Morphology of the tubercle of zuckerkandl and its importance in thyroid surgery a rajapaksha, r fernando, n ranasinghe, s iddagoda abstract the tubercle of zuckerkandl zt is an embryological remnant of the thyroid gland. The purpose of this study was to investigate incidence and morphology of the zuckerkandl s tubercle. This tubercle arises from the lateral anlage the thyroid gland develops from two anlages, and while the median analge is larger, the lateral one is. Variations of recurrent laryngeal nerve rln and zuckerkandl s tubercle zt, which is posterior extension of lateral lobes, may affect safety of thyroidectomy. Zuckerkandls tubercle journal of the american college of surgeons. Emil zuckerkandl described it in 1902 as the processus posterior glandulae thyreoideae. What is the embryology and anatomy of the thyroid gland. Zuckerkandl tubercle zt is a lateral projection from the lateral. The superior parathyroid gland, also derived from the 4th branchial cleft, is commonly located close to and cephalad to the tubercle. Two cases of enlarged zuckerkandls tubercle of the.
The tubercle of zuckerkandl zt is an embryological remnant of the thyroid gland. This has a relationship with the recurrent laryngeal nerve rln. It has two dna binding domains, the paired domain and the homeodomain, in addition to a cterminal transactivation domain. One such anomaly, the tubercle of zuckerkandl tzn, is a posterolateral extension of the thyroid gland that has also been called as the posterior horn of thyroid described for the first time by otto madelung in 1867 and later by emil zuckerkandl 18491910. Endocrine pancreas the transcription factor pax6 functions in the specification and maintenance of the differentiated cell lineages in the endocrine pancreas. This paper presents two cases of this uncommon situation. It arises for embryological reasons, and it can be a reliable anatomical landmark for identifying the recurrent laryngeal nerve during thyroid surgery.
This tubercle has been documented in the surgical literature due to its relevance in locating the recurrent laryngeal nerve. To define the incidence of a distinct tubercle of zuckerkandl tz and confirm its anatomical relationships with the recurrent laryngeal nerve and the superior parathyroid gland. Prospective study on 144 patients 48 males, 96 females undergoing thyroidectomy 35 hemithyroidectomies, 109 total thyroidectomies from september 1st 2010. The tubercle of zuckerkandl extends off of the posterior and lateral aspect of the thyroid lobes. The tubercle of zuckerkandl tz, which is the remant of the lateral thyroid process, is an important ana tomic structure that serves as a reliable landmark for the recurrent laryngeal nerve in thyroid surgery. Review of surgical anatomy of tubercle of zuckerkandl and its. Pdf embryological descent, remnants and implications for. It is of variable size, from a hugely expanded mass down to just a small tongue of tissue, wrapped around the recurrent nerve and often extending behind the trachea and oesophagus. Many homeostatic processes that occur within the body are dependent on various supporting hormonal systems for efficient functioning. Grades of zuckerkandls tubercle in normal thyroids springerlink. After freeing the tubercle of zuckerkandl and berry ligament, the rln returned back to its usual position in tracheaesophageal groove. When enlarged, it is a reliable landmark for the rln because the nerve almost always courses medial and deep to it 15. Tubercle of zuckerkandl e4ent ear, nose, throat, head.
Review of surgical anatomy of tubercle of zuckerkandl and. We did not find a zuckerkandl s tubercle individualised as an ectopic thyroid 0. Zuckerkandls tubercle of the thyroid gland in association. Relationship between the zuckerkandl s tubercle and entrance point of the inferior laryngeal nerve.
Meticulous technique, combined with an understanding of thyroid embryology and anatomy, is the foundation of the surgical management today. Total and hemithyroidectomy were surgical procedures in 60 and 40 patients, respectively. Its close relationship to the recurrent laryngeal nerve rln makes it an important surgical landmark. The shape of the zuckerkandl s tubercle was sessile 70. Although the structure is named after zuckerkandl, it was discovered first by otto madelung in 1867 as the posterior horn of the thyroid. To study the incidence of the tubercle of zuckerkandl zt among indian patients subjected to thyroid surgery at a tertiary care cancer centre and its relevance in localization of recurrent laryngeal nerve rln. Pdf relationship between the zuckerkandls tubercle and. Surgical anatomy was studied in 87 right and 73 left lobes. Tubercle of zuckerkandl tz is the posterior or posterolateral extension of thyroid gland.
Emil zuckerkandl, born in hungary in 1849, studied at the university of vienna where he was trained as an anatomist and surgeon. Tubercle definition of tubercle by medical dictionary. Pdf morphology of the tubercle of zuckerkandl and its importance. Zt has a relation with the recurrent laryngeal nerve rln. Gemsenjaeger, atlas of thyroid surgery isbn 97831450319 2009 georg thieme verlag kg 176 index functional autonomy and 70, 8889 multinodular goiter 75.
