Patients Underwent Neck Exploration Research Articles

Penetrating neck trauma” - Enigma to surgeons: A case report with review of literature

: We report for the first time a case of penetrating injury to carotid artery by a stone piece during welding using hammer.: A 26, year old male labourer presented with a penetrating neck injury by a stone piece. As the patient was stable, NCCT neck was done which revealed a metallic foreign body obliterating the right carotid space. CT Angiography was also done to rule out any vascular injury. The patient underwent neck exploration during which foreign body was removed and right carotid artery repair was done with 4-0 prolene. : The patient had no complications and showed no sequalae from this injury during follow up.: CT angiography should be done in all patients who are stable to rule out injury to great vessels before neck exploration .

Extruded Screw From Cervical Spine Hardware Causing Vocal Fold Paralysis.

Dysphonia and dysphagia are often observed among patients presenting to the otolaryngology clinic. One of the more common etiologies includes iatrogenic injury to the recurrent laryngeal nerve (RLN) as a known complication of head and neck surgeries such as thyroidectomy or anterior approaches to the cervical spine. Most often, RLN injury occurs in this context due to traction or transection of the nerve. No reports on delayed presentation of RLN injury from the extrusion of cervical spine hardware (screw) could be found in the peer-reviewed literature. We present a case of a 63-year-old woman who presented to the otolaryngology office with a 3-month history of hoarseness and difficulty swallowing. The patient's past medical history was significant for a motor vehicle accident (MVA) 6 years prior resulting in right arm radiculopathy and subsequent anterior cervical discectomy with spinal decompression and fusion (ACDF) at C5-C6 and C6-C7 approximately 3 months after the MVA. Strobovideolaryngoscopy revealed right vocal fold immobility. Computed tomography scan revealed that a screw from the right side of the ACDF hardware migrated approximately 2 cm with compression of the RLN. The patient underwent neck exploration with removal of the extruded hardware and microdirect laryngoscopy with right vocal fold injection laryngoplasty. Intraoperatively, the extruded screw was found embedded within the RLN fibers. This case represents the first report to our knowledge of extrusion of cervical spine hardware screw resulting in delayed RLN injury and vocal fold paralysis.

Severe hypercalcemia secondary to parathyroid adenoma: Series of four consecutive cases at a tertiary care hospital in Qatar.

In most cases of parathyroid adenoma (PA), it is not palpable and physical examination shows no remarkable findings. Hence diagnosis requires an index of suspicion. The current paper describes four cases of severe hypercalcemia secondary to PA. Case 1 - 29 years old Sudanese female with history of nausea/vomiting, fatigue, loss of appetite and bone aches. She had large palpable left lower neck swelling, and high calcium and PTH. Ultrasound (US) neck and SPECT/CT scan after sestamibi injection showed left inferior PA. Case 2-73 years old Sudanese male referred with history of abdominal pain and flatulence. He had severely high calcium, elevated parathormone (PTH), and high 24-hour urine calcium. US and SPECT/CT showed a left inferior PA. Case 3-54 years old Bangladeshi male, referred with history of renal colic/urolithiasis. Laboratory results showed severely high calcium and PTH levels. US and SPECT/CT scan showed right inferior PA. Case 4-35 years old Tunisian female, 12 weeks pregnant, referred with recurrent nausea and vomiting of increasing frequency from the second week of pregnancy. Laboratory tests revealed severe hypercalcemia and high PTH. US showed two parathyroid lesions. The patients were admitted as emergency cases and investigations diagnosed severe hypercalcemia secondary to PA. All patients underwent neck exploration and PA excision. Histology confirmed PA. The four cases were swiftly assessed and treated before progressing into the more serious hypercalcemic crisis which can lead to grave consequences, particularly in the case of the pregnant female. All patients recovered with no complications and were clinically well with normal calcium level on follow up. Severe hypercalcemia must be swiftly and thoroughly assessed to prevent the more serious hypercalcemic crisis. Clinicians need to be suspicious of parathyroid adenoma as a probable cause. Severe hypercalcemia is often accompanied with vomiting, and in pregnant females, this could be mistaken for hyperemesis gravidarum. Excision of the parathyroid adenoma treats the condition and follow up of serum calcium and PTH confirms the favorable outcome of surgery.

