Management of patients with rectus sheath hematoma: Personal experience.

BACKGROUND/PURPOSE: Rectus sheath hematoma (RSH) is a rare clinical entity. It can be mistaken for other intra-abdominal disorders, which can result in diagnostic and therapeutic difficulties. This study was undertaken to analyze the clinical presentation, diagnostic modalities, and management of patients affected with RSH. METHODS: Between January 2008 and June 2011, eight patients (5 men and 3 women with a mean age of 53 years) with RSH were evaluated according to demographic characteristics, clinical and radiological findings, and methods of treatment. RESULTS: Six patients developed RSH after anticoagulant therapy; one after local trauma, and one after laparoscopic intervention. Six patients were treated nonsurgically; one patient underwent embolization of the inferior epigastric artery and one underwent ligation of the bleeding vessel. The average hospital stay was 6 days. There were no mortality or thromboembolic complications. CONCLUSION: RSH is a rare nonneoplastic entity that is usually associated with abdominal trauma and/or anticoagulant therapy. The gold standard for diagnosis is computed tomography, and ultrasonography can be used in follow-up. The treatment of choice is nonsurgical therapy because RSH is a self-limited condition. Surgical intervention should be reserved for cases with hemodynamic instability.

Spontaneous rupture of an umbilical hernia in a cirrhotic patient with ascites A case report and review of the literature.

The authors, report a case of spontaneous rupture of an umbilical hernia in a cirrhotic patient with ascites and perform a literature review. Their results and the published data suggest that it is preferable to perform elective surgery after stabilization of the ascites and the patient's general condition in order to prevent complications and mortality. KEY WORDS: Ascites, Hernioplasty, Spontaneous hernia rupture.

[Radiation exposure and thyroid cancer]. / Radiazioni ionizzanti e cancro tiroideo.

Thyroid cancer is the most common malignant tumor of the endocrine system. The most frequent type of thyroid malignancy is papillary carcinoma. Thyroid cancer's incidence rates have increased over the last three decades throughout the world. Numerous studies have documented that radiation exposure is a well-established risk factor for the thyroid cancer. It has been reported that exposure to external medical radiation or to external and internal radiation from atomic bomb explosions, nuclear tests or nuclear accidents leads to an increased risk for thyroid cancer. The risk of thyroid cancer is maximal during the first years of life and decreases with increasing age at exposure due to morphologic and functional heterogeneity in the thyroid tissue of children and adults. Also it has been indicated that iodine deficiency increases the risk of the thyroid cancer related to radioactive iodines in case of exposure to radioactive iodines in childhood and the stable iodine supplementation reduces this risk. Ionizing radiation produces a range of mutations in irradiated cells of the thyroid. The prevalence of RET/PTC mutations is significantly higher in papillary carcinomas from childhood patients with the precedent history of radiation.

Losartan vs. amlodipine treatment in elderly oncologic hypertensive patients: a randomized clinical trial.

Elderly neoplastic patients frequently may show hypertension and hyperuricemia, before and after chemotherapeutic treatments. The purpose of this study was to evaluate the efficacy of losartan which is an antihypertensive drug with uricosuric properties vs. amlodipine in hypertensive neoplastic elderly patients. This was an open-labeled, randomized, comparative trial. The study was performed as a 30-day study. Seventy patients with cancer were randomly assigned to receive losartan or amlodipine. Blood pressure (BP), blood urea nitrogen (BUN) levels, creatinine, serum and urinary uric acid, creatinine and uric acid clearance were determined before and after chemotherapy. One day after chemotherapy in losartan group vs. amlodipine group we observed a significant difference in urinary uric acid (p<0.001) of 18 mg/24 h vs. 40 mg/24 h. Thirty days after chemotherapy we observed a significant difference in azotemia of 0.0 mg/dl vs. 3.8 mg/dl (p<0.001), serum uric acid of 0.05 mg/dl vs. 0.49 mg/dl (p<0.001), urinary uric acid (p<0.001) of 23 mg/24 h vs. 0.0 mg/24 h, GFR of 2 ml/min/1.73 m(2) vs. -8 ml/min/1.73 m(2) (p<0.05) and systolic BP (SBP) of 3.6 mmHg vs. 0.8 mmHg (p<0.05). The findings of the present study support the effective role of losartan compared to amlodipine in treating hypertension and hyperuricemia in elderly patients under chemotherapeutic treatment.

