The relation of recurrent laryngeal nerve to inferior thyroid artery and extralaryngeal nerve branching may increase the risk of vocal cord paralysis in thyroidectomy.

PURPOSE: The anatomical variations of the recurrent laryngeal nerve (RLN) are common during thyroidectomy. We aimed to evaluate the risk of RLN paralysis in case of its anatomical variations, retrospectively. METHODS: The patients with primary thyroidectomy between January 2016 and December 2019 were enrolled. The effect of age, gender, surgical intervention, neuromonitorisation type, central neck dissection, postoperative diagnosis, neck side, extralaryngeal branching, non-RLN, relation of RLN to inferior thyroid artery (ITA), grade of Zuckerkandl tubercle on vocal cord paralysis (VCP) were investigated. RESULTS: This study enrolled 1070 neck sides. The extralaryngeal branching rate was 35.5%. 45.9% of RLNs were anterior and 44.5% were posterior to the ITA, and 9.6% were crossing between the branches of the ITA. The rate of total VCP was 4.8% (transient:4.5%, permanent: 0.3%). The rates of total and transient VCP were significantly higher in extralaryngeal branching nerves compared to nonbranching nerves (6.8% vs. 3.6%, p = 0.018; 6.8% vs. 3.2%, p = 0.006, respectively). Total VCP rates were 7.2%, 2.5%, and 2.9% in case of the RLN crossing anterior, posterior and between the branches of ITA, respectively (p = 0.003). The difference was also significant regarding the transient VCP rates (p = 0.004). Anterior crossing pattern increased the total and transient VCP rates 2.8 and 2.9 times, respectively. CONCLUSION: RLN crossing ITA anteriorly and RLN branching are frequent anatomical variations increasing the risk of VCP in thyroidectomy that cannot be predicted preoperatively. This study is the first one reporting that the relationship between RLN and ITA increased the risk of VCP.

A unique complication of thyroidectomy for Hashimoto's thyroiditis: central retinal artery thrombosis.

BACKGROUND: Central retinal artery occlusion (CRAO) is a rare ophthalmological emergency and also a unique complication after thyroid surgery. METHODS: We present the first case of CRAO following thyroid surgery in a patient with Hashimoto's thyroiditis, along with a variety of interventions to overcome this complication. RESULTS: A 42-year-old female patient suffering from sudden vision loss following total thyroidectomy was diagnosed with CRAO. Hyperbaric oxygen therapy was started within the postoperative first 6 hours. CONCLUSION: Although it is extremely rare, it should be noted that patients may experience retinal artery occlusion following the thyroid surgery. Immediate evaluation of patients with visual impairment in the early postoperative period, and planning of emergent hyperbaric oxygen therapy for the management are critical.

Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) for primary hyperparathyroidism: Turkey's experience.

AIM: Parathyroid surgery has witnessed a significant evolution with the introduction of more efficacious preoperative localization imaging techniques and the use of rapid intraoperative parathormone assays. Parathyroid surgery can now be performed with the minimum of invasion. Through the adaptation of the transoral endoscopic thyroidectomy vestibular approach (TOETVA), the technique has now been adopted for parathyroid surgery, known as the transoral endoscopic parathyroidectomy vestibular approach (TOEPVA). We present here the initial experiences of 11 centers carrying out TOEPVA surgery in Turkey. MATERIALS AND METHODS: Participating in the study were 11 centers, all of which were tertiary care institutions carrying out endocrine surgery. A retrospective review was made of 35 primary hyperparathyroidism patients who underwent the TOEPVA procedure between July 2017 and January 2020. RESULTS: Of the total 35 patients, 32 patients underwent the TOEPVA procedure successfully. All patients but one were female, and the mean age was 47.2 (20-73) years. According to localization studies, 18 of the lesions were lower left, 12 were lower right, 3 were upper right and 2 were upper left. The mean operative time was 116 (30-225) min, and three cases were converted to an open procedure. Simultaneous thyroidectomy was performed in seven cases. The average PTH level dropped to normal within 20 min. after the resection in all cases. The complication rate was 19% (ecchymosis, subcutaneous emphysema, nasal bleeding, surgical site infection and seroma). There were neither recurrent nerve palsies, nor mental nerve root or branch injuries. The average hospital stay was 1 day. No persistence was documented on follow up. CONCLUSION: TOEPVA is a "hidden scar" parathyroidectomy procedure that can be safely performed on parathyroid adenomas, in cases that have scar-related concerns. Having its own procedure-related complications, the procedure provides satisfactory objective results, particularly in centers experienced in endoscopic and endocrine surgery.

