunctiva, ganglioneuromas of the intestine and marfanoid appearance
Diagnosis
Determination of serum calcitonin by RIA, in a patient with a thyroid mass.
ACE carcinoembryonic antigen

Treatment
They do not respond to radioactive iodine or thyroxine, they do not respond to external radiation, so the treatment of choice is surgical, total thyroidectomy, should be performed unilateral or bilateral lymph node dissection of the neck.

ANAPLASTIC CARCINOMA Undifferentiated
carcinomas constitute 10% of malignant tumors of the thyroid.
They usually appear after 50 years of age.
The ratio between men and women is 1.3: 1 It
can come from a differentiated tumor, 50% of patients are in the 7th or 8th decade of life.
The tumor is not encapsulated and may extend beyond the boundaries of the gland, invading adjacent structures.
Histology
From spindle cells to multinucleated giants, there are numerous mitoses, there may be areas of papillary or follicular carcinoma.
Patients usually present with painful growth of the thyroid, which is often fixed and does not move with swallowing, produces compression and presents nodes.
Progress quickly.
Give mtts. in lungs and bones.
Treatment
Total thyroidectomy, modified neck dissection, definitive tracheostomy in some cases.
External radiotherapy to relieve pain.
The radioactive iodine is not effective.
Some cycles of chemotherapy are performed with Doxorubicin, vincristine and chlorambucil.

LYMPHOMA AND SARCOMA
Lymphoma is rare, many lesions were previously diagnosed as anaplastic carcinomas.
Only 13 cases of Hodgkin’s disease of primary origin in the thyroid have been diagnosed.
When the tumor is circumscribed, total thyroidectomy is indicated, with radiotherapy of the cervical ganglia.

METASTASIC CARCINOMA Thyroid
metastases occur in 2% to 4% of patients who die from malignancy. The bronchogenic carcinomas constitute 20% of the secondary thyroid metastases, in another series the mtts. The most common was hypernephroma, the average age in this series was 56 years.

THYROID SURGERY
Needle biopsy by Vim Silverman
Aspiration biopsy
Nodulectomy
Hemithyroidectomy, also called lobectomy, which may be total or subtotal, leaving a remnant of the gland.
Subtotal or total thyroidectomy.
Total thyroidectomy with unilateral or bilateral cervical lymph node dissection. (Operation command)
A transverse or collar incision is made in the lower region of the neck, skin, cell and musclecutaneo neck section; digital or blunt dissection with gasite mounted up over the superior border of the thyroid cartilage, above and to the suprasternal recess below, in front of the white line, condensation of the superficial cervical aponeurosis and the middle cervical aponeurosis, also called the leaf superficial of the deep cervical aponeurosis.
The white line is opened, the sternocleidohyoid and sternothyroid muscles are refuted, some authors section them close to their superior insertion, so as not to denervar them because the innervation reaches them by the hypoglossal loop from below, the choice of the muscular section depends on the size of the the operative piece at times.
The lobe is lateralized identifying the middle thyroid veins that are ligated and sectioned between double ligatures; this allows to visualize the upper and lower pole.
The suspensory ligament of the gland is sectioned and the superior pedicle, constituted by the superior thyroid artery and veins, is ligated from within, between double ligatures, it must be treated not to injure the superior laryngeal nerve, the external branch of this nerve is the which must be protected.
The gland is then retracted medially and superiorly to identify and ligate the inferior thyroid vessels, and identify the recurrent laryngeal nerve so as not to injure it.
At this point, a total lobectomy can be chosen in the case of a tumor, or a remnant can be left in 2 to 4 gs of posterior thyroid tissue in whom the operation was performed due to primary hyperthyroidism.
During exposure of the posterior surface of the thyroid, the parathyroid and vascular pedicles should be identified and preserved.
By means of cutting dissection, the lobe is then dissected away from the surface of the trachea and the isthmus is then released from the anterior part of the trachea.
If there is a pyramidal lobe, it is removed at this time.
When a lobe is removed by a lesion that is benign, the anterior and posterior edges of the remaining lobe are approximated. In case of hyperthyroidism, where we leave a remnant tissue having previously made a crown of delicate, mosquito-like clamps, such as transient hemostasis of the parenchyma vessels, transfictive points are made of the small pedicles formed and then the outer and inner edges of the parenchyma are approximated. the formed navy.
Hemostasis is controlled, covered with the sternothyroid and sternocleidohyoid muscles, a laminar drainage is left in the surgical area and the white line is sutured. The edges of the upper and lower flaps are sutured, approximating the sectioned edges of the neck musclecutaneo and finally the edges of the skin are approximated with Michel’s agrafes or sutures with mechanical stapler.

