General Surgery
SMLE
Endocrine
Abdulqader Taha Almuallim
PGY5 General Surgery Resident
© Abdulqader Almuallim 2024 - All Copyrights reserved
Triple
Assessment of
Thyroid
Clinical Radiological Histopathological
History and
Physical US FNA
Examination
Thyroid swelling
TSH
High Low
(Hypothyroidism) (Hyperthyroidism)
US and FNA
According to Thyroid Scan
TIRAD
Hot Nodule Cold Nodule
Ablation or
FNA
Medical therapy
TIRADs
TIRAD1 TIRAD2 TIRAD3 TIRAD4 TIRAD5
Benign Not Mildly Moderately Highly
suspicious suspicious suspicious suspicious
No FNA FNA FNA
No FNA FNA (>1cm)
(>2.5cm) (>1.5cm)
F/U F/U
F/U (>1cm)
(>1.5cm) (>0.5cm)
Bethesda
system
I II III IV V VI
Non-diagnostic Follicular neoplasm Suspicious for
Benign AUS/ FLUS / Suspicious for Malignant
or unsatisfactory follicular neoplasm Malignancy
Molecular
Repeat US Follow-up Repeat FNA Lobectomy Lobectomy
testing
Molecular Total Total
Lobectomy
testing Thyroidectomy Thyroidectomy
Lobectomy
Hashimoto’s
thyroiditis
• Autoimmune thyroiditis.
• Most common cause of goitrous hypothyroidism.
• Presentation: Hypothyroidism, Painless, firm, rubbery
enlargement
• Dx: TSH, T4/T3, Ant-microsomal and Antithyroglobulin
antibodies
• Tx:
• Self limiting.
• Levothyroxine
Grave’s disease
• Autoimmune thyroiditis.
• Most common cause of Hyperthyroidism.
• Diffuse enlargement, thyrotoxicosis, exophthalmos and pretibial
myxedema
• Tx:
• Medical: Methimazole, PTU and B-Blocker.
• Radioactive iodine ablation.
• Surgical: Total thyroidectomy.
Grave’s disease
• Methimazole:
• 1st line therapy.
• Used in pre-operative period.
• SE: Rash. Pruritis and Agranulocytosis.
• PTU:
• 1st trimester pregnancy.
• Methimazole not tolerable.
• SE: Hepatotoxic.
• B-Blocker: Non-selective (Propranolol)
Grave’s disease
• Radioactive iodine ablation:
• Preferred for medical therapy without significant risk of
radiation induced cancer.
• Worsen eye symptoms.
• SE: Worsen Arrythmia in elderly, teratogenic.
• Surgical therapy:
• Obstructive goiter, Side effect of anti-thyroid drugs, pregnancy,
intolerance or contraindication to radioactive iodine.
• Total or near total thyroidectomy.
• Should be done when patient is euthyroid.
Thyroglossal
duct cyst
• The most common congenital anomaly in the neck.
• It is connection between thyroid gland and base of the
tongue.
• Presentation: Swelling, sinus or abscess.
• Diagnosis:
• FNA: Colloid material with some squamous cells.
• US: To confirm the presence of normal thyroid in the neck.
• Treatment:
• Surgical excision: Sistrunk procedure.
• When infected: Antibiotics (No Drainage)
Thyroid Cancer
• Papillary/Follicular:
• Well differentiated tumors.
• Papillary (Most common) Follicular (2nd most common)
• T1 (< 2cm) T2 (>2-4 cm) T3 (3a >4 | 3b: Invades strap muscles) T4 (4a-
Invades prevertebral fascia 4b- Major neck or mediastinal vessels)
• N1 (LN Metastasis).
• Staging (Age <55)
• Stage I: Any T | Any N | M0
• Stage II: Any T | Any N | M1
• Staging (Age >55)
• Stage I (T1, N0, M0) | Stage II (T1-3, N0-1, M0) |Stage III (T4a, Any N, M0)
Stage IV (T4b, Any N, M0) (Any T, Any N, M1)
Thyroid Cancer
• Papillary
• Tx: Surgical Management:
• Tumor >1cm (Total thyroidectomy)
• Tumor <1cm + Average risk patient (Hemithyroidectomy)
• Total thyroidectomy recommended for patients <15 years old, or
previous neck radiation.
• Follicular:
• Total thyroidectomy for any proven cancer.
Thyroid Cancer
• Medullary
• Parafollicular in origin.
• Slowly growing.
• More aggressive (LN Metastasis in 80%).
• Need screening for MEN IIa and IIb.
• Tx:
• Total thyroidectomy with central LN Dissection.
• Follow-up:
• Thyroglobulin (Papillary/Follicular)
• Calcitonin (Medullary)
Hyperparathyroidism
• It can be 1ry, 2ry or 3ry
• Primary: duo to functioning adenoma, Hyperplasia or carcinoma.
• Secondary: duo to conditions of hypocalcemia.
• Tertiary: duo to autonomous functioning after renal transplant.
Presentation:
• 70% Asymptomatic
• signs and symptoms of hypercalcemia.
Hyperparathyroidism
• Diagnosis:
Hyperparathyroidism PTH Calcium Phosphate
Primary High High Low
Seconday High Low High
Trtiary Very High High High
Persistent/Recurrent
hyperparathyroidism
• Persistent: evidence of hyperparathyroidism immediately or within 6
months of the surgery. Caused by:
• Missed or Ectopic adenoma/hyperplasia.
• Residual/metastatic disease of parathyroid cancer.
• Dissemination of adenoma after rupture of capsule.
• Recurrent: Occurs after 6 months. Caused by:
• Hyperfunction of the remaining normal glands.
For Contact:
ATMuallim
