Glándula tiroidea humana: Importante para la vida
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Transcript of Glándula tiroidea humana: Importante para la vida
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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
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
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/