Zuckerkandl s tubercle zt is defined as the extension of the lateral lobes of the thyroid, composing of thyroid tissue only. They are present in most patients and occur more commonly on the right and in the longitudinal center 50% of the lobe 1,2. The autism dysmorphology measure adm was developed to provide an efficient and reliable method to identify children with general dysmorphology on physical examination. Ultraligation of the upper pt and individual ligation and division of the lateral, inferior, medial tubercle suspensory ligament recurrent laryngeal nerve e c branches of the inferior artery are. This is also the region where on the right side, in approximately 1% of cases, a.
Its close relationship to the recurrent laryngeal nerve rln makes it an. In most cases the nerve traverses just medial to the tubercle and is hidden from view until the tubercle is medially retracted. Articletitle relationship between zuckerkandl s tubercle and the inferior laryngeal nerve including the laryngeal branches surg today 37 109. Ralph waldo emerson, journals, 1863 zuckerkandl s tubercle is a distinct, welldocumented anatomical feature of the thyroid gland, with a plausible embryological basis of genesis. The effects of the hormones it produces can be seen throughout all systems in the body. Zuckerkandl tubercle zt is a lateral projection from the lateral thyroid lobe which is a constant landmark for finding the recurrent laryngeal nerve during thyroid surgery. This tubercle is the most posterior pyramidal extension of pure thyroid tissues of the lateral lobes of the thyroid gland in the area of the ligament of berry. A 60yearold female patient with large multinodular goiter was treated with total thyroidectomy. Each of these remnants plays a critical role in thyroi. Thyroid gland to form a tubercle known as zuckerkandl tubercle. The tubercle of zuckerkandl tz, which is the remant of the lateral thyroid process, is an important anatomic structure that serves as a reliable landmark for the recurrent laryngeal nerve in thyroid surgery. The zuckerkandl s tubercle zt of the thyroid gland is a well.
Zuckerkandls tubercle is a pyramidal extension of the thyroid gland, present at the most posterior side of each lobe. Incidence and morphology of the zuckerkandls tubercle. Zuckerkandl s tubercle rln rln the left recurrent laryngeal nerve rln laryngeal entry point of rln gurleyik e. Identification and preservation of the recurrent laryngeal nerve is a major concern during thyroidectomies.
The zuckerkandl tubercle is generally found in 63% to 80% of patients undergoing thyroidectomy and is located between the superior and inferior lobes pointing toward the tracheoesophageal groove fig. The tubercle of zuckerkandl is a poorly known and variable anatomical feature of the thyroid gland which may not, in fact, be so rare. Vc 2011 the american laryngological, rhinological and otological society, inc. Furthermore, removal of the tz is critical for the adequate performance of a total thyroidectomy. Emil zuckerkandl 18491910, an austrian anatomist who described a lateral projection of the thyroid gland, was an early pioneer of clinical anatomy. A recent case of zt with a nodular configuration caused clinical concern but was shown on biopsy to be normal thyroid tissue. Department of anatomy embryology, university of crete medical school, crete. The posterior thyroid tubercle, also known as zt, is an important surgical landmark due to its close proximity to the recurrent laryngeal nerve. Forty specimens 80 sides were examined for this project, including 24 males and 16 female. The tubercle of zuckerkandl is characterized as being a thickening in the thyroid gland where the ultimobranchial body merges with the median thyroid anlage and can enlarged to become a nodular process 48. The thyroid gland is an endocrine organ located in the neck that participates in a myriad of systemic processes.
Musajo, fg, mangiante, g, ischia, a, marchiori, l, benati, g, mainente, m, et al. Grades of zuckerkandls tubercle in normal thyroids. It is the condensed thyroid parenchyma located in the cricothyroid junction. In 1901, he described these encapsulated light brown organs joined by an isthmus, on the anterior surface of the aorta, just between the origin of the inferior mesenteric artery and the bifurcation of the iliac arteries. A useful anatomical landmark for detecting both the recurrent laryngeal nerve and the superior parathyroid during thyroid surgery jisup yun 1, yong sang lee 2, jeong joo jung 2, kee hyun nam 2, woong youn chung 2, hang seok chang 2, cheong soo park 2. Out of 39 records, 25 studies, reported total number of sides where tz was studied with prevalence percentages n 4231 sides. Presence and size of the zt was prospectively assessed during thyroidectomies done at a single surgical unit during 20. It is made up of small spherical cells that contain. Zuckerkandl tubercles are the projections of normal thyroid tissue from the posterior or posteromedial margin of the thyroid gland that extend posterior to the tracheoesophageal groove. The tubercle was first described by otto madelung in 1867 as posterior horn of the thyroid. The phenotype of pax6 knockout mice suggests nonredundant functions of the transcription factor in the. Incidence and importance of the tubercle of zuckerkandl in. Zuckerkandls tubercle teeth disambiguation page providing links to topics that could be referred to by the same search term this disambiguation page lists articles associated with the. Its close relationship to the recurrent laryngeal nerve rln.
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