HYPOPATHYROIDISM 
This is more frequent as a complication of thyroid surgery, by removal of the gland, trauma or devascularization.
Transient hypoparathyroidism can occur after resection of a parathyroid adenoma, or most of the tissue in a parathyroid hyperplasia.
Idiopathic hypoparathyroidism is a rare disease of unknown cause. Antiparatiroids
have been detected in some of these cases. It may have as a reason for consultation signs of hypocalcemia and a great increase in neuromuscular excitability.
Spontaneous pictures of hypocalcemia and tetany.
Provocative signs: Chvostek When percussing the masseterial region
Trousseau: midwife’s hand is produced by stimulation (carpopedal spasm)
ECG shows prolongation of the QT interval
Treatment with calcium gluconate via EV
oral calcium
In permanent hypoparathyroidism, 50,000 to 100,000 daily units of vitamin D
PTH is dosed in those who are receiving treatment for permanent postoperative hypoparathyroidism, when PTH is detected, the doses of vitamin D are gradually reduced.
Avoid a diet rich in phosphate or oxalate, anticonvulsants and tranquilizers, which reduce the absorption of calcium at the intestinal level.
Avoid the ingestion of estrogens that prevent the removal of calcium bone.
Avoid fursemide that increases the elimination of calcium in urine.

HYPERPARATHYROIDISM 
It can present by hyperplasia, adenomas and even parathyroid carcinomas. Also non-parathyroid tumors that produce a substance similar to the hormone
It is also possible that a patient with a secondary hyperparathyroidism due to kidney or intestinal disease, develop hypercalcemia.
Adenomas of main cells
Adenomas of clear cells
Adenomas of oxyphilic cells
The diagnosis of adenoma is made by the presence of a large hypercellular gland and other normal ones.
Hyperplasias are found in patients with familial hyperparathyroidism and in the NEM.
Parathyroid carcinoma is rare and does not represent more than 1% of the non-selected series. One can think of carcinoma when there is hypercalcemia and a palpable mass in the neck.
The capsular invasion may not be indicative of carcinoma, the post-surgical recurrence is a malignancy data.
The patient’s death is rare due to tumor growth and spread. It is more common that morbidity and mortality occur due to persistent progressive
hypercalcemia. Hypercalcemia can also be produced by mtts. of tumors in bone or by tumors that produce a substance similar to PTH, this clinical syndrome associated with hypercalcemia and hypophosphatemia is called pseudohyperparathyroidism or ectopic hyperparathyroidism.
Hypercalcemia of breast cancer without mtts. Osteos would be due to a sterol similar to vitamin D
Prostaglandin E 2 produces hypercalcemia by stimulating bone resorption and is a causative agent of hypercalcemia that occurs in patients who have malignant tumors.
Hyperparathyroidism occurs very rarely before puberty, the most common age is between 30 and 70 years.
It is more common in women than men, ratio 2: 1
Symptoms
It is manifested by nephrocalcinosis, (decreased renal function). Hypercalcemia, greater elimination of phosphates, which cause a relative urinary alkalosis and renal calcium precipitation.
Fibrous osteitis, (subperiosteal bone resorption) bone demineralization
Arthralgias
Muscle weakness
Recurrent calcium phosphate kidney stones.
Psychiatric symptoms, depression, fatigue
hypertension due to increased calcium and kidney damage.
Ulcers and pancreatitis
Band keratitis
Diagnostic data
Determinations of calcium (elevated), phosphate (low), PTH, alkaline phosphatase (high) and chloride (elevated above 102 meq) Bone
biopsy
Bone Densitometry Bone
x-rays (moth-eaten skull), costal lesions
Radiographs of the kidneys
Location of the hyperfunctioning parathyroid glands.
CT scan of the chest and neck, methionine scan selenium, 99 Tc
The massage of the side of the neck in which the adenoma is found gives an increase of the hypercalcemia, in the opposite side it is negative and maintains its levels.
Selective catheterization of thyroid veins and PTH dosing.