4/25/2017 ThyroidAnatomy:Overview,Structure,FasciaandLigament

ThyroidAnatomy
Updated:Aug24,2015
Author:DominiqueDorion,MD,MSc,FRCSC,FACSChiefEditor:ArlenDMeyers,MD,MBA
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OVERVIEW

Overview
Thethyroidisahighlyvascular,brownishredglandlocatedanteriorlyinthelowerneck,extending
fromthelevelofthefifthcervicalvertebradowntothefirstthoracic.TheglandvariesfromanHto
aUshapeandisformedby2elongatedlaterallobeswithsuperiorandinferiorpolesconnectedby
amedianisthmus,withanaverageheightof1215mm,overlyingthesecondtofourthtracheal
rings.(Seetheimagebelow.)Theisthmusisencounteredduringroutinetracheotomyandmustbe
retracted(superiorlyorinferiorly)ordivided.Occasionally,theisthmusisabsent,andthegland
existsas2distinctlobes.Thevideobelowdepictsanultrasonographicviewoftherightlobeofthe
thyroidgland.[1,2]

Thyroidgland,anteriorandlateralviews.
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Eachlobeis5060mmlong,withthesuperiorpolesdiverginglaterallyattheleveloftheoblique
linesonthelaminaeofthethyroidcartilage.(Thevideobelowdepictsanultrasonographicviewof
therightlobeofthethyroidgland.)Thelowerpolesdivergelaterallyatthelevelofthefifthtracheal
cartilage.Althoughthyroidweightvaries,itaverages2530ginadults(itisslightlyheavierin
women).Theglandenlargesduringmenstruationandpregnancy.

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Sonogramofanormalrightlobeofthethyroidgland.VideocourtesyofDavidLFrancis,MD.
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Aconicalpyramidallobeoftenascendsfromtheisthmusortheadjacentpartofeitherlobe(more
oftentheleft)towardthehyoidbone,towhichitmaybeattachedbyafibrousorfibromuscular
band,thelevatorofthethyroidgland.Remnantsofthethyroglossalductmaypersistasaccessory
nodulesorcystsofthyroidtissuebetweentheisthmusandtheforamencaecumofthetongue
base.Usually,2pairsofparathyroidglandslieinproximitytothethyroidgland.(Seealso
EmbryologyoftheThyroidandParathyroids.)

Innervationofthethyroid

Principalinnervationofthethyroidglandderivesfromtheautonomicnervoussystem.
Parasympatheticfiberscomefromthevagusnerves,andsympatheticfibersaredistributedfrom
thesuperior,middle,andinferiorgangliaofthesympathetictrunk.Thesesmallnervesenterthe
glandalongwiththebloodvessels.Autonomicnervousregulationoftheglandularsecretionisnot
clearlyunderstood,butmostoftheeffectispostulatedtobeonbloodvessels,hencetheperfusion
ratesoftheglands.

Structure
Underthemiddlelayerofdeepcervicalfascia,thethyroidhasaninnertruecapsule,whichisthin
andadherescloselytothegland.Extensionsofthiscapsulewithinthesubstanceoftheglandform
numerousseptae,whichdivideitintolobesandlobules.Thelobulesarecomposedoffollicles,the
structuralunitsofthegland,whichconsistofalayerofsimpleepitheliumenclosingacolloidfilled
cavity(seetheimagebelow).

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Folliclesofthethyroidgland,consistingofalayerofsimpleepitheliumenclosingacolloidfilledcavity.
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Thiscolloid(pinkonhematoxylinandeosin[H&E]stain)containsaniodinatedglycoprotein,
iodothyroglobulin,aprecursorofthyroidhormones.Folliclesvaryinsize,dependinguponthe
degreeofdistention,andtheyaresurroundedbydenseplexusesoffenestratedcapillaries,
lymphaticvessels,andsympatheticnerves.

