Clinical Anatomy of the Thyroid and Adrenal Glands
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1 Clinical Anatomy of the Thyroid and Adrenal Glands Handout download: 28 October 2003 Lawrence M. Witmer, PhD Department of Biomedical Sciences College of Osteopathic Medicine Ohio University Athens, Ohio
2 thyroid cartilage common carotid a. isthmus 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 4 th or 5 th tracheal ring Attaches to cricoid cartilage via suspensory ligament cricoid cartilage variation (from Hollinshead 1968) pleural cupola From Netter s Atlas thyroid lobes
3 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
4 Questions 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?
5 pretracheal fascia investing fascia platysma sternohyoid Cervical Fascia sternothyroid buccopharyngeal fascia thyroid alar fascia trachea sternocleidomastoid recurrent laryngeal n. carotid sheath parathyroid prevertebral fascia From Netter s Atlas
6 Strap Muscles thyroid cartilage sternocleidomastoid (cut) hyoid bone thyrohyoid omohyoid sternohyoid sternothyroid internal jugular v. cricothyroid thyroid From Netter s Atlas Attachment of sternothyroid to oblique line on thyroid cartilage prevents superior expansion of thyroid
7 normal strap muscles trachea Thyroid CT C7 esophagus Compression and displacement of trachea by thyroid tumor Thyroid ( ) displaced trachea thyroid tumor internal jugular v. common carotid a. C7 sternocleidomastoid From web reference 1 normal From Ellis et al. 1991
8 superior thyroid a. superior thyroid v. external laryngeal n. cricothyroid m. Anterior View Vascular Supply & Relations pyramidal lobe thyroid middle thyroid v. internal jugular v. pretracheal lymph node inferior thyroid a. common carotid a. inferior thyroid v. From Netter s Atlas recurrent laryngeal n.
9 superior thyroid a. Posterior View Vascular Supply & Relations external laryngeal n. inferior constrictor m. thyroid inferior thyroid a. parathyroids recurrent laryngeal n. common carotid a. esophagus From Netter s Atlas recurrent laryngeal n.
10 common carotid a. thyroid Recurrent Laryngeal N. & Suspensory Lig. of Berry inferior thyroid a. & branches recurrent laryngeal n. Variation in relationship of recurrent laryngeal n. to inferior thyroid a. From Netter s Atlas recurrent laryngeal n. (from Hollinshead 1968) inferior thyroid a. & branches
11 superior thyroid a. & v. (cut) thyroid Recurrent Laryngeal N. & Suspensory Lig. of Berry Variation in relationship of recurrent laryngeal n. to suspensory lig. susp. lig. superficial to ligament deep to ligament parathyroids inferior thyroid a. & branches From Netter s Atlas recurrent laryngeal n. passes thru gland (from Hollinshead 1968) splits around ligament
12 suspensory ligament of Berry thyroid Recurrent Laryngeal N. & Suspensory Lig. of Berry Variation in relationship of recurrent laryngeal n. to suspensory lig. susp. lig. superficial to ligament deep to ligament recurrent laryngeal n. trachea From Sasou et al inferior thyroid a. passes thru gland (from Hollinshead 1968) splits around ligament
13 Case Presentation 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. cyst Preliminary Diagnosis: Thyroglossal Cyst thyroid cartilage From Moore & Persaud 2003
14 Questions 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?
15 Thyroid Development From Moore & Persaud 2003
16 Ectopic Thyroid Tissue From Moore & Persaud 2003
17 Possible Locations of Thyroglossal Duct Cysts From Moore & Persaud 2003
18 sympathetic trunk T13 T12 T11 T10 spinal cord Adrenal Overview splanchnic nerves preganglionic fibers to chromaffin cells in medulla preaortic ganglia (celiac, aorticorenal) From Gray s Atlas From Netter s Atlas adrenal cortex adrenal medulla corticosteroids, androgens catecholamines (esp. epinephrine)
19 inferior phrenic a. inferior phrenic v. superior adrenal aa. (from inferior phrenic a.) Vascular Supply & Relations middle adrenal aa. (from aorta) adrenal gland inferior adrenal aa. (from renal a.) adrenal v. IVC (cut) left renal v. From Netter s Atlas
20 pararenal fat adrenal gland Perirenal fascia of Gerota transversalis fascia Toldt s fascia (ant. layer of Gerota s f.) peritoneum liver kidney L2 colon Gerota s fascia perirenal fat From Netter s Atlas Zuckerkandl s fascia (post. layer of Gerota s f.) psoas fascia
21 Imaging Adrenal tumor liver IVC aorta pancreas right adrenal left adrenal From web reference 3 T11 From Ellis et al crus of diaphragm
22 References Print Ellis, H., B. Logan, and A. Dixon Human Cross-Sectional Anatomy: Atlas of Body Sections and CT Images. Butterworth-Heinemann, London. Hollinshead, W. H Anatomy for Surgeons: Volume 1. The Head and Neck, Second Edition. Harper & Row, New York. Moore, K. L. and A. F. Dalley Clinically Oriented Anatomy. Lippincott, Williams, & Wilkins, Baltimore. Moore, K. L. and T. V. N. Persaud The Developing Human: Clinically Oriented Embryology. Saunders, Philadelphia. Netter, F. H The CIBA Collection of Medical Illustrations, Volume 8: Musculoskeletal System. CIBA-Geigy, Summit Atlas of Human Anatomy, 2nd. Ed. Novartis, East Hanover. Sasou, S., S. Nakamurak, and H. Kurihara Suspensory ligament of Berry: its relationship to recurrent laryngeal nerve and anatomic examination of 24 autopsies. Head & Neck 20: Younes, N. A., and D. H. Badran The cricothyroid space: a guide for successful thyroidectomy. Asian Journal of Surgery 25(3): Web 1. Thyroid tumor: 2. Adrenal surgery: 3. Adrenal surgery: 4. Gray s Anatomy of the Human Body:
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