Innervation of the human cricopharyngeal muscle by the recurrent laryngeal nerve and external branch of the superior laryngeal nerve.

PURPOSE: The major component of the upper esophageal sphincter is the cricopharyngeal muscle (CPM). We assessed the contribution of the laryngeal nerves to motor innervation of the CPM. METHODS: We performed an intraoperative electromyographic study of 27 patients. The recurrent laryngeal nerve (RLN), vagus nerve, external branch of the superior laryngeal nerve (EBSLN), and pharyngeal plexus (PP) were stimulated. Responses were evaluated by visual observation of CPM contractions and electromyographic examination via insertion of needle electrodes into the CPM. RESULTS: In total, 46 CPMs (24 right, 22 left) were evaluated. PP stimulation produced both positive visual contractions and electromyographic (EMG) responses in 42 CPMs (2080 ± 1583 µV). EBSLN stimulation produced visual contractions of 28 CPMs and positive EMG responses in 35 CPMs (686 ± 630 µV). Stimulation of 45 RLNs produced visible contractions of 37 CPMs and positive EMG activity in 41 CPMs (337 ± 280 µV). Stimulation of 42 vagal nerves resulted in visible contractions of 36 CPMs and positive EMG responses in 37 CPMs (292 ± 229 µV). Motor activity was noted in 32 CPMs by both RLN and EBSLN stimulation, 9 CPMs by RLN stimulation, and 3 CPMs by EBSLN stimulation; 2 CPMs exhibited no response. CONCLUSIONS: This is the first study to show that the EBSLN contributes to motor innervation of the human CPM. The RLN, EBSLN, or both of the nerves innervate the 90, 75, and 70 % of the CPMs ipsilaterally, respectively.

Contribution of intraoperative neural monitoring to preservation of the external branch of the superior laryngeal nerve: a randomized prospective clinical trial.

PURPOSE: The purpose of this study was to evaluate the effect of intraoperative neuromonitoring (IONM) on the injury rate of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy. METHODS: A total of 133 consenting patients (98 female, 35 male; mean age, 45.6 ± 11.7 years) undergoing thyroidectomy were randomly assigned to 2 groups. In group 1 (n = 65 patients, 105 nerves), superior thyroid pole dissection was performed with no attempt to identify the EBSLN; in group 2 (n = 68 patients, 106 nerves), IONM was used to identify the EBSLN during surgery. EBSLN function was evaluated by intraoperative electromyography of the cricothyroid muscle. The EBSLN Voice Impairment Index-5 (VII-5) was conducted preoperatively and at 1, 3, and 6 months postoperatively. The primary outcome was the prevalence of EBSLN injury. The secondary outcomes were the identification rate of the EBSLN using IONM and changes in postoperative voice performance. RESULTS: EBSLN injury was detected in eight (12.3%) patients and nine (8.6%) nerves in group 1 and in one (1.5%) patient and one (0.9%) nerve in group 2 (patients, p = 0.015; nerves, p = 0.010). IONM contributed significantly to visual (p < 0.001) and functional (p < 0.001) nerve identification in group 2. The VII-5 indicated more voice changes in group 1 than 2 at 1, 3, and 6 months postoperatively (p = 0.012, p = 0.015, and p = 0.02, respectively). CONCLUSION: IONM contributes to visual and functional identification of the EBSLN and decreases the rate of EBSLN injury during superior pole dissection. Routine use of IONM to identify the EBSLN will minimize the risk of injury during thyroidectomy.

The functional role of the pharyngeal plexus in vocal cord innervation in humans.

