clinical anatomy of the thyroid and adrenal glands

Clinical Anatomy of theClinical Anatomy of theThyroid and Adrenal GlandsThyroid and Adrenal Glands

Lawrence M. Witmer, PhDLawrence M. Witmer, PhDProfessor of AnatomyProfessor of AnatomyDepartment of Biomedical SciencesCollege of Osteopathic MedicineOhio UniversityAthens, Ohio [email protected]

Handout download:http://www.oucom.ohiou.edu/dbms-witmer/gs-rpac.htm

25 September 2007

http://www.bartleby.com/107/272.html#i1174

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

thyroidcartilage

commoncarotid a.

cricoidcartilage

isthmus

thyroid lobespleuralcupola

From Netter’s Atlas

variation(from

Hollinshead 1968)

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:Preliminary Diagnosis:Tumor of the left lobe of the thyroidTumor of the left lobe of the thyroid

1. Why does the mass move up and down on swallowing?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

Fascia & SpacesFascia & Spaces

Skandalakis’ SurgicalAnatomy 2004

Moore &Dalley 2006

superficialsuperficialfasciafascia

skin

fat

platysma

veins (ant. &ext. jug.) andcutaneous nn.

deep fascia(investing layer)platysma

C7C7


Moore &Dalley 2006

sternocleido-mastoid

Deep FasciaDeep Fascia

3. prevertebral fascia4. carotid sheath

1. investing fascia1. investing fascia2. pretracheal fascia

C7C7


Moore &Dalley 2006


3. prevertebral fascia4. carotid sheath

1. investing fascia2. pretracheal fascia2. pretracheal fascia

a. muscular layera. muscular layerb. visceral layerb. visceral layer thyroid gland

trachea & larynx

esophagus

C7C7


Skandalakis’ Surgical Anatomy 2004

thyroidcartilage

cricoidcartilage

suspensory ligamentsuspensory ligamentof Berryof Berry

visceral layer of pretrachealfascia (false capsule)

true capsule

thyroid gland

pretrachealfascia

Moore &Dalley 2006


Moore &Dalley 2006


3. prevertebral fascia3. prevertebral fascia4. carotid sheath4. carotid sheath

1. investing fascia2. pretracheal fascia

common carotid a. (andsympathetic plexus)

internal jugular v.

vagus n.(and carotid

sinus n.)

deepcervicallymphnodes

C7C7

pretrachealfascia

prevertebralfascia

trachea

Skandalakis’ SurgicalAnatomy 2004

Fascia & SpacesFascia & Spacespretrachealfascia

Moore &Dalley 2006

retropharyngeal(retrovisceral)

space

visceralspace

of Stilescarotidsheath

not discussed today:• suprasternal space of Burns• “Danger space” of Grodinsky & Holyoke

Strap Muscles

sternohyoidsternothyroid

thyroidthyroid

sternocleidomastoid(cut)


thyrohyoid

omohyoid

internal jugular v. cricothyroid

hyoid bone

thyroidcartilage

Attachment of sternothyroid to oblique line on thyroid cartilage prevents superior expansion of thyroid

1. Why does the mass move up and down on swallowing?

2. What can explain the difficulty breathing?2. What can explain the difficulty breathing?



Questions

Thyroid CTC7

sternocleidomastoid

trachea

C7

strap muscles

Thyroid ( )Thyroid ( )

esophagus

From Ellis et al. 1991From Ellis et al. 1991

internaljugular v.

commoncarotid a.

From web reference 1From web reference 1

displaced trachea thyroidtumor

Compression and displacementof trachea by thyroid tumor

normal

normal



3. What structures would be endangered by subtotal or 3. What structures would be endangered by subtotal or total thyroidectomy?total thyroidectomy?


Questions

superior thyroid a.

thyroidthyroid


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


superior thyroid a.

thyroidthyroid


inferior thyroid a.parathyroids

common carotid a.

inferiorconstrictor m.

external laryngeal n.

esophagusrecurrent laryngeal n.

recurrent laryngeal n.

Posterior View




4. Why is the nature of the patient4. Why is the nature of the patient’’s voice of interest s voice of interest postoperatively?postoperatively?