Thyroid Rupture Secondary to Blunt Neck Trauma: A Case Report

Aim To discuss the clinical presentation of thyroid rupture following blunt neck trauma and highlight key management principles for the case. Methods A 45-year-old female motorcycle passenger with a pre-existing right thyroid nodule hit her right anterior neck against a bottle during sudden stop and developed painful right neck swelling, odynophagia, and hoarseness. She was seen at the emergency room 5 hours post-injury, awake, cooperative, and ambulatory, without stridor or dyspnea at room air. On examination, she had ecchymoses behind her right tonsillar pillars; her neck was grossly swollen and was tender on palpation without subcutaneous emphysema. Laryngoscopy showed good left vocal cord mobility while the right vocal cord had a visible hemorrhage and limited abduction due to the mass effect of the hematoma seen at the right aryepiglottic area extending toward the right piriform fossa and the right parapharyngeal area. Intact bilateral vocal cord adduction was noted upon phonation. Contrast-enhanced computed tomography revealed hematoma formation in the right thyroid lobe area with extension to the right side of the oropharyngeal region, anterior cervical, parapharyngeal, and retropharyngeal space, confirming the aerodigestive tract narrowing and leftward deviation previously noted. Baseline thyroid function tests were normal. Under general anesthesia, the patient underwent neck exploration where the ruptured right thyroid lobe was resected, and the hematoma was evacuated. Results Postoperatively noted significant improvement in neck swelling, odynophagia, and hoarseness. Transient subclinical hyperthyroidism remained asymptomatic and resolved upon outpatient follow-up. A year after the surgery, the patient had a well-healed cervical scar, complete hematoma resolution, and regained her pre-morbid phonation. Conclusion Thyroid gland rupture should be among the considerations for patients presenting with tender neck swelling, progressive hoarseness, and/or dyspnea following neck trauma. Prompt airway assessment and close monitoring for potential compromise are essential to avoid fatal sequelae of external airway compression. Management varies from close observation to surgical neck exploration and should be personalized depending on the severity of thyroid injury and symptomatology.

SUCCESSFUL PERIOPERATIVE MANAGEMENT OF HIGH-RISK ELDERLY PATIENTS WITH ADVANCED HEAD & NECK CANCER IN THE COVID ERA. OUR EXPERIENCE.

INTRODUCTION: Elderly patients with advanced head and neck cancer undergoing major surgery are at high risk due to their co-morbidities and prolonged procedures. Thus, they often require admission in the ICU. PURPOSE: We herein describe the perioperative management of elderly patients, with significant comorbidities, surgically treated for stage II-IV head and neck cancer with a specialized anesthesia protocol in the COVID-19 era. MATERIAL - METHOD: In total, 11 consecutive patients (4 female, 7 male, mean age 74 years, ASA III-IV), with advanced cancer involving oral mucosa, salivary glands and metastatic skin cancer were treated in UHL between 3/2021 and 3/2022. Operation duration varied from 5 to 13 hours, as the extent of disease necessitated extirpation and reconstruction with free or regional flaps in most cases. Hence, an individualized and patient-centered approach was implemented, with the preanesthetic evaluation, the utilization of both an enhanced recovery (ERAS), specialized anesthesia protocol and the prompt postoperative care delivered by the anesthesia team. . RESULT: No intraoperative adverse events were reported. Admissions in ICU were obviated. One patient underwent neck exploration for bleeding control being treated with therapeutic doses of LMWH (grade IIIb Clavien-Dindo). One more patient required blood transfusion (grade II Clavien-Dindo). Donor site wound breakdown was recorded in 4 patients (grade IIIa Clavien-Dindo). Hospital length ranged from 5 to 14 days. 30-day mortality was 0%. CONCLUSION: Good rapport between involved teams along with the implementation of an individualized perioperative approach of this patient cohort resulted in an uneventful outcome amid the COVID-19 pandemic.

P23-8 Multiple endocrine neoplasia type 2a syndrome: A tertiary care center experience in Pakistan

