Molecular Alterations and Comprehensive Clinical Management of Oncocytic Thyroid Carcinoma: A Review and Multidisciplinary 2023 Update.

Importance: Oncocytic (Hürthle cell) thyroid carcinoma is a follicular cell-derived neoplasm that accounts for approximately 5% of all thyroid cancers. Until recently, it was categorized as a follicular thyroid carcinoma, and its management was standardized with that of other differentiated thyroid carcinomas. In 2022, given an improved understanding of the unique molecular profile and clinical behavior of oncocytic thyroid carcinoma, the World Health Organization reclassified oncocytic thyroid carcinoma as distinct from follicular thyroid carcinoma. The International Thyroid Oncology Group and the American Head and Neck Society then collaborated to review the existing evidence on oncocytic thyroid carcinoma, from diagnosis through clinical management and follow-up surveillance. Observations: Given that oncocytic thyroid carcinoma was previously classified as a subtype of follicular thyroid carcinoma, it was clinically studied in that context. However, due to its low prevalence and previous classification schema, there are few studies that have specifically evaluated oncocytic thyroid carcinoma. Recent data indicate that oncocytic thyroid carcinoma is a distinct class of malignant thyroid tumor with a group of distinct genetic alterations and clinicopathologic features. Oncocytic thyroid carcinoma displays higher rates of somatic gene variants and genomic chromosomal loss of heterozygosity than do other thyroid cancers, and it harbors unique mitochondrial DNA variations. Clinically, oncocytic thyroid carcinoma is more likely to have locoregional (lymph node) metastases than is follicular thyroid carcinoma-with which it was formerly classified-and it develops distant metastases more frequently than papillary thyroid carcinoma. In addition, oncocytic thyroid carcinoma rarely absorbs radioiodine. Conclusions and Relevance: The findings of this review suggest that the distinct clinical presentation of oncocytic thyroid carcinoma, including its metastatic behavior and its reduced avidity to radioiodine therapy, warrants a tailored disease management approach. The reclassification of oncocytic thyroid carcinoma by the World Health Organization is an important milestone toward developing a specific and comprehensive clinical management for oncocytic thyroid carcinoma that considers its distinct characteristics.

Intraoperative Parathyroid Hormone Monitoring In Normohormonal Primary Hyperparathyroidism: How Low Do You Go?

OBJECTIVE: The primary goal of this study was to determine in patients with normohormonal primary hyperparathyroidism (NHHPT) what percent reduction in post-excision intraoperative parathyroid hormone (IOPTH) from baseline would yield a rate of cure comparable to that in patients with classical primary hyperparathyroidism (PHPT). METHODS: This is a retrospective cohort study of patients who underwent parathyroidectomy between July 2013 and February 2020. Demographic data, preoperative, intraoperative, and postoperative metrics were collected. Patients with NHHPT were compared to those with classical PHPT. Subgroup analyses were performed. RESULTS: Of the 496 patients included in the study, 66 (13.3%) were of the normohormonal variant based on preoperative intact parathyroid hormone (PTH) levels and 28 (5.6%) based on baseline IOPTH levels. The cure rates in the two normohormonal groups were not significantly different from their classical counterparts (98.4% and 100.0% vs. 97.1%, p = 1.000). The median percent decline in post-excision IOPTH from baseline that achieved cure in the normohormonal groups were 82.6% and 80.4% compared to their respective controls at 87.3%, p = 0.011 and p = 0.001. Although the rate of multiglandular disease was higher in one of the normohormonal variant groups, this difference was due to a higher rate of double adenomas, not four-gland hyperplasia. CONCLUSION: Patients with NHHPT undergoing parathyroidectomy can expect cure rates similar to that in patients with classical PHPT. The results of this study indicate that achieving an 80% drop or more in IOPTH levels predicts a high likelihood of cure. This is true irrespective of whether the patient is deemed normohormonal based on preoperative or intraoperative testing. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2480-2484, 2024.

Emerging Imaging Technologies for Parathyroid Gland Identification and Vascular Assessment in Thyroid Surgery: A Review From the American Head and Neck Society Endocrine Surgery Section.

