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Hello, everyone and welcome to our medical education event today. Um which everything is great. Everything is great. Mohammed. Thank you very much. Um, we are here. I'm joined by um Miss Narayan. I should have checked how to say your name. I do apologize. Um It's gonna be super interactive. We've got about nine or 10 questions for you to answer that will pop up on your screen and we want you to answer those. It's really important that you do cos we want this to be interactive. Um If you're using your phone, what you'll see, you'll see the slide come up with a question on it. If you just click the chat box on your phone, you will then be able to pick your choice. Ok? You'll still be able to hear us, you'll still be able to hear everything, but if you're on a phone, you'll need to click the little chat box. Otherwise if you're in er, on a laptop, it'll pop up on your screen and you'll see it. Ok? Um As always pop your questions in the chat and we'll get, we'll get to them right at the end of the event. Probably and then your feedback form will be emailed to you and your attendance certificate will be on your middle account once you filled out your feedback form. Ok. So I'm gonna hand you straight over and I'll be in charge of the polls. Ok. Thank you very much. Thank you, Sue. Lovely to meet you all today. Um Well, I'm Miss Naan and currently on leave from my job as local consultant, NT which enables me to do a little bit of teaching. And today's topic is a thyroid nodule, a clinical dilemma. The main focus of my talk today would be clinical applications in all these areas. So, um how does the knowledge of epidemiology help you with your patient um face to face, relevant anatomy, embryology as relevant to surgery. Um a very focused examination investigation. And then finally, this allows you to practice evidence based management. There are some fun quizzes along the way and that those enable you to interact and give me a little bit of feedback so that we know we're all on the same page. So here we go. So 4 to 7% of the population are understood to have palpable thyroid nodules and this increases to 19 to 67% when if we used a tool such as the ultrasound to investigate the neck. Sadly of these up to 5 to 15% depending on which part of the world um you are in. Um these thyroid nodules can be malignant certain areas in the world such as the Himalayan mountain region are known to be iodine deficient. And so there's a higher prevalence of thyroid disease in such areas. Chernobyl and Fukushima nuclear disasters um created areas of nuclear fallout where it's been noted that benign and malignant thyroid nodules have been on the increase. So if you look at the general population, patients who are older and more women suffer thyroid nodules, it's also been found that obesity uh or patients with higher BMI have higher risk of thyroid nodules. So when you take history in a patient who has come to your clinic, for instance, you would focus on family history of previous thyroid cancers as, as a predilection for higher risk in such individuals, uh have they had radiation exposure previously. And also um it's more common to have malignancy in the male patient with thyroid nodule very briefly. Uh We'll go over physiology mainly because it allows you to um provide appropriate medical management in your patients with a thyroid nodule. For example, if somebody had had surgery and you need to check what medication they are on and how it affects their system, so that the brain, the hypothalamic region produces uh thyro uh tropin releasing hormone and that then affects the anterior lobe of the pituitary, which then creates thyroid stimulating hormone, which is released into the blood. And that targets the receptors in the thyroid gland, the thyroid gland, as you know, produces what is popularly known as T three and T four. The thyroid hormones. Tyrosine is a um amino acid which then binds with iodine. Um using the enzymes tyrosine kinase and they produce mono and diiodothyronine which then bind together and form T three and T four. Um tri iodothyronine and tetraiodothyronine. Um there is a feedback mechanism such that when T three and T four increase in the blood stream, um this has a feedback effect on the hypothalamus, pituitary and thyroid axis. So, when T three T four increases, TSH decreases, it then reduces the amount of hormone produced by the thyroid gland. So this means that we um can monitor the patient by checking the thyroid stimulating hormone levels, uh and T three T four levels in the blood in a particular patient anatomy. Again, this is just applied anatomy. So the largest endocrine gland of the body is the thyroid gland and it releases its hormones directly into the blood. It's therefore a ductal gland. By