Classical understanding of the function of the pharyngeal plexus in humans is that it relies on both motor branches for innervation of the majority of pharyngeal muscles and sensory branches for the pharyngeal wall sensation. To date there has been no reported data on the role of the pharyngeal plexus in vocal cord innervation. The aim of this study is to evaluate whether or not the plexus pharyngeus contributes to the innervation of the vocal cords. One hundred twenty-five sides from 79 patients (59 female, 20 male) undergoing thyroid surgery with intraoperative neuromonitoring were prospectively evaluated. While vocal cord function was evaluated with endotracheal tube surface electrodes, cricothyroid and cricopharyngeal muscle electromyographic recordings were obtained with a pair of needle electrodes. The ipsilateral pharyngeal plexus, external branch of the superior laryngeal nerve, and recurrent laryngeal nerve were stimulated with a monopolar probe at 1 mA. With stimulation of the plexus pharyngeus on 125 operated sides, positive electromyographic waveforms were detected from five ipsilateral vocal cords (accounting for 3.2% of all vocal cords monitored and 6.3% of patients). The mean EMG amplitude of the vocal cords with stimulation of the plexus pharyngeus was 147 ± 35.5 µV (range 110-203). In one case, the long latency time of 19.8 ms correlated with innervation by the glottic closure reflex pathway. The short latencies seen in the other four cases [3.9 ± 1.1 ms (range 3.2-5.5)] correlated with direct innervation. In some cases, the plexus pharyngeus may contribute to vocal cord innervation by reflex or direct innervation patterns in humans.

Laparoscopic adrenalectomy in a patient with situs inversus totalis.

Situs inversus totalis(SIT) is a relatively rare condition involving transposition of both the abdominal and thoracic viscera. SIT typically presents as left to right reversal of the viscera combined with dextrocardia, while the individual organs function is normal. Although there are no obvious abnormalities in the function of transposed organs, anatomical irregularity causes important technical difficulties in the surgical treatment of these patients. In this study, we aim to report surgical challenges in laparoscopic adrenalectomy in a patient with SIT.

The risk of hypocalcemia in patients with parathyroid autotransplantation during thyroidectomy.

OBJECTIVE: Thyroidectomy is the most common cause of hypocalcemia. Preservation of parathyroid glands in situ is essential in preventing this complication. The aims of our study were to review patients who underwent parathyroid gland autotransplantation during thyroidectomy, and to compare hypocalcemia rates in patients with and without autotransplantation. MATERIAL AND METHODS: Parathyroid gland autotransplantation was performed in 43 (7.9%) of 543 patients who underwent thyroidectomy between 2008 and 2012. RESULTS: Forty-four parathyroid glands were autotransplanted in 43 patients, including 36 women and 7 men. The median age was 55 (range: 30 to 68). The most common cause of autotransplantation was vascular comprise of the parathyroid gland. Early postoperative hypocalcemia developed in 37% of patients with autotransplantation, and none developed permanent hypocalcemia. Transient and permanent hypocalcemia rates were 9.6% and 0.4% in patients without autotransplantation, respectively. The risk of transient hypocalcemia was significantly high in patients with parathyroid autotransplantation (p<0.001). There was no difference between the two groups in terms of permanent hypocalcemia (p=0.156). CONCLUSION: Despite meticulous dissection, parathyroid glands can be devascularized or removed inadvertently during thyroidectomy. Parathyroid autotransplantation is the best method to maintain parathyroid gland function. Although the risk of transient hypocalcemia is increased following parathyroid autotransplantation, long-term results are satisfactory.

A palsied recurrent laryngeal nerve should be explored and evaluated by intraoperative neuromonitoring during secondary thyroidectomy: report of two cases.