Epithelialcellsareof2types:principalcells(ie,follicular)andparafollicularcells(ie,C,clear,light
cells).Principalcellsareresponsibleforformationofthecolloid(iodothyroglobulin),whereas
parafollicularcellsproducethehormonecalcitonin,aproteincentraltocalciumhomeostasis.
Parafollicularcellslieadjacenttothefollicleswithinthebasallamina.

FasciaandLigament
Thethyroidglandisensheathedbythevisceralfascia,adivisionofthemiddlelayerofdeep
cervicalfascia,whichattachesitfirmlytothelaryngoskeleton.Theanteriorsuspensoryligament
extendsfromthesuperiormedialaspectofeachthyroidlobetothecricoidandthyroidcartilage.
Theposteromedialaspectoftheglandisattachedtothesideofthecricoidcartilage,firstand
secondtrachealring,bytheposteriorsuspensoryligament(ie,Berryligament).Thisfirm
attachmentoftheglandtothelaryngoskeletonisresponsibleformovementofthethyroidgland
andrelatedstructuresduringswallowing.

Onitswaytothelarynx,therecurrentlaryngealnerveusuallypassesdeeptotheBerryligamentor
betweenthemainligamentanditslateralleaf.Deeptotheligament,butlateraltothenerve,isa
posteromedialportionofthethyroidlobe,whichmaybeoverlookedduringthyroidectomy.

StrapMuscles
Thelateralsurfaceofthethyroidiscoveredbythesternothyroidmuscle,anditsattachmenttothe
obliquelineofthethyroidcartilagepreventsthesuperiorpolefromextendingsuperiorlyunderthe
thyrohyoidmuscle.Moreanteriorlyarethesternohyoidandsuperiorbellyoftheomohyoidmuscle,
overlappedinferiorlybytheanteriorborderofthesternocleidomastoidmuscle.Thesternohyoid
andsternothyroidmusclesarejoinedinthemidlinebyanavascularfasciathatmustbeincisedto
retractthestrapmusclelaterallyinordertoaccessthethyroidglandduringthyroidectomy.Ifstrap
musclesaretobetransectedforbetterexposure,dosohighintheneck,becausethemotornerve
supplyfromtheansacervicalisentersthesemusclesinferiorly.

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VascularAnatomyandLaryngealInnervation
Thearterialsupplytothethyroidglandcomesfromthesuperiorandinferiorthyroidarteriesand,
occasionally,fromthethyroideaima.Thesearterieshaveabundantcollateralanastomoseswith
eachother,ipsilaterallyandcontralaterally.Thethyroidimaisasinglevesselthat,whenpresent,
originatesfromtheaorticarchortheinnominatearteryandentersthethyroidglandattheinferior
borderoftheisthmus.(Seetheimagebelow.)

Distributionofthyroidarterieswithassociatedlaryngealnerve,anteriorview.
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Superiorthyroidarteryandsuperiorlaryngealnerve
Thesuperiorthyroidarteryisthefirstanteriorbranchoftheexternalcarotidartery.Inrarecases,it
mayarisefromthecommoncarotidarteryjustbeforeitsbifurcation.Thesuperiorthyroidartery
descendslaterallytothelarynxunderthecoveroftheomohyoidandsternohyoidmuscles.The
arteryrunssuperficiallyontheanteriorborderofthelaterallobe,sendingabranchdeepintothe
glandbeforecurvingtowardtheisthmus,whereitanastomoseswiththecontralateralartery.

