Appendicular mass imitating a malignant cecal tumor on f18-FDG PET/CT study: a case report

Fluoro-Deoxy-Glucose Positron Emission Tomography/Computerized Tomography scan is a very useful method in the diagnosis and follow-up of gastrointestinal malignancies, although it may cause confusion in differential diagnosis

Thyroid Hemiagenesis Associated with Hyperthyroidism

WOS: 000215209500081PubMed: 26185699Thyroid hemiagenesis (TH), very rare congenital anomaly, is generally asymptomatic. We report two cases of TH with hyperthyroidism. Case One. The patient presented with signs and symptoms of thyrotoxicosis. Physical examination revealed asymmetric nodular goitre at right lobe. Biochemical analysis revealed the diagnosis of hyperthyroidism. Ultrasound showed multinodular hypertrophy in the right lobe and absence of the left lobe. Nuclear scan, confirming absence of the left lobe, showed hot nodules in the right one. The diagnosis was toxic multinodular goitre. Case Two. The thyroid was not palpable in this patient presented with signs and symptoms of thyrotoxicosis. Biochemical analysis revealed the diagnosis of autoimmune thyrotoxicosis. Ultrasound showed mild diffuse hyperplasia of the right lobe and agenesis of the left lobe. Nuclear scan, confirming absence of the left lobe, showed increasing diffuse uptake of radiotracer in the right one. The diagnosis was Graves' disease in this patient. After antithyroid medication, the patients were surgically treated with total excision of the thyroid tissue. TH is sometimes associated with disorders of the thyroid. Hyperthyroidismmakes THcases symptomatic. During evaluation of patients, ultrasound and nuclear scan usually report agenesis of one lobe and establish the diagnosis of TH. The surgical treatment is total removal of hyperactive tissue and total excision of the remaining lobe

Intraoperative Monitoring of External Branch of the Superior Laryngeal Nerve: Functional Identification, Motor Integrity, and its Role on Vocal Cord Function

WOS: 000466370000010PubMed: 28952819Purpose: Beside recurrent laryngeal nerve (RLN), protection of the external branch of the superior laryngeal nerve (EBSLN) is required for complication-free thyroid surgery. This study investigates the contribution of intraoperative neuromonitoring (IONM) to identification and motor integrity of the EBSLN. Methods: This prospective study was performed on 245 EBSLNs in 147 patients with thyroid surgery. The rate of visual identification, contribution of IONM to functional localization, the rate and levels of recordable waveform amplitude from vocal cord (VC) movement were determined during surgery. Results: 164 (66.9%) EBSLNs were visually identified and additional 74 branches were functionally identified by IONM. Additional identification rate of IONM was 30.2%. Seven (2.9%) EBSLNs could not be identified during surgery. Cricothyroid muscle (CTM) twitch established functional integrity in 97.1% of EBSLNs. Electrophysiological stimulation of 151 (63.4%) EBSLNs created waveform amplitude >100 mu V that mean amplitude level was calculated as 186 mu V, and an amplitude >300 mu V was recorded in 19 of 151 (12.6%) EBSLNs. Conclusions: In addition to visual identification, surgeons can functionally localize the EBSLN with the assistance of IONM that CTM twitch is a reliable evience for functional integrity of the EBSLN. In the majority of patients, stimulation of the EBSLN creates recordable waveform amplitude thus the EBSLN appears to be a second source of motor innervations for intrinsic laryngeal muscles

Double Pyramidal Lobe of the Thyroid Gland

WOS: 000439486200013PubMed: 29588265

Motor Interconnections Between Superior and Inferior Laryngeal Nerves

WOS: 000450937400086PubMed: 29774175Introduction Anatomical studies on human cadavers have established anastomoses between laryngeal nerves. However, we need to functionally identify motor communication via these anastomoses between the recurrent laryngeal nerve (RLN) and the external branch of the superior laryngeal nerve (EBSLN) in living bodies. We aim to establish motor interconnections using intraoperative nerve monitoring (IONM). Methods IONM of 112 EBSLNs and RLNs in 62 thyroidectomy cases was used to establish motor functions of laryngeal nerves. Electrophysiological parameters were recorded, and cricothyroid muscle (CTM) contraction was observed after stimulation of laryngeal nerves. Results Eighty (71.4%) EBSLNs were visually identified, and 109 (97.3%) EBSLNs were functionally identified with CTM contraction. Stimulation of 74 (67.9%) EBSLNs induced contraction of laryngeal muscles and generated wave amplitude from intrinsic laryngeal musculature. The stimulation of the RLN induced CTM contraction in 65 (58%) of the 112 muscles. The mean conductivity powers of the EBSLN and of the RLN to intrinsic laryngeal musculature were calculated as 231.3 mu V and 1354.5 mu V, respectively. Conclusion Recordable waveform amplitude with EBSLN stimulation yielded motor relations between laryngeal nerves. CTM contraction after stimulation of the RLN confirmed these relations. These results of IONM established motor interconnections between superior and inferior laryngeal nerves in the majority of patients. The EBSLN may have an effect on motor innervations for intrinsic laryngeal muscles via motor interconnections