Multiple endocrine neoplasia type 2a (MEN-2a) is a rare autosomal dominant disorder. Available literature in the subcontinent is limited. Here we report a case series of MEN-2a patients from two families. This case series was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Center. We included 2 families that fulfilled clinical criteria for MEN-2a. Five patients were clinically diagnosed with MEN-2a syndrome. Mean age at presentation was 22.4 yrs. All 5 patients had medullary thyroid cancer (MTC). Four patients had pheochromocytoma and 1 patient had a nonfunctioning adrenal incidentaloma. One patient had primary hyperparathyroidism (PHPT). All 5 patients underwent total thyroidectomy and 4 patients underwent adrenalectomy. One patient underwent neck exploration surgery for PHPT. Post treatment, 4 patients had resolution of MTC, 1 patient has calcitonin levels which remain high and is under investigation. All 4 patients had resolution of pheochromocytoma post surgery. Only one patient had all three manifestations of MEN-2a. None of the patients underwent genetic testing due to non-availability; therefore MEN-2a was diagnosed purely on clinical grounds. Both families were advised screening for MEN-2a syndrome of all first-degree family members. In this case series, age, clinical presentation and outcomes were like those reported in literature. In our practice we face various challenges such as logistics, lack of availability of genetic testing, financial constraints and poor follow up. Given the above limitations, would the management recommendations for family members of clinically diagnosed MEN-2a patients be the same as for patients who have had positive genetic testing, as international guidelines suggest measures like prophylactic thyroidectomies based on genetic testing. More studies are needed from the subcontinent so that recommendations for MEN 2-a can be made specific to this population.

SAT-LB302 From Urolithiasis to Genetic Testing: An Unusual Presentation of MEN-4 Syndrome

Background:Germline mutations in the CDKN1B gene are responsible for Multiple Endocrine Neoplasia Type 4 (MEN 4) syndrome (Alrezk et al. 2017). Around 20 cases have been reported to date. Here, we report on a new MEN4 family which possibly extends the phenotypic spectrum attributable to germline mutations in CDKN1B. Clinical Case: A 56-year-old female presented with urolithiasis & was found to have hypercalcemia (serum calcium of 2.76 mmol/l ref. 2.12-2.62 mmol/l). Workup was in keeping with primary hyperparathyroidism (PHPT) (PTH 28.7 pmol/l ref. 1.50-9.30 pmol/l; phosphorus 0.89 mmol/l ref. 0.80-1.45 mmol/l). Sestamibi & US of the neck revealed no clear parathyroid adenoma. Two incidental thyroid nodules were benign on FNA cytology.The patient underwent neck exploration & a single enlarged parathyroid gland was removed. Pathology showed an enlarged hypercellular gland. Her calcium & PTH normalized after surgery but recurrence was documented a year later. Her family history was significant for PHPT in two brothers & a history of kidney stones in a third brother. Multi-gene panel testing (CASR, CDC73, CDKN1B, MEN1, RET, Invitae Corp.) revealed a pathogenic variant (PV) in CDKN1B (c.215delG). The patient underwent a 2 ½ parathyroidectomy with subsequent normalization of her calcium & PTH. Further work-up showed a 4.5mm non-secreting pituitary adenoma. Plasma metanephrines & NE were intermittently elevated. Serum gastrin was also mildly elevated 83 pmol/l (<53 pmol/l). A Ga68-DOTATATE PET scan was negative. Her 23-year-old daughter tested positive for the familial PV. She is asymptomatic & has normal calcium & PTH; pituitary function is normal except for an elevated IGF-1 at 63.9 nmol/l (ref 13.3- 42.6 nmol/l) with borderline growth hormone during OGTT (0.40 ug/l). Her pituitary MRI was normal. One brother with history of prostate cancer, PHPT & partial parathyroidectomy has tested positive for the familial CDKN1B variant. A second brother was also found to carry the familial variant & was clinically asymptomatic.Endocrinological workup has revealed he has PHPT, elevated chromogranin A at 196.2 ng/ml (ref <=82), calcitonin at 25 ng/l (normal <=9 ng/l), IFG1 (35.3 nmol/L ref. 13-21) but normal plasma metanephrines. An MRI of the sella shows an 8mm hypoenhancing lesion. On CT, a retroperitoneal hyperenhancing 4cm mass adjacent to the left ilio-psoas was seen, in keeping with a paraganglioma; additionally, he has a congenital left atrophic kidney & ureter. Two additional brothers; one with history of non-Hodgkin’s lymphoma, PHPT & partial parathyroidectomy & a second brother, also with prostate cancer & recurrent renal stones, have yet to be tested. Conclusions: A new MEN4 family is described here which expands the spectrum of clinical manifestations of this syndrome. Of great interest in our cases is the presence of paraganglioma, urological malformation, & pre-clinical GH/IGF1 elevation.

