Ebook Oral and maxillofacial surgery cliniscs: Part 2
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Ebook Oral and maxillofacial surgery cliniscs: Part 2
ELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2on and Management of Thyroid NodulesJames I. Cohen, MD, PhDa’*, Kelli D. Salter, MD, PhDb* Department of Otolaryngologyi Head and Neck Surgery. Oregon Health & Science University.3181 SH' Sain Jackson Park Road. PV-01. Portland. OR 97239-3098, USA bDepartment of General Surgery. Oregon Health & Scie Ebook Oral and maxillofacial surgery cliniscs: Part 2nce University,3181 .SH' Sam Jackson Park Road. L223. Portland. OR 97239-31198. USAAlthough it is well documented that thyroid nodules arc a common clEbook Oral and maxillofacial surgery cliniscs: Part 2
inical disorder, significant controversy persists as to ideal management strategies. Population studies suggest that approximately 3% to 7% of adults ELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2, the advent and implementation of high-resolution radiographic imaging has significantly impacted the discrepancy between clinically evident disease and incidentally discovered disease. High-resolution ultrasound (US) can delect thyroid nodules in 20% to 67% of randomly selected individuals, with a Ebook Oral and maxillofacial surgery cliniscs: Part 2 higher frequency in women and the elderly [3 8]. Moreover. 20% to 48% of patients who have a single palpable nodule have additional nodules identifieEbook Oral and maxillofacial surgery cliniscs: Part 2
d on US. This discrepancy is further supported by data from autopsies conducted for medical reasons unrelated to thyroid disorders. Such data suggest ELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2oid disease in the general population remains unknown.As the incidence of thyroid nodules has exhibited a steady rise over the past decade, so too has the incidence of thyroid cancer, rhe National Cancer Institute estimates the number of new cases and deaths from thyroid cancer in the United Stales Ebook Oral and maxillofacial surgery cliniscs: Part 2in 2007 to be 33,550 and 1.530.* Corresponding author.E-mail address: cohenj@ohsu.edu (J.I. Cohen)respectively [10]. These numbers have steadily increEbook Oral and maxillofacial surgery cliniscs: Part 2
ased from the reported 13.000 number of new cases and 1000 thyroid cancer associated deaths in 1994 [10 I2|. However, despite the notable increase in ELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2yroid cancer likely reflects the implementation of technology with increased sensitivity and specificity for detecting thyroid nodules. Such technology increases the need for physicians to improve their ability to differentiate benign from malignant thyroid lesions, because the clinical importance o Ebook Oral and maxillofacial surgery cliniscs: Part 2f thyroid nodules rests on the need to exclude thyroid cancer.Incidentally discovered nodules present the same risk for malignancy (~ 10%) as palpableEbook Oral and maxillofacial surgery cliniscs: Part 2
nodules if they are equivalent in size [3 6,13). Therefore, the physician who finds an incidental thyroid nodule is faced with the challenge of deterELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2malignant nodule, which requires more aggressive treatment, presents a diagnostic dilemma. Because of the high prevalence of incidental disease, it is neither economically feasible nor necessary to surgically excise all. or even most, thyroid nodules. It is essential that the physician develop and f Ebook Oral and maxillofacial surgery cliniscs: Part 2ollow a reliable, cost-effective strategy for diagnosis and treatment of incidentally found thyroid nodules. This article provides practical guidelineEbook Oral and maxillofacial surgery cliniscs: Part 2
s. algorithms, and current recommendations for the effective diagnosis and management of thyroid nodules incidentally discovered by physiciansI (M2-36ELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2TER432managing patients lor other medical reasons. Important elements of the history and physical examination, laboratory evaluation, and imaging modalities are reviewed, and a suggested management strategy is presented. This outline is not intended to be all inclusive, nor docs it preclude addition Ebook Oral and maxillofacial surgery cliniscs: Part 2al evaluation, according to the specific clinical situation. Furthermore, the specific management of hypothyroidism, hyperthyroidism, or thyroid maligEbook Oral and maxillofacial surgery cliniscs: Part 2
