THYROID/PARATHYROID

Thyroid gland,

1. Pretracheal fascia:
a. surrounds thyroid
b. Extends from hyoid bone to
fibrous pericardium
c. Encloses trachea, larynx,
pharynx, thyroid
d. Parathyroids and venous
plexus lie between layers
 Investing layer of DCF

Pretracheal fascia
 Muscular portion of
Investing layer of deep cervical fascia pretracheal layer of DCF

Pretracheal layer
of dcf
 Thyroid gland

• Surrounded by thin fibrous capsule of

connective tissue
• External to this is pretracheal fascia
derived from deep cervical fascia
• Attached to cricoid and thyroid cartilages
• Thus, moves up and down with larynx
during swallowing
 omohyoid

Investing sternohyoid
layer

scm

sternothyroid
omohyoid

sternohyoid

sternothyroid
 I. Introduction/General Information
A. Thyroid
1. Endocrine gland
a. Lobes are cone shaped
b. Apex extends to oblique line
of thyroid cartilage
2. Highly vascular
 Thyroid, General Information, continued …

3. Anterior & lateral to

larynx, trachea
4. Lobes connected by
an isthmus
5. Pyramidal lobe may
be present
6. Normally not
palpable
 The Thyroid Gland

• Located in the
anterior region of the
neck
 Thyroid Gland, Anterior and Posterior Views

Thyroid Gland: anterior view (left); and posterior view (right)

Thyroid, General Information, continued …

8. Isthmus crosses tracheal

cartilages 2-4
9. Base located ~4-6th tracheal cartilage
10. Thyroxin function: regulates basic
metabolism in all cells
II. Detailed Anatomy
A. Thyroid
1. Largest endocrine gland
2. Extends fr C-5 to T-1
3. Highly vascular
4. Weighs ~20 - 30 grams
 Thyroid gland

• Clasps the pharynx,

larynx, esophagus and
trachea like a shield
• Lies deep to
sternothyroid and
sternohyoid
• Each lobe [5cm]
extends to level of 6th
tracheal cartilage
 Thyroid gland
• Size varies greatly
• Larger in women
• Enlarges dur pregnancy
• May enlarge slightly dur menstruation
Thyroid, Detailed Anatomy, continued …

5. Pyramidal lobe
a. present in ~ 33% of population.
b. Extends upward from isthmus
c. anterior to thyroid cartilage
Thyroid, Detailed Anatomy, continued …

d. Embryologic remnant of
thyroglossal duct
e. formerly connected cecum of
tongue to thyroid diverticulum
f. Site of developing gland
Pyramidal Lobe of the Thyroid Gland

Pyramidal Lobe

Thyroid Gland, Anterior View

Thyroid, Detailed Anatomy, continued …

c. Lobes:
1. Attached to cricoid cartilage
by ligaments
2. Medial surface adapted to
larynx and trachea
 Thyroid, Detailed Anatomy, cont …

3. Lobes related posteriorly to the

esophagus
4. Posterolateral surface
a. related to carotid sheath
b. overlaps carotid artery
 Thyroid, Detailed Anatomy, con’t…

d. Isthmus
1. 1.25 cm x 1.25 cm
2. Crosses @
tracheal rings ~2-4
3. Rarely absent
Thyroid gland vascular, continued …

6. Highly vascular gland supplied by four large arteries

a. R & L inferior thyroid artery
b. R & L superior thyroid artery
 BLOOD SUPPLY (THYROID GLAND)
• Superior thyroid artery
• 1st anterior branch of
External Carotid Art
• Descends the lateral part of
the neck under the superior
belly of omohyoid and
sternothyroid muscles
• Above the level of the
superior pole, accompanied
by the external laryngeal
branch of the superior
laryngeal nerve
 BLOOD SUPPLY (THYROID GLAND)
• Nerve parallels artery until
it reaches the superior
lobe where it courses
under the sternothyroid to
insert in the cricothyroid
muscle
• High ligation of STA may
affect nerve
• Dysphonia, denervates
CT muscle (regulation of
pitch)
• No sensation to mucosa
of pyriform sinus and
false vocal cords
 BLOOD SUPPLY (THYROID GLAND)
• Inferior thyroid artery
• Arises from the thyrocervical
trunk
• Branch of 1st part of
subclavian artery level of the
1st rib
• Ascends vertically for a short
distance before turning
medially, forming an arching
loop and entering the
tracheoesophageal groove
 BLOOD SUPPLY (THYROID GLAND)

