外科宫颈疾病.pptx

Cervical DiseaseContentAnatomy & Function1Common Cervical Disease2Surgery & Risks3Anatomy LocationThyroid catilageC2-C4 tracheal ringLocation & AdjoinLocation & AdjoinSuperior laryngeal nerveParathyroid glandRecurrent laryngeal nerveNormal ThyroidCervical Lymph NodesCervical Lymph nodes Level I: Submental and Submandibular nodes Level Ia: Submental triangle Level Ib: Submandibular triangle Level II: Upper Level III: Middle Jugular nodes Level IV: Lower Level V: Posterior triangle group Level VI: Anterior triangle group Level VII: Upper mediastinal nodescentral groupFunctions of ThyroidFunctions of ThyroidThyroid HormonesSynthesis, Storage, SecretionControls How Quickly the body uses energy, makes proteinsControls How Sensitive the body is to other hormonesCalcium HomeostasisCalcitoninContentAnatomy & Function1Common Cervical Disease2Surgery & Risks3Common DiseasesSimple Goiter Hyperthyroidism Thyroid Adenoma ThyroiditisBenignPapillary cacinoma Follicular cacinoma Anaplastic cacinoma Medullary cacinomaMalignantStrict Operation IndicationSurgical Comprehensive TreatmentSimple GoiterSimple GoiterFirst Symptomsbe felt as a lump in the throatThyroid Nodulesbe seen as a lump in the front of the neckGenerally no systemic symptoms, the BMR is normal; Early diffuse symmetrically, then nodule emerge (enlarge quickly), turns into Simple GoiterManifestations1Tracheal compression (most common)2Oppress Recurrent laryngeal nerve (hoarseness)3Oppress Esophagus (dysphagia)Simple Goiter may turns to Secondary Hyperthyroidism & CancerationSimple GoiterSimple GoiterSimple GoiterEtiology: Iodine Deficiency;-Synthesize & Secrete Disable.Prevention: Iodine salt.Therapy : 1. Physiological Goiter in Pubertas or Gestation period = Foods rich in iodine; 2. Diffuse Goiter 4cm) Goiter affect normal life & beauty.Choice of Surgical Procedure Nodule extirpation Partial thyroidectomy Subtotal thyroidectomy (Near) total thyroidectomy HyperthyroidismHyperthyroidismHyperthyroidismprionClassificationPrimary hyperthyroidism85%-90%, diffuse enlargement, bilateral symmetry , exophthalmos, autoantibody(+), secrete high levels of T3, T4Thyroid adenoma(10% canceration): no exophthalmos, tissues around the thyroid atrophySecondary hyperthyroidismafter nodules, above 40y, asymmetry, no exophthalmos, myocardial damage easilySurgery Indicationsa) Secondary Hyperthyroidism or Hyperactive Adenoma ；b) Moderate or above Primary Hyperthyroidism ；c) Large gland hyperthyroidism, accompanied by compression symptoms or Substernal goiter;d) Recurrence after ATD or I131 treatment (adult 1-2y, children 3m) or Intolerance of drugs;e) Huge, suspect canceration；f) Early and mid-term pregnancy with the above indications (3-6m, operate during mid-term pregnancy ）.Contraindication: Adolescent hyperthyroidism Medullary Follicular Papillary Rare lymphatic sarcoma,.IRVulnerable PopulationPathologyMetastasisPrognosisPapillary Cancer70%35-40y femaleDifferentiate well,Grow slowly,Multicenter trend,Low malignancy degreeLymph node metastasis in early phase95% 10y survival rateFollicular Cancer15%Female around 50yOutgrow,Moderate malignancy degreeBlood metastasis tendency, only 10% lymph wayModerateMedullary Cancerrare35-40yOriginated in the follicle cells (C cell), no acinar structures, with amyloidosis; secrete Calcitonin/5-HT; Moderate malignancyBlood & lymph node metastasisModerateAnaplastic Cancer5-10 %old peopleOutgrow,Highly aggressive50% lymph node metastasis in early phase, invade around,blood metastasis Poor,An average of 3 to 6 monthsMedullary carcinoma can secret :calcitonin (Low calcium symptoms); 5-HT (carcinoid syndrome, diarrhea, palpitation, facial flushing).May combine MEN.Manifestation Local compression symptoms Local invasion symptoms：esophagus，sympathetic nerve（Horner sign），recurrent laryngeal nerve（hoarseness, difficulty breathing），superficial branch of cervical plexus （skin of ear, neck, occiput , shoulder feel pain）； Possible family history（ medullary thyroid carcinoma, Parathyroid Adenoma, pheochromocytoma ） lymph node metastasis.Lymph node cleaning sequence： VIIVIIIIIVIChoice of Surgical ProcedureCentral Compartment DissectionLateral Compartment DissectionLateral Compartment DissectionEndocrine Endocrine therapy: control TSH in low level; no heyperthyroidism is principle; regular monitoring. Medications: firstpostoperation feedback inhibition the secretion of to prevent recurrence;radioactive iodine treatment is invalid.Radioactive nuclide therapy : destroy hidden lesions in residual glands; detect recurrence & metastasis; elevate the value of TG as tumor markers after surgery.for advanced unresectable; should not be surgery;distant metastasis: total thyroidectomy is necessery;Radiotherapy: Anaplastic carcinoma with poor prognosis , non-operative therapy firstThyroiditis & AdenomaThyroiditis & AdenomaThyreoiditisSubacute ThyroiditisChronic Lymphocytic Thyroiditis (Hashimoto thyroiditis) Etiology : May be virus infection . Clinical feature: After upper respiratory tract infection , thyroid pain & discomfort. Therapy: has obvious curative effect. Attention: No Antibiotics !Etiology : Autoimmune DiseaseClinical feature: Diffuse GoiterTherapy: Replacement TherapyThyroid NoduleThyroid AdenomaPapillaryFollicular 2 typesyoung femalesSolitary nodule, poor growth, canceration rate: hyperactive adenoma, Symptoms of hyperthyroidism concurrently;Surgery first.ContentAnatomy & Function1Common Cervical Disease2Surgery & Risks3Types of ThyroidectomyNear total thyroidectomy Partial thyroidectomy Subtotal thyroidectomyTotal thyroidectomyHemithyroidectomyHartley Dunhill operationComplication Superior laryngeal n.injuryDyspnea & AsphyxiaHypoparathyroidismOthersLaryngeal recurrent n. injuryThyroidectomyThyrotoxic CrisisPostoperative ComplicationsA) Dyspnea & Asphyxia: most critical; 48h after operation Hematoma Laryngeal edema Tracheal collapse Bilateral laryngeal recurrent nerve injuryPostoperative ComplicationsB) Laryngeal recurrent nerve injury: Temporary or Permanent Manifestation: Unilateral injury cause Hoarseness; Bilateral injury cause Aphonia, Dyspnea.Laryngeal recurrent nerve Risk Factors: huge lump, oppress or invade nerve, second (multiple) surgery, etc.Postoperative ComplicationsC) Superior laryngeal nerve injury: Manifestation： Internal branch injury: Water Choke to Cough; External branch injury: Vocal cord Slack, Weak Pronunciation, 3w Recovery.Postoperative ComplicationsD) Hypoparathyroidism: gland 1 can maintain normal function Manifestation: in most cases Hypocalcemia; 1-7d after operation, Chvostek & Trousseau (+). Treatment: Severe: Ca2+ supplements iv. 10% Calcium Gluconate 10ml 45min iv. Mild & moderate: VitD3+ Ca2+ supplementsHypoparathyroidism Risk Factors: second (multiple) surgery, huge lump, located on the back side, etc.Protection of ParathyroidPostoperative ComplicationsE) Thyrotoxic crisis (thyroid storm) : rare but severe; may occur when a thyrotoxic patient becomes very sick or physically stressed. Manifestation: in 2d, progress fast: fever39, HR 120-140bpm, associated with Vomiting, Watery diarrhoea, Dysphoria, Coma, Delirium or Indifference of sleepiness, low BP, Systemic lupus etc. Treatment: Symptomatic treatment; Medicine：PTU first choice.Postoperative ComplicationsF) Others: Hypothyroidism(1y), Relapse(5y), damage of trachea, esophagus or cervical large blood vessels, infection of incision, etc.After the removal of a thyroid, patients usually take a prescribed oral synthetic thyroid hormone - Levothyroxine (Synthroid) - to prevent hypothyroidism.Common neck mass部位部位单发性肿块单发性肿块多发性肿块多发性肿块颌下颏下区颌下腺炎、颏下皮样囊肿急、慢性淋巴结炎颈前正中区甲状舌管囊肿、甲状腺疾病颈侧区囊状淋巴管瘤、颈动脉体瘤、血管瘤急、慢性淋巴结炎、淋巴结结核、转移性肿瘤、淋巴瘤锁骨上窝转移性肿瘤、淋巴结结核颈后区纤维瘤、脂肪瘤急、慢性淋巴结炎腮腺区腮腺炎、腮腺肿瘤Scar on the neckEndoscopic ThyroidectomyScarless neck essential for human beautyEndo-Breast AreolaEndo-AreolaAfter CCDPost-Operation