Simultaneous medullary carcinoma and differentiated thyroid cancer. Case report.

BACKGROUND: Medullary thyroid cancer (MTC) is an uncommon and aggressive tumour representing only 5-10% of all thyroid malignancies. MTC arises from parafollicular thyroid cells (C-cells) producing calcitonin hormone. Differentiated thyroid cancer (DTC) is the most frequent thyroid tumour (papillary or follicular), representing 80% of all thyroid cancer. DTC derives from follicular thyroid cells, that come from the central thyroid sketch. The association between medullary and papillary thyroid cancer is rare. Several cases have been reported of mixed carcinomas. CASE REPORT: We report two cases of associated medullary and papillary carcinomas in two different foci in patients with respectively Graves' disease and multinodular goiter. A young woman affected by Grave's disease and multinodular goiter under pharmacological treatment with antithyroidal drugs underwent total thyroidectomy. The histopathological examination revealed the presence of a medullary carcinoma of the middle third of right lobe (1.1 cm) with an adjacent papillary microcarcinoma (0.5 cm). A 72-years-old woman, affected by euthyroid multinodular goiter, underwent total thyroidectomy. The pathological findings were two microcarcinomas, medullary (0.44 cm) in the left lobe and papillary (0.22 cm) in the right lobe. CONCLUSION: We can speculate that this coexistence is inferred, not having shown a specific cause that justifies the association between the two types of tumour and the high prevalence of papillary carcinoma.

Post-thyroidectomy hypocalcemic syndrome: predictive value of early PTH. Preliminary results.

AIM: The aim of this study is to determine an early measured serous PTH cut-off value below which it's possible to predict post-thyroidectomy hypocalcaemia outbrake. MATERIALS OF STUDY: Ninety-three consecutive patients having a benign thyroid pathology were submitted to total thyroidectomy. In all the patients serous post-surgery intact PTH and total calcium were measured within an hour from weaning. 65 patients were measured a second time 18 hours from surgery. We searched for a correlation between the post-surgery PTH values at 1 and 18 hours from surgery with the calcemia at 1 and 18 hours from surgery. We carried out a one-year follow-up for each patient. Hypocalcemia developed in 26 patients (27.95%). It was transitory in twenty-two patients (23.65%) and permanent in 4 patients (4.3%). No correlation was found between PTH1 and Cal (p = 0.8). Statistically relevant correlation (p = 0.008) was found between PTH1 and Ca2. The correlation between PTH2 and Ca2 (p = 0.001) turns out to be even more relevant. We also calculated a found that 9.5 pg/dl was PTH1 cut-off value below which it is possible to predict hypocalcemia onset (p = 0.001). DISCUSSION AND CONCLUSIONS: Early post-surgery PTH measuring is a highly predictive test of post-surgery hypocalcemia. We identified a PTH1 cut-off value of 9.5 pg/dl, below which hypocalcemia onset is extremely frequent. This assessment permits us to establish an adequate drug prophylaxis, thus avoiding the related symptoms. We can also perform one-day surgery thyroidectomy in patients showing normal PTH values.

Cervico-mediastinal goiter: is telescopic exploration of the mediastinum (video mediastinoscopy) useful?

Surgeons are aware that most mediastinal goiters can be excised through a Kocher transverse collar incision, but in rare circumstances a partial-complete median sternotomy or a thoracotomy are mandatory. During an operation to remove a large cervico-mediastinal goiter (CMG) a profound, not massive, bleeding in the anterior mediastinum developed. Bleeding was unsuccessfully treated with packing. Instead, to perform an urgent sternotomy we used telescopic imaging to identify the source of hemorrhage, and a metallic clip was used to stop the bleeding. Since then we have prospectively used the telescope in the case of large CMG causing compression of an adjacent structure. This report is a preliminary communication demonstrating the technique. Telescopic exploration of the mediastinum was performed in seven patients. The goiters were located in the middle mediastinum in five patients and in the anterior and middle mediastinum in one, respectively. The use of a telescope can help the surgeon during the removal of a large mediastinal goiter. It facilitates a) the visualization of the intrathoracic tributaries reducing the risk of hemorrhage, b) the research of ectopic thyroid gland, and finally c) minimizes the risk of complications of a median sternotomy.

Giant mediastinal parathyroid adenoma: a case report.

