QuestionSBA
QuestionChoice
Hypocalcemia is an important complication of thyroid surgery due to disruption of parathyroid gland function. However, there are no symptoms of hypocalcemia described
32485
c
IV calcium gluconate
QuestionChoice
High flow oxygen is an important immediate step in management given that the patient is desaturating due to airway obstruction. However, the most appropriate definitive management step is to relieve the obstruction by evacuating the haematoma
32486
d
High flow oxygen
QuestionChoice
This patient has acute airway obstruction secondary to a neck haematoma. Neck haematoma is a life-threatening complication of thyroid surgery and can present with signs of airway obstruction (e.g. stridor, respiratory distress), dysphagia, hoarseness and a painful neck mass. Definitive management is with an urgent return to theatre to open the stitches and evacuate the haematoma
32483
a
Open stitches and evacuate haematoma
QuestionChoice
Steroids may be used as a supportive measure to reduce oedema that may be contributing to airway obstruction in this context; however, it is not the definitive step in management
32487
e
IV methylprednisolone
QuestionChoice
Although stridor is a feature of anaphylaxis, the clinical context suggests airway obstruction secondary to a neck haematoma
32484
b
IM adrenaline
Concept
Chapter
# Summary

Thyroid cancer, although an uncommon malignancy, is the most prevalent cancer of the endocrine system. It encompasses several types, including papillary, follicular, medullary, anaplastic, and thyroid lymphoma. These types differ in frequency, age of presentation, metastatic patterns, associated conditions, and prognosis. Key diagnostic investigations include thyroid ultrasound, fine-needle aspiration, and measurement of serum thyroid-stimulating hormone (TSH) and calcitonin levels. Management strategies are largely determined by the type and stage of thyroid cancer, and generally involve surgery, radioactive iodine treatment, external beam radiation, targeted therapy, or chemotherapy.

# Definition

Thyroid cancer is a malignant tumour that originates in the cells of the thyroid gland, a butterfly-shaped organ located at the base of the neck that produces hormones that regulate the body's metabolism.

# Aetiology

Thyroid cancer results from genetic changes or mutations that allow cells to grow and multiply rapidly. The accumulation of these abnormal cells forms a tumour. The type of thyroid cancer is determined by the specific cell type within the thyroid that has become cancerous.

# Types of Thyroid Cancer

1.  **Papillary Thyroid Cancer**: Constitutes around 70% of all cases (think **P**apillary = **P**opular). Generally presents between 30-40 years of age and can metastasise to bone and lung. Small tumours carry an excellent prognosis.
    
2.  **Follicular Thyroid Cancer**: This type is more common in areas with low iodine and among women, and typically presents between 30-60 years of age. It tends to metastasise to lung and bones rather than locally invade.
    
3.  **Medullary Thyroid Cancer**: Comprising around 5% of thyroid cancer cases, it originates from calcitonin-producing C-cells. It can present with hypocalcaemia and diarrhoea due to increased calcitonin. While 75% of cases are sporadic, it is associated with Multiple Endocrine Neoplasia (MEN) syndrome type 2A and 2B. Metastasis often occurs to lymph nodes, and the prognosis is worse than papillary and follicular carcinoma.
    
4.  **Anaplastic Thyroid Cancer**: The rarest form, it generally presents between 60-70 years old. Characterised by its aggressive nature, patients present with rapidly growing masses. The prognosis is extremely poor with a median survival rate of 8 months.
    
5.  **Thyroid Lymphoma**: Accounts for 10% of thyroid cancers and is typically Non-Hodgkins lymphoma. It is mainly seen between 50-80 years old and is strongly associated with Hashimoto's thyroiditis.
    

# Signs and Symptoms

While the symptoms vary depending on the type of thyroid cancer, some common signs and symptoms include a lump or swelling in the neck, voice changes, difficulty swallowing, pain in the neck and throat, and persistent cough.

# Differential Diagnosis

The differential diagnosis for a patient presenting with a thyroid mass includes:

1.  **Benign thyroid nodules**: Often asymptomatic, may present with compressive symptoms like dysphagia and dyspnea.
2.  **Thyroiditis (Hashimoto's or De Quervain's)**: Pain and swelling of the thyroid gland, with Hashimoto's often presenting with hypothyroid symptoms.
3.  **Thyroid cyst**: A fluid-filled sac in the thyroid, often asymptomatic but may cause neck swelling.
4.  **Goitre**: Swelling in the neck due to enlarged thyroid gland, often accompanied by hypothyroid or hyperthyroid symptoms depending on the cause.

# Investigations

Thyroid cancer investigations include thyroid ultrasound for imaging of the gland, fine-needle aspiration for cytology, and measurement of serum thyroid-stimulating hormone (TSH) and calcitonin levels to determine the function of the gland and the activity of medullary thyroid cancer, respectively.

# Management

Management of thyroid cancer is dependent on the type and stage of the disease, but strategies typically involve:

1.  **Surgery**: Thyroidectomy or lobectomy, often followed by radioactive iodine treatment.
2.  **Radioactive Iodine (RAI) Treatment**: Used post-surgery to destroy remaining thyroid tissue and treat thyroid cancer cells throughout the body.
3.  **External Beam Radiation Therapy (EBRT)**: Employed in inoperable cases or to relieve symptoms in advanced disease.
4.  **Targeted Therapy**: Used for advanced or metastatic disease, including tyrosine kinase inhibitors.
5.  **Chemotherapy**: Used sparingly, often in combination with radiation for anaplastic thyroid cancer.

## Complications of Thyroid Surgery
-   **Hypocalcaemia** may arise due to accidental injury or removal of the parathyroid glands during thyroid surgery. Symptoms include tingling in the hands and face, muscle spasms, and, at its most severe, ventricular arrhythmias.
-   **Hypothyroidism** is a guaranteed outcome of total thyroidectomy and may occur following a partial thyroidectomy. Patients will need to be on lifelong thyroxine replacement therapy post-surgery.
-   **Damage to the recurrent or superior laryngeal nerves** results from surgical interference with these nerves. This leads to hoarseness and dyspnoea. Management of laryngeal nerve damage may involve speech therapy or reconstructive surgery.
-   **Neck haematoma** arises from post-operative bleeding within the neck. Can be confirmed with USS or CT, but if threatens airway function requires immediate surgical intervention.
-   **Thyrotoxic storm** can occur due to the manipulation of the thyroid gland in a patient who is hyperthyroid. Management of thyrotoxic storm includes beta-blockers, antithyroid medications, and supportive care.

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Quesmed Tutorial: Thyroid Disease
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The definitive management of acute airway obstruction due to a neck hematoma is an urgent return to the operating theatre to open the stitches and evacuate the hematoma, relieving the obstruction.
A 43-year-old woman is recovering following a total thyroidectomy the previous day. The surgical notes reveal an uncomplicated operation, and all observations post-operatively have been normal.

The on-call doctor is called to see the patient urgently as her oxygen saturations have dropped acutely to 90% on room air. On assessment, the patient can speak in short sentences only and is using her accessory muscles. Examination of the lung fields are unremarkable; however, there is an intermittent high pitched sound heard on inspiration and an erythematous neck swelling.

Which of the following is the most appropriate definitive step in management?
a