Huge toxic goiter extending to the posterior mediastinum; Case report with literature review

The role of early postoperative parathyroid hormone level after total thyroidectomy in prediction of hypocalcemia

Background

Estimation of parathyroid hormone (PTH) after thyroid surgery helps to predict the development of hypocalcemia and allows early intervention and management with oral calcium and/or vitamin D supplementation in the postoperative period.

Patients and methods

This retrospective study included 57 patients who underwent total or completion thyroidectomy within 4 years. Measurement of serum PTH level was done 3 h after surgery for its change and prediction of hypocalcemia.

Results

The mean age was 42.11 years, females constituted 46 patients (80.7%), the main surgical procedure was total thyroidectomy in 51 patients (89.5%), and the main cause for surgery was multinodular goiter in 33 patients (57.8%). Three hours after surgery 47 patients (82.5%) had serum PTH levels of >10 pg/ml (mean 28.06) and 44 patients (77.2%) had normal serum calcium (mean 8.66). Most of these 47 patients (82.46%) didn't require postoperative supplementation, while from other 10 patients (17.5%) with serum PTH level of <10 pg/ml, 7 patients (12.28%) required both oral calcium and vitamin D, and 3 patients (5.26%) required only oral vitamin D.There was a significant correlation between the 3-h postoperative PTH level and hypocalcemia (P-value 0.000). The type of pathology had no significant association with lowserum PTH level after surgery (P-value 0.166).

Conclusion

PTH measurements at 3 h after total thyroidectomy is an accurate predictor for the development of hypocalcemia and allows starting early calcium and/or vitamin D supplements for the asymptotic patients with PTH level of less than 10 pg/ml, which is considered a high-risk group. Also it facilitates a safe and early (2nd ^t day post operative) discharge of those patients with serum PTH levels greater than 10 pg/ml without any supplements.

Further studies are needed to compare the result of early serum PTH level with the day one serum PTH level after total thyroidectomy to predict hypocalcemia.

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Symptomatic parathyroid dysfunction is a common complication after total or completion thyroidectomy.

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Some studies recommend the routine estimation of parathyroid hormone level after thyroid surgery.

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Routine usage of oral calcium and/or vitamin D reduce hypocalcemia incidence.

Mature cystic teratoma of the neck misdiagnosed at cystic hygroma; Case report

BACKGROUND

Teratomas arise from primordial germ cells which arrest during its migration from the hindgut allantois the gonads during the first weeks of gestational life, they may occur in both gonadal and extra-gonadal locations. They occur in 1/40,000 live births. The most common anatomical locations are the sacro-coccygeal region and the ovary, neck teratomas constituted about 1.5%. Malignant transformation has been reported.

CASE PRESENTATION

A 2-year-old boy presented with a gradually enlarging mass in the left side of the neck causing stridor and difficulties in respiration especially during sleep, the parents noticed difficulties during swallowing. The mass was misdiagnosed as cystic hygroma and the patient underwent 2 sessions of sclerotherapy with no improvement. Clinical examination showed a large mass in the left side of the neck which was multilobulated causing tracheal shift to the opposite side. There were no signs of inflammations over the mass. CT-scan showed evidence of enhancing multi-cystic lesion with multiple flecks of calcification. Complete surgical resection was done successfully and the histopathological study of the mass showed mature elements of ectodermal, mesodermal, and ectodermal germinal layers which was consistent with mature cystic teratoma. The follow up showed no postoperative complications.

CONCLUSION

Mature cystic teratoma of the neck is very rare and may be difficult to be differentiated both clinically and radiologically from other neck masses. The accurate diagnosis must be made before any kind of treatment is started. Complete surgical resection is the main management option and required to decrease the recurrence.

Parental history of coronary artery disease among adults with hypothyroidism: Case controlled study

Background

Thyroid dysfunction has a negative impact on coronary artery diseases (CAD) through several changes in its risk factors like dyslipidemia, glucose intolerance, and components of metabolic syndrome. Parental history of premature CAD may be an important risk factor for their offspring.

Objective

To investigate whether overt and subclinical hypothyroidism and the risk of atherosclerosis are present in adults with parental history of CAD.

Materials and methods

This case control study included 135 hypothyroid patients and 100 age-sex matched controls. Data were analyzed regarding CAD risk factors, hormonal and biochemical measures including retinol Binding Protein-4, fasting serum insulin, high-sensitivity C-reactive protein, lipid profile, fasting serum glucose, and serum malondialdehyde.

Results

Parental history of CAD was significantly higher in overt hypothyroidism than subclinical group (P = 0.001). The level of RBP-4 in hypothyroid patients was significantly higher than euthyroid subjects (P = 0.03), and was higher in hypothyroid patients with positive parental history of CAD (p = 0.01). There were positive relationships between RBP-4 and related cardiovascular risk factors and with hypothyroidism, its sensitivity and specificity were 47.9% and 42.5% respectively. The positive predictive value was 60.8% and the negative predictive value was 30.4%. Hypothyroid patients with parental history of CAD had a risk of 3.7 times more than the euthyroid subjects.

Conclusions

In hypothyroidism patients, parental history of CAD is a predictor of future coronary events and the related risk factors. RBP-4 is positively correlated with waist circumference, BMI, lipid profile, High-sensitivity CRP, MDA, fasting serum glucose, fasting serum insulin, HOMA indices and TSH.

Squamous cell carcinoma of the thyroid gland in an elderly female presenting as a rapidly enlarging thyroid mass

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Squamous cell carcinoma of the thyroid gland is an extremely rare tumor.

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It may be primary tumor within the thyroid gland or as a component of anaplastic or undifferentiated tumors.

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The tumor has a very aggressive clinical behavior with a median survival of few months.

Background

Squamous cell carcinoma of the thyroid gland is an extremely rare tumor with a very aggressive clinical behavior and poor prognosis. The tumor may arise as a primary tumor within the thyroid gland or as a component of anaplastic or undifferentiated thyroid tumors.

Case presentation

A 70-year-old lady with history of long standing multinodular goiter presented with progressive enlargement of a midline nodule for 3 months which was associated with dyspnea and dry cough. The mass was hard and fixed. The voice was normal, other parts of the general examination were unremarkable. Fine needle aspiration was done for the mass which revealed malignant cells mixed with inflammatory cells. During surgery there was a hard and fixed mass arising from the isthmus of the thyroid gland that was locally invading, complete excision was not possible, debulking was done. Histopathology showed moderately differentiated squamous cell carcinoma of the thyroid gland. The tumor underwent local progression 6 months later and the patient was sent for radiotherapy.

Conclusion

When thyroid tumor is advanced at time of diