Thyroid

Using ultrasonic preoperative thyroid volume to determine incision length for minimally invasive thyroid surgery

August 26, 2015     Austin P. Daly, MD; Massi Romanelli-Gobbi, MD; Jeffrey L. Miller, MD; David Rosen, MD; David M. Cognetti, MD; Edmund A. Pribitkin, MD
article

Abstract

The determination of the volume of a diseased thyroid lobe or an entire gland by preoperative ultrasonography may enable surgeons to select candidates for a minimally invasive approach to thyroid lobectomy or total thyroidectomy. We retrospectively reviewed the charts of 71 adults who had undergone minimally invasive nonendoscopic thyroid surgery at our hospital from January 2007 through May 2009. We compiled data on ultrasonic preoperative thyroid volumes and operative incision lengths. Of the 71 patients, 40 had undergone lobectomy and 31 had undergone total thyroidectomy. The lobectomy group was evenly subdivided into two groups based on the median volume of the affected lobe; 20 patients had a volume of <28.32 ml and 20 had a volume of >28.32 ml. The incision length ranged from 2.0 to 3.8 cm (mean: 3.1 ± 0.53) in the smaller-volume lobectomy group and from 2.5 to 5.0 cm (mean: 3.7 cm ± 0.71) in the larger-volume lobectomy group; the difference was statistically significant (p < 0.01). The 31 patients in the total thyroidectomy group were subdivided on the basis of the median volume of the entire thyroid gland; 16 patients had a volume of <49.24 ml and 15 had a total volume of >49.24 ml. The incision length in those two groups ranged from 2.5 to 4.0 cm (mean: 3.4 ± 0.53) and 3.6 to 6.0 (mean: 5.1 ± 0.99), respectively; again, the difference was statistically significant (p < 0.001). The findings of our study suggest that preoperative ultrasonographic thyroid lobe volume or total thyroid gland volume can be used to determine the appropriate minimum length for the surgical incision.

Unusual sites of metastasis of papillary thyroid cancer: Case series and review of the literature

August 26, 2015     Rafael Antonio Portela, MD; Garret W. Choby, MD; Andrea Manni, MD; David Campbell, MD; Henry Crist, MD; David Goldenberg, MD
article

Abstract

Papillary thyroid cancer (PTC) is the most common malignancy of the thyroid gland. It typically spreads via lymphatic extension. The rate of regional PTC metastasis to the neck is relatively high, while metastases outside the deep cervical chain are rare. Distant metastases are found in only 1% of patients with PTC at the time of surgery; the two most common sites are the lung and bone. We report 4 cases of PTC metastasis to unusual sites: (1) the occipital skull and internal jugular vein, (2) the parapharyngeal space, (3) the sternocleidomastoid muscle, and (4) the right atrium of the heart. It has been well documented that aggressive distant metastasis is a characteristic of PTC, and it is known to be an indicator of a poor prognosis. Some of our patients' sites of metastatic disease have not been previously reported. Patients in this series exhibited aggressive histologic findings, including columnar cell and follicular variants of papillary disease. In addition, all 4 patients demonstrated “PET-avid” disease with decreased iodine avidity.

Post-thyroidectomy hypocalcemia: Impact on length of stay

July 20, 2015     Joe Grainger, FRCS; Mohammed Ahmed, MRCP; Rousseau Gama, FRCPath; Leonard Liew, FRCS; Harit Buch, FRCP; Ronald J. Cullen, FRCS
article

Abstract

Hypocalcemia is a recognized complication following thyroid surgery. Variability in the definition of hypocalcemia and different opinions on its management can lead to unnecessary patient morbidity and longer hospital stays as a result of inappropriate or untimely treatment. Therefore, we developed a management guideline for the recognition and treatment of post-thyroidectomy hypocalcemia, and we conducted a retrospective study to assess its impact on length of stay (LOS). Between April 1, 2007, and March 31, 2009, 29 adults had undergone a total or completion thyroidectomy at our large district general hospital. Of this group, postoperative hypocalcemia (defined as a serum calcium level of <2.00 mmol/L) developed in 13 patients (44.8%) during the first 3 postoperative days. Our guideline went into effect on July 1, 2009, and from that date through June 30, 2010, 18 more adults had undergone a total or completion thyroidectomy. Of that group, hypocalcemia developed in 7 patients (38.9%); the guideline was actually followed in 5 of these 7 cases (71.4%). In the preguideline group, the development of hypocalcemia increased the mean LOS from 2.0 days to 7.0 days (p < 0.001). The management of postoperative hypocalcemia in these cases was highly variable and was dictated by variations in practice rather than patient needs. In the postguideline group, postoperative hypocalcemia increased the mean LOS from 2.7 days to only 3.7 days (p = 0.07). While the difference between LOS in the two hypocalcemic groups did not reach statistical significance, we believe it merely reflects the relatively small number of patients rather than any lack of guideline efficacy. The implementation of a simple flowchart guideline for the management of postoperative hypocalcemia in our hospital has resulted in more uniform management and a reduced LOS.