Questions

Skandalakis’ Surgical Anatomy 2004

4% intrathyroid

42% paratracheal

48% tracheoesoph. groove

6% paraesophageal

4%42%

48%

6%C7

variation invariation inrecurrent laryngealrecurrent laryngeal

nerve positionnerve position(n = 204)(n = 204)

Recurrent Laryngeal N.& Suspensory Lig. of Berry



Variation in relationship of recurrentlaryngeal n. to inferior thyroid a.

thyroidthyroid

inferior thyroida. & branches

common carotid a.

recurrentlaryngeal n.



(from Hollinshead 1968)



Variation in relationship of recurrentlaryngeal n. to suspensory lig.

thyroidthyroid



superior thyroida. & v. (cut)

parathyroids

susp. lig.susp. lig.


superficial toligament

deep toligament

splits aroundligament

passes thrugland


From Sasou et al. 1998

thyroidthyroid

inferior thyroid a.recurrentlaryngeal n. trachea

suspensory ligamentsuspensory ligamentof Berryof Berry

Variation in relationship of recurrentlaryngeal n. to suspensory lig.

susp. lig.susp. lig.


superficial toligament

deep toligament

splits aroundligament

passes thrugland

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 lays 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.

cystthyroid

cartilage

From Moore & Persaud 2003

1. What is the embryonic derivation of a thyroglossal cyst?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

Thyroid Development


1. What is the embryonic derivation of a thyroglossal cyst?

2. Why did the mass move upwards on swallowing?2. Why did the mass move upwards on swallowing?

3. Why did the surgeon look for thyroid tissue on the tongue?

Questions

Thyroid Development


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 3. Why did the surgeon look for thyroid tissue on the tongue?tongue?

Questions

Ectopic Thyroid Tissue

Moore & Dalley 2006

thyroid gland

thyroglossal duct

pyramidal lobe

cervical thyroidcervical thyroid

thyroid cartilage

accessoryaccessorythyroid tissuethyroid tissue

hyoid bone

lingual thyroidlingual thyroid

foramen cecum

tongue

Possible Locations of Thyroglossal Duct Cysts


Adrenal Overview


spinalcord

sympathetictrunk

splanchnicnerves

preaorticganglia(celiac,

aorticorenal)

adrenaladrenalcortexcortex

adrenaladrenalmedullamedulla

T10T11T12T13

preganglionicfibers to

chromaffin cellsin medulla

— corticosteroids, androgens

— catecholamines (esp. epinephrine)

From Gray’s Atlas





superior adrenal aa.(from inferior phrenic a.)

adrenaladrenalglandglandmiddle adrenal aa.

(from aorta)

inferior adrenal aa.(from renal a.)

inferior phrenic a. inferior phrenic v.

adrenal v.

left renal v.

IVC (cut)


Perirenal fascia of Gerotaadrenaladrenalglandgland

peritoneum

L2L2L2

Gerota’sfascia

pararenalfat

perirenalfat

Toldt’s fascia(ant. layer of Gerota’s f.)

Zuckerkandl’s fascia(post. layer of Gerota’s f.)

psoasfascia

liverliver

coloncolon

kidneykidney

transversalisfascia

Imaging

aortaIVC

T11

pancreasliver

rightadrenal

leftadrenal

crus of diaphragmFrom Ellis et al. 1991From Ellis et al. 1991

From web reference 3From web reference 3

Adrenal tumor

ReferencesReferencesPrintEllis, 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. and A. F. Dalley. 2006. Clinically Oriented Anatomy. 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.———. 1997. Atlas of Human Anatomy, 2nd. Ed. Novartis, East Hanover.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.

Web1. Thyroid tumor: http://www.auntminnie.com/ScottWilliamsMD2/nucmed/Tumor/Thallium/Thallium.htm2. Adrenal surgery: http://www.emedicine.com/med/topic3018.htm3. Adrenal surgery: http://www.surgery.wisc.edu/general/patients/endocrine.shtml4. Gray’s Anatomy of the Human Body: http://www.bartleby.com/107/

clinical anatomy of the thyroid and adrenal glands

Documents