Importance: Identification and preservation of parathyroid glands (PGs) remain challenging despite advances in surgical techniques. Considerable morbidity and even mortality result from hypoparathyroidism caused by devascularization or inadvertent removal of PGs. Emerging imaging technologies hold promise to improve identification and preservation of PGs during thyroid surgery. Observation: This narrative review (1) comprehensively reviews PG identification and vascular assessment using near-infrared autofluorescence (NIRAF)-both label free and in combination with indocyanine green-based on a comprehensive literature review and (2) offers a manual for possible implementation these emerging technologies in thyroid surgery. Conclusions and Relevance: Emerging technologies hold promise to improve PG identification and preservation during thyroidectomy. Future research should address variables affecting the degree of fluorescence in NIRAF, standardization of signal quantification, definitions and standardization of parameters of indocyanine green injection that correlate with postoperative PG function, the financial effect of these emerging technologies on near-term and longer-term costs, the adoption learning curve and effect on surgical training, and long-term outcomes of key quality metrics in adequately powered randomized clinical trials evaluating PG preservation.

Pediatric intraoperative nerve monitoring during thyroid surgery: A review from the American Head and Neck Society Endocrine Surgery Section and the International Neural Monitoring Study Group.

Children are more likely to experience recurrent laryngeal nerve (RLN) injury during thyroid surgery. Intraoperative nerve monitoring (IONM) may assist in nerve identification and surgical decision making. A literature review of pediatric IONM was performed and used to inform a monitoring technique guide and expert opinion statements. Pediatric IONM is achieved using a variety of methods. When age-appropriate endotracheal tubes with integrated surface electrodes are not available, an alternative method should be used. Patient age and surgeon experience with laryngoscopy influence technique selection; four techniques are described in detail. Surgeons must be familiar with the nuances of monitoring technique and interpretation; opinion statements address optimizing this technology in children. Adult IONM guidelines may offer strategies for surgical decision making in children. In some cases, delay of second-sided surgery may reduce bilateral RLN injury risk.

Intraoperative Nerve Monitoring in Thyroidectomies for Malignancy: Does It Matter?

BACKGROUND: Recurrent laryngeal nerve (RLN) injury and postoperative hypocalcemia are potential complications of thyroidectomy, particularly in malignancy. Intraoperative nerve monitoring (IONM) remains controversial. We sought to evaluate the impact of IONM on these complications using a national data set. METHODS: The American College of Surgeons National Surgical Quality Improvement Program thyroidectomy-targeted data set was queried for patients who underwent thyroidectomies from 2016 to 2017. Patients were grouped according to IONM use. Logistic regression models were constructed to evaluate associations of variables with 30-day hypocalcemic events (HCEs) and RLN injury. Associations were expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). A subgroup analysis was performed of patients with malignancy. RESULTS: A total of 9527 patients were identified; 5969 (62.7%) underwent thyroidectomy with IONM and 3558 (37.3%) without. By multivariable analysis, IONM had protective associations with HCE (OR = .81, 95% CI = .68-.96; P = .013) and RLN injury (OR = .83, 95% CI = .69-.98; P = .033). Malignancy increased risk of HCE (OR = 1.21, 95% CI=1.01-1.45; P = .038) and RLN injury (OR = 1.22, 95% CI = 1.02-1.46; P = .034). A large proportion (5943/9527, 62.4%) of patients had malignancy; 3646 (61.3%) underwent thyroidectomy with IONM and 2297 (38.7%) without. In the subgroup analysis, IONM had stronger protective associations with HCE (OR = .73, 95% CI = .60-.90; P = .003) and RLN injury (OR = .76, 95% CI = .62-.94; P = .012). DISCUSSION: Malignancy was associated with increased risk of HCE and RLN injury. Intraoperative nerve monitoring had a protective association with HCE and RLN injury, both overall, and in the malignant subgroup. Intraoperative nerve monitoring was correlated with improved thyroidectomy outcomes, especially if the indication was malignancy. This warrants further study to clarify cause and effect.

Parathyroid Gland Autofluorescence Characteristics in Patients With Primary Hyperparathyroidism.