the 24th day of gestation, the embryo starts developing from the 1st and 2nd pharyngeal pouches, uh the thyroid and enlarge and this develops in the area called the foramen cecum, which is in the base of the tongue. And then it travels down uh in front of the hyoid bone, in front of the thyroid cartilage and down to its final resting position forming a butterfly like uh thyroid gland, enveloping the second to four tracheal rings in the midline and then extending um around the thyroid cartilages. In terms of its blood supply, it receives that from the uh external branch of the uh carotid. So, external carotid artery gives off the superior thyroid artery, which uh is found at the superior pole of the thyroid. It's also supplied by the inferior thyroid artery, which comes from the thyrocervical trunk, arising from the subclavian artery and that supplies uh the mid and lower portions of the thyroid gland. Uh It crosses the recurrent laryngeal nerve, uh which supplies the intrinsic muscles of the larynx are responsible for movements of the vocal cords. This nerve runs in the trachea of aal groove behind the thyroid gland closely related to it and can potentially be damaged during thyroid surgery. It also loops around the aortic arch as it ascends into the neck behind the thyroid gland um and can be damaged in the uh mediastinum on the, that's on the left side, on the right side, the nerve is a little bit more superficial and loops around the uh subclavian artery. And so it right it anatomically during surgery, you'll find that it lies a little bit more obliquely on the right side and more vertically and a little bit deeper on the left side. The veins drain um via the superior, middle and inferior thyroid veins into the brachycephalic eventually. So, um move to the next slide. So when you take a history, you would ask about when they developed the thyroid nodule, the duration, how long has it been present? Has it suddenly presented itself? Which means that you're suspecting a thyroid cyst or hemorrhage, um, into the swelling or it could have been present for a long time and somebody told them at home, oh, you've got a swelling. Uh, they may have pressure symptoms saying that they've suddenly started coughing, change in voice, breathlessness on lying down, pressure symptoms affecting their swallow. They may have symptoms of hyper underactive thyroid disease such as tremors, weight loss, weight gain change in the um skin. For example, it's also important to take a general medical history. So that you have an idea as to, are they fit for surgery? Should they require this? Are there any blood thinners? Um Do they have co PD condition of the heart and the lungs? Um examination classically involves um looking at the neck. So you would ask them to remove clothing and expose from the clavicle to the mandible, the entire area of the neck. And um you would examine um in by look, listen and and for you methods. So examination would be classically directed at where is the lump on the left? Right in the midline? How many lumps are there? Are there any other swellings like lymph nodes? Is the patient? Breathless, is a noisy breathing. Um Is a change in voice. Do they sound hoarse? You would then ask permission to feel the neck, you'd stand behind the patient, put your hands around, bring and feel the um swelling. See if you can get below the swelling. And if you can't, this would be a sign that you should consider a retrosternal extension of the thyroid gland into the chest. Does it feel cystic soft, firm, hard? Can you move it? Does it look as though it's fixed to adjacent structures? You can ask the patient to swallow um and see if this moves a digluta. Um but you can see and also feel with your hands. So we also examine um the vocal cords that to this is nowadays done with a fiber optic laryngoscope pass through the nose and you ask the patient to phonate, say e and check for vocal cord movements. This confirms that patient has normal vocal cord movement or vocal cord palsy. As the case may be previously, we used to use the mirror introduced through the mouth. Um You get the patient to extrude the tongue and hold uh hold it with your left hand, use the mirror with your right. And um you would need to use some kind of ding um method so that you can see clearly vocal cord movements in the mirror. So just gives me a bit of a rest. So this is a question for you. Please put your answers on the pole. What structures in the neck move with the dilatation? Are you swallowing? So the larynx, thyroid, thyroglossal cyst pretracheal lymph nodes, all of the above or just one of them just give you 30 seconds to answer. So, so most people have said um all of the above which would be true. The question would be why, why do all of these structures move when you swallow? Because they're