• Most of branches penetrate posterior

aspect of lateral lobe
• Anastomoses with STA near the superior
pole
• Small vessels intermingle with recurrent
laryngeal nerve
Thyroid gland vascular, continued …
Venous drainage
a. Superior thyroid vein  int jugular vein [ IJV ]
b. Middle thyroid vein IJV
c. Inferior thyroid veinbrachiocephalic vein

Inferior
Thyroid
Vein
 BLOOD SUPPLY (THYROID GLAND)

• 2 pairs of arteries
– Superior thyroid a
– Inferior thyroid a
• 3 pairs of veins
– Superior thyroid v
– Middle thyroid v
– Inferior thyroid v
 Sup thyroid art and vein

Middle thyroid
vein

Inf thyroid artery

Inf thyroid vein

Thyroid gland, continued …

Lymph vessels
1. In interlobular connective
tissue between lobes
2. Connect with network in wall of
gland
3. terminate in thoracic and
right lymphatic ducts
Surgical Anatomy:
Lymphatics
 Thyroid gland, continued …

Muscular landmarks
a. Sternocleidomastoid
muscles lie laterally
b. Longus colli (prevertebral)
muscles lie posteriorly
c. “Strap” muscles lie
anteriorly

Strap Muscles
Thyroid gland, continued …

Autonomic innervation via

a. Cervical portion of sympathetic
trunk
b. Parasympathetic fibers arise from
Vagus X
 INNERVATION (THYROID GLAND)

• Autonomic nervous
system
• Parasympathetic
fibers ~ vagus nerve
• Sympathetic fibers ~
superior, middle,
inferior sympathetic
ganglia of the
sympathetic trunk
 Sympathetic trunk

Recurrnt laryngeal
nerve [Vagus]
Detailed Anatomy, continued …

Treatment considerations
a. Superior thyroid artery is
accompanied by superior
laryngeal nerve
b. Inferior thyroid artery is
accompanied by recurrent
laryngeal nerve
 Detailed Anatomy, continued …

c. Damaging nerves
results in partial or total
paralysis of larynx
SLN injury – unable to
reach high pirch
RLN injury –VC
paralysis, hoarse voice
II. Parathyroid glands

1. Usually four – two on each side

(2 to 8 is normal)
2. Posterior surface of thyroid
3. Embedded w/in thyroid gland
4. Regulate calcium/phosphate levels
5. Required for life
 Parathyroid Glands (Post. view of thyroid)

Parathyroid Glands are located on the posterior aspect

of the thyroid; sometimes the tissue is embedded
within thyroid tissue.
 Parathyroid Gland, Detailed Anatomy

B. Parathyroid glands
1. Yellow-brown
2. ovoid or lentiform structures
3. weigh ~ 50 mg each
4. Measure 3-10 mm x 2-6 mm x 1-4 mm
Parathyroid Glands, con’t….

5. Lie between posteromedial

thyroid lobes and carotid sheath
6. Close proximity to:
a. Tracheoesophageal groove
b. longus colli muscles
Parathyroid Glands, continued …

7. Position of superior glands is more

predictable
8. Aberrant glands may lie between
trachea and thyroid
9. Blood, lymphatic and nerve supply:
same as for thyroid
 Parathyroid Gland Anatomy
• Four Parathyroid
glands are usually
found posterior to
the thyroid gland
• Weight =50mg each
• Parathyroid hormone
(PTH) is made by
these glands
 PARATHYROID GLAND

• Superior pair ~ posterior aspect of the

superior pole of the lateral lobes of the
thyroid gland and close to the recurrent
laryngeal nerve (constant location)
ANATOMY (PARATHYROID GLAND)

• Inferior pair ~ posterior aspect of the

inferior pole of the lateral lobes of the
thyroid gland
• Pathologic enlargements of the inferior
PTG may extend to the trachea and
esophagus
• Maintain serum calcium and phosphorus
levels
Parathyroid g
34F w/ anterior neck mass
III. Thyroid/Parathyroid Diseases
A. Ultrasound useful in differentiating
cystic from complex or solid masses
B. Thyroid Cysts
1. Typical cystic appearance
2. Colloid cysts
3. Thyroglossal duct cysts
Pathology, cont…

3. Thyroid scan
Warm, hot or cold nodule
4. Only 20% of thyroid masses are
simple cysts
 END
• Lab on Monday
• Radioanatomy lec on Tue/Thurs
• Lab again on Friday
• Exam on Jan 22
Pathology, cont…