Two cases of thyroid rupture after blunt cervical trauma

July 20, 2015     Ji Hoon Shin, MD; Yong Bae Ji, MD; Jin Hyeok Jeong, MD; Seung Hwan Lee, MD; Kyung Tae, MD
article

Abstract

The consequences of thyroid gland rupture following blunt cervical trauma can be quite grave. Almost all of these cases are associated with preexisting thyroid lesions; the traumatic rupture of a previously normal thyroid gland is very rare. Both surgical and nonsurgical management techniques have been advocated for thyroid injuries, but there is still no consensus on treatment. We report cases of thyroid gland rupture following blunt cervical trauma in 2 patients: a 24-year-old man with a previously normal thyroid and an 8-year-old boy with a preexisting thyroid nodule. The man was treated surgically and the boy was treated conservatively. Based on our experience with these cases and our review of the literature, we propose treatment guidelines for thyroid injuries.

Parathyroid localization using 4D-computed tomography

April 27, 2015     Darrin V. Bann, PhD; Thomas Zacharia, MD; David Goldenberg, MD, FACS; Neerav Goyal, MD, MPH
article

To decrease the risk of iatrogenic cancers associated with 4D-CT, several groups have used one- or two-phase imaging protocols to identify parathyroid adenomas.

Protracted hypocalcemia following post-thyroidectomy lumbar rhabdomyolysis secondary to evolving hypoparathyroidism

March 2, 2015     Usman Y. Cheema, MD; Carrie N. Vogler, PharmD, BCPS; Joshua Thompson, PharmD; Stacy L. Sattovia, MD, FACP; Srikanth Vallurupalli, MD
article

Abstract

Rhabdomyolysis is characterized by skeletal muscle breakdown. It is a potential cause of serious electrolyte and metabolic disturbances, acute kidney insufficiency, and death. Recently, rhabdomyolysis has been increasingly recognized following certain surgical procedures. We discuss the case of a morbidly obese 51-year-old woman who developed postoperative rhabdomyolysis of the lumbar muscles following a prolonged thyroidectomy for a large goiter. We discuss how her morbid obesity, the supine surgical position, the duration of surgery (including prolonged exposure to anesthetic agents), and postoperative immobility contributed to the development of rhabdomyolysis. Immediately after surgery, the patient developed hypocalcemia, which was likely due to rhabdomyolysis since her serum parathyroid hormone level was normal. Later, however, persistent hypocalcemia despite resolution of the rhabdomyolysis raised a suspicion of iatrogenic hypoparathyroidism, which was confirmed by a suppressed parathyroid hormone level several days after surgery. In post-thyroidectomy patients with risk factors for rhabdomyolysis, maintaining a high degree of clinical suspicion and measuring serum creatine kinase and parathyroid hormone levels can allow for an accurate interpretation of hypocalcemia.

Previous gastric bypass surgery complicating total thyroidectomy

March 2, 2015     Bianca Alfonso, MD; Adam S. Jacobson, MD; Eran E. Alon, MD; Michael A. Via, MD
article

Abstract

Hypocalcemia is a well-known complication of total thyroidectomy. Patients who have previously undergone gastric bypass surgery may be at increased risk of hypocalcemia due to gastrointestinal malabsorption, secondary hyperparathyroidism, and an underlying vitamin D deficiency. We present the case of a 58-year-old woman who underwent a total thyroidectomy for the follicular variant of papillary thyroid carcinoma. Her history included Roux-en-Y gastric bypass surgery. Following the thyroid surgery, she developed postoperative hypocalcemia that required large doses of oral calcium carbonate (7.5 g/day), oral calcitriol (up to 4 μg/day), intravenous calcium gluconate (2.0 g/day), calcium citrate (2.0 g/day), and ergocalciferol (50,000 IU/day). Her serum calcium levels remained normal on this regimen after hospital discharge despite persistent hypoparathyroidism. Bariatric surgery patients who undergo thyroid surgery require aggressive supplementation to maintain normal serum calcium levels. Preoperative supplementation with calcium and vitamin D is strongly recommended.

