A nonsurgical trauma causing bilateral adductor palsy of the vocal folds following total thyroidectomy

Introduction: Continuous intraoperative nerve monitoring (C-IONM) during thyroid surgery can be used to assess the recurrent laryngeal nerve (RLN) function and preventing unilateral and bilateral palsy. The main advantage of C-IONM using temporary implantable vagus electrode compared with the intermittent format (I-IONM) is the real-time monitoring of RLN integrity during thyroid mobilization and RLN dissection.1 Indeed, the I-IONM format using the handheld stimulation probe exposes the RLN to the risk of injury in between two stimulations. Therefore, the injury of the nerve can only be detected after the damage has already occurred, allowing to set to zero only bilateral RLN palsy by means of avoiding contralateral procedure (two-step surgery).2 In contrast, C-IONM provides the opportunity to perform the critical surgical actions necessary to avoid the impending RLN injury and enables to recover the RLN function after loss of signal, allowing to avoid even unilateral RLN palsy. Hereby we presented a video of a total thyroidectomy for a huge multinodular goiter performed with the help of C-IONM. Materials and Methods: A 54-year-old woman presented with a huge multinodular goiter. A total thyroidectomy performed with the help of C-IONM was planned. The surgical steps were illustrated and the anatomical structures identified. Results and Conclusions: C-IONM is a safe additional tool for thyroidectomy, which enables to perform the corrective maneuvers to avoid permanent nerve injury. If adequately used, it could prevent bilateral and unilateral RLN palsy. It results of great help in difficult cases, such as huge or recurrent multinodular goiter. No competing financial interests exist. Runtime of video: 7 mins 13 secs

Background: Thyroid surgery is the mainstay of the treatment of surgical goiters. Treatment modalities for the surgical management of goiter include lobectomy, sub-total thyroidectomy, near-total thyroidectomy and total thyroidec-tomy.Aim of Study: To compare current surgical management of thyroid diseases in Assuit University Hospital with man-agement guidelines, planning for improving our management of thyroid diseases and correct obstacles to achieve reduction in the morbidity and mortality result from thyroid diseases.Patients and Methods: Our study included 60 patients who were admitted to General Surgery Department with any thyroid disease during a period of six months and managed surgically. All patients had neck ultrasound and FNAC was done for suspicious cases for malignancy. Benign solitary nodular goiter was managed by unilateral lobectomy and isthmusectomy. MNG was managed by total and sub-total throidectomy. Malignant goiter was managed according to cytology with total thyroidectomy being done for most cases. Controlled toxic goiter was managed by total or sub-total thyroidectomy. All cases were subjected to pre-and post-operative layrngoscopic examination for assessement of vocal cord mobility. Post-operative histopathology is amust in all cases.Results: Mean age of the studied patients was 39.18±11.75 years with range between 15 and 63 years. Out of 60 patients, 49 (81.7%) patients were females and 11 (18.3%) patients were males. 17 (28.3%) of the studied had toxic manifestations and 15 (25%) patients were on anti-thyroid medications. Iodine deficiency was noticed in 9 (15%) patients while 7 (11.7%) patients had endemic goiter. Out of the studied patients, 5 (8.3%) patients had family history of thyroid disease.Unilobar enlargement presented in 12 (20%) patients while 48 (80%) patients had Bilobar thyroid enlargement. Diffuse goiter presented in 4 (6.7%) patients and nodular goiter in 56 (93.3%) patients, 13 (21.7%) solit all patients were subjected to thyroid function tests (TSH, free T3 and T4) before and after thyroidectomy. It was noticed that there were significant improvement in level of TSH, free T3 and free T4 after thyroidectomy (p<0.05).FNAC was done in 41 (68.3%) patients. Total thyroidec-tomy was performed in 43 (71.7%) patients while 10 (16.7%) and 7 (11.7%) patients had subtotal thyroidectomy and uni-lateral lobectomy with isthmusectomy respectively. The most frequent complications post-operatively were hoarseness of the voice and choking occurred in 18 (30%) and 16 (26.7%) patients respectively. Injury of RLN occurred in 5 (8.3%) patients.All of those patients received replacement therapy and none of them received chemotherapy or iodine therapy.Post-operative complications were frequent in those patients had total thyroidectomy where hoarseness of the voice, chocking and injury of recurrent laryngeal nerve oc-curred in 13 (30.2%), 12 (27.9%) and 5 (11.6%) patients respectively.In case of subtotal thyroidectomy 4 (40%) patients had choking and 4 (40%) patients had hoarseness of the voice. Only one patient from those had unilateral thyroidectomy had post-operative complication in form of hoarseness of the voice.Duration of surgeon experience was less than 5 years in majority of cases (56.7%) while in 16 (26.7%) and 10 (16.7%) patients duration of surgeon experience was 5-10 and more than 10 years respectively. With experience less than 5 years, post-operative complications were; 3 patients had R.L.N. injury, 12 patients had hoarseness of voice, and 10 patients had chocking. With surgical experience between 5 to 10 years, complications were; 2 patients had R.L.N. injury, 4 patients had hoarseness of voice, and 5 patients had chocking. While with experience more than 10 years, the complications were so minimal with only 2 patients had transient hoarseness of voice and chocking.In case of controlled toxic goiter; 15 (75%), 3 (15%) and 2 (10%) patients had total, subtotal and unilateral thyroidec-tomy respectively. In case of simple goiter; 7 (58.3%) patients had total thyroidectomy, 4 (8.3%) patients had unilateral thyroidectomy and 1 (8.3%) patient had subtotal thyroidectomy.21 (75%) patients from those with multinodular goiter had total thyroidectomy, 6 (21.4%) had subtotal thyroidectomy and 1 (3.6%) patient had unilateral thyroidectomy.Conclusion: In our study, no major difference was noticed between our surigal management strategy of thyroid diseases and international guidelines. Pre-operative assessement was focused with neck U/S and FNAC being the most important investigations. Choice of the type of operation was based on the type of thyroid disease and the risk of post-operative complications was considered.post-operative complications in the form of RLN injury, hypothyroidism and hypo-parathyroidism were markedly decreased.