Recurrent Goiter Presented with Marine-Lenhart Syndrome 27 Years After Initial Surgery

WOS: 000488108400002PubMed: 31723527Marine-Lenhart syndrome (MLS), a rare form of hyperthyroidism, is the coexistence of Graves' disease (GD) and autonomously functioning thyroid nodule(s). Herein, we report a case of recurrent goiter presented with MLS. A 52-year-old man presented at our department with recurrent goiter, exophthalmia, and symptoms of hyperthyroidism. In addition to clinical signs and thyroid eye disease, suppressed thyroid-stimulating hormone (TSH) and high free thyroxine (FT4) and autoantibody levels lead to the diagnosis of GD. Thyroid ultrasound and nuclear scan showed the presence of a large, solid, and functioning "hot" nodule in the right lobe. Thus, in recurrent goiter cases, the diagnosis was MLS, wherein autoimmune hyperthyroidism was associated with the functioning nodule. Following medical control with methimazole, the patient underwent total excision of recurrent goiter. Levothyroxine (LT4) therapy was prescribed to maintain normal serum hormone levels. At follow-up, the gradual decrease in serum levels of autoantibody was detected. This patient is a very rare example of MLS that occurs in recurrent goiter case. Clinical signs, serum hormone and autoantibody levels, thyroid ultrasound, and nuclear scan establish the correct diagnosis of this specific and rare disorder. Thyroid surgery and total removal of glandular tissue provides definitive control of hyperthyroidism and obviates autoimmune reaction

Non-recurrent nerve from the vagus anterio-medially located in the carotid sheath

WOS: 000370846300017PubMed: 26504426Non-recurrent inferior laryngeal nerve (ILN) arising from the vagus nerve is a rare anatomic variation. The vagus descends vertically in the cervical neurovascular bundle, between and posterior to common carotid artery (CCA) and internal jugular vein (IJV). The vagus has also some anatomic variations. We present a case of two coincident anatomic variations both ILN and the vagus nerve. A patient with multinodular goiter was surgically treated with total thyroidectomy. Both two ILNs were identified, fully exposed and preserved along their cervical courses. We found that the right non-recurrent ILN directly arises from cervical vagal trunk, and enters the larynx at usual point after a short transverse course parallel to the inferior thyroid artery. The vagus nerve, easily exposed after dissection of the right lobe of the thyroid gland, is located medially to the CCA. We discovered the association of non-recurrent ILN and medially located vagus nerve in the same patient. Non-recurrent nerve and medially located vagus nerve in the cervical neurovascular bundle are two different variations. The coincidence of right non-recurrent ILN arising from cervical part of the vagus medial to the CCA in the same patient is a very interesting feature. The safety of thyroid operations is dependent on proper identification, dissection and full exposition of ILN. The safe procedure requires complete knowledge on the anatomy of neural structures including all their anatomic variations

Location of motor fibers within branches of the recurrent laryngeal nerve with extralaryngeal terminal bifurcation; Functional identification by intraoperative neuromonitoring

WOS: 000363005800021PubMed: 26054316Background. Extra laryngeal terminal bifurcation (ETB) of the recurrent laryngeal nerve (RLN) is an anatomic variation that threatens the safety of thyroid operation. Therefore, it is important to identify motor function in nerve branches to preserve appropriate motor activity. Intraoperative neuromonitoring (IONM) is an accepted procedure to identify motor function of the RLN. Methods. We established the operative anatomy of RLNs with ETB in 47 patients. The main trunk, bifurcation point, and the branches were identified and exposed completely during thyroid operation. The location of motor fibers within nerve branches was investigated by identifying motor function via IONM. Wave amplitudes were recorded after electrophysiologic stimulation. Results. A total of 61 RLNs had ETBs with anterior and posterior branches. Bifurcation occurred early along the pre-arterial (proximal) segment in 13% of bifid RLNs. IONM showed motor function in all anterior branches. IONM identified motor activity in 4 (18%) posterior branches of 22 right, 3 (8%) posterior branches of 39 left, and 7 (12%) posterior branches of all 61 RLNs with ETB. The rate of recorded wave amplitudes of motor function in seven posterior branches was between 14 and 78% of those of corresponding anterior branches. Conclusion. In the RLN, the anterior branch always and the posterior branch uncommonly contain motor fibers. Wave amplitude analysis showed that motor function in the posterior branch is weaker than that in the anterior branch. On the basis of the location of motor fibers in both branches, total exposure and preservation of anatomy and function of all branches of the RLN is mandatory for complication-free thyroid surgery. Electrophysiologic testing may be as an important adjunct to visualization of the nerve with anatomic variation.Duzce University Scientific Research ProjectsDuzce University [DUBAP 2012.04.02.121]This study is based on the project supported by Duzce University Scientific Research Projects (Project No. DUBAP 2012.04.02.121)

Extralaryngeal terminal division of the inferior laryngeal nerve: Anatomical classification by a surgical point of view

Background. Complete anatomic knowledge including all variations of the inferior laryngeal nerve (ILN) is mandatory for thyroid surgeon. Extralaryngeal terminal division (ETD) of the ILN has significant importance for the safety of thyroidectomy. Material and Methods. Surgical dissection of 200 ILNs was performed on 100 cases. The presence of ETD of the nerve was determined intraoperatively. We propose by a surgical point of view a regional (segmental) classification of ETD of the ILN along its cervical course. Results. ETD has been observed in 54/200 nerves (27%). Great majority are bifurcated nerves (trifurcation 2%). Four types of ETD are classified. In type 1 (arterial; 46.3%), ETD has occurred near inferior thyroid artery (ITA). In type 2 (postarterial; 31.5%), division has been found on postarterial segment. In type 3 (prelaryngeal; 11%), division has been located very close to laryngeal entry point. In type 4 (prearterial; 11%), ETD has occurred before the nerve crossing the ITA. Conclusions. ETD of the ILN is a common anatomical variation. The bifurcation occurs in the ILN at various distances from laryngeal entry point. The classification increasing surgeons' awareness may help to simplify identification and exposure of terminal branches. Preservation of both extralaryngeal terminal branches of the ILN has paramount importance for the safety of thyroid operations. © 2013 Emin Gurleyik

Surgical anatomy of bilateral extralaryngeal bifurcation of the recurrent laryngeal nerve: Similarities and differences between both sides

Background: Anatomical variations of the recurrent laryngeal nerve (RLN) such as extralaryngeal terminal bifurcation is an important risk for its motor function. Aims: The objective is to study surgical anatomy of bilateral bifurcation of the RLNs in order to decrease risk of vocal cord palsy in patients with bifurcated nerves. Materials and Methods: Surgical anatomy including terminal bifurcation was established in 292 RLNs of 146 patients. We included patients with bilateral bifurcation of RLN in this study. Based on two anatomical landmarks (nerve-artery crossing and laryngeal entry), the cervical course of RLN was classified in four segments: Pre-arterial, arterial, post-arterial and pre-laryngeal. According to these segments, bifurcation point locations along the cervical course of RLNs were compared between both sides in bilateral cases. Results: RLNs were exposed throughout their entire courses. Seventy (48%) patients had bifurcated RLNs. We identified terminal bifurcation in 90 (31%) of 292 RLNs along the cervical course. Bilateral bifurcation was observed in 20 (28.6%) patients with bifurcated RLNs. Bifurcation points were located on arterial and post-arterial segments in 37.5% and 32.5% of cases, respectively. Pre-arterial and pre-laryngeal segments contained bifurcations in 15% of cases. Comparison of both sides indicated that bifurcation points were similar in 5 (25%) and different in 15 (75%) patients with bilateral bifurcation. Permanent nerve injury did not occur in this series. Conclusion: Bilateral bifurcation of both RLNs was observed in approximately 30% of patients with extralaryngeal bifurcation which is a common anatomical variation. Bifurcation occurred in different segments along cervical course of RLN. Bifurcation point locations differed between both sides in the majority of bilateral cases. Increasing surgeons’ awareness of this variation may lead to safely exposing bifurcated nerves and prevent the injury to extralaryngeal terminal branches of RLN. © 2014, North American Journal of Medical Sciences. All rights reserved