SAT-058 A Rare Case of Primary Hyperparathyroidism in a Pediatric Patient

Introduction: Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder in adult patients, but it is rare in pediatric patients. It is usually diagnosed when patients present with symptomatic hypercalcemia or known complications. In children, atypical presentation often results in delayed diagnosis and increased morbidity. We report a 10-year-old boy presenting with abdominal pain and emesis, found to have hypercalcemia and, ultimately, PHPT. His genetic evaluation was notable for a mutation in the RET gene (3.2C>A) of unknown clinical significance. Case presentation: A 10-year-old male with a history of constipation presented to the emergency department with five days of abdominal pain and emesis. Initial workup revealed high serum calcium (Ca) of 17.3 mg/dL (8.7-10.7) and ionized Ca (ICal) of 2.01 mmol/L (0.95-1.32). Further evaluations revealed low phosphorus level 3.5 mg/dL (4.5-6.5) and high parathyroid hormone level (iPTH) of 329.2 pg/mL (8.0-85.0). These findings were consistent with PHPT. Neck US demonstrated a cervical mass in the mid-right thyroid measuring 0.5 x0.3 x0.5cm, questionable for parathyroid adenoma, which was confirmed with 99mTc-MIBI scintigraphy and neck CT. His Ca level initially responded to fluid resuscitation and Lasix, with Ca level decreasing to 13.6. However, on hospital day two, his Ca level became refractory to all interventions, rising to 16 and prompting the use of bisphosphonates. The patient underwent neck exploration with partial parathyroidectomy and lymph node excision. Pathology revealed hypercellular parathyroid tissue consistent with parathyroid hyperplasia. Intraoperatively iPTH was reduced from 3,134.7 to 79.8 and remained within normal limits since. Postoperatively course was uncomplicated, and the patient was discharged home on oral Ca carbonate and vitamin D. A genetic evaluation was remarkable for a change in the RET gene (3.2C>A), a finding of unknown clinical significance. This change has not been seen in association with an individual who fulfills the clinical diagnosis of MEN2A. To further determine if the variant identified in the RET gene is a benign variant, the mother was tested for MEN2A and was negative. Father could not be tested, but family history was significant for thyroid malignancies. The patient is currently doing well four months postoperatively. His Ca level remains normal. Due to the genetic finding and the concern of MEN2A syndrome, the patient is followed closely by pediatric endocrinology and genetics. Conclusion: PHPT is a common endocrine disorder in adults but rare in children. The diagnosis of pediatric PHPT is almost always delayed due to atypical presentation and rarity of the disease. As secondary organ damage is common, a multi-organ assessment is mandatory. Due to the association with other syndromes, a genetic evaluation should be performed.

Management of Laryngotracheal Trauma: A Five-Year Single Institution Experience

Laryngotracheal trauma is a rare life-threatening emergency that requires early identification and immediate intervention. Here, we present 26 patients with laryngotracheal trauma from a tertiary hospital in India. The aim was to describe the clinical presentation and management of laryngotracheal trauma patients. This was a retrospective study of laryngotracheal trauma patients treated between January 2011 and March 2016. Patients who presented with a breach in the laryngotracheal framework were included, while those who had penetrating neck injuries superficial to strap muscles/platysma, burn injuries, caustic ingestion, or endotracheal injuries were excluded from the study. Of 253 patients with neck injury, 26 (23 adults, three children; 21 males, five females; age range, 5-60 years) presented with a breach in the laryngotracheal framework (15 blunt neck-trauma patients and 11 penetrating neck-trauma patients). The most common cause of neck injury was road traffic accidents, seen in 12 patients (46.2%). Computed tomography (CT) was performed in all blunt trauma cases and in four patients with penetrating trauma. All penetrating trauma patients underwent neck exploration. Twelve blunt trauma patients (46.1%) were managed conservatively, while three (11.5%) required surgical intervention. The most common neck exploration finding noted in patients with a penetrating injury was fracture of the thyroid cartilage, which was seen in eight patients (30.8%). Twenty patients (76.9%) had a normal voice, five patients (19.2%) had a hoarse voice, and one patient (3.8%) had a breathy voice post treatment. Early intervention of laryngotracheal trauma is crucial. The role of a CT scan is essential in decision making in blunt trauma cases.

Pediatric penetrating neck trauma: Hard signs of injury and selective neck exploration.