INTRODUCTION: Our aim was to evaluate the findings of intraoperative nerve monitoring (IONM) in two cases with preoperative vocal cord palsy. Case 1: a 61-year-old female with recurrent goiter underwent secondary thyroidectomy. The preoperative evaluation of the vocal cords revealed right vocal cord paralyses without atrophy. The right recurrent laryngeal nerve (RLN) was found to be anatomically intact and preserved. The electrical responses of the vocal cords were elicited via IONM. Case 2: a 26-year-old male, who presented with preoperative right vocal cord palsy with atrophy, underwent completion thyroidectomy secondary to papillary carcinoma. The right RLN was explored and found to be tied and interrupted. There was no signal from the RLN with IONM. CONCLUSION: Even in cases with vocal cord palsy detected preoperatively, the nerve should be explored intraoperatively, and should never be sacrificed before an evaluation by nerve monitoring. A palsied RLN which has electrical activity should be protected to maintain the vocal cord's neural tone and to prevent its atrophy.

Preoperative Preparation in Hyperthyroidism and Surgery in the Hyperthyroid State.

Hyperthyroidism is a clinical condition that develops due to the excessive production and secretion of thyroid hormones by the thyroid gland, leading to an elevated concentration of thyroid hormones in tissues. Hyperthyroidism is characterized by low TSH and elevated T3 and/or T4, with the most common causes being Graves' disease, toxic multinodular goiter, and solitary toxic adenoma. T3 is the peripherally active form of thyroid hormone, affecting nearly each tissue and system. The most prominent aspects of hyperthyroidism are related to the cardiovascular system. The treatment of hyperthyroidism includes three options: antithyroid drugs (ATDs), radioactive iodine therapy (RAI), and surgery. Among these treatment modalities, surgery is considered as the most effective one. For patients who are candidates for surgery, preoperative preparation is required to ensure that the thyroidectomy can be performed under optimal conditions. Preoperative preparation should be a combination therapy aimed at preventing the synthesis, secretion, and peripheral effects of thyroid hormones from the thyroid gland. Medications that can be used in this treatment include thionamides, beta-blockers, iodine, corticosteroids, cholestyramine, perchlorate, lithium, and therapeutic plasma exchange. These treatment options can be combined based on the patient's condition. While it is recommended that patients be made euthyroid through preoperative antithyroid treatment to prevent the feared complication, which is the thyroid storm, the supporting evidence is limited. Preoperative treatment does not prevent against thyroid storm whether the patient is euthyroid or hyperthyroid during surgery. Whether surgery should be delayed until biochemical euthyroidism is achieved in hyperthyroid patients remains a topic of debate. Recent studies suggest that thyroidectomy can be safely performed during the hyperthyroid phase by experienced anesthesiologists and surgeons without precipitating thyroid storm or increasing intraoperative and postoperative complications. Although achieving the euthyroid state before surgery is ideal in hyperthyroid patients, it is not always possible. Factors such as allergies to medications, drug side effects, treatment-resistant disease, patient noncompliance, and the urgency of definitive treatment are critical in determining whether hyperthyroidism can be controlled preoperatively. When surgery is necessary in hyperthyroid patients without achieving euthyroidism, the patient's overall condition and comorbidities should be evaluated together by the anesthesiologist, surgeon and endocrinologist, with particular attention to stabilizing the cardiovascular system. We believe that in hyperthyroid patients who are cardiovascularly stable during the hyperthyroid phase, thyroid surgery may not need to be delayed and can be performed safely.

Risk Factors for Right Paratracheal Posterolateral Lymph Node Metastasis in Papillary Thyroid Cancer.

