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Anatomy & Pathologyof the Thyroid
Teresa M Bieker, MBA, RT, RDMS, RDCS, RVT
Lead Diagnostic Medical Sonographer
University of Colorado Hospital
Denver Colorado
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Objectives
• Anatomy and Pathology of the thyroid and surrounding structures
• Identify suspicious characteristics of thyroid nodules
• Types and occurrences rates of thyroid cancers
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Embryology of the Thyroid
Formation of the thyroid begins approximately at the 4th week of gestation
The two lobes are connected by the thyroglossal duct (at the level of the tongue)
By the 7th week, the thyroid should be descended to the level of the trachea
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Anatomy of the Thyroid Right and left lobes are located
anterolateral to the trachea & esophagus Right and left lobes are connected midline
by the isthmus Size (adults)
Length: 4-6cm AP: 1.3-1.8cm Isthmus: 4-6mm
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Neck Muscles
Strap muscles (anterior) sternohyoid sternothyroid omohyoid
Sternocleidomastoid (lateral) Longus colli (posterior)
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Neck Vessels
Thyroid Vessels superior thyroid arteries and veins inferior thyroid arteries and veins
Major Neck vessels carotid artery jugular vein
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Function of the Thyroid
Produce, store, secrete thyroid hormones
Thyroid hormones are important for: Proper growth Development Metabolism Body temperature Heart rate/rhythm
Iodine metabolism: converts iodine from food into thyroid hormones
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Thyroid Hormones
TSH (Thyroid Stimulating Hormone) T3 (Triiodothyronine) T4 (Thyroxine) Calcitonin Antibodies Thyroglobulin (TG)
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Thyroid Hormones
• TSH: – Stimulates the thyroid to produce T4 and
then T3. – Controlled by the pituitary gland
• T4/T3:– Produced by the thryoid
• TSH/T4 work together
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Thyroid Hormones• Calcitonin
– Produced by the thryoid– Helps to regulate calcium levels
• Antibodies– Typically present in autoimmune thyroid
diseases (Graves, Hashimoto’s)• TG
– Produced by thyroid tissue– Tumor marker
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Indications for Neck Ultrasound• Palpable enlargement• Abnormal thyroid hormone levels• Palpable mass• Swelling in the neck• Asymmetry of the neck• Redness and/or tenderness• Difficulty swallowing• Post thyroidectomy evaluation
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Scanning Technique Patient Position
Supine with neck extended Elevating the head 20o in larger
patients may be helpful Neck rotation
Transducer Frequency 7-15 MHz
Image optimization Scanning Planes
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Congenital Anomalies Pyramidal lobe
10-40% of patients Arises superiorly from isthmus
Shape variations Missing isthmus “H” shape
Ectopia (rare, follows embryological path) Agenesis
One lobe Complete
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Pyramidal lobe
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Agenesis of the Right Thyroid
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Diffuse Thyroid Pathology
Hyperthyroidism (Grave’s Disease) Hypothyroidism Thyroiditis
Acute Chronic
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Hyperthyroidism (Grave’s Disease) Overproduction of thyroid hormone
Low TSH, high T3, T4 Causes
Abnormal hormone production Pituitary tumor Thyroid nodule/neoplasm
Symptoms: Increased metabolism Weight loss, increased appetite Nervous energy Tremors Excessive sweating Palpitations Heat intolerance Fatigue Exophthalmos
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Hyperthyroidism (Grave’s Disease)
Sonographic Appearance: Enlarged Heterogeneous Hypervascular
Treatment: Radioactive iodine Medication Surgery
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Hypothyroidism Under secretion of hormone production
High TSH, low T3, T4 Causes
Low intake of iodine Thyroid hormone failure Pituitary disease
Symptoms: Weight gain Hair loss Increased tissue around eyes Intellectual and motor slowing Cold intolerance Constipation Deep voice Myxedema (coma, life threatening)
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Hypothyroidism
Sonographic appearance Variable in size and echogencity
Treatment Medication
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Acute/Subacute Thyroiditis Acute
Rare, caused by bacterial infection Painful, firm, enlarged thyroid, may see
abscess Patients have neck swelling, fever, pain
Subacute (de Quervain’s Disease) Diffuse inflammatory disease Painful enlarged thyroid Thyroid appears large and hypoechoic
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Chronic Thyroiditis-Hashimoto’s Autoimmune disease, often resulting in
hypothyroidism Increased risk for papillary thyroid cancer Symptoms
Cold intolerance, weight gain, fatigue Sonographic appearance
Enlarged, hypoechoic, heterogenous thyroid with fibrous strands
May have scalloped edges Multiple lymph nodes “Burned out” thyroid late in disease
Treatment (medication)
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Hashimoto’s Thyroiditis (early)
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Hashimoto’s Thyroiditis (burn out)
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Riedel’s Thyroiditis
• Rare• Thyroid tissue is replaced by dense
fibrous tissue• Thyroid is hard (stone-like) and fixed• Can cause tracheal compression• Can treat with steroids and possible
surgery
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Benign Focal Thyroid Pathology
Colloid Adenomas Goiters Cysts
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Colloid Nodules• Colloid is product of the thyroid that
consists of thyroglobulin and serves as a storage reservoir for thyroid hormones
• Reservoirs can form within the thyroid and fill with colloid and colloid crystals
• Anechoic with echogenic focus/foci with comet tail artifact
• Overwhelmingly benign
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Insert colloid pix
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Adenomas Usually benign Single or multiple Normal labs unless functioning Sonographic appearance
Focal with smooth borders May have hypoechoic “halo” May have rim calcification Range in size and echogenicity
Patients are usually asymptomatic
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Adenoma
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Goiter Thyroid is enlarged (can have neck tightness
difficulty swallowing) Causes:
Iodine deficiency Hereditary Medications
Can be associated with Graves disease Toxic vs Non Toxic Goiter:
Toxic: Nodules are functioning, causing changes in lab values