OBJECTIVE: Near-infrared imaging for intraoperative parathyroid gland (PG) detection has recently commanded significant attention. The PTeye (Medtronic, Minneapolis, MN) is a probe-based system for near-infrared autofluorescent evaluation of PGs. This study was designed to evaluate the capabilities of the PTeye in the setting of surgery for primary hyperparathyroidism. STUDY DESIGN: Prospective, Cohort study. METHODS: This single-institution, prospective cohort study included all patients undergoing parathyroidectomy for primary hyperparathyroidism with presumed single gland disease from June 2020 to December 2020. Absolute intensity and intensity ratios, with the thyroid as the control tissue, were obtained for the adenoma, ipsilateral normal PG, and adjacent tissue. The ability of the PTeye to function when not in direct contact with tissue was measured. RESULTS: Twenty-two patients were included. The median intensity ratio for the in situ adenomas was 4.38 (interquartile range [IQR]: 2.03-5.87), ipsilateral normal PGs 6.17 (IQR: 3.83-7.67), strap muscle 0.47 (IQR: 0.30-0.60), and fat 0.20 (IQR: 0.17-0.47). All normal PGs and 21/22 adenomas demonstrated autofluorescence above the detection threshold. The PTeye functioned at a maximum distance of separation of 10 mm through saline medium and 6 mm through clear solid medium. CONCLUSION: This study confirms the PTeye's ability to recognize PGs with a high degree of precision. The device was found to function properly even with the probe not in direct contact with the tissue. Although adenomatous PGs appear to demonstrate altered autofluorescent properties from normal PGs, additional research is required to determine if these differences are clinically useful. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:715-721, 2022.

Hyperparathyroidism subsequent to radioactive iodine therapy for Graves' disease.

BACKGROUND: The development of primary hyperparathyroidism (PHPT) after radioactive iodine (RAI) treatment for thyroid disease is poorly characterized. The current study is the largest reported cohort and assesses the disease characteristics of patients treated for PHPT with a history of RAI exposure. METHODS: A retrospective analysis comparing patients, with and without a history of RAI treatment, who underwent surgery for PHPT. RESULTS: Twenty-eight of the 469 patients had a history of RAI treatment, all for Graves' disease. Patients with a history of RAI exposure had similar disease characteristics compared to control; however, patients with a history of RAI treatment had a higher rate of recurrence (7.4% vs 1.2%, p = 0.012). CONCLUSION: PHPT in patients with a history of RAI treatment can be approached in the same manner as RAI naive PHPT patients; however, the risk of recurrence of PHPT in RAI exposed patients may be higher.

Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement.

BACKGROUND: This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking. METHODS: An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements. CONCLUSIONS: This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.

Salivary and lacrimal dysfunction after radioactive iodine for differentiated thyroid cancer: American Head and Neck Society Endocrine Surgery Section and Salivary Gland Section joint multidisciplinary clinical consensus statement of otolaryngology, ophthalmology, nuclear medicine and endocrinology.

BACKGROUND: Postoperative radioactive iodine (RAI) administration is widely utilized in patients with differentiated thyroid cancer. While beneficial in select patients, it is critical to recognize the potential negative sequelae of this treatment. The prevention, diagnosis, and management of the salivary and lacrimal complications of RAI exposure are addressed in this consensus statement. METHODS: A multidisciplinary panel of experts was convened under the auspices of the American Head and Neck Society Endocrine Surgery and Salivary Gland Sections. Following a comprehensive literature review to assess the current best evidence, this group developed six relevant consensus recommendations. RESULTS: Consensus recommendations on RAI were made in the areas of patient assessment, optimal utilization, complication prevention, and complication management. CONCLUSION: Salivary and lacrimal complications secondary to RAI exposure are common and need to be weighed when considering its use. The recommendations included in this statement provide direction for approaches to minimize and manage these complications.

Increased prevalence of neural monitoring during thyroidectomy: Global surgical survey.