Objectives: The incidence of papillary thyroid cancer (PTC) is increasing, and due to the favorable postoperative survival rates, the extent of surgery should be carefully determined, and complications during the operation should be avoided. The recurrent laryngeal nerve (RLN) divides the right paratracheal lymph node (RPTLN) into anteromedial and posterolateral compartments due to its anatomical course on the right and left sides of the neck, and the posterolateral lymph nodes are in close proximity to the RLN. Due to the risk of this complication, in this study, we aimed to determine the risk factors for the development of right paratracheal posterolateral lymph node (RPTPLLN) metastasis in PTC. Methods: Between 2013 and 2022, patients who underwent central neck dissection (CLND) or central and lateral neck dissection due to the presence of PTC in the right lobe of the thyroid gland were included in the study. Descriptive data, along with preoperative imaging findings and postoperative pathology findings, were retrospectively evaluated. Results: The data of 55 patients who met the criteria were statistically analyzed. Of these patients, 24 (43.6%) were male and 31 (56.4%) were female. The mean age was 47.9±17.5 years (range: 16-81). The mean tumor size was 2.17±1.43 cm (range: 0.4-7.0). RPTPLLN was observed in 13 patients (23.6%). Univariate analysis revealed that extrathyroidal extension (p=0.008), lymphovascular invasion (p=0.044), presence of right paratracheal anteromedial (RPTAMLN) metastasis (p=0.001), and presence of left paratracheal metastasis (p=0.049) were statistically significant factors. However, in the multivariate analysis, only the presence of RPTAMLN was determined to be a significant variable (p=0.035). Conclusion: In patients undergoing surgery for PTC, the risk of metastasis in the RPTPLLN should be considered higher when there is metastasis in the RPTAMLN. We believe that formal dissection of the RPTLN should be considered for optimal evaluation in patients with tumors in the right lobe where central dissection is planned. Posterolateral dissection (PLD) should be routinely performed in the presence of clinical lymph nodes in the RPTAMLN. When a decision cannot be made, PLD may not be performed if the anteromedial tissue is examined with frozen pathology and the result is negative.

Coexistence of Thyroglossal Cyst and Thyroid Disease in Adults: Surgical Outcomes From A Single Center.

Objectives: Thyroglossal cysts (TGCs) usually present during childhood and before the age of 30, however, they can also be seen in adults, even in advanced age. Nodular thyroid disease is also common in adults. In the literature, there is an ongoing debate regarding the differences in clinical presentation, gender, and postoperative recurrence of TGC between children and adults. In this study, we aimed to process the data of adult patients who underwent surgery for TGC in our clinic, along with the data on concurrent thyroid disease and thyroid surgery. Methods: The data of patients over 18 years old who were operated on for TGC at the General Surgery Clinic of Sisli Hamidiye Etfal Training and Research Hospital between 2018 and 2024 were retrospectively evaluated. Results: A total of 16 patients with a mean age of 43.94±12.98 (21-67) years, were included in the study (11 F/5 M). The diagnosis of TGC was made in 12 patients (75%) by ultrasonography (USG), in 1 patient (6.25%) by computed tomography, in 1 patient (6.25%) by magnetic resonance imaging (MRI), and in 2 patients (12.5%) incidentally intraoperatively. 13 patients (81.25%) underwent the Sistrunk procedure, and 3 patients (18.75%) underwent cyst excision. Among the 16 TGC patients, papillary thyroid cancer in the cyst was detected in one patient (6.25%) preoperatively. During preoperative evaluation, nodular thyroid disease was found in 12 patients (75%). Of these, papillary thyroid cancer was detected in 3 patients (18.75%) preoperatively. Of the TGC group, 3 (18.75%) underwent thyroidectomy for thyroid malignancy, and five (31.25%) underwent additional thyroid surgery for nodular thyroid disease. The patients were followed for a mean of 22.63±18.32 months (3-67 months), and no recurrence of TGC was observed during the follow-up period. Conclusion: In patients with TGC, thyroid diseases and the requirement for thyroidectomy due to benign or malignant thyroid disease are not uncommon. Patients with TGC should be evaluated for thyroid disease before surgical treatment. While the Sistrunk procedure is the standard surgical technique in the treatment of TGC, in adults, if the cyst terminates below the hyoid bone, total cyst excision without removing the central portion of the hyoid bone may be sufficient.

Electrophysiological monitoring of the nonrecurrent inferior laryngeal nerve and radiological evaluation of concurrent vascular anomalies.