Selective neck exploration and computed tomography angiography (CTA) in penetrating neck trauma have been well described in adults. However, data in the pediatric population are sparse. The extent to which these practices have been adopted in pediatric patients is unknown. Retrospective, single-center cohort study of pediatric penetrating neck trauma for the years 2001 to 2014 in a dedicated children's hospital/Level 1 pediatric trauma center. Clinical data, sensitivity and specificity of hard signs (active hemorrhage, airway compromise, expanding hematoma, crepitus, and so on) and soft signs of injury (bruit, voice change, stridor, laceration less than 2 cm, nonexpanding hematoma, and so on), and trends in imaging were examined. A total of 44 patients were identified with penetrating neck trauma. The majority of these patients were male (55%) aged 8 months to 18 years and a median of 7.3 years. Sixteen patients underwent neck exploration with 13 major injuries identified in 10 patients. Nineteen patients had associated injuries. Ten patients had at least one hard sign of injury, and 16 patients had only soft signs of injury. The sensitivity and specificity of hard signs of injury were 100% (95% confidence interval [CI], 59-100%) and 94.4% (95% CI, 79-99%), respectively. Soft signs only had a sensitivity and specificity of 100% (95% CI, 39-100%) and 75.5% (95% CI, 60-86%), respectively. Positive and negative predictive values were 4.8% and 100%, respectively, for both hard and soft signs. The number of CTA studies increased over time but was not statistically significant. Forty (90%) patients were discharged home and two patients died. These results suggest that management of penetrating neck trauma in children includes selective neck exploration based on physical examination and the use of CTA in stable patients, similar to current adult recommendations. We did not observe evidence of missed injuries over the study period. Therapeutic/care management, level IV.

Open and Endoscopic Management of Fourth Branchial Pouch Sinus – Our Experience

Introduction Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common and usually present with recurrent left thyroid lobe abscesses. Objectives The authors present their experience in treating such cases that were observed exclusively in children. Methods The study involved performing a retrospective review of five cases in PSG Institute of Medical Sciences & Research. All cases were evaluated radiologically and with Direct Rigid hypopharyngoscopy. Definitive surgery was performed, including hemithyroidectomy. Results The patients consisted of five children, two boys and three girls. All of them presented with recurrent episodes of neck infection. Investigations performed included computed tomography (CT) fistulography, rigid hypopharyngoscopy and ultrasound, which were useful in preoperatively delineating pyriform sinus fistulous tract. All patients underwent neck exploration with excision of the fistulous tract and hemithyroidectomy. Upon follow-up, all patients are asymptomatic. Conclusions Recurrent neck abscesses in a child should alert the clinician to the possibility of a fourth branchial arch anomaly; therefore, children with this condition require a complete evaluation so the anomaly can be ruled out.

Selective management of penetrating neck injuries using “no zone” approach

Selective management has been the standard management protocol in penetrating neck injuries (PNIs) since this approach has significantly reduced unnecessary neck exploration. The purpose of this study is to evaluate outcomes of selective management in PNIs using the "no zone" approach, in which the management is guided mainly by clinical signs and symptoms, not the location of the neck wounds. A retrospective study was performed in patients treated for PNIs at King Chulalongkorn Memorial Hospital (KCMH) from January 2003 to December 2013. The patients with hard signs of neck injury (i.e., active bleeding, significant haematoma, massive subcutaneous emphysema, and air bubbling through the neck wound) underwent emergency neck exploration. The asymptomatic patients and the patients with soft signs (other symptoms) were considered to be candidates for selective management. Data collection included demographic data, emergency department parameters, details of neck injury, and outcomes in terms of mortality, negative exploration rate, and missed injury rate. Eighty-six PNI patients were treated at KCMH from 2003 to 2013, 64 of which sustained stab wounds, 12 gunshot wounds, 4 shotgun wounds, and 6 other causes. Thirty-six patients presenting with hard signs underwent immediate neck exploration and there were 2 negative explorations. Twenty-six patients with soft signs underwent selective investigations (including computed tomographic angiography in 21 patients), 5 patients required neck explorations due to positive results of the investigations with one negative exploration. All of the twenty-four asymptomatic patients were managed with close observation, none required subsequent neck exploration. There was no missed injury found in the present study. Successful non-operative management was carried out in 45 patients (52%). The overall negative exploration rate was 7% (3 in 41 patients undergoing neck exploration). Two patients with hard signs died from associated chest injuries (mortality rate 2%). Selective management of penetrating neck injuries based on physical examination and selective use of investigations (no zone approach) is safe and simple with low negative exploration rate and no missed injury.