OBJECTIVE: To investigate intraoperative nerve monitoring (IONM) use among thyroid surgeons. METHODS: A 25-question survey was used to assess attitudes regarding IONM use. Surveys were sent to surgeons registered to the American Academy of Otolaryngology-Head and Neck Surgery, International Association of Endocrine Surgeons, and American Head and Neck Society. RESULTS: Among 1,015 respondents, 83% reported using IONM (65.1% always using IONM and 18.1% reporting selective use). For selective users, a majority reported using IONM for reoperative cases (95.1%) and in cases with preoperative vocal cord paralysis (59.8%). When comparing location, there was a significant difference in IONM implementation (P < 0.001), with 70.4% of North American responders using it ubiquitously compared to 27.4% of non-North American responders. Preoperative laryngeal exam was performed more universally by North American surgeons and more selectively by non-North American surgeons (P < 0.001). Other attitudes toward their implementation and the postoperative laryngeal exam were similar. Surgeons ≤45 years of age and those with ≤15 years of practice used IONM more than their peers (P < 0.001). Thyroid surgery volume, fellowship training, and type of practice had no bearing on IONM use. CONCLUSION: The prevalence of IONM in thyroid and parathyroid surgeries has increased significantly over the past decade, with 83% of surgeons using IONM in some or all cases. Although IONM use may be more ubiquitous in North America, attitudes toward its implementation and pre- and postoperative laryngeal exams are fairly uniform. IONM use is more prevalent among younger surgeons, whereas its use has no correlation with thyroid surgery volume or type of practice. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1097-1104, 2020.

Surgical impact of a dedicated endocrine surgeon on an academic otolaryngology department.

OBJECTIVES: Endocrine surgery is emerging as a dedicated subspecialty in otolaryngology. We assess the impact of an endocrine surgeon on an academic otolaryngology department's thyroid and parathyroid surgery volume. METHODS: A retrospective study of overall endocrine caseloads and resident case logs at a single academic center in the Midwest was performed. All thyroid and parathyroid cases performed by the otolaryngology department at an academic center from 2011 to 2017 were reviewed. In September 2012, an otolaryngologist who had completed an American Head and Neck Society endocrine surgery fellowship joined the faculty. The volume of endocrine surgery performed by the residents was also analyzed. Comparison of means and linear regression models were performed. RESULTS: From 2011 to 2012, the department performed a mean of 77 thyroid and 11.5 parathyroid surgeries annually. After the endocrine surgeon joined the department, this increased to an average of 212.8 thyroidectomies (P < 0.01) and 72.4 parathyroidectomies (P < 0.01) a year. The head and neck surgeons and generalists still performed an average of 42.4 thyroidectomies and 2.6 parathyroidectomies a year. For graduating residents, the average number of thyroid/parathyroid cases increased from 42.5 in 2012 to 151 in 2016. CONCLUSION: The addition of a fellowship-trained endocrine surgeon substantially increased the thyroid and parathyroid surgical volume of the otolaryngology department. Importantly, generalists and head and neck surgeons in the department continued to perform a significant number of these cases. Departments seeking similar surgical growth and expanded resident experience may consider the value of engaging a dedicated endocrine surgeon. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:832-835, 2020.

A faster parathyroidectomy: Techniques to shorten non-surgical operating room time.

OBJECTIVE: To assess the capacity of different techniques to reduce non-operative times during parathyroid surgery. The impact of monitored anesthesia care (MAC) instead of general anesthesia, and the pre-operative placement of a second peripheral intravenous catheter (PIV) were analyzed. METHODS: A retrospective case series at an academic medical center was performed to study patients undergoing parathyroidectomy by a single surgeon between November 2013 and October 2016. Three operating room (OR) time measurements were compared: pre-incision time, post-closure time, and total OR time. RESULTS: Surgeries performed under MAC (n = 21) had statistically shorter pre-incision (33.2 min vs. 39.7 min, p < .001), post-closure (10.1 min vs. 16.2 min, p = .002), and total operative times (113.0 min vs. 151.5 min, p < .001) compared to those in which general anesthesia (n = 169) was used. Of the 169 patients who underwent general anesthesia, 25 had a second PIV placed preoperatively and 144 had only a single PIV. All 3 time periods were statistically shorter in patients who had a second PIV versus those who had only a single PIV (pre-incision 32.2 min vs. 41.0 min, p < .001; post-closure 12.2 min vs. 16.9 min, p < .001; total 117.9 min vs. 157.4 min, p < .001). CONCLUSIONS: In patients undergoing parathyroid surgery in which ioPTH levels will be used, the placement of a second PIV in the pre-operative holding area and performance of surgery under MAC can significantly shorten non-operative and total OR time.