Purpose: The objective of this study was to characterize the electrophysiological characteristics of nonrecurrent inferior laryngeal nerves (NRILNs) that were dissected via intraoperative neuromonitoring (IONM) and concomitant vascular anomalies in patients with NRILNs. Methods: A retrospective analysis was conducted on 7865 patients who underwent thyroidectomy with IONM at three tertiary referral centers. The study included 42 patients in whom an NRILN was detected. IONM data and postoperative vocal cord (VC) examinations were recorded for all patients. The absence of an initial vagal EMG response and/or a short (<3.5 ms) latency period during the initial vagal stimulation or the inability to identify the RLN within the Beahrs triangle was considered highly suspicious for the presence of an NRILN. Postoperative cross-sectional imaging was performed in 36 out of 42 patients to assess any concurrent vascular anomalies. Results: The prevalence of NRILN was 0.53%. An NRILN was suspected due to EMG findings in 32 (76%) patients and the inability to identify the RLN within the Beahrs triangle in the remaining 10 (24%) patients. The mean right VN latency period was 3.05 ± 0.15 ms. The V1 latency period of the right VN was shorter than 3.5 ms in 39 (93%) and longer than 3.5 ms in 3 (7%) patients. One of these three patients with latency>3.5ms had a large mediastinal goiter. Transient VC paralysis occurred in one (2.4%) patient. Of the 36 patients with postoperative imaging data, 33 (91.4%) had vascular anomalies. All 33 patients had aberrant right subclavian arteries, and 13 (39.4%) also had accompanying additional vascular anomalies. Conclusion: The NRILN is an anatomical variation that increases the risk of nerve injury. Observation of an absent EMG response and/or a short latency period during the initial vagal stimulation facilitates the detection of an NRILN at an early stage of thyroidectomy in the majority of patients.

Comparison of transoral endoscopic thyroidectomy vestibular approach and open conventional thyroidectomy regarding inflammatory responses, pain, and patient satisfaction: a prospective study.

Introduction: The application of transoral endoscopic thyroidectomy vestibular approach (TOETVA) is becoming widespread throughout the world. We primarily aimed to evaluate the severity of surgical trauma in TOETVA and conventional open thyroidectomy (COT) regarding the inflammatory response including the comparison of surgical stress markers [interleukin-6 (IL-6), C-reactive protein (CRP), white blood cell (WBC)]. Material and method: This non-randomized prospective study enrolled two groups with 20 patients each: COT group and TOETVA group. Patients aged 18-65 years with benign thyroid disease; with fine needle aspiration biopsy results of Bethesda III, IV or Bethesda V, VI (<1 cm nodule); thyroid volume <50 cm3; nodule diameter <4 cm; female gender without a previous neck, chin, and/or oral surgery; without vocal cord paralysis preoperatively; and patients in euthyroid state were enrolled to the study. Preoperative, postoperative second hour, first day, and second day CRP, WBC, and IL-6 levels were evaluated. Pain intensity was evaluated with the visual analog scale (VAS) score on the 2nd and 12th hour, 1st and 2nd days postoperatively. Results: All the patients were female and mean age was significantly higher in the COT group. The operative time was significantly longer in the TOETVA group. No significant difference was found between the two groups regarding IL-6 levels. In the TOETVA group, postoperative second hour WBC value (p = 0.044) and first (p = 0.002) and second day (p = 0.005) CRP values were significantly higher. In the TOETVA group, the lower lip and lower chin VAS scores were significantly higher at 2nd and 12th hour, on the first and second days. The anterior neck VAS score was significantly higher in the TOETVA group at the second hour (p = 0.025). General and cosmetic satisfactions were similar at the 15th and 30th days in both groups. Conclusion: The longer operative time and higher postoperative CRP level and VAS score in the chin and lower lip in the TOETVA group suggested that the method is not a minimally invasive technique compared to COT. However, the presence of similar total complication rates and early postoperative general and esthetic satisfaction that improves over time in both groups suggests that the clinical effect of increased magnitude of systemic inflammatory response in TOETVA might be temporary and acceptable.

The relationship of pre-operative vitamin D and TSH levels with papillary thyroid cancer.