The increasing use of intraoperative neuromonitoring (IONM) in thyroid surgery has revealed the need to develop new strategies for cases in which a loss of signal (LOS) occurs on the first side of a planned total thyroidectomy. This study reviews the experience of the authors in using IONM for planned total thyroidectomy after LOS on the first thyroid lobe. The aims were to estimate the incidence of LOS on the first side of resection and to compare intraoperative strategies applied after this event. Intermittent IONM was performed with stimulation of both the vagal nerve and the recurrent laryngeal nerve (RLN) (V1, R1, R2, V2). Patients underwent pre- and postoperative laryngoscopy. Before surgery, patients were informed that staged thyroidectomy might be required. This study analyzed 803 consecutive thyroid procedures. Of these, V2 LOS (<100 mcV) occurred after first lobe exeresis in 23 (2.8%) procedures. The surgical procedure was stopped in 20 cases (ie, staged thyroidectomy was performed). In three cases with malignancy and severe comorbidity (ASA score 3-4), total bilateral thyroidectomy was performed as planned. No cases of bilateral RLN palsy occurred. Postoperative laryngoscopy confirmed RLN palsy in 21 of the 23 cases. All true positive patients received speech therapy. Patients who had false positive LOS (n = 2) or malignancy (n = 8) and patients who were symptomatic (n = 7) received completion thyroidectomy within 6 months. One patient received radioactive iodine therapy for hyperthyroidism. Two patients received follow up. Neuromonitoring changes the surgical decision-making process in a multidisciplinary manner. A shared decision-making process involving the patient, anesthesiologist, and endocrinologist is suggested. In the case of intraoperative LOS on the first-operated side in a planned total thyroidectomy, the thyroid surgeon essentially has three options for surgery on the contralateral side: 1) Perform staged thyroidectomy. This option is recommended in bilateral goiter, Graves' disease, or low-risk thyroid carcinoma (differentiated or medullary thyroid carcinoma). The aim is to avoid bilateral vocal cord palsy. Two-stage completion surgery is delayed until recovery of ipsilateral nerve function. 2) Perform subtotal resection on the contralateral side ventrally to the RLN plane at a safe distance from the nerve. The aim is to avoid further disease recurrence and revision surgery. 3) Perform total thyroidectomy as planned for advanced thyroid carcinoma (including undifferentiated thyroid carcinoma). The aim is to improve disease control through radioactive iodine therapy, radiation therapy, or target therapy immediately after surgery. 4.