Evaluating contemporary pain management practices in thyroid and parathyroid surgery: A national survey of head and neck endocrine surgeons.

BACKGROUND: There is currently a lack of evidence-based guidelines regarding postoperative opioids after thyroid and parathyroid surgery. This study aimed to objectively characterize contemporary postoperative pain management practices via a national survey of head and neck endocrine surgeons. METHODS: A standardized electronic survey was distributed to the membership of the American Head and Neck Society's Endocrine section. RESULTS: A total of 102 surgeons completed the survey representing a 34% response rate. In all, 65.7% of respondents utilize opioids with wide variations in the total morphine equivalents prescribed. Practice environment (χ2 = 10.0; P = 0.04) and performing preoperative pain counseling (χ2 = 9.7; P = 0.002) were significantly associated with a decreased likelihood of prescribing postoperative opioids. Utilization of non-opioid pain management strategies was common and significantly associated with performing outpatient surgery (χ2 = 6.2; P = 0.013) and preoperative pain counseling (χ2 = 4.5; P = 0.034). CONCLUSIONS: Pain management practice patterns vary significantly among head and neck endocrine surgeons which further emphasize the need for evidence-based guidelines.

Safety and feasibility of a novel recurrent laryngeal nerve monitoring technique.

OBJECTIVES/HYPOTHESIS: Continuous intraoperative nerve monitoring (CIONM) during thyroidectomy is promising technology that may reduce the incidence of recurrent laryngeal nerve (RLN) injuries. However, the current technique for CIONM, in which a stimulating probe is placed on the vagus nerve, has not been widely adopted because of concerns regarding its invasiveness and safety. A new method with the lead positioned on the RLN may overcome these objections and promote greater adoption of CIONM. This study was conducted to serve as the first step in determining the safety and feasibility of an RLN-based CIONM approach. STUDY DESIGN: Case series with planned data collection. METHODS: Fifty patients scheduled to undergo thyroidectomy were enrolled. In all cases, after identification of the RLN, a lead designed for CIONM was placed on the nerve. The lead was then left in place for a minimum of 2 minutes, and CIONM data were recorded. Laryngeal electromyographic (EMG) characteristics were assessed just before the lead was placed on the RLN and after it was removed. Pre- and postoperative fiberoptic laryngoscopy was performed to assess vocal cord function in all patients. RESULTS: In 49 patients (98%), the probe was successfully positioned on the RLN, and CIONM data were generated. On average, 1.4 attempts per patient were required to properly place the lead. No accidental dislodgements of the lead occurred during the experiments. No patients demonstrated significant EMG changes from baseline after manipulation and stimulation of the RLN. The average CIONM time was 175.7 s (range, 138-212 s), and the average CIONM amplitude and latency were 675.2 µV (range, 211.0-1405.2 µV) and 1.8 ms (1.25-1.9), respectively. All patients had normal bilateral vocal cord function preoperatively and at the first postoperative visit. CONCLUSIONS: This study demonstrates the apparent safety and viability of a CIONM technique using a lead placed directly on the RLN. Future investigations are warranted of this promising method, which may promote more widespread adoption of CIONM during thyroidectomy to reduce RLN injuries. LEVEL OF EVIDENCE: 4 Laryngoscope, 2018.

International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal.

This publication offers modern, state-of-the-art International Neural Monitoring Study Group (INMSG) guidelines based on a detailed review of the recent monitoring literature. The guidelines outline evidence-based definitions of adverse electrophysiologic events, especially loss of signal, and their incorporation in surgical strategy. These recommendations are designed to reduce technique variations, enhance the quality of neural monitoring, and assist surgeons in the clinical decision-making process involved in surgical management of recurrent laryngeal nerve. The guidelines are published in conjunction with the INMSG Guidelines Part II, Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer-Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data. Laryngoscope, 128:S1-S17, 2018.

INCIDENTAL THYROID NODULES: RACE/ETHNICITY DISPARITIES AND OUTCOMES.