OBJECTIVE: Our goal in this study is to analyze the correlation between papillary thyroid cancer (PTC) with elevated thyroid-stimulating hormone (TSH) levels and deficiency of vitamin D. METHODS: Patients who underwent thyroidectomy, also with available vitamin D test results preoperatively, were included in the study. The patients were separated into two different categories as having papillary thyroid carcinoma (Group 1), benign diseases (Group 2). According to the TSH (mUI/mL) level and vitamin D values, patients were categorized into four quarters. RESULTS: Preoperatively, TSH level (mean±SDmUI/mL) was higher in Group 1 (2.04±1.55) compared to Group 2 (1.82±1.94) significantly (p=0.029). Preoperatively, vitamin D levels (mean±SD) were higher in Group 1 (15.88±10.88) than in Group 2 (12.94±10.26) significantly (p=0.011). There was no significant difference between Group 1 and Group 2 according to the vitamin D deficiency (65.5%, 72.8%; respectively (p=0.472)). When categorized with reference to pre-operative vitamin D levels, the proportion of patients in Group 2 and Category 1 was higher significantly (p=0.031). CONCLUSION: Although the pre-operative TSH level was significantly higher in papillary thyroid carcinoma than benign thyroid diseases, the categorical distributions of the patients according to the TSH value were similar and the TSH values overlapped. Pre-operative mean vitamin D levels were similar in both PTC and benign thyroid disease groups so PTC was not associated with vitamin D deficiency.

Persistent and Recurrent Primary Hyperparathyroidism: Intraoperative Supplemental Methods, Basic Principles of Surgery, and Other Treatment Options.

Reoperative parathyroid surgery is challenging even for experienced surgeons. Cure rates are lower than primary surgery. Good anatomical and embryological knowledge is important. Preoperatively, a comprehensive surgical strategy should be planned. Pre-operative imaging modalities should be used extensively to find the overlooked gland to have a possibility to perform focused parathyroid surgery to avoid possible complications. One of the important developments is the new ancillary methods to find overlooked parathyroid glands. Orthotopic and possible ectopic locations should be known well by the surgeon to increase the surgical success rate. Reoperative parathyroid surgery needs a distinctive approach compared to primary parathyroid surgery. Basic principles include the selection of the incision and route for entering the thyroid region, use of ancillary methods, and intraoperative nerve monitoring and also require a meticulous dissection. Obtaining a surgical cure is difficult and high surgical caution is needed. Post-operative complication rates are higher compared to primary parathyroid surgery. Other treatment methods and medical treatment options may be evaluated in a patient who cannot undergo surgery.

Predictive Factors Affecting the Development of Lateral Lymph Node Metastasis in Papillary Thyroid Cancer.

Objectives: Lateral lymph node metastasis (LLNM) in papillary thyroid cancer (PTC) determines the extent of surgery to be performed and the prognosis of the disease. In this study, we aimed to evaluate the clinicopathological risk factors affecting the development of LLNM. Methods: We retrospectively evaluated the demographic and clinicopathological data of 346 cases with PTC who were operated in our clinic between May 2012 and September 2020. The patients were divided into 2 groups as patients with LLNM (Group 1) and without LLNM (Group 2). Results: Thirty-six (10.4%) patients out of 346 patients with PTC had LLNM. A statistically significant difference was found between Group 1 and Group 2 regarding the male gender (M/F: 38.9% vs. 21.6%; p=0.020), tumor size (2.30±1.99 cm vs. 1.31±1.40 cm; p=0.000), lymphovascular invasion (69.4 vs. 20.6%; p=0.000), multicentricity (69.4% vs. 35.5%; p=0.000), multifocality (p=0.000), aggressive variant (22.2% vs. 9.4%; p=0.000), extrathyroidal extension (50% vs. 16.1% p=0.000), central lymph node metastasis (CLNM) rates (75% vs. 6.5%; p=0.000), and ≥3 cm lymph node metastasis (48.5% vs. 0%, p=0.000), distant metastasis (2.1% vs. 0%, p=0.000), respectively. Multivariance analysis determined the presence of CLNM as an independent risk factor for the development of LLNM. Conclusion: The presence of CLNM in patients with PTC was determined as an independent risk factor for the development of LLNM. Although there has been increasing debate about prophylactic central neck dissection (pCND) in LLNM, pCND should still be considered in these patients as the rate of CLNM is high in patients with LLNM. CLNM might be a reference for surgeons to determine the extent of surgery. In addition, the presence of CLNM is important for close follow-up for the early detection of LLNM recurrence.

Management of Thyroid Nodules.