Multiple Functional Parathyroid Cysts

A 43-year-old gentleman was diagnosed with primary hyperparathyroidism during treatment for kidney stones. Serum calcium measured 11.28 mg/dL (normal range, 8.8–10.4), with an elevated serum PTH of 155 pg/mL (normal range, 16–65). He underwent preoperative tumor localization studies. Tc scintigraphy did not show any abnormal tracer uptake. Neck ultrasound identified two large, bilateral, cystic structures in relation to the lower lobes of the thyroid (Figure 1, A and B). Analysis of fluid aspirated from these lesions revealed an extremely high level of PTH ( 5000 pg/mL). The patient underwent neck exploration and removal of bilateral tumors located adjacent to the lower lobes of the thyroid gland and weighing 20 and 2.8 g. The upper parathyroid glands were not enlarged. Histological analysis confirmed cystic parathyroid tumors (Figure 1C). The patient achieved remission postoperatively (serum calcium, 9.52 mg/dL; and PTH, 31 ng/mL). Functional cystic parathyroid tumors are uncommon and occur in only 1–2% of cases of hyperparathyroidism (1). Predominantly cystic multigland disease is exceptionally rare and may not be detected preoperatively. Tumors can be mistaken radiologically for thyroid cysts, but aspiration of the cyst fluid can be useful in confirming their origin (2). Thyroid cyst fluid contains high levels of thyroglobulin, whereas lesions of parathyroid origin have extremely elevated concentrations of PTH. Ultrasound also facilitates the aspiration of cysts with real-time image guidance. This may induce remission of hyperparathyroidism, but relapse is common when cyst fluid accumulates. Injection of ethanol or tetracycline into a functional parathyroid cyst may be curative (3). However, most patients require a parathyroidectomy.

Tumor Proximity to the Recurrent Laryngeal Nerve in Patients with Primary Hyperparathyroidism Undergoing Parathyroidectomy

Recurrent laryngeal nerve (RLN) injury is a rare complication for patients undergoing neck exploration for primary hyperparathyroidism (pHPT). Distances between RLNs and parathyroid adenomas have not been previously published. In this study we used a RLN monitor to identify the RLN and to measure the proximity to parathyroid tumors. Patients with pHPT (n=136) underwent neck exploration and had the clinical data recorded prospectively. Adenomas were recorded in 1 of 4 locations (right upper, right lower, left upper, left lower). Measurement of RLN to adenoma distances were recorded intraoperatively with the gland in situ. The RLN location was confirmed with a RLN monitor. The average RLN to adenoma distance was 0.52±0.52cm. Adenomas in the right upper position were significantly closer to the nerve (0.25±0.39cm) compared with adenomas in the left upper (0.48±0.61cm, p=.03), left lower (0.70±0.53cm, p<.001), and right lower position (1.02±0.56cm, p<.001). Left upper adenomas were also significantly closer to the nerve compared with right lower adenomas (p<.001). Adenomas in the right upper position abutted the nerve more often (47%) compared with adenomas in other positions (p=.001). There were no perioperative characteristics that predicted tumor abutment. There were no permanent RLN injuries. In patients with sporadic pHPT, parathyroid adenomas in the right upper location have, on average, greater proximity to the RLN and are more often directly abutting compared with adenomas in other locations.

Management of Patients with Primary Hyperparathyroidism and Concurrent Thyroid Disease: An Evolving Field

The presence of thyroid disease can complicate the evaluation and surgical management of patients with primary hyperparathyroidism (PHPT). Retrospective analysis has shown that approximately 20–50% of patients with PHPT also have thyroid disease. 1–3 The reported incidence of thyroid malignancy in patients with PHPT is approximately 3–4%. 1,4 There is no uniformly accepted protocol for the evaluation of patients with thyroid pathology before operative intervention for PHPT. Neck exploration for PHPT normally provides excellent access to the thyroid, whereas minimally invasive parathyroidectomy offers a more limited exposure of the thyroid gland. The increased application of the minimally invasive approach has increased the reliance on preoperative imaging. Modalities for localizing abnormal parathyroid glands such as 99m Tcsestamibi scintigraphy (Tc-MIBI), I-123, and neck ultrasound can also identify thyroid pathology. Onkendi et al. analyzed the results from a series of patients with PHPT and concurrent thyroid nodules who underwent dual-isotope Tc-MIBI and radioiodine (I-123) subtraction imaging. 5 The most significant finding is that the phenotype Tc-MIBI-Hot/I-123-Cold has a negative predictive value for malignancy of 90%. Patients with the Hot/Cold phenotype were almost 3 times as likely to have a malignant thyroid lesion, indicating that these patients should be evaluated more aggressively with a lower threshold for fine-needle aspiration biopsy (FNAB) and thyroid resection. Patients with thyroid nodules that had any other phenotype (Hot/Hot, Cold/Hot, Cold/Cold) had a much lower potential for thyroid malignancy, and therefore, it may be appropriate to treat these patients with close follow-up rather than FNAB or thyroid resection. Onkendi et al. further identified a group of patients who were found during surgery to have a false-positive imaging result, characterized by a Hot/Cold scan with no abnormal parathyroid found corresponding to the imaging localization. Patients with underlying thyroid malignancy were more likely to have a false-positive parathyroid scintigraphy (45% compared to 22% of patients with benign thyroid disease). These data indicate that patients undergoing neck exploration who are found to have a false-positive dual imaging result should have further intraoperative evaluation for the potential of an undiagnosed thyroid malignancy.

