1. There has been a paradigm shift in the surgical management
of Graves’ disease with increased use of total or near-total
thyroidectomy, rather than subtotal thyroidectomy.
2. Familial nonmedullary thyroid cancer is increasingly being recognized
as a separate entity. Surgeons must be aware of the potential for
false negative fine-needle aspiration biopsy in this setting.
3. Total thyroidectomy is the surgical treatment of choice for most
thyroid cancers, provided complication rates are low.
4. The widespread use of positron emission tomography scanning for
staging various malignancies and ultrasound for vascular screening
is leading to an increased incidence of thyroid incidentalomas.
Management should be based on assessment of the individual patient’s
risk following complete clinical and fine-needle aspiration biopsy
5. Focused mini-incision parathyroidectomy, after appropriate localization,
has become the procedure of choice for the treatment of sporadic
6. Parathyroidectomy has been shown to improve the classic and so-called nonspecific
symptoms and metabolic complications of primary hyperparathyroidism.
7. Very high calcium and parathyroid hormone levels in a patient
with primary hyperparathyroidism should alert the surgeon to the
presence of a possible parathyroid carcinoma.
8. Subclinical Cushing’s syndrome is characterized by subtle
abnormalities in corticosteroid synthesis, and many of its manifestations
appear to be treated by adrenalectomy.
9. Fine-needle aspiration biopsy has a very limited role in the
evaluation of adrenal incidentalomas unless the patient has previously
had a cancer and should only be performed after appropriate biochemical
studies have been performed to rule out pheochromocytoma.
10. Adrenocortical cancer can be difficult to diagnose even on pathology
examination so that continued follow-up of patients with resected
seemingly benign tumors is advised.
Goiters (from the Latin guttur, throat), defined
as an enlargement of the thyroid, have been recognized since 2700 b.c. even
though the thyroid gland was not documented as such until the Renaissance period.
In 1619, Hieronymus Fabricius ab Aquapendente recognized that goiters
arose from the thyroid gland. The term thyroid gland (Greek thyreoeides,
shield-shaped) is, however, attributed to Thomas Wharton in his Adenographia (1656).
In 1776, the thyroid was classified as a ductless gland by Albrecht
von Haller and was thought to have numerous functions ranging from
lubrication of the larynx to acting as a reservoir for blood to
provide continuous flow to the brain, to beautifying women’s
necks. Burnt seaweed was considered to be the most effective treatment
The first accounts of thyroid surgery for the treatment of goiters
were given by Roger Frugardi in 1170. In response to failure of
medical treatment, two setons were inserted at right angles into
the goiter and tightened twice daily until the goiter separated.
The open wound was treated with caustic powder and left to heal.
However, thyroid surgery continued to be hazardous with prohibitive
mortality rates (>40%) until the latter half of the nineteenth
century, when advances in general anesthesia, antisepsis, and hemostasis
enabled surgeons to perform thyroid surgery with significantly reduced
mortality and morbidity rates. The most notable thyroid surgeons
were Emil Theodor Kocher (1841–1917) and C.A. Theodor Billroth
(1829–1894), who performed thousands of operations with
increasingly successful results. However, as more patients survived
thyroid operations, new problems and issues became apparent. After
total thyroidectomy, patients (particularly children) became myxedematous
with cretinous features. Myxedema was first effectively treated
in 1891 by George Murray using a subcutaneous injection of an extract
of sheep’s thyroid and later, Edward Fox demonstrated that
oral therapy was equally effective. In 1909, Kocher was awarded
the Nobel Prize for medicine in recognition “for his works
on the physiology, pathology, and surgery of the thyroid gland.”
The thyroid gland arises as an outpouching of the primitive foregut around
the third week of gestation. It originates at the base of the tongue at
the foramen cecum. Endoderm cells in the floor of the pharyngeal anlage
thicken to form the medial thyroid anlage (Fig.
38-1) that descends in the neck anterior to structures that
form the hyoid bone and larynx. During its descent, the anlage remains
connected to the foramen cecum via an epithelial-lined tube known
as the thyroglossal duct. The epithelial cells
making up the anlage give rise to the thyroid follicular cells.
The paired lateral anlages originate from the fourth branchial pouch
and fuse with the median anlage at approximately the fifth week
of gestation. The lateral anlages are neuroectodermal in origin
(ultimobranchial bodies) and provide the calcitonin producing parafollicular
or C cells, which thus come to lie in the superoposterior region
of the gland. Thyroid follicles are initially apparent by 8 weeks, and
colloid formation begins by the eleventh week of gestation.
Thyroid embryology—early development of the
median thyroid anlage as a pharyngeal pouch.
[Reproduced with permission from Embryology
and developmental abnormalities, in Cady B, Rossi R (eds): Surgery
of the Thyroid and Parathyroid Glands. Philadelphia: WB
Saunders, 1991, p 6.]
Duct Cyst and Sinus
Thyroglossal duct cysts are the most commonly encountered congenital
cervical anomalies. During the fifth week of gestation, the thyroglossal
duct lumen starts to obliterate, and the duct disappears by the eighth
week of gestation. Rarely, the thyroglossal duct may persist in whole,
or in part. Thyroglossal duct cysts may occur anywhere along the
migratory path of the thyroid although 80% are found in
juxtaposition to the hyoid bone. They are usually asymptomatic but
occasionally become infected by oral bacteria, prompting the patient
to seek medical advice. Thyroglossal duct sinuses result from infection of
the cyst secondary to spontaneous or surgical drainage of the cyst and
are accompanied by minor inflammation of ...