OBJECTIVE: Black patients have a significantly lower incidence of well-differentiated thyroid cancer (WDTC) compared to all other race/ethnic groups, while white patients appear to be at greater risk. This study examines incidental thyroid nodules (ITNs) to assess whether racial disparities in WDTC arise from a differential discovery of ITNs-perhaps due to socioeconomic disparities-or reflect true differences in thyroid cancer rates. METHODS: A retrospective review was performed of all patients who underwent fine-needle aspiration (FNA) of thyroid nodules by our academic medical center's endocrinology division between January 2006 and December 2010. Medical records were reviewed to identify whether the biopsied thyroid nodule was discovered incidentally through nonthyroid-related imaging or identified by palpation. RESULTS: FNAs were performed on 1,369 total thyroid nodules in 1,141 study patients; 547 (48%) were classified as white, and 593 (52%) were classified as nonwhite. Among this cohort, 36.6% of patients underwent biopsy for an ITN. White patients were 1.6 times more likely to have undergone a biopsy for a nodule that was incidentally identified compared to nonwhites ( P<.0001). Indicators of socioeconomic status (SES) did not have a significant association with ITNs. Within the ITN cohort, 4.9% of nonwhite patients were found to have a thyroid malignancy compared to 12.9% of white patients ( P<.01). CONCLUSION: The higher incidence of thyroid cancer in white patients appears to be not only due to diagnostic bias, but also to a true difference in cancer prevalence. ABBREVIATIONS: FNA = fine-needle aspiration; ITN = incidental thyroid nodule; SEER = Surveillance Epidemiology and End Results; SES = socioeconomic status; WDTC = well-differentiated thyroid cancer.

Comparison of incidental versus palpable thyroid nodules presenting for fine-needle aspiration biopsy.

BACKGROUND: Many attribute the rise in incidence of thyroid cancer to a deluge of radiologically identified incidental thyroid nodules. The clinical implications are unclear. METHODS: A review was performed of all patients who underwent fine-needle aspirations of thyroid nodules by our academic medical center's Endocrinology Division between 2006 and 2010. Medical records were reviewed to identify whether the thyroid nodule was discovered incidentally or by palpation. RESULTS: Of 1153 patients, 37.4% underwent a biopsy because of an incidental thyroid nodule. These patients were significantly more likely to be >45 years old, men, white race, and with a body mass index >30 kg/m2 . Of the 17.2% of incidentalomas that led to surgery, 8.5% were found to be thyroid cancer. CONCLUSION: Thyroid nodules discovered incidentally are increasing the diagnosis of subclinical thyroid cancers. Not investigated previously, our study found that the mode of detection was not related to malignancy or surgery.

Remote Access Robotic Facelift Thyroidectomy: A Multi-institutional Experience.

BACKGROUND: Robotic facelift thyroidectomy (RFT) was developed as a new surgical approach to the thyroid gland using a remote incision site. Early favorable results led to this confirmatory multi-institutional experience. METHODS: Prospectively collected data on consecutive patients undergoing RFT in five North American academic endocrine surgical practices were compiled. Surgical indications, operative times, final pathology, nodule size, complications, and postoperative management (drain use and length of hospital stay) were evaluated. RESULTS: A total of 102 RFT procedures were undertaken in 90 patients. All but one of the patients (98.9 %) were female, and the mean age was 41.9 ± 13.1 years (range 12-69 years). The indication for surgery was nodular disease in 91.2 % of cases; 8.8 % were completion procedures performed for a diagnosis of cancer. The mean size of the largest nodule was 1.9 cm (range 0-5.6 cm). The mean total operative time for a thyroid lobectomy was 162 min (range 82-265 min). No permanent complications occurred. There were 4 cases (3.9 %) of transient recurrent laryngeal nerve weakness, no cases of hypocalcemia, and 3 (2.9 %) hematomas. There were no conversions to an anterior cervical approach. The majority of patients were managed on an outpatient basis (61.8 %) and without a drain (65.7 %). CONCLUSIONS: RFT is technically feasible and safe in selected patients. RFT can continue to be offered to carefully selected patients as a way to avoid a visible cervical scar. Future prospective studies to compare this novel approach to other remote access approaches are warranted.