Non Toxic: non functioning
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Goiter
Sonographic appearance Multiple nodules Nodules vary in size and echogenicity Heterogeneous gland
Treatment & Symptoms depend on thyroid size and hormone levels
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Goiter
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Cysts True cysts are uncommon Cystic appearing lesions are usually
degenerating adenomas or colloid nodules
Sonographic appearance: display cystic characteristics may have internal echoes and irregular walls
Alcohol ablation is a treatment option
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Cysts
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Malignant Pathology
Papillary Carcinoma Follicular Carcinoma Medullary Carcinoma Huthle Cell Carcinoma Anaplastic Carcinoma (Giant Cell) Lymphoma Metastasis to Thyroid
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Papillary Carcinoma
Most common type of thyroid cancer Cause usually unknown, but more common in
females Symptoms:
Palpable nodule Asymptomatic Thyroid hormones can be normal or
abnormal Slow growing, least aggressive thyroid cancer Spreads through lymphatic system
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Papillary Carcinoma Sonographic appearance
One or multiple nodules with irregular borders
Typically hypoechoic, but can vary Microcalcifications (strong sign) Increased internal vascularity May see multiple central or lateral
lymph nodes Treatment
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Follicular Carcinoma Second most common thyroid cancer More common in females Not aggressive but can metastasize Tends to spread through bloodstream Sonographic appearance
One or multiple nodules with irregular borders Vary in echogenicity, may have calcifications Increased internal vascularity Thick, irregular halo
Treatment
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Medullary Carcinoma Often familial More aggressive than papillary or follicular Often secretes calcitonin Likely to metastasize to lymph nodes Sonographic appearance
Hypoechoic mass(s) that may contain multiple calcifications
May also have lymph node/liver metastases Treatment
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Hurthle Cell Uncommon Not aggressive but likely to
metastasize (nodes, blood, lungs, bone)
Sonographic appearance is variable Treatment
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Anaplastic (Giant cell) Least common, most aggressive, most
lethal Neck is tender, mass is hard and fixed Rapidly growing Invades neck muscles, vessels, trachea Sonographic appearance
large hypoechoic mass Treatment
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Lymphoma
• Typically non-Hodgkin’s type• Rapidly growing, hypoechoic, lobulated
mass• Prognosis varies depending on stage
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Metastsis to Thyroid Typically from melanoma, breast and
renal cell Primary is typically diagnosed Patients feels neck fullness, palpable
mass Sonographic appearance
Solid, homogeneous, hypoechoic without calcifications
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Parathyroid Glands Anatomy Hormones Pathology
Adenomas Hypoparathyroidism Hyperparathyroidism
primary secondary
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Parathyroid Anatomy Four parathyroid glands
2 superior 2 inferior (more variable in location)
Normal glands are small 1 x 3 x 5 mm
Function Produce parathyroid hormone which
regulates blood calcium levels
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Parathyroid Adenomas
Typically just one gland is affected Sonographic appearance
enlarged round homogeneous and hypoechoic
Treatment
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Hypoparathyroidism
Post thyroidectomy complication Clinical diagnosis Symptoms:
Numbness at mouth, then into extremities Seizures Cardiac arrhythmias/arrest
Temporary or chronic Treatment:
Calcium and Vitamin D supplements (IV and oral)
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Primary Hyperparathyroidism Usually caused by functioning adenomas High calcium levels during routine lab work
Symptoms: Often asymptomatic Can develop fatigue, depression, weakness Severe symptoms: constipation, confusion, painful
bones, renal stones Sonographic appearance
Enlarged Round Homogeneous and hypoechoic
Treatment
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Secondary Hyperparathyroidism Found in patients with chronic renal failure
unable to produce vitamin D leading to decrease in calcium levels. More parathyroid hormone is produced trying to increase calcium levels
Sonographic appearance enlarged parathyroids, often bilateral
Uncommon (due to the success of dialysis)
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Secondary Hyperparathyroidism
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Salivary Glands
Location Parotid Submandibular Sublingual
Appearance Pathology
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Salivary Glands• Parotid
– Anterior to ear, largest gland, triangular• Submandibular
– Deep to mandible• Sublingual
– Under tongue, small, not seen well by ultrasound
• Sonographic appearance– Homogeneous and echogenic
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Salivary Gland Pathology
Susceptible to infection and inflammation
Patients can have swelling, pain, fever Ultrasound helpful in identifying
possible fluid collections or abscess
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Other Neck Lesions
Thyroglossal Duct Cyst Branchial Cleft Cyst Carotid Body Tumor
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Thyroglossal Duct Cyst Congenital anomaly Located midline, anterior to trachea More commonly seen in children Sonographic appearance
Anechoic to hypoechoic Can contain debris or fluid level
Treatment
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Branchial Cleft Cyst Fetal remnant Located slightly to the right or left of midline
and anterior to the sternocleidomastoid Sonographic appearance
Anechoic to hypoechoic Can contain debris or fluid level
Treatment
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Carotid Body Tumor/Paraganglioma Rare, typically benign, slow growing Usually unilateral, located at carotid
bifurcation, and fed by the ECA Patients feel neck mass or have a
sudden change in blood pressure Sonographic appearance
Round, smooth borders Typically hypervascular
Treatment
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Carotid Body Tumor
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Thyroid Nodule Summary
Benign Nodules: Wider then tall Cystic Hyper/iso/
hypoechoic Thin halo Well defined Course calfications Peripheral flow
• Malignant Nodules:– Taller then wide– Hypoechoic– Thick, incomplete
halo– Absent halo– Spiculated– Microcalcifications– Internal flow