nancies is beyond the scope of this article. These lesions should be specifically managed by a multidisciplinary team, including, al a minimum, an endELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2 nodule from a thyroid carcinoma. Multiple diagnostic methods must be used to increase the accuracy of the diagnosis. Fig. I provides a basic algorithm of diagnostic modalities typically used in the initial evaluation of a thyroid nodule. Generally, the inability to accurately differentiate benign f Ebook Oral and maxillofacial surgery cliniscs: Part 2rom malignant nodules warrants operative removal of the lesion.History tillEbook Oral and maxillofacial surgery cliniscs: Part 2
of adjacent cervical lymph nodes, remain the diagnostic cornerstone in evaluating a patient whohas a thyroid nodule. Unfortunately, neither the histoELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2 an increased risk for malignancy and, therefore, warrant further discussion [3 6]. Factors that present a high risk for thyroid cancer include: history of head and neck or total body radiation; family history: rapid growth; hard, fixed nodule; and/or regional, cervical lymphadenopathy. Factors that Ebook Oral and maxillofacial surgery cliniscs: Part 2 present a moderate risk include: male gender; age younger than 30 or older than 60 years; and/or persistent local symptoms (hoarseness, dysphagia, dyEbook Oral and maxillofacial surgery cliniscs: Part 2
sphonia, dyspnea).A history of head and neck or total body irradiation is a well-known risk factor for subsequent development of thyroid cancer. The iELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2]. Therefore, the incidental finding of a thyroid nodule in a patient who has had prior radiation exposure requires careful and complete evaluation, although by itself it docs not justify removal if the workup should prove negative.Despite high levels of intraobserver and interobserver variations, c Ebook Oral and maxillofacial surgery cliniscs: Part 2areful inspection and palpation of the thyroid, the anterior neck compartments. and the lateral neck compartments should always be performed. TextureEbook Oral and maxillofacial surgery cliniscs: Part 2
and size of the nodule should be documented. A firm or hard, solitary or dominant nodule with an increasedFig. 1. Diagnosis and management of thyroid ELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2tropin).HVAI.I.I.M1ON AND MANAGHMKNI Oh IHYKOID NODI I.ES433rale of growth that clearly differs from the rest of the gland suggests an increased risk for malignancy [2,4.6]. The presence of multiple nodules (symptomatic or asymptomatic) does not decrease the likelihood that any one of them is a carc Ebook Oral and maxillofacial surgery cliniscs: Part 2inoma, as was once thought, although the overall incidence of malignancy in a multinodular gland is the same as that for any given nodule (*~10%) [3 6Ebook Oral and maxillofacial surgery cliniscs: Part 2
.19,20]. Each nodule should he evaluated on its own merit regardless of the number of nodules present. Finally, ipsilateral or contralateral cervical ELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2milial trait or syndrome [21 24j. Although medullary thyroid carcinoma (MIC) accounts for only approximately 10% of all thyroid carcinomas. 25% of MTCs occur secondary to an inherited cancer risk, namely familial MIC (<2%) and multiple endocrine neoplasia (MEN 2A. -*25% or MEN 2B. <2%) [23-25]. Muta Ebook Oral and maxillofacial surgery cliniscs: Part 2tions in the RETpvolo-oncogcnc are responsible for all three conditions [23 25]. Patients diagnosed with M IC should undergo genetic testing to determEbook Oral and maxillofacial surgery cliniscs: Part 2
ine if mutations in the RET proto-oncogene arc present.Papillary and follicular carcinomas, the two most common forms of thyroid cancer, may also presELSEVIERSAUNDERSOral Maxillofacial Surg Clin N Am 20 (2008) 431 443ORAL AND MAXILLOFACIAL SURGERY CLINICS of North AmericaThyroid Disorders: Evaluatio Ebook Oral and maxillofacial surgery cliniscs: Part 2Cowden syndrome, and Werner (adult progcroid) syndrome arc al increased risk for development of thyroid cancer[21.22.25]. Families with adenomatous polyposis (FAP or Gardner syndrome) show an increased incidence (2%) of papillary thyroid cancers, which tend to be multicentric (65%). exhibit a higher Ebook Oral and maxillofacial surgery cliniscs: Part 2 fe-male-to-male ratio (6:1), and develop at a younger age (third decade) [21.22,25]. Patients who have Cowden syndrome have up to a 10% lifetime riskEbook Oral and maxillofacial surgery cliniscs: Part 2
for follicular or papillary thyroid cancer, with follicular being, the most common[21.22.25]. Approximately 70% to 85% of people with (À>wden syndromGọi ngay
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