A 65 year old female patient suffering from multinodular goitre and from hypercalcaemic syndrome which had been and was being treated with drugs for a number of years. The patient undergoes total thyroidectomy. Surgical neck and anterior mediastinum exploration was negative for sick parathyroids. Neck and chest TC and 'TC sestamibi scintigraphy showed the presence of a 7 cm hyperfunctional ectopic parathyroid tissue in the postero-superior mediastinum infiltrating oesophagus. Video bronchoscopy revealed an extrinsic compression of the trachea. The patient underwent surgery. Through right postero-lateral thoracotomy and mediastinal pleura incision, the adenoma excision was carried out. The histological examination revealed a potentially malignant parathyroid adenoma with infiltration, without over-reaching the capsule. The surgical treatment resulted in an immediate resolution of the clinical symptomatology. One year later, the follow up was shown no observable relapse with normal calcium and PTH values. Today, the tendency to minimally invasive surgery, an accurate preoperative localization of the adenoma and the use of techniques such as intra-surgical nuclear mapping through manual gamma probes, selective angiography, venous intraoperative dosage of PTH and intra-surgical ultrasound scan.

Necrotizing fasciitis. Case report.

Necrotizing fasciitis (NF) is an infection localized at the fascial structures (both the superficial and deep ones) layering the muscles though never affecting them. NF death rate is very high (20-40%). NF can be a post-surgery, traumatic or infective complication and its prognosis quoad vitam is fatal without a timely and correct therapy. A 57-year-old woman was got into observation due to her temperature, left thigh pain, erythema and tumefaction in the left groin-crural seat. She suffered from obesity, insulin-dependent mellitus diabetes and modest but chronic renal failure and ischaemic cardiopathy from previous Acute Myocardial Infarctions. It was then started a wide-spectrum antibiotics therapy. But after just six hours there took place a rapid development of the clinical picture with the appearance of haemorrhagic-content blisters and areas of cutaneous necrosis. The patient therefore underwent-under general anaestesia-multiple incisions in the groin-crural seat and on the ipsilateral thigh. The multiple biopsies carried out during the operation too underwent cultural and histomorphopathological analysis. The anatomic pathological study highlighted the presence of necrosis of the fascia, vascular thrombosis and myonecrosis. The cultural analysis of the tissue biopsies showed a polymicrobial infection. Both the pharmacological therapy and the surgical cleaning were carried out daily but without any improvement of the clinical picture. On the eighth day a worsening of the patient's general conditions took place, with a multiple organ failure determining the patient's exitus.

Klebsiella pneumoniae pulmonary infection with thyroid abscess: report of a case.

Thyroid abscess is a rare clinical entity, usually associated with a pyriform sinus fistula. A prompt diagnosis is important because it may progress rapidly into a life-threatening condition. We report a very unusual case of thyroid abscess associated with a lung infection, both caused by Klebsiella pneumoniae. The patient was treated successfully with a culture-appropriate antibiotic and an uneventful thyroid lobectomy. A delay in diagnosis of morbidities associated with a thyroid abscess may result in rapid exacerbation of this condition; therefore, prompt and appropriate treatment is mandatory for a successful outcome.

[Thyroid diseases in elderly patients]. / Disfunzioni tiroidee in età geriatrica.

AIM OF THE STUDY: To evaluate the differences about incidence, kind and clinical features of thyroid diseases in young and elderly patients. MATERIALS AND METHODS: Our study has been conducted in Endocrine Surgery Unit, "S. Luigi and S. Currò" Hospital in Catania, from January 2001 to December 2003. In this period 621 patients affected with different thyroidopathies were observed. They were divided in two groups: elderly (65 years or older), named Group A, and young subjects (under 65 years old), named Group B. Group A included 147 people aged between 65 and 89, with F:M = 3.9:1. Our study was founded on clinical and laboratory evaluation of thyroid hormones and antibodies (AAT, AMT) and subsequently an ultrasonographical evaluation, that has been completed, in some cases, with cytologic examination (FNAc). CONCLUSION: The main aspect about thyroid diseases is the different and atypical presentation in the elderly in comparison to young patients, with subsequent difficult diagnosis due to common symptoms to thyroidopathies rather than to physiological ageing. The most common thyroid dysfunctions in elderly are the autoimmune thyroidopathies, responsible of hypothyroidism. Such condition, in elderly, is often clinically irrelevant.