Thyroid gland follicular carcinoma

March 2, 2015     Lester D.R. Thompson, MD
article

The recommended treatment is lobectomy or total thyroidectomy, with or without radioablation. The choice depends on the size and stage of the tumor, extent of lymphovascular invasion, and patient's age.

Arrested development: Lingual thyroid gland

January 19, 2015     Mark R. Williams, MRCS(ENT); Vivek Kaushik, FRCS(ORL-HNS)
article

Most patients with lingual thyroid are asymptomatic and are diagnosed incidentally following a radiologic investigation for another condition of the head and neck.

IgG4-related disease of the thyroid: A consideration in the differential diagnosis of an expanding thyroid mass

January 19, 2015     Irina Chaikhoutdinov, MD; Eelam Adil, MD, MBA; Michael D.F. Goldenberg, BA, MA; Henry Crist, MD
article

Riedel thyroiditis is a rare inflammatory process associated with IgG4; it involves the thyroid and surrounding cervical tissue, and it is associated with various forms of systemic fibrosis.

Simultaneous non-Hodgkin lymphoma of the external auditory canal and thyroid gland: A case report

December 19, 2014     BeeLian Khaw, MD; Shailendra Sivalingam, MS-ORL; Sitra Siri Pathamanathan, MBBS; Teck S. Tan, MBChB, MRCS; Manimalar Naicker, MPath
article

Approximately 25% of all cases of extranodal non-Hodgkin lymphoma (NHL) occur in the head and neck region; NHL of the external auditory canal (EAC) and thyroid gland are rare. Specific immunohistochemical staining of the excised tissue is required to confirm the final pathologic diagnosis. We report the case of a 53-year-old woman with underlying systemic lupus erythematosus and autoimmune hemolytic anemia that were in remission. She presented with chronic left ear pain, a mass in the left EAC, and rapid growth of an anterior neck swelling that had led to left vocal fold palsy. High-resolution computed tomography (CT) of the temporal bone and CT of the neck detected a mass lateral to the left tympanic membrane and another mass in the anterior neck that had infiltrated the thyroid gland. The patient was diagnosed with simultaneous B-cell lymphoma of the left EAC and thyroid gland. She was treated with chemotherapy. She responded well to treatment and was lost to follow-up after 1 year. To the best of our knowledge, the simultaneous occurrence of a lymphoma in the EAC and the thyroid has not been previously described in the literature.

Acute exacerbation of Hashimoto thyroiditis mimicking anaplastic carcinoma of the thyroid: A complicated case

December 19, 2014     Hiroaki Kanaya, MD; Wataru Konno, MD; Satoru Fukami, MD; Hideki Hirabayashi, MD; Shin-ichi Haruna, MD
article

The fibrous variant of Hashimoto thyroiditis is uncommon, accounting for approximately 10% of all cases of Hashimoto thyroiditis. We report a case of this variant that behaved like a malignant neoplasm. The patient was a 69-year-old man who presented with a right-sided anterior neck mass that had been rapidly growing for 2 weeks. Fine-needle aspiration cytology revealed clusters of large multinucleated cells suggestive of an anaplastic carcinoma. A week after presentation, we ruled out that possibility when the mass had shrunk slightly. Instead, we diagnosed the patient with an acute exacerbation of Hashimoto thyroiditis on the basis of laboratory findings. We performed a right thyroid lobectomy, including removal of the isthmus, to clarify the pathology and alleviate pressure symptoms. The final diagnosis was the fibrous variant of Hashimoto thyroiditis, with no evidence of malignant changes. Physicians should keep in mind that on rare occasions, Hashimoto thyroiditis mimics a malignant neoplasm.

Page
of 7Next