all attached to the larynx, which is enveloped along with the thyroid, gland, thyroglossal cyst if it's present and pretracheal lymph nodes in something called the cervical um visceral fascia or pretracheal fascia. That's correct mahmud. So, um this is the deep part of the deep cervical fascia which attaches the thyroid gland by a condensation called Berry's ligament attached to the cricoid cartilage. So, when you swallow, that would move unless it's um the lump is malignant and it's attached to other structures. Similarly, the lymph nodes are also enveloped in the pretracheal fascia or subvisceral fascia and they will move when you swallow. The only additional factor is in thyroglossal cyst. When you ask them to ask the patient to protrude the tongue, then they um the thyroglossal cyst will move um but not the other structures because often the thyroglossal cyst is attached to the hyoid bone which uh will move with the tongue. Yes. Um That is correct. There is ligament attaches to the uh cricoid cartilage. So when you move your larynx, all of these structures will move. Um Next question, your cardiothoracic surgeon has sent you a patient postoperatively following heart surgery or some other cardiothoracic procedure. What do you think that this patient is likely to have? That's great. Um Most of you got that answer right? It's hoarseness of voice. Um Because as I explained previously in the anatomy, um section, the left recurrent laryngeal nerve winds around the aortic arch and because of its longer course in the mediastinum in the chest as it runs towards the neck, uh from the vagus nerve, it can potentially get damaged by conditions in the chest, including cardiac surgery, uh or any lung tumor, for example. So, um it can also get damaged to post thyroid surgery and it is the left which is more uh prone to damage uh by cardiothoracic events because it runs along a course on the left side. Um It can also be damaged by following spinal surgery. So these are the three main things to think of when patient comes to you with vocal cord palsy, particularly on the left side or change in voice. And you may have colleagues from the cardiothoracic department or the spinal team sending your patients for examination. So we'll go to the next question. Where is the principal blood supply of the thyro uh for the thyroid gland come from superior middle or inferior thyroid arteries, thyroid, aema artery, all of the above. So it's actually the inferior thyroid artery which supplies the majority of the blood supply. It also the thyroid gland. I mean, also has dual blood supply from the opposite side because um small blood vessels cross the midline, supplying from both sides. We talk a lot during thyroid surgery of the difficulty. And there are special techniques to ligate the superior thyroid artery um to prevent damage to the external branch of the superior laryngeal nerve during surgery. However, it is the inferior thyroid artery which supplies majority of the blood to the thyroid gland. Um You're right, all of them, the middle thyroid artery is very rarely present but and thyroid aema artery arises from the brachiocephalic. And uh again, it's only present in 4% but all of them do supply the thyroid gland. Thank you for that. The next question is what type of cells make up the thyroid gland, epithelial cells, follicular cells, parafollicular cells secretory cells, all of the above. So it's all of the above and the principal cells which make up the thyroid gland. The functional unit is the follicular cell which then forms follicles and they um produce colloid which contains the thyroid hormones that said the parafollicular cells uh create the C cells contain c cells which produce calcitonin. They're all secretory cells because the endocrine gland secretes hormones. Um The follicular cells are epithelial cells. They arise from the endo endodermal um layer in the pharyngeal pouches. So, yes, all of these cells are present in the thyroid gland. The last question for now, which of the following are thyroid hormones, thyroglobulin, triiodothyronin, tetraiodothyronine, calcitonin, diiodothyronine, all of the valve. So the thyroglobulin is not a hormone, it's a protein. So it's formed in the thyroid follicle and it, um, most of it remains inside the gland, but a small amount extrudes into the arterial blood supply. And therefore, this can be, is used as a tool for monitoring patients, um, who've had thyroid surgery, a total thyroidectomy and radioactive iodine ablation. We'll be coming to this a little bit later again. But thyroglobulin is a protein. All the others are thyroid hormones. Diiodothyronine is a precursor hormone. Um, so I see not many people got that right. Calcitonin is also a hormone produced from thyroid glands and it's used to monitor medullary thyroid