[Some ecomorphologic aspects of nodular goiter]. / Su alcuni aspetti ecomorfologici dei noduli tiroidei.

AIM OF THE STUDY: Determine microcalcifications' rule in nodular goiter, to classify those calcifications and identify US features suspect for tumoral pathology. MATERIAL AND METHODS: In Endocrine Surgery Unit we ultrasonographically detected 655 patients in a period of twelve months (Jan to Dec 2005). Patients aged from 22 to 75 years. Multinodular goiter were 42% and solitary nodular 33.8%, higher than other studies, as we checked selected patients. We determined microcalcification' incidence in nodular goiter and thyroiditis and studied their correlations with tumours. We also studied other US features suspect for malignant lesions. We divided microcalcifications in four groups. Thyroiditis prevalence was 55.8%. Microcalcifications' prevalence was 32.3%, divided as follow: Type I 18.1%, type II 4%, type III 81.8%, type IV 9%. In 9% of patients was present more than one kind of calcifications. Microcalcification rate was 28.9% in inflammatory disease, 55.17% in multinodular goiter and 18, 18% in single thyroid nodules. "Suspect" microcalcifications were present in 9% of whole thyroid pathology and in 12% of MNG. The majority of microcalcifications belonged to type III and their nature is questionable. Several Authors mentioned microcalcifications as a sensitive and highly specific feature for tumour diagnosis. Microcalcifications have a 59.2% sensitivity rate and a specificity rate of 85.8-95%. Their diagnostic accuracy is 77.4%. Other us suspect features are hypoecogenicity and irregular nodule outline. CONCLUSIONS: Ultrasonography remains an operator-dependent exam and it's necessary a correct interpretation of morphological data. Meticulous characterization of all ultrasonographic criteria enounced above is useful to reach satisfactory results and identify suspect lesions.

Giant recurrent fibromatosis of the breast: a case report. Clinical features and implications for treatment.

Fibromatosis of the breast is a benign but locally aggressive neoplasm, which has been described under various names including extra-abdominal desmoid tumour and aggressive fibromatosis. It is a rare condition, accounting for approximately 0.2% of all solid tumours of the breast. Clinically and radiologically the lesion mimics breast cancer and the definitive diagnosis is provided by histology. A high risk of local recurrence is a characteristic of this disease. Radical excision of the tumour with clear histological margins decreases the likelihood of recurrence. The possible association between breast implants and mammary fibromatosis has been reported. In this study we report a case of giant fibromatosis of the breast observed in a young patient and its extensive recurrence, involving all quadrants of the breast, the pectoralis major muscle, the rectus abdominis muscle sheath and the costal layer. The main clinical and pathological characteristics of this rare disease are illustrated, emphasizing the difficulties encountered both in the diagnosis of the primary lesion and in the management of its giant recurrence, particularly as regards the possibility of obtaining a radical surgical excision and the option of performing breast reconstruction.

Decrease of serum carnitine levels in patients with or without gastrointestinal cancer cachexia.

AIM: To evaluate the levels of serum carnitine in patients with cancer in digestive organs and to compare them with other cancers in order to provide new insights into the mechanisms of cachexia. METHODS: Fifty-five cachectic patients with or without gastrointestinal cancer were enrolled in the present study. They underwent routine laboratory investigations, including examination of the levels of various forms of carnitine present in serum (i.e., long-chain acylcarnitine, short-chain acylcarnitine, free carnitine, and total carnitine). These values were compared with those found in 60 cancer patients in good nutritional status as well as with those of 30 healthy control subjects. RESULTS: When the cachectic patients with gastro-intestinal cancer were compared with the cachectic patients without gastrointestinal cancer, the difference was -6.8 micromol/L in free carnitine (P < 0.005), 0.04 micromol/L in long chain acylcarnitine (P < 0.05), 8.7 micromol/L in total carnitine (P < 0.001). In the cachectic patients with or without gastrointestinal cancer, the difference was 12.2 micromol/L in free carnitine (P < 0.001), 4.60 micromol/L in short chain acylcarnitine (P < 0.001), and 0.60 micromol /L in long-chain acylcarnitine (P < 0.005) and 17.4 micromol/L in total carnitine (P < 0.001). In the cachectic patients with gastrointestinal cancer and the healthy control subjects, the difference was 15.5 micromol/L in free carnitine (P < 0.001), 5.2 micromol /L in short-chain acylcarnitine (P < 0.001), 1.0 micromol/L in long chain acylcarnitine (P < 0.001), and 21.8 micromol/L in total carnitine (P < 0.001). CONCLUSION: Low serum levels of carnitine in terminal neoplastic patients are decreased greatly due to the decreased dietary intake and impaired endogenous synthesis of this substance. These low serum carnitine levels also contribute to the progression of cachexia in cancer patients.