Cephaladtothesuperiorpole,theexternalbranchofthesuperiorlaryngealnerverunswiththe
superiorthyroidarterybeforeturningmediallytosupplythecricothyroidmuscle.Highligationofthe
superiorthyroidarteryduringthyroidectomyplacesthisnerveatriskofinadvertentinjury,which
wouldproducedysphoniabyalteringpitchregulation.Thecricothyroidartery,apotentially
bothersomebranchofthesuperiorthyroidartery,runscephaladtotheupperpoleandrunstoward
themidlineonthecricothyroidligament.Thisvesselcanbelaceratedduringemergent
cricothyroidotomy.[3]

Inferiorthyroidarteryandrecurrentlaryngealnerve

Theinferiorthyroidarteryarisesfromthethyrocervicaltrunk,abranchofthesubclavianartery.It
ascendsverticallyandthencurvesmediallytoenterthetracheoesophagealgrooveinaplane
posteriortothecarotidsheath.Mostofitsbranchespenetratetheposterioraspectofthelateral
lobe,asshownbelow.

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Distributionofthyroidarterieswithassociatedlaryngealnerve,posteriorview.
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Theinferiorthyroidarteryhasavariablebranchingpatternandiscloselyassociatedwiththe
recurrentlaryngealnerve(seenintheimagebelow).Thelatteralsoascendsinthe
tracheoesophagealgrooveandentersthelarynxbetweentheinferiorcornuofthethyroidcartilage
andthearchofthecricoid.Therecurrentlaryngealnervecanbefoundafteritemergesfromthe
superiorthoracicoutlet,inatriangleboundedlaterallybythecommoncarotidartery,mediallyby
thetrachea,andsuperiorlybythethyroidlobe.

Thyroidgland,anteriorandlateralviews.
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Therelationshipbetweenthenerveandtheinferiorthyroidarteryishighlyvariable,as
demonstratedbytheclassicworkofReed,whoin1943described28variationsinthisrelationship.
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Thenervecanbefounddeeptotheinferiorthyroidartery(40%),superficially(20%),orbetween
branchesoftheartery(35%).[4]Significantly,therelationshipbetweennerveandarteryonone
sideoftheneckissimilartothatfoundontheothersideinonly17%ofthepopulation.
Furthermore,attheleveloftheinferiorthyroidartery,branchesoftherecurrentlaryngealnerve
thatareextralaryngealmaybepresent(5%).Preservationofallofthosebranchesisimportant
duringthyroidectomy.

AnotherhinttothelocationoftherecurrentlaryngealnerveistheZuckerkandltubercle,an
extensionofthethyroid,whichisclosetotheBerryligament.[5]Onrareoccasions,therecurrent
laryngealnervemaypassdirectlyfromthevagustothelarynx,closetothesuperiorthyroid
vessels.Thisformationisnearlyalwaysobservedontherightsideandisassociatedwitha
retroesophagealsubclavianartery.However,theformationcanoccurontheleftsideincasesof
transpositionofthegreatvessels.

VenousDrainageandLymphatics
Threepairsofveinsprovidevenousdrainageforthethyroidgland(seetheimagebelow).The
superiorthyroidveinascendsalongthesuperiorthyroidarteryandbecomesatributaryofthe
internaljugularvein.Themiddlethyroidveinfollowsadirectcourselaterallytotheinternaljugular
vein.Theinferiorthyroidveinsfollowdifferentpathsoneachside.Therightpassesanteriortothe
innominatearterytotherightbrachiocephalicveinoranteriortothetracheatotheleft
brachiocephalicvein.Ontheleftside,drainageistotheleftbrachiocephalicvein.Occasionally,
bothinferiorveinsformacommontrunkcalledthethyroidimavein,whichemptiesintotheleft
brachiocephalicvein.

Distributionofthyroidveins.
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Lymphaticdrainageofthethyroidglandisextensiveandflowsmultidirectionally.Immediate
lymphaticdrainagecoursestotheperiglandularnodestotheprelaryngeal(Delphian),pretracheal,
andparatrachealnodesalongtherecurrentlaryngealnerveandthentomediastinallymphnodes.
Regionalmetastasesofthyroidcarcinomacanalsobefoundlaterally,higherintheneckalongthe
internaljugularvein.Thiscanbeexplainedbytumorinvasionofthepretrachealandparatracheal
nodescausinganobstructionofnormallymphflow.

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