cancer investigations. So when a patient comes to you, you have examined them and they're quite anxious, you're going to offer some investigations so that you can come to a diagnosis. So, um your principle, the investigation would be the ultrasound scan of the neck. And um in this country, we do something called ultrasound guided fine needle aspiration, which also provides you um cytology, uh which means that it allows you to sample the cells which are found in the thyroid nodule, which allows you then to figure out whether the thyroid nodule is benign or malignant. Very occasionally, we may request CT chest and neck, uh or MRI of the neck and CT of the chest depending on which hospital you're working in. Um This is because the patient may present, not only with a thyroid nodule, but they may also have lymph nodes in the neck, um, or they have chest symptoms and you're suspecting a retrosternal goiter, which means that the thyroid gland is uh has descended into the chest. Um, occasionally. Um, now and again, you may get a referral saying this patient has undergone a pet scan and there's been a pick up in the thyroid gland and they want you to investigate this further. You do the same investigate by doing an ultrasound and ultrasound guided needle aspiration. Um but most commonly, the uptake on a pet scan is seen in autoimmune thyroiditis, or thyroid, primary thyroid malignancy. Every patient will also need free T three T four and TSH blood test to check the thyroid function status. Are they e thyroid, which means normal hormone levels or are they hypothyroid? Meaning low T three T four and high TSH. Remember the feedback mechanism or they are hypofunctioning, meaning they have low T three T four. So, um if they have hyperfunctioning thyroid nodule, then free T three T four will be elevated and TSH would be suppressed. Um If you're suspecting hyper active thyroid nodule graves disease or hypothyroidism, then you would do thyroid autoantibodies also um such as TPO or thyroid peroxidase autoantibody or thyroid stimulating hormone receptor antibody. Um I would advise strongly to look up the British Thyroid Association guidelines which describe the ultrasound appearances and classify them as U 1 to 5 So the radiologist will class uh look at the ultrasound appearance of the thyroid gland, the thyroid nodule and tell you are there multiple nodules? What is the size of the nodule? Uh are both lobes of the thyroid affected? Um What does it, the architecture of the nodule look like? Are there any calcification spots inside? What is the blood, uh vascularity looking like and so on? And based on these findings, they will classify the nodule as U one which is a normal thyroid U two, which is benign or U 34 or five in America, they use the thyroids classification and the results are expressed S tr 1 to 5 based on a point system, I'll give you references for this at the end um which will be shared and so you can then uh download these classifications for your reference. Um We look at the needle aspiration results and the pathologist would classify this as th 1 to 5 uh which goes from benign to malignant cells which helps you. Then as a clinician, make a decision with your patient as to what you would offer the patient next in America, they would use the Beth Testa system and this has six diagnostic categories. In addition, the TNM classification will help you to explain prognosis to your patient um If you're dealing with uh thyroid cancer. So the British Thyroid Association classification says, um so your ultrasound report would say you one, this means that the, it may have felt like a nodule to you. But when they did an ultrasound examination, they found the thyroid gland to be normal. U two means benign thyroid. Um gland U three means indeterminate. They are unable to say whether this is cancer or not cancer. Uncertainty exists. Um U four is suspicious for malignancy and U five, it looks like it's definitely malignant on ultrasound. So the thyrax which is thyroid imaging, um radiology and data uh reporting, sorry thyroid imaging reporting and data system classification, which is used in America goes from T one to T tr 1 to 5 and is roughly similar to this tr one in that case means it's benign. Um T two, tr two is nonsuspicious and the others go from mild, moderate to highly suspicious for cancer. So, um if the once the ultrasound has been done, your radiologist may say no, this is benign. The patient doesn't need a needle aspiration, doesn't need um any cytology done. In which case, you just reassure the patient. And that is the end of the matter. If they are worried about it, you could potentially offer them a one year follow up to see if there's any new changes and you could repeat an ultrasound. But in this country, we mostly discharge them. So um if it is T