C. Structures of Carotid Sheath

1. Jugular vein, carotid artery
2. Delineate lateral aspect of thyroid
3. Jugular vein lateral to carotid artery
a. vein has greater diameter
b. Is distensible on valsalva
maneuver
Transverse Section of Thyroid Gland

Trachea

Thyroid Gland, Left Lobe

Sternocleidomastoid Muscle

Internal Jugular Vein

Common Carotid Artery

Brachial Plexus
Esophagus
Gray-Scale anatomy, continued

D. Thyroid is more homogeneous and

echogenic than surrounding muscle
1. Sternocleidomastoid (lateral)
2. Longus colli (posterior)

E. US is less helpful w/ complex masses

or diffuse parenchymal disorders
Gray-Scale Anatomy, continued …

F. Parathyroids are difficult to see

1. Size and location are variable
2. Usually:
a. moderately echogenic
b. well-circumscribed
c. capsule around
d. anterior to longus colli
e. medial to common carotid a.
Parathyroids, continued …

3. Longus Colli (“prevertebral”) Muscles

a. Attachments:
1. O = cervical vertebrae
2. I = cervical vertebrae
b. Action: twists, bends neck
c. Lie posterior
IV. Thyroid Diseases
A. Metastasis from thyroid cancer
1. May invade local structures
a. trachea
b. esophagus
c. carotid artery
d. jugular vein
Thyroid Diseases, con’t…

2. Innervation may be involved

a. Voice, speech changes
b. Horner’s Syndrome of eye
1. droopy eye
2. dryness
3. small pupil
 Thyroid Diseases, continued …

B. Cystic Masses
1. Colloid cyst:
a. Contains thyroglobulin
b. May have hemorrhagic center
c. May be aspirated
Thyroid Follicles showing Colloid

Thyroid Follicles
with colloid
containing Thyroid
hormones
Thyroid Diseases, continued …

2. Branchial cleft cyst

a. Usually more cephalic
b. Non-closure of a branchial
cleft
c. lie laterally
Thyroid Diseases, continued …

3. Thyroglossal Duct Cyst

a. Lies @ midline
b. Represents non-closure of
thryoglossal duct
c. Congenital anomaly:
1. retention of tract
2. between thyroid and
foramen cecum
Thyroglossal Duct Cyst, Thyroid Disease, continued …

d. Usually surrounded by hyoid

bone
e. More frequently diagnosed in
pediatric age groups
f. may be asymptomatic
Thyroid, continued …

g. Incidence in patients undergoing

thyroid surgery:
1. 4% have this cyst
2. 28% of those with the cyst
are > 50 years old

h. Symptoms: painless swelling at

midline of neck
Thyroid, continued …

i. Treatment:
1. excision of cyst & central
hyoid bone
2. < 1% accompanied by
cancer

j. Account for ~ 70% of

congenital cysts of neck
k. may appear at any location
along duct
 Thyroid Diseases, continued …

C. Complex/Solid Masses (Neoplasm)

1. Adenoma
a. Well-encapsulated
b. Usually solitary
c. Homogeneous
Thyroid Diseases, Adenomas, continued …

c. May be complex, with

1. sonolucent halo
2. echogenic center

d. 50% of thyroid cancers are

papillary adenocarcinomas
2. Complex  solid masses show
increased malignancy
 Adenoma of the Thyroid Gland

• Note atrophy of the left

lobe with the tumor
protruding from it
• Right lobe may
hypertrohy to
compensate for loss of
function in L. lobe
Thyroid, continued …

3. Goiter
a. Enlargement of thyroid gland
b. due to insufficient iodine
c. Gland appears nodular with
irregular outline
d. Grossly enlarged
Goiter, continued …

e. Nodules have variable

echogenicity
f. Treatable with iodine in diet
g. More common inland, and
before iodized salt
 Types of Goiters

Simple Goiter (L) and Nodular (Toxic) Goiter (R)

D. Parathyroid Diseases
1. Benign adenoma
a. Relatively common
b. usually results in
hyperparathyroidism
2. Cancers are rare
3. Surgical excision gives > 90%
cure rate
 Parathyroid Diseases

• Pathogenesis of
Hyperparathyroidism
– PTH increases blood
calcium levels
– Acts on bone,
kidneys, small
intestines
Hyperparathyroidism

Long-term Effects on the Skeletal System