Pain and surgical outcomes with and without neck extension in standard open thyroidectomy: a prospective randomized trial.

BACKGROUND: The purpose of this study was to compare surgical outcomes between those patients who underwent open thyroidectomy with and without neck extension. METHODS: One hundred eighty patients were randomized into 2 groups, with neck extension (group I) and without neck extension (group II). Outcomes included pain score on postoperative day 0, day 1, and the first clinic visit, operating time, blood loss, recurrent laryngeal nerve (RLN) injury, and hypoparathyroidism. RESULTS: Pain scores in group II were significantly lower on postoperative day 1 (2.38 vs 3.08; p = .022) and at the first clinic visit (0.57 vs 0.78; p = .026). There was a significant direct correlation between degree of neck extension and pain score on day 1 (p = .159 and p = .033). Other outcomes seemed comparable. However, the overall RLN injury rate was not significantly different between the 2 groups (5.3% vs 2.0%; p = .212). CONCLUSION: Compared to group I, pain on postoperative day 1 and at the first visit in group II were significantly less, but both groups had similar overall RLN injury rate.

Is vocal cord asymmetry seen on transcutaneous laryngeal ultrasonography a significant predictor of voice quality changes after thyroidectomy?

BACKGROUND: Vocal cord asymmetry (VCA) on laryngoscopic examination (LE) may suggest voice impairment after thyroidectomy, but LE may cause patient discomfort. We aimed to correlate the presence of postoperative VCA assessed by noninvasive transcutaneous laryngeal ultrasonography (TLUSG) with voice quality changes after thyroidectomy. METHODS: A total of 169 patients scheduled for thyroidectomy completed two validated voice symptoms questionnaires-the GRBAS (grade, roughness, breathiness, asthenia, strain) scale and the voice impairment score (VIS)-and underwent TLUSG and LE at 1 day before and 7-10 days after thyroidectomy. Postoperative VCA was apparent in 51 patients on TLUSG (group I), whereas there was no VCA in the other 118 patients (group II, controls). The GRBAS scale and VIS results were compared between the groups. RESULTS: Before operation, the two groups had comparable preoperative GRBAS and VIS status. After operation, the "grade" and "roughness" components on the GRBAS scale were significantly worse in group I than in group II: 0.24 versus 0.07 (p = 0.016) and 0.33 versus 0.14 (p = 0.022), respectively. "Grade" and "roughness" in the GRBAS scale significantly worsened after the operation in group I: from 0.04 to 0.24 (p = 0.008) and from 0.02 to 0.33 (p = 0.001), respectively. They did not change in group II. Also, the overall VIS was significantly worse after thyroidectomy in group I: 4.97 versus 12.97 (p < 0.001). CONCLUSIONS: VCA seen on TLUSG significantly correlated with "grade" and "roughness" components on the GRBAS scale and the overall VIS. Thus, VCA might be used as a surrogate of postoperative voice changes.

A prospective, assessor-blind evaluation of surgeon-performed transcutaneous laryngeal ultrasonography in vocal cord examination before and after thyroidectomy.

INTRODUCTION: Transcutaneous laryngeal ultrasonography (TLUSG) is a promising alternative to direct laryngoscopy in assessing perioperative vocal cord function. This study sought to evaluate the accuracy of TLUSG in assessing vocal cord function. METHODS: Altogether, 204 patients underwent TLUSG and direct laryngoscopy before and after elective thyroidectomy. For both examinations, vocal cord movements were independently graded. Grade I meant both vocal cords had normal movement; grade II meant ≥1 vocal cord had decreased movement; and grade III meant ≥1 vocal cord had no movement. Grade II or III on direct laryngoscopy was defined as vocal cord paresis or palsy (VCP). To assess accuracy, TLUSG findings were correlated with direct laryngoscopy findings. RESULTS: No patient had preoperative VCP, and 17 had unilateral postoperative VCP. The overall postoperative VCP rate was 5.1%. TLUSG failed to assess VCs in 11 (5.4%) postoperative patients. Of these, 2 had VCP and 9 had no VCP on direct laryngoscopy. Postoperative TLUSG had a sensitivity, specificity, positive predictive value, and negative predictive value of 93.3%, 97.8%, 77.8%, and 99.4%, respectively. Of the 175 patients with grade I on TLUSG, only 1 (<1%) had grade II VCP on direct laryngoscopy. CONCLUSION: TLUSG is a promising, noninvasive tool for selecting patients to undergo direct laryngoscopy before and after thyroidectomy.