sorry, U three, U four or U five on ultrasound, then the patho uh radiologist will go on to put a needle and take some sampling from the thyroid nodule. It's called fine needle aspiration cytology. Um It's done on an outpatient basis and you might get the following uh categories as a report. So the report is described as Tai 1 to 5. And Taiwan means that the cytology was inadequate to give a diagnosis or it's drawn fluid and blood and it looks like it's a cyst. But the cells are not enough to say whether it's benign or not. In type two, they have enough cells to say this is benign. And you can reassure your patients that they could leave the thyroid swelling alone. It doesn't require surgery. It um you can just reassure and discharge them. However, if there is some concern, let's say that the thyroid ultrasound says ac three and but on needle aspiration, it comes back as thy two. In which case, you would then suggest that they have a repeat ultrasound, guided needle aspiration and say uh three months or six months. So ty three means indeterminate. It's not clear whether this is definitely malignant and T three A which is a subcategory shows that there are some atypical cells which raises worry. And T three F means it looks like there are follicular cells in the sample. And this could be because it's a follicular adenoma means it's a benign or it could be a follicular carcinoma. Um That being the case, um we would uh T three F um along with Ty four, which is suspicious for malignancy and TY five, which is definitely malignant. We would just, um, discuss these patients at the thyroid MDT and then, uh, consider a management plan if it's thy three F sometimes, um, we may choose to repeat ultrasound, guided FNA, a fine needle aspiration, or you may just go offer surgery to the patient uh, without further investigations. Now, in America, they follow the Bethesda system and it has six categories which roughly approximates to the Thai 1 to 5 in the UK. Um You can download this from the internet decision making. I would get uh advice, becoming familiar with the nice guidelines um which are followed in the UK which allows you to make a management plan. So I have more or less told you um using the previous slide, what needs to be thought about when you get a result such as Taiwan, you would just offer repeat sampling. OK? If it's th one C meaning it's cystic nodule and the cells you got are insufficient. You would also offer repeat sampling in type two and type two C which is benign. Um Yes, you can consider a repeat ultrasound in say three or six months or if the ultrasound showed you two, which is benign, then you could even discharge the patient. And if they have further concerns, you can advise them to come back for a further investigation in the future. So T three A um you would request repeat sampling, repeat, ultrasound, guided fine needle aspiration or to get more cells, you could consider something called a core needle biopsy, which is uses a larger B needle. And this also can be done as an outpatient procedure um with the injection of bit of local anesthetic to the site um is done under ultrasound guidance and usually performed by radiologists. Uh All the surgeons also do this. Um If it's T three F type four or type five, you would uh like I said, discuss it with your fellow surgeons, pathologists, radiologists. Um that you think you would consider offering uh a diagnostic hemithyroidectomy. If the thyroid nodule is on one side, um If there are multiple nodules, you may even consider a total thyroidectomy. So, um decision making is not easy, it's complex. Um And the nice guidelines will really help and you can go back to this again and again as you get more patients through your door. So, planning management um following investigations, it gives you an idea. Is this malignancy you're dealing with or is it a benign condition? And you can discuss the results with your patient in a follow up appointment and then decide on a management plan. Mostly this would involve repeat ultrasound guided needle aspiration. Um so that you have two samples and you can have a bit more certainty when you discuss with your patient. Ok. So, um if it's benign, majority of thyroid nodules are benign if you go back to the first slide, I said it's about 5 to 15% only that are malignant. So 95% of patients have benign condition. And in such case, if, if it's a small thyroid nodule, um it's U two th two, then you could just discharge the patient and say, just reassure them nothing further needs doing. If it's a large thyroid nodule, it's causing pressure symptoms. Uh Even if it's benign patient may want to have surgery, you would then have to discuss the risks of surgery and either, and list this patient for surgery or refer to a surgical colleague. Um If it's a hyperfunctioning thyroid nodule or you're managing somebody with graves disease, autoimmune thyroiditis, they would, you would refer to the endocrine team for further management with medication, um possibly radio iodine. Um But if the other option is surgery again, um if the patient has a malignant tumor, you would first discuss this at something called the thyroid multidisciplinary team meeting and then um, explain to the patient management plan. So thyroid MDT is usually attended by the pathologist who has done the fine needle aspiration, uh or who is an expert in thyroid cellular pathology. And um, it's a review where there may be doubts as to, is it t three or T four? Um The, the, if there's a CT scan or an MRI and ultrasound findings, these are also discussed uh the patient factors such as is the patient fit for surgery. Are they at high risk of general anesthetic? Is the patient willing for surgery? There are patients who prefer to um, not have, have the operation and if they have a low grade malignancy, um they may opt for observation such as micropapillary, uh less than one centimeter papillary thyroid cancer. Sorry for that. Um If it's a thyroid nodule involving only one side, you might consider diagnostic thyroid he hemithyroidectomy. Um in a patient with T three F type four or type five cytology. And if on the final histology, the patient has definitive malignancy. Um You would discuss this again at the thyroid MDT and then follow up with a completion thyroidectomy. Occasionally the decision is made to do total thyroidectomy at the primary operation. Um So you may require, the patient may require completion thyroidectomy. And then you may also discuss that um in well differentiated thyroid cancer sensitive to iodine. They may need radioactive iodine ablation, meaning removal of the microscopic cells that may not have fully been cleared during surgery. And this allows for such patients who have had total thyroidectomy and radioiodine ablation to have follow up surveillance with blood tests and ultrasound scan here. They would be followed up with thyroglobulin uh test uh initially every three months and then every six months and an ultrasound scan to check for any recurrence in the thyroid bed. They would also have initially in well differentiated thyroid cancers. Um they would be uh given levothyroxine usually T four, occasionally T three for TSH suppression to prevent regrowth of the thyroid. Um, tissue surgical planning and risks you would need to do. Look at the patient factors is the patient on a blood thinner. In which case, you'd have to make arrangements um for that patient to have alternative medication. And probably with this patient will require overnight stay even though the operation may only um be a small um hemithyroidectomy with small volume disease. Um You would look at comorbidities and optimize the breathing airway problems if they have any and any heart disease. Occasionally, s iodine may be required in a patient with hyperthyroidism to reduce the vascularity of the gland. But your if you work closely with an endocrine surgeon, uh sorry endocrinologist, they would help you with this. Um You would look at the imaging um to see if lymph nodes also need dissection. So central compartment dissection, if lateral ly lymph nodes in the neck are involved, um you would also have to plan for that. Um If the thyroid gland is descending into the chest, there is a possibility that patient may need um sternotomy uh or excision of other structures to which the thyroid gland he is stuck, such as the trachea, for instance, in very advanced tumors, the risks you would discuss commonly um uh immediate risk such as bleeding, infection, pain, the scar in the neck, uh change in voice, which could be because of laryngeal edema from uh intubation or the nerve. Uh, recurrent laryngeal nerve has actually been damaged, uh causing hoarseness. And the patient may have damage to the parathyroid glands which lie um on the back of the thyroid gland and for a number and they get either devascularized, meaning the blood supply gets affected during surgery, uh leading to low calcium levels and Vitamin D and they may need supplementation, especially in the 1st 4 to 6 weeks, postoperatively following which the glands may recover if they, unless they've been removed and not reimplanted. I'm sorry, the picture quality is not good. Um Apologies for that. Um So the long term risks are thyroid hormone replacement. So even when you do partial thyroidectomy, such as a hemithyroidectomy, a large percentage up to 50% may have um may develop um low hypofunction of the thyroid gland and may require levothyroxine uh supplementation. Uh If you've had total thyroidectomy, then the patient will be required to start levothyroxine immediately following surgery or T three depending on whether