Hepatitis C virus in elderly cancer patients.

BACKGROUND: There are few studies about the relationship between HCV and the development of other tumors. We consider the prevalence of HCV infection in elderly cancer patients who have tumors different from that in hepatocellular carcinoma and non-Hodgkin's lymphoma. METHODS: We evaluated the prevalence of HCV infection in 236 elderly cancer patients in comparison with 300 elderly volunteers. Cancer patients presented a variety of tumors other than hepatocarcinoma and lymphoma, namely, colorectal (n=66), breast (n=44), bladder (n=40), prostate (n=30), lung (n=22), kidney (n=15), pancreatic (n=6), thyroid (n=5), cervical (n=4), melanoma (n=3) and vaginal (n=1). RESULTS: Among the 236 elderly cancer patients, 87 were positive for HCV antibodies (36%) and, among the 300 elderly patients, 32 were positive (10%). A comparison between the two groups revealed a statistically significant difference (p<0.001) between patients with kidney cancer, bladder cancer or prostate cancer, and the control group. CONCLUSIONS: The high anti-HCV prevalence in elderly cancer patients may be due to several mechanisms. These patients are more prone to acquire an HCV infection because of their frequent hospitalizations and the immunological changes in patients with tumors may lower their threshold for HCV infection.

[Papillary carcinoma in an isthmic thyroglossal duct cyst: clinical considerations]. / Il carcinoma papillifero in cisti del dotto tireoglosso a sviluppo istmico: considerazioni su un' osservazione clinica.

Cancer in a thyroglossal duct cyst is uncommon (incidence: approximately 1%). There are about 250 reported cases in the literature, most of which are papillary cancers or, less frequently, squamous or follicular carcinomas. The preoperative diagnosis of thyroglossal duct cyst carcinoma may be facilitated by an ultrasound neck examination or fine needle aspiration cytology (FNAc). As reported in the literature, however, the diagnosis is often obtained only at histopathological examination. We describe a case of a 43-year-old male patient with a papillary carcinoma in an isthmic thyroglossal duct cyst. Ultrasound of the neck demonstrated a nodular hypo-anechogenic cystic neoformation of the isthmus of the thyroid, while Fnac was not diagnostic. An isthmectomy of the thyroid was initially performed. Frozen examination of the cystic lesion revealed a papillary carcinoma in the thyroglossal duct cyst. A total thyroidectomy with central lymphectomy was therefore performed. Carcinoma in the thyroglossal duct has a low mortality (5-year mortality: < 2%), but a long-term follow-up is mandatory, due to the low, short-and medium-term recurrence rate.

[Hashimoto thyroiditis. Possible cause or consequence of a malignant thyroid tumor]. / Tiroidite di Hashimoto: possibile causa o conseguenza del tumore tiroideo maligno.

AIM OF THE STUDY: The Authors performed a retrospective study on their case records in order to analyze the epidemiological aspects of association between Hashimoto thyroiditis and differentiated thyroid carcinoma. MATERIALS AND METHODS: From January 2004 to December 2005 the Authors performed 282 total thyroidectomy for any thyroid pathology. All patients were studied preoperatively even dosing antithyroid antibodies. In the study are included patients who presented histological finding of both Hashimoto thyroiditis and carcinoma. RESULTS: Eleven patients (23.9%) of 46 patients operated on for differentiated thyroid carcinoma also presented histological finding of thyroiditis. Association of thyroiditis and carcinoma was present in 39.2% of histologically detecied thyroiditis (28 patiems). CONCLUSIONS: Pathophysiological relationship between Hashimoto thyroiditis and DTC are still unclear, although a certain association of theese two anatomo-clinic entity has been demonstrated. We can't yet say if Hashimoto thyroiditis advance and facilitale tumour arising or thyroiditis is a reaction to neoplasia or these two pathologies are indipendeni each other, although both are present in the same patient.

[Thyroid microcarcinoma in benign thyroid diseases]. / Il microcarcinoma tiroideo nelle tireopatie benigne.