Parathyroid carcinoma in a 30-year-old man: a diagnostic and management challenge.

Parathyroid carcinoma is a rare endocrine malignancy, accounting for less than 1% of cases of primary hyperparathyroidism. Patient-related factors such as age and sex, as well as the biological features and management of the cancer, influence mid-term and long-term survival. We report a case of a young man with an unusual presentation of parathyroid carcinoma. The patient presented with left thigh swelling, which had been present for 6 months without other symptoms of hypercalcemia. On computed tomography scan a hypodense lesion, 30 × 20 × 20 mm in size, was seen in the posterior thyroid. There was no evidence of cervical lymphadenopathy or local infiltration. On a Sestamibi scan, a hot spot was seen in the lower pole of left thyroid lobe. Cervical neck exploration was performed. The patient subsequently underwent surgery and a parathyroid tumor was excised. The tumor was adherent to the thyroid capsule, but there was no evidence of invasion. After surgery, the patient's calcium and parathyroid hormone levels normalized, but histology confirmed parathyroid carcinoma with capsular and vascular invasion. The patient was offered reoperation, but declined, and developed recurrent parathyroid carcinoma 2 years later. In this report, we aim to present the challenges in managing parathyroid carcinoma and discuss factors that might contribute to future locoregional recurrences. This case also highlighted several issues, including the challenge of ascertaining the diagnosis before surgery and the dilemma of reoperation after simple excision.

A systematic review and meta-analysis of prophylactic central neck dissection on short-term locoregional recurrence in papillary thyroid carcinoma after total thyroidectomy.

BACKGROUND: Prophylactic central neck dissection (pCND) at the time of total thyroidectomy (TT) remains controversial in clinically node-negative (cN0) papillary thyroid carcinoma (PTC). Despite occult central lymph node metastases being common, it is unclear if removing these metastases initially would reduce future locoregional recurrence (LRR). This systematic review and meta-analysis aimed at comparing the short-term LRR between patients who underwent TT with pCND and those who underwent TT alone. METHODS: A systematic review of the literature was performed to identify studies comparing LRR between patients with PTC who underwent TT + pCND (group A) and those who underwent TT alone (group B). Inclusion criteria were cN0 patients, with each comparative group containing > 10 patients, and with the number of LRR and mean follow-up duration available. The pooled incidence rate ratio (IRR) was used for calculating the LRR rate between the two groups. Other parameters evaluated included postoperative radioiodine (RAI) ablation, surgically related complications, and overall morbidity. Meta-analysis was performed using a fixed-effects model. RESULTS: Fourteen studies matched the selection criteria. Of the 3331 patients, 1592 (47.8%) belonged to group A, while 1739 (52.2%) belonged to group B. Relative to group B, group A was significantly more likely to have postoperative RAI ablation (71.7% vs. 53.1%; odds ratio [OR] = 2.60 [95% confidence interval (CI) = 2.12-3.18]), temporary hypocalcemia (26.0% vs. 10.8%; OR = 2.56 [CI = 2.04-3.21]), and overall morbidity (33.2% vs. 17.7%; OR = 2.12 [CI = 1.75-2.57]). When temporary hypocalcemia was excluded, overall morbidity was similar between the two groups (7.3% vs. 6.8%; OR = 1.07 [CI = 0.78-1.47]). Group A had a significantly lower risk of LRR than group B (4.7% vs. 8.6%; IRR = 0.65 [CI = 0.48-0.86]). CONCLUSIONS: Group A was more likely to have postoperative RAI ablation, temporary hypocalcemia, and overall morbidity than group B. Temporary hypocalcemia was the major surgical morbidity in pCND and, when excluded, the overall morbidity appeared similar between the two groups. Although our meta-analysis would suggest that those who undergo TT + pCND may have a 35% reduction in risk of LRR than those who undergo TT alone in the short term (< 5 years), it remains unclear how much of this risk reduction is related to increased use of RAI ablation and potential selection bias in some of the studies examined.

A systematic review and meta-analysis comparing the efficacy and surgical outcomes of total thyroidectomy between harmonic scalpel versus ligasure.

BACKGROUND: Both ultrasonic coagulation (Harmonic Scalpel) (HS) and bipolar coagulation (Ligasure) (LS) are new energy devices commonly used in open thyroidectomy. This systematic review aimed at comparing the efficacy and surgical outcomes of total thyroidectomy (TT) between HS and. LS. METHODS: A systematic review of the literature was performed to identify studies comparing HS and LS. Intraoperative outcomes, surgically related complications, overall morbidity, and hospital stay were evaluated. Meta-analysis was performed using a fixed-effects model. RESULTS: There were 8 studies that matched the selection criteria. Of the 963 patients who underwent TT, 433 (45.0 %) used HS (HS group) while 530 (55.0 %) used LS (LS group). Compared with LS, the HS group had significantly less volume of blood loss by 2.22 ml (95 % CI = 0.26-4.23 ml) (standardized mean difference [SMD] = -0.2, 95 % CI = -0.38 to -0.02) and reduced total operating time by 3.32 minutes (95 % CI = 1.62-5.03 minutes) (SMD = -0.28, 95 % CI = -0.42 to -0.15). There was no significant difference in temporary postoperative hypocalcemia (OR = 1.29, 95 % CI = 0.88-1.90), permanent postoperative hypocalcemia (OR = 1.45, 95 % CI = 0.23-9.26), temporary recurrent laryngeal nerve (RLN) injury (OR = 1.34; 95 % CI = 0.66-2.71), permanent RLN injury (OR = 1.00; 95 % CI = 0.25-4.03), hematoma (OR = 1.00; 95 % CI = 0.3-3.31), overall morbidity (OR = 1.21, 95 % CI = 0.87-1.69), and hospital stay (SMD = -0.03; 95 % CI = -0.07 to 0.01). CONCLUSIONS: Compared with LS, using HS in TT significantly reduced the volume of blood loss and operating time. However, the clinical significance of these findings remained questionable because the overall mean difference appeared small. There was no significant difference in the rate of complications, overall morbidity, and hospital stay between the two devices.

Thyroid surgery for elderly patients: are they at increased operative risks?

An increasing elderly population, a rising incidence of differentiated thyroid carcinoma (DTC), and a rising incidence of benign nodular disease with age are all contributing to a rise in thyroid operations for the elderly. Literature review on the outcome and safety of thyroid surgery in elderly patients has been filled with conflicting results and this subject remains controversial. Although most single-institution studies conducted by high-volume surgeons did not find significant differences of complication rates in elderly when compared with younger cohorts, they often lacked the power necessary to identify subtle differences and suffered from various selection and referral biases. Recent evidence from large population-based studies concluded that thyroid surgery in the elderly was associated with higher complication rates. One of the major contributing factors for the increased complication rate was because most elderly patients suffered from many preexisting comorbidities. Therefore, elderly patients who have abnormal thyroid findings should complete a thorough preoperative workup and better postoperative care after undergoing any thyroid surgery. Furthermore, these high-risk patients would benefit if they could be referred to high-volume, specialized surgical units early. In this systemic review, we aimed to evaluate different issues and controversies in thyroidectomy for elderly patients.