they need radioactive iodine um ablation. So they may also need calcium, Vitamin D supplementation in the long term. Uh If there's vocal cord palsy, you would uh check to look for recovery and if it recovers within one year, nothing more needs doing, they may benefit from um a speech and language therapist, uh speech therapy advice. Um Ultimately, if the walking cord does not recover, um you may have to do another procedure to improve the voice. Um The nice guidelines, as I explained, uh the latest one from December 2022 will help um you manage variations on this theme. Um for specific patients, how you can make decisions uh ongoing treatment with um levothyroxine in differentiated thyroid cancers monitoring and follow up of these patients, uh follow up used to be lifelong and now for low risk patients, we have stopped doing that. Um The the guidelines are also helpful for the providers of thyroid cancer services and also for patients. So, um last few things before we end, how do you classify thyroid ultrasound findings? Would you just classify it as benign versus malignant uh U classification, pi classification U two classification TNM classification? Ok. So for reasons of time, I'm just going to go through the answers. Now, it is the U classification in, in the UK or the Tiads classification in America. And next one is, how would you classify the cytology results after needle aspiration? Would that be the needle classification? U classification T classification TNM classification or the U two classification? Ok. So that's the th classification. Cytology is classified as th 1 to 5 and um four is highly suspicious for malignancy. Five is definitely malignant two is benign. Th one is inadequate and you have to repeat uh the needle aspiration. Next question is following thyroid surgery. The most common cause of postoperative bleeding is bleeding from the skin flaps, bleeding from superior thyroid artery, superior thyroid vein, bleeding from the inferior thyroid artery or from the thyroid beds. So, for reasons of um time, I'm just going to give you the answer to this one bleeding from the flap. So that is slightly different in that when you look at the patient, yes, there's a swelling in the neck but the neck may appear bluish and you know that the bleeding is quite superficial, uh causing the change in color in the skin. But where there is sudden severe swelling and if you put a drain in the drain is fully red, um then you suspect that it may be a deep bleeding from deeper in. And the superior thyroid artery is a common site of bleeding, but most of the minor bleeds come from the skin flaps. So next one, um risks of thyroid surgery, which you would discuss with your patient bleeding, hoarseness, hypothyroidism, hypocalcemia, thyroid storm, all of the above. So I would say all of the above. Um, thyroid stone is a condition which can occur when the patient is hyper um having surgery for hyperthyroidism, which is why we sometimes use LS iodine to saturate the thyroid receptors and reduce vascularity to prevent thyroid storm. This occurs mainly with a sudden gush of hormones released into the bloodstream. Uh and this causes the patient to have tachycardia and cardiothoracic effects. Um The condition is systemic and needs intensive care, monitoring and support from the medical colleagues. So all of these are the risks of thyroid surgery, but thyroid storm is pretty rare these days. Last question about tetany. So, is it a symptom of hypocalcemia, CT sign trosia sign becoming positive muscle spasm, peripheral nerve irritability. Um all of the above. So that's the answer to that one. Um The low calcium, low Vitamin D levels postoperatively cause the patient to have nerve um irritability, peripheral nerve irritability that causes involuntary muscle spasms and where this is not overtly seen, uh The patient may complain of numbness in the hands and feet. If you tap the face in front of the ear, the patient's facial muscles will go into spasm that's called short stick sign, which is that one, c and if you use a BP cuff to raise the systolic pressure in the arm, then you'll find that the hands go, fingers go into spasm. Um And that's called trosia sign. Um So the answer is all of the above. Thank you very much for attending. And uh the final um slide is bibliography and that gives you the resources that I've used today to provide you with an evidence based management. Um And practice. Thank you everyone for listening. I think we've gone. Uh We've just made it in time. Um Would you have any time to answer some questions? No problem. I've got two in the chat. If you can, can you see the chat? OK. From to, oh, I've got three ish is just on a roll. Can you see them there? How does molecular testing play a role in the differentiation between atypia of un? Oh, undetermined