Life-Threatening Hypocalcemia following Subtotal Parathyroidectomy in a Patient with Renal Failure and Previous Roux-en-Y Gastric Bypass Surgery

Background. Roux-en-Y gastric bypass (RYGB) can result in calcium and vitamin D deficiency. Parathyroid surgery carries the risk of immediate and long-term hypocalcemia. Methods and Results. We describe a 54-year-old woman with history of end-stage renal disease and gastric bypass surgery who developed calciphylaxis requiring a 3.5-gland parathyroidectomy. Seven weeks later, she presented with weakness, perioral numbness, leg cramps, a positive Chvostek's sign, hypotension, prolonged QT-interval, and serum calcium of 5.4 mg/dL. Oral and intravenous calcium, calcitriol, and high calcium bath hemodialysis were given. She required 18 days of intravenous calcium and an outpatient maintenance regimen of calcitriol 6 mcg/day, calcium carbonate 8 grams/day, calcium citrate 1.2 grams/day, and ergocalciferol 50,000 IU/week. Conclusion. The patient's life-threatening prolonged hypocalcemia and large requirements of calcium and calcitriol were due to a combination of malabsorption, hypoparathyroidism, and renal failure. Special considerations should be given to bariatric surgery patients undergoing neck exploration.

Penetrating Neck Trauma in Operation Iraqi Freedom

To examine the surgical outcomes of penetrating neck trauma patients in Operation Iraqi Freedom (OIF) and compare treatment and perioperative survival to historical data with low-velocity penetrating neck trauma seen in a noncombat clinical setting. Case series with chart review. Air Force Theater Hospital at Balad Air Base, Iraq. The surgical management of penetrating neck trauma by 6 otolaryngologists deployed over a 30-month period at the United States Air Force Theater Hospital in Balad, Iraq, was retrospectively reviewed. The presenting signs and symptoms, operative findings, and outcomes of patients who underwent neck exploration for high-velocity penetrating neck trauma were determined. A treatment algorithm defining the management of both high-velocity and low-velocity penetrating neck trauma is recommended. One hundred and twelve neck explorations for penetrating neck trauma were performed in OIF over 30 months. Ninety-eight percent of these neck injuries were due to high-velocity projectiles. In patients, zone 1 injuries occurred in 10%, zone 2 injuries in 77%, zone 3 injuries in 5%, combined zone 1/2 injuries in 5%, and combined zone 2/3 injuries in 3%. The positive exploration rate (patients with intraoperative findings necessitating surgical repair) was 69% (77/112). The mortality of patients undergoing neck exploration for high-velocity penetrating neck trauma was 3.7%. The perioperative mortality and the positive exploration rate for high-velocity penetrating neck trauma by deployed surgeons in OIF are very comparable to those rates seen in civilian centers managing low-velocity penetrating neck trauma.

Technetium-99m Sestamibi Scintigraphy Pattern in Patients with Secondary Hyperparathyroidism