Outpatient thyroidectomy has become slowly accepted with various published reports predominantly examining partial or subtotal thyroidectomy. Concerns regarding the safety of outpatient total and completion thyroidectomy remain, especially with regard to vocal fold paralysis, hypocalcemia, and catastrophic hematoma. We aimed to evaluate the safety of outpatient thyroid surgery in a large cohort by retrospectively comparing outcomes in those who underwent outpatient (n = 251) versus inpatient (n = 291) completion or total thyroidectomy between February 2009 and February 2015. Outpatient completion and total thyroidectomy had lower rates of temporary hypocalcemia (6% vs 24.4%; P < 0.001) and no significant difference in rates of return to emergency department (1.2% vs 1.4%), hematoma formation (0.8% vs 0.7%), temporary (2% vs 4.1%) or permanent (0.4% vs 0.7%) vocal fold paralysis, or permanent hypocalcemia (0.4% vs 0%) compared with the inpatient group. Outpatients requiring calcium replacement had shorter duration of postoperative calcium supplementation (44.4 ± 59.3 days vs 63.3 ± 94.4 days; P < 0.001). Our data demonstrate similar safety in outpatient and inpatient total and completion thyroidectomy.

Background: Total thyroidectomy is currently the preferred treatment for thyroid cancer, multinodular goitre (MNG) and Graves' disease.However, many surgeons choose not to perform total thyroidectomy to treat benign thyroid diseases owing to the associated risk of postoperative hypoparathyroidism, recurrent laryngeal nerve damage and bleeding.We reviewed 100 total thyroidectomies performed for benign thyroid diseases, when surgery was indicated.Objective: Assessment whether total thyroidectomy is safe and can be considered as the optimal surgical approach for treating benign thyroid diseases.Patients and methods: This study was conducted on 100 patients presented by thyroid swellings and admitted to Mansoura University Hospitals, Endocrine Surgery Unit over one year during the period between November, 2017 and October, 2018.All patients were submitted to careful history taking, clinical examination and radiological and laboratory investigations.Total thyroidectomy was done to all patients.Patients were evaluated early postoperative at 1, 6 and 12 months by sr.TSH, total & ionized calcium, PTH and vocal cord assessment.Results: Preoperative diagnoses in our patients revealed that there were 74 cases MNG (74%), 2ry toxic 19 cases (19%) and 1ry toxic 7cases (7%).The incidence of permanent bilateral recurrent laryngeal nerve palsy was 0% and that of permanent unilateral recurrent laryngeal nerve palsy was 1%.Whereas the incidence of temporary unilateral recurrent laryngeal nerve palsy was 5%.Permanent hypocalcaemia occurred in 2% and overall temporary hypocalcaemia occurred in 8% of patients.Hemorrhage requiring repeat surgery occurred in 1% of patients. Conclusion:In our study, total thyroidectomy showed no significant operative and/or postoperative complications.Also, it was noticed that total thyroidectomy operation gave very good results in patients with benign thyroid diseases provided that they were done in qualified center and by experienced endocrine surgeons.

Benign bilateral thyroid disease is the most common indication for surgery in endemic iodine-deficiency regions. Total thyroidectomy is currently the preferred treatment for thyroid cancer, multinodular goiter and Graves disease; however, many surgeons and endocrinologists choose not to perform or recommend total thyroidectomy to treat benign thyroid diseases. We sought to assess whether the results support the hypothesis that total thyroidectomy is safe and can be considered as the optimal surgical approach for treating BTD in endemic region such as Bulgaria. A total of 500 patients underwent thyroid operation between 2007 and 2009. We excluded patients with thyroid cancer or suspicion of thyroid malignancy. We evaluated indications for total thyroidectomy, complication rates, local recurrence rate and long-term outcome after total thyroidectomy. Diagnoses before surgery were multinodular goiter (n = 300), Graves disease (n = 100) and Toxic multinodular goiter (n = 100). The incidence of permanent bilateral recurrent laryngeal nerve palsy was 0% and that of permanent unilateral recurrent laryngeal nerve palsy and permanent hypocalcaemia was 1.8–5%. Haemorrhage requiring repeated surgery occurred in 4.5–13% of patients. There was no wound infection, and postoperative mortality was 0%. Total thyroidectomy is safe and is associated with a low incidence of disabilities. Furthermore, our study showed that total thyroidectomy is the optimal procedure, when surgery is indicated, for Graves disease and toxic multinodular goiter, as total thyroidectomy has the advantages of immediate and permanent cure and no recurrences.

Bilateral Recurrent Laryngeal Nerve Injury in Total Thyroidectomy With or Without Intraoperative Neuromonitoring. Systematic Review and Meta-analysis

Contribución de la neuroestimulación a la seguridad en la extubación traqueal tras tiroidectomía total. Estudio prospectivo con electrodos de aguja

Value of recurrent laryngeal nerve monitoring in the operative strategy during total thyroidectomy and parathyroidectomy

BACK GROUND: Thyroidectomy is a common surgery with an extremely low mortality, with specific morbidities which are related to the experience of the surgeon. Very low morbidity rates with specialised centers. Thyroid surgery is associated with few complications and no fatality. Post-operative complications may be as insignificant as edema of the flap or as dangerous and life threatening as hemorrhage or respiratory obstruction. Complications are less with sound surgical technique and good preoperative preparation. OBJECTIVES: 1. The objective of the study is to compare complication rates of Bilateral sub total thyroidectomy (SBT), near total thyroidectomy (NTT) Hemithyroidectomy (Total lobectomy and isthmusectomy), and Total thyroidectomy (TT) in cohort of patients undergoing surgery for various thyroid disorders. 2. To compare complication rates after thyroidectomy for benign diseases and malignant diseases. 3. To identify ways to avoid the post operative complications. METHODOLOGY: It is a prospective study conducted from September 2016 to August 2017 in one hundred patients who underwent thyroidectomy surgery in our hospital which includes ninety three female and seven male patients. All basic investigation along with vocal cord examination and special investigation like thyroid profile and serum calcium is done in all patients in the study group. Meticulous pre operative preparation is done in all cases. FNAC is done in all cases of goitre under study group. Finally the outcome of various thyriodectomy procedures and their post operative complications along with nature of histopathological reports were compared. The morbidity and mortality associated with each procedure and nature of the disease were compared in this study. RESULTS: In our study flap edema occurred more frequently, that too more frequent after total thyroidectomy (12%). Seroma occurred in eight cases (8 %) but subsided rapidly. The incidence of recurrent laryngeal nerve (vocal cord) palsy is 7 % and superior laryngeal nerve palsy in four patients (4%). These complications were transient. Recovered spontaneously over the time. Post operative hypo parathyroidism occurred in four patients who underwent total thyroidectomy for malignant thyroid disorders. These incidence is due to surgical clearance for malignant disease. This study also reveals complication rates were more for total thyroidectomy than any other procedures. Incidences of other complications are also higher in bilateral total thyroidectomy. Thyroid storm, oesophageal injury and death were nil in our study group. This study revealed that the hemithyroidectomy is an extremely safe procedure without any complication. CONCLUSION: The following conclusions are drawn from this study: 1. This study shows that the total thyroidectomy or hemithyroidectomy can be done with very low complication rate in cases of benign thyroid disease affecting the whole gland. 2. Recurrent laryngeal nerve palsy , hypo parathyroidism induced hypocalcemia were occuring in total thyroidectomy procuredes in malignant thyroid disorder patients than benign disorders. 3. Thyroid carcinoma, recurrent goiter, toxic goiter and total thyroidectomy are risk factors for post operative complication. 4. There is a risk of recurrence with bilateral subtotal thyroidectomy. Because total thyroidectomy carries a risk of complication similar to that for bilateral subtotal thyroidectomy, it is no logical to avoid total resections. Therefore near total or total thyroidectomy may be the operation of choice for multinodular goiter. 5. Complications and sequelae of thyroid surgery can yet be reduced by careful evaluation of the surgical and medical therapeutic options to have more precise surgical indications, a thorough knowledge of the surgical anatomy, a rigorous surgical technique, a systematic dissection of recurrent laryngeal nerve and meticulousness during the procedure. 6. I conclude that the operative skills and experience of the Surgeon and the malignant nature of the disease are the determining factors for the complications in thyroidectomy procedures.

Thyroid cancer: The case for total thyroidectomy

Lesión bilateral del nervio laríngeo recurrente en tiroidectomía total con o sin neuromonitorización intraoperatoria. Revisión sistemática y metaanálisis

Background: The use of total thyroidectomy in benign thyroid disease treatment is not universal. A total of 60 total thyroidectomies performed for benign thyroid diseases. The Aim of the study was to evaluate the role of total thyroidectomy in patients with presumed bilateral benign thyroid disease, with special emphasis on the incidence of two major post-operative complications namely hypoparathyroidism and recurrent laryngeal nerve palsy. Methods: It was a prospective study, A total of 60 patients who underwent total thyroidectomy for benign thyroid diseases between January 2016 to January 2018 were studied in department of general surgery at St Martha’s hospital, Bangalore. The patients were followed up for a period of nine months for post-operative complications. Results: Most of the patients were in the fifth decade of life, Female outnumbered males. Female: male ratio was 4.5:1. Amongst the 60 patients in the present study, the incidence of transient recurrent unilateral laryngeal nerve palsy was seen in 5 %, temporary hypocalcemia in 20%, permanent hypocalcemia in 3.3%, and permanent unilateral laryngeal nerve palsy in 1.66%. Malignancy detected after histopathological examination was in 8.33% of the patients. There was no wound infection, hematoma, bilateral RLN palsy and post-operative mortality. Conclusion: Total thyroidectomy for benign thyroid disease can eliminate any subsequent risk of malignant change in thyroid glands. A low complication rate can be achieved with meticulous surgical technique. Total thyroidectomy can be performed safely and can be considered as valuable option for treating benign bilateral thyroid diseases.

Background Carcinomas arising in the thyroglossal duct cysts are rare, accounting only for about 0.7–1.5 % of all thyroglossal duct cysts.1–3 Synchronous occurrence of thyroglossal duct carcinoma and thyroid carcinoma is reported to be even rarer.4 Traditionally, surgical treatments of such coexisting thyroglossal duct cyst carcinoma (TGDCa) and papillary thyroid carcinoma (PTC) were typically performed through a single transverse or double incisions on the overlying skin. A longer, extended cervical incision might be required if neck dissection is necessary. Though this method provides the operator with the optimal surgical view, the detrimental cosmetic effect on the patient of possessing a scar cannot be avoided, despite the effort of the surgeon to camouflage the scar by placing the incision in natural skin creases. Recently, the authors have previously reported the feasibility of robot-assisted neck dissections via a transaxillary and retroauricular (“TARA”) approach or modified face-lift approach in early head and neck cancers.5,6 On the basis of the forementioned surgical technique, we demonstrate our novel technique for robot-assisted Sistrunk’s operation via retroauricular approach as well as robot-assisted neck dissection with total thyroidectomy via transaxillary approach.

Surgical treatment of graves' disease: Subtotal or total thyroidectomy?