Intraoperative Posterior Cricoarytenoid Muscle Electromyography May Predict Vocal Cord Function Prognosis after Loss of Signal during Thyroidectomy

Purpose Intraoperative posterior cricoarytenoid muscle (PCAM) electromyography (EMG) may be useful for predicting postoperative vocal cord function (VCF) and prognosis of vocal cord palsy (VCP) in patients with intraoperative loss of signal (LOS). Materials and Methods Thirty out of 395 patients having LOS detected by intraoperative neural monitoring (IONM), were applied intraoperative PCAM EMG. Results VCP was present in all Type 1 injury RLNs (16) (100%) and in 8 (57%) of 14 RLNs with Type 2 injury (p = 0.005). 14 out of 30 LOS patients (47%) had positive PCAM EMG amplitudes. The sensitivity, specificity, positive and negative predictive values and accuracy rates for predicting postoperative VCP via PCAM EMG, were calculated as 66.7%, 100%,100%, 42.86% and 73.33%. The negative PCAM EMG was related to VCP in both Type 1 and Type 2 LOS. VCP recovery time of Type 1 LOS patients was significantly longer than that of Type 2 LOS patients (p = 0.009). In Type 2 LOS, VCP recovery time was significantly longer in negative PCAM EMG patients compared to positive PCAM EMG patients (p = 0.046). Conclusion Negative PCAM EMG is associated with the postoperative VCP. Type 1 injury results in VCP regardless of PCAM EMG results, and VCF recovers after a longer period compared to Type 2 LOS. In Type 2 LOS, positive PCAM EMG may result in VCP by 40%. However, the presence of negative PCAM EMG is related to the postoperative VCP in all patients and the recovery time is longer compared to positive PCAM EMG patients

Ectopic mediastinal thyroid tissue: cervical or mediastinum originated?

A 22-year-old female patient was admitted to our clinic after both clinical and laboratory findings suggested hyperthyroidism. At pre-operative magnetic resonance imaging (MRI), we detected a substernal goitre with lobulated outlines at the inferior of the right lobe that extended 5 cm inferior to the carina. The thyroid mass extended to the mediastinum and was totally extracted by cervical incision. Postoperatively, a residual thyroid mass of 8.5×9×10 cm in size, was detected on MRI at the median part of the anterior mediastinum. The isolated mediastinal thyroid mass was then extracted by sternotomy. We believe that, because of the close anatomical relationship between the thyroid tissue extending cervically and the mass detected in the mediastinum, the mediastinal mass might have developed from the cervical thyroid tissue residues by pushing the cervical thyroid or it might have mechanically entered the mediastinum

Supernumerary ectopic parathyroid glands. Persistent hyperparathyroidism due to mediastinal parathyroid adenoma localized by preoperative single photon emission computed tomography and intraoperative gamma probe application. Hormones (Athens) 2009;8:144-9

ABSTRACT Ectopic and/or supernumerary parathyroid glands are a major cause of persistent and recurrent Hyperparathyroidism (HPT). For this reason, it is widely accepted that preoperative localization should be performed to improve the surgical results in patients with persistent or recurrent HPT. Primary HPT (pHPT) was diagnosed incidentally in a 50-year old female patient during a preoperative examination for hernia. No pathologic parathyroid gland was detected in the preoperative Tc-99m Methoxybutylisonitrile (MIBI) scintigraphy and Ultrasonography (US). Cervical exploration was performed bilaterally. Four parathyroid glands were located adjacent to the thyroid gland. A fifth was detected in front of the cricoid cartilage. All five of them were of normal histology. Postoperatively, hypercalcemia persisted. Single Photon Emission Computed Tomography (SPECT) was performed before the second operation and radioguide surgery was carried out by median sternotomy. SPECT showed a parathyroid adenoma in the middle of the anterior mediastinum which was excised (size 1x0.5x0.5 cm) using a gamma probe. In conclusion, SPECT and intraoperative gamma probe application may help to detect the parathyroid adenomas, especially if they are small in size and buried in the adipose tissue. Such localization shortens the duration of the operation and reduces the possibility of complications

A Rare Presentation of Autonomously Functioning Papillary Thyroid Cancer: Malignancy in Marine-Lenhart Syndrome Nodule

Objective. Marine-Lenhart Syndrome (MLS) is defined as concomitant occurrence of autonomously functioning thyroid nodule (AFTN) with Graves’ disease (GD). Malignancy in a functional nodule is rare. We aimed to present an extremely rare case of papillary thyroid cancer in a MLS nodule with lateral lymph node metastases. Case. A 43-year-old male presented with hyperthyroidism and Graves’ ophthalmopathy. On Tc99m pertechnetate scintigraphy, a hyperactive nodule in the left upper thyroid pole was detected and the remaining tissue showed a mildly increased uptake. The ultrasonography demonstrated 15.5 × 13.5 × 12 mm sized hypoechoic nodule in the left upper pole of the thyroid and round lymph nodes on the left side of the neck. Fine needle aspiration biopsy (FNAB) of the nodule and lymph node revealed cytological findings consistent with papillary cancer. Total thyroidectomy with central and left modified radical neck dissection was performed. On pathologic examination, two foci of micropapillary cancer were detected. The skip metastases were present in three lymph nodes on the neck. Conclusion. AFTN can be seen rarely in association with GD. It is not possible to exclude malignancy due to the clinical and imaging findings. In the presence of suspicious clinical and sonographic features, FNAB should be performed

Surgical approaches for papillary microcarcinomas: Turkey’s perspective

Objectives: The incidence of papillary microcarcinomas, which are defined as thyroid cancers of <10mm in size, has been increasing in the last decade. Herein, we present internet-based questionnaire results performed by the Turkish Association of Endocrine Surgery with the aim to evaluate the perspective of the management of papillary microcarcinomas in Turkey. Material and Methods: The user-friendly questionnaire consisted of 13 questions in total. These questions mainly addressed the surgical management of nodules and cancer of <1 cm in size. Patient management before, during, and after surgical intervention was also included; additionally, the “active surveillance approach” was questioned. Results: There were 420 responders in total who were of multidisciplinary origin (endocrinologists, surgeons, nuclear medicine specialists, pathologists, and oncologists). Total thyroidectomy was the predominant treatment approach (65%) for the classical type of microcarcinoma limited in one lobe, whereas in cases of microcarcinomas incidentally diagnosed during hemithyroidectomy, complementary surgery approach was advised by 40% of the responders. The responders found capsule invasion (86%) and patient based management (94%) of high importance. The percentage of the responders who recommended radioactive iodine ablation in incidental cancers having no aggressive criteria was 51%. The survey participants that were against routine central dissection in these cases accounted for 73% of the responders. The recommendation of active surveillance (follow-up without any interventional therapy) was limited with 9% responders. Conclusion: The results of the questionnaire demonstrated that there have been various choices in Turkey for the surgical treatment of the papillary microcarcinomas