Thyroid nodules are common and the prevalence varies between 4 and 7% by palpation and 19-68% by high-resolution USG. Most thyroid nodules are benign, and the malignancy rate varies between 7 and 15% of patients. Thyroid nodules are detected incidentally during clinical examination or, more often, during imaging studies performed for another reason. All detected thyroid nodules should be evaluated clinically. The main test in evaluating thyroid function is thyroid stimulating hormone (TSH). If the serum TSH level is below the normal reference range, a radionuclide thyroid scan should be performed to determine whether the nodule is hyperfunctioning. If the serum TSH level is normal or high, ultrasonography (US) should be performed to evaluate the nodule. US is the most sensitive imaging method in the evaluation of thyroid nodules. Computed tomography (CT) and magnetic resonance imaging are not routinely used in the initial evaluation of thyroid nodules. There are many risk classification systems according to the USG characteristics of thyroid nodules, and the most widely used in clinical practice are the American Thyroid Association guideline and the American College of Radiology Thyroid Imaging Reporting and Data System. Fine needle aspiration biopsy (FNAB) is the gold standard method in the evaluation of nodules with indication according to USG risk class. In the cytological evaluation of FNAB, the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is the most frequently applied cytological classification. TBSRTC is a simplified, 6-category reporting system and was updated in 2023. The application of molecular tests to FNAB specimens, especially those diagnosed with Bethesda III and IV, is increasing to reduce the need for diagnostic surgery. Especially in Bethesda III and IV nodules, different methods are applied in the treatment of nodules according to the malignancy risk of each category, these are follow-up, surgical treatment, radioactive iodine treatment, and non-surgical ablation methods.

Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Pre-Operative Evaluation.

Primary hyperparathyroidism (pHPT) is the most common cause of hypercalcemia and currently the only definitive treatment is surgery. Although the success rate of parathyroidectomy is over 95% in experienced centers, surgical failure is the most common complication today. Persistent HPT (perHPT) is defined as persistence of hypercalcemia after parathyroidectomy or recurrence of hypercalcemia within the first 6 months, and recurrence of hypercalcemia after a normocalcemic period of more than 6 months is defined as recurrent HPT (recHPT). In the literature, perHPT is reported to be 2-22%, and the rate of recHPT is 1-15%. perHPT is often associated with misdiagnosed pathology or inadequate resection of hyperfunctioning parathyroid tissue, recHPT is associated with newly developing pathology from potentially pathologically natural tissue left in situ at the initial surgery. In the pre-operative evaluation, the initial diagnosis of pHPT and the diagnosis of perHPT or rec HPT should be confirmed in patients who are evaluated with a pre-diagnosis (suspect) of perHPT and recHPT. Surgery is recommended if it meets any of the recommendations in surgical guidelines, as in patients with pHPT, and there are no surgical contraindications. The first preoperative localization studies, surgical notes, operation drawings, if any, intraoperative PTH results, pathological results, and post-operative biochemical results of these patients should be examined. Localization studies with preoperative imaging methods should be performed in all patients with perHPT and recHPT with a confirmed diagnosis and surgical indication. The first-stage imaging methods are ultrasonography and Tc99m sestamibi single photon tomography Tc99mMIBI SPECT or hybrid imaging method, which is combined with both single-photon emission computed tomography and computed tomography (SPECT/CT). The combination of USG and sestamibi scintigraphy increases the localization of the pathological gland. In the secondary stage, Four-Dimensional computer tomography (4D-CT) or dynamic 4-dimensional Magnetic Resonance Imaging (4D-MRI) can be applied. It is focused on as a secondary stage imaging method, especially when the lesion cannot be detected by conventional methods. Positron Emission Tomography (PET) and PET/CT examinations with 11C-choline or 18F-fluorocholine are promising imaging modalities. Invasive examinations can rarely be performed in patients in whom suspicious, incompatible or pathological lesion cannot be detected in noninvasive imaging methods. Bilateral jugular vein sampling, selective venous sampling, parathyroid arteriography, imaging-guided fine-needle aspiration biopsy, and parathormone washout are invasive methods.