Surgical strategy in thyroid disease.

Over the past 8 years, 311 patients have undergone surgical treatment by the senior authors for thyroid disease. Over 80% of the cases were performed by the head and neck surgical service at Olive View County Hospital, Sylmar, Calif, with the remainder performed at UCLA-affiliated institutions. This service is an important source of thyroid surgical training for UCLA head and neck residents who rotate through this major affiliate. The purpose of this communication is to review our experience with these cases; to describe our overall surgical strategy; and to detail the specifics of our surgical procedure, which we have developed to safely train residents in the treatment of these challenging cases. This article deals with the specific problems of preservation of the recurrent nerve, the parathyroid glands, and the techniques for reimplantation of injured parathyroid glands; the management of larger, substernal thyroid glands; and our techniques for partial thyroid surgery. In addition, the difficult decisions in the management of thyroid cancer, such as completion thyroidectomy; the management of lymph node mestastases; and how tracheal, esophageal, or laryngeal invasion should be managed are discussed. An initial section describing the general preoperative examination of these patients is also included, so that the proper surgical strategy can be developed prior to entering the operating room.

Autotransplantation of parathyroid tissue into sternocleidomastoid muscle.

Four cases of secondary hyperparathyroidism were treated by total parathyroidectomy with autotransplantation into the sternocleidomastoid muscle. These total parathyroidectomy patients are presented to demonstrate the reliability of parathyroid autotransplantation into the sternocleidomastoid muscle. Our technique is described in detail, and all procedures were successful. In one case, the patient was found, in retrospect, to have an adenoma in the transplanted parathyroid tissue. When the patient developed graft-dependent hypercalcemia, a portion of the graft was easily excised under local anesthesia and the patient became normocalcemic. Parathyroid tissue should be transplanted into the sternocleidomastoid muscle rather than other sites because of easy accessibility, one operative site, less graft ischemia, a low incidence of infection, and a high success rate due to excellent blood supply.