INTRODUCTION: Thyroid microcarcinoma is a malignant thyroid tumor with potential multifocality and a maximum of 1 cm of diameter. This carcinoma has been discovered more frequently like incidentaloma. AIM OF THE STUDY: To appraise the incidence of MCT in the benign thyroid diseases and the advantages offered from the total thyroidectomy, performed for benign diffused thyroid diseases, which surgical treatment "therapeutic" performed for these malignant tumors. MATERIALS AND METHODS: The study was conducted on 600 patients operated with total thyroidectomy for benign thyroid disease, admitted from 1999 to 2003. RESULTS: All patients were alive and free of disease at last control. DISCUSSION: The MCT is a carcinoma that presents frequently a behavior little malignant and a good prognosis. His principal characteristic is the absence of clinical demonstrations. Therefore his discovery, almost always accidental on a thyroid removed for other pathology, it has signaled by histologic study CONCLUSIONS: Thyroid microcarcinoma is a slow growing tumor, with a good prognosis and with a good disease-free survival. It can present a better aggressiveness for his multifocal localization and invasion. Therefore total thyroidectomy can be considered best treatment and also be surgical treatment oncologically correct for this tumor.

[The lobe of Zuckerkandl: an important sign of recurrent laryngeal nerve]. / Il lobo di Zuckerkandl: faro del nervo laringeo ricorrente.

INTRODUCTION: The accurate acquaintance of the anatomy of the thyroid gland allows reduction of complications to interventions of thyroidectomy, where for the existing topography, the nervous and vascular structures could result vulnerable. The identification of Zuckerkandl's tuberculum could reduce the lesions to the recurrent laryngeal nerve, for constant relationship between the recurrent laryngeal nerve and tuberculum. MATERIALS AND METHODS: The Authors have studied 605 patients underwent to thyroid surgery for benign or malignant thyroid diseases. The aim was to verify if the incidence of recurrent nerve lesions can be reduced with the identification of the Zuckerkandl's tuberculum and with a knowledge of its anatomical relationships with vascular, nervous and glandular structures near the thyroid. RESULTS: The Zuckerkandls tuberculum was found in the majority of the cases, with prevalence to the right. Its identification has allowed an immediate and safe identification of recurrent laryngeal nerve, with setting of time of the operation and especially with setting of possible injury to the recurrent nerves. DISCUSSION: The lobe of Zuckerkandl is the extension of the lateral lobes of the thyroid, composed of thyroid tissue only and so it can be interested in thyroid lesions. This tubercle is considered a constant anatomical landmark for the recurrent laryngeal nerve and the superior parathyroid glands. The knowledge of the lobe of Zuckerkandl is essential to perform "safety thyroidectomy", without injury for the vascular and nervous structures. CONCLUSIONS: TZ identification is not always easy and/or possible but, when that happens become aware of possible, systematically, the isolation of the recurrent nerve and of the superior parathyroid gland, preserve such structures from possible lesions in surgery of the thyroid gland.

[Zuckerkandl's tuberculum: could it be useful in thyroid surgery?]. / Il tubercolo di Zuckerkandl: è un ausilio nella chirurgia della tiroide?

A thorough knowledge of thyroid anatomy could reduce the incidence of lesions to the inferior laryngeal nerve. In view of its relationship with the recurrent laryngeal nerve and the parathyroid gland, Zuckerkandl's tuberculum should be considered an anatomical landmark for the recurrent laryngeal nerve in thyroid surgery. The aim of the study was to verify whether the identification of Zuckerkandl's tuberculum could be useful to reduce the incidence of recurrent laryngeal nerve lesions. Four hundred and thirty-two patients underwent thyroid surgery over the period from January 2001 to December 2003 for benign (377 patients) or malignant disease (55 patients). Three-hundred and forty-eight (81%) underwent total thyroidectomy. Zuckerkandl's tuberculum was found in 74.5% of patients, with a high prevalence in the right lobe: in 5% of patients it was grade I, in 50% grade II and in 45% grade III. Its presence was associated with the recurrent laryngeal nerve in almost all cases. Eight of the patients undergoing total thyroidectomy suffered recurrent nerve paralysis, only 4 of which proved definitive. Identification of Zuckerkandl's tuberculum allows safer isolation of the recurrent laryngeal nerve and superior parathyroid gland dissection.