significance and follicular neoplasm for Beth. Beth. I don't know if you can still hear me but um, it is a research tool at the moment in the UK. We're not yet using this, but occasionally we do send patients for molecular testing And if uh I understand that BR ACR gene um has a higher predilection for malignancy. Also, um the classical um categories of thyroid malignancy, well differentiated medullary, undifferentiated anaplastic. These are changing now and we have based on molecular testing, other categories. Um for instance, the N I uh P FT where it is noninvasive papillary um tumor in a, in a, in a follicle and uh treatment for that would just be a thyroid lobectomy. I understand would suffice for that. So you're right. Molecular testing will soon take off and um improve management for everybody. Thank you for that question. She also asks, do we always opt for lobectomy when we have a tip here of undetermined significance. Not really no. Um with Atypia, what I skipped to say was that we would do a blood test TPO would have significance in that situation. So you would do thyroid peroxidase um antibody test to see is there hyperactivity? And um it is less likely that a patient with hyperthyroid nodule, not impossible but less likely that that patient has a malignancy. But um there is controversy in the literature on this. Um what we would do in such a case is repeat the fine needle aspiration. And if possible do core biopsy under ultrasound guidance, uh which will give more tissue for analysis and this may then change the um uh th staging, sorry thigh grading and help with definite management. Ok. Well, thank you for that. She asks one more and hopefully, I can say the words a well defined hypo nodules, largest, largest measuring one centimeter by 8.7 centimeters in the left hem thyroid in a 28 year old. What is your interpretation on this? And what is your recommendation, recommendation for this patient? The thyroid function test shows a euthyroid state. Thyroid function shows few thyroid state well defined hypoechoic nodules. So the pathologist will be able to classify this as um because you're saying that patient has had a hemithyroidectomy and they'll be able to say we don't know, we no longer need to look at the ultrasound appearances, which is what hypoechoic nodules mean. Um Oh, I see. This was before surgery. 8.7 centimeters in the left hemithyris. And what is your interpretation? I would uh definitely request because it's not isoechoic, it's hypoechoic and I don't know what the other um appearances are is what does the patient have central vascularity in the nodule? Um Is the peripheral vascularity is the calcification, calcified spots. So based on that your pathologist, sorry, a cytologist will be able to give you better and more information um on the after needle aspiration. Um I think what you're asking is based on simply the ultrasound appearances. The fact that it's 8.7 centimeters um is a little bit worrying. It depends on how fast this has grown. Um I would definitely request um fine needle aspiration in this case. And as it's quite big patient may be amenable to have a core biopsy. Um and that will give you a more definitive answer. Um Previously, it was thought that um lung uh thyroid nodules more than four centimeters should definitely have surgery. But a large series have now shown that if the thyroid node anything over two centimeters and growing um does not seem to show a higher predilection for malignancy. Thank you. Perfect. I think that's us. So um everyone uh delegates, your feedback form will be in your inbox, er, if you can complete that, that'd be great. There are some um er stuff that I will pass on to um Gina after you've completed that once your feedback is completed, your attendant certificate will be on your medal account um for you to download and I'm hoping we will see you in future events. It looks like the talk was, it says excellent lecture on thyroid. Amazing. So I think it went down very, very well. Um So thank you. It was a very helpful lecture. Um You've got a lot of thanks there. Excellent presentation. I literally stayed home from work for this session. Oh, well. Oh, dear Tia. I hope you don't get into trouble for that. I'm sorry. Um, it was not uh visible for some people to read. I did try to make it big as big as um without allowing the slides to look distorted. But um all of these are easily available online. So the links on this page are your most important ones to help you practice safely. So, thank you all for today. I'll share this, I'll share your talk and I'll share this slide as catch up the picture, please. No, I just share this one slide as their catch up. So, thank you very much. Everyone will say goodbye now. Thank you so much for joining us and we'll see you at another middle education.