complications of end stage renal disease (ESRD). We aimed in this investigation to explore the role of Technetium-99m sestamibi (99mTc MIBI) scintigraphy in the pre-operative assessment of refractory hyperparathyroidism in hemodialysis (HD) patients. Methods: Dual-phase 99mTc MIBI parathyroid scintigraphy was performed for 23 patients with ESRD who have persistent intact parathyroid hormone (iPTH) levels exceeding 300 pg/ml. Based on scintigraphy results, 13 patients underwent neck exploration during which only glands with positive scintigraphy findings were removed. Results: Among the six patients who had iPTH levels < 800 pg/ml, only one patient had positive scintigraphy findings (16.7%). Among the 17 patients who had iPTH levels ≥ 800 pg/ml, 16 patients had positive scintigraphy findings (94.1%). 99mTc MIBI scan detected 23 positive sites of focal trace uptake in those 17 patients. Partial parathyroidectomy was performed for 13 patients, removing in total 19 glands, while four patients declined surgery. On histological examination, 12 glands showed diffuse hyperplasia, four glands showed nodular hyperplasia and three glands revealed parathyroid adenoma. The three glands with parathyroid adenoma were correctly identified prior to surgery by 99mTc MIBI scintigraphy. The long-term outcomes of these patients are now being monitored. Conclusion: ESRD patients with iPTH level ≥ 800 pg/ml are more likely to have positive sites of focal tracer uptake on MIBI scan than patients with lower iPTH levels. Dual-phase 99mTc MIBI scintigraphy has the ability to correctly identify parathyroid adenoma prior to surgical exploration in these patients. Keywords: Hyperparathyroidism, parathyroid adenoma, parathyroid hyperplasia, scintigraphy, 99mTc sestamibi

SECONDARY AND TERTIARY HYPERPARATHYROIDISM: ROLE OF PREOPERATIVE LOCALIZATION

The usefulness of both technetium Tc-99m sestamibi (MIBI) scintigraphy and ultrasonography (USG) scan for the detection of enlarged parathyroid glands secondary to renal hyperparathyroidism is rarely addressed. A retrospective study from July 1999 to June 2005 was carried out on patients with secondary and tertiary hyperparathyroidism to determine the role of preoperative localization. In the 5 years, 73 patients with renal hyperparathyroidism underwent initial bilateral neck exploration with total parathyroidectomy. Four patients underwent neck exploration with parathyroidectomy for persistent hyperparathyroidism. Two patients underwent neck exploration with parathyroidectomy for recurrent hyperparathyroidism. For patients with initial secondary/tertiary hyperparathyroidism, MIBI scintigraphy correctly showed 101 of 276 (36.6%) surgically confirmed enlarged parathyroids, whereas USG scan showed 99 of 276 (35.9%) surgically confirmed enlarged parathyroids. For persistent or recurrent secondary/tertiary hyperparathyroidism, MIBI scintigraphy and USG scan had sensitivity of 100 and 50%, respectively. In conclusion, preoperative localization studies have a limited value when used before first neck exploration in secondary/tertiary hyperparathyroidism because of the poor results in identifying all parathyroid glands. In persistent/recurrent hyperparathyroidism, it may play a useful role in localization of the missed or ectopic parathyroid gland.

The Utility of Intraoperative Bilateral Internal Jugular Venous Sampling With Rapid Parathyroid Hormone Testing

To determine the utility of routine perioperative bilateral internal jugular venous sampling of parathyroid hormone (BIJ PTH) for localization during parathyroid surgery. Venous sampling for PTH is a useful tool for parathyroid localization in patients undergoing reoperative surgery for hyperparathyroidism (HPT). With the development of intraoperative rapid PTH (ioPTH) testing, internal jugular PTH sampling with ioPTH testing to guide operative localization has been shown to be possible in select, difficult cases. However, the value of BIJ PTH for patients with HPT is unclear. Between May 2004 and February 2006, 216 consecutive patients underwent neck exploration for HPT by one surgeon. Of these, 168 patients had BIJ PTH. Internal jugular venous blood was drawn from both left and right sides and analyzed for PTH using a rapid PTH assay. BIJ PTH levels were defined as lateralizing if >5% differences were observed between the right and left internal jugular vein samples. Of the 168 patients, 120 (71.4%) had a single parathyroid adenoma, 15 (8.9%) had double adenoma, and 33 (19.6%) had hyperplasia. The cure rate after parathyroidectomy was 98.2%. There were no complications related to BIJ PTH sampling. Sensitivity and positive predictive value of BIJ PTH for primary hyperparathyroidism were 80% and 71%, respectively. BIJ PTH was diagnostic in 95 cases (62.9%) in primary HPT. BIJ PTH successfully localized an abnormal gland in 26 of 45 (57.8%) in patients with negative sestamibi scanning. BIJ PTH was especially helpful in 18 of 168 (10.7%) cases when intraoperative peripheral parathyroid hormone did not fall by 50% and BIJ PTH successfully localized the hyperfunctioning glands. In patients with HPT, BIJ PTH is safe and effective, providing additional localization information in the majority of cases. BIJ PTH is particularly useful in the setting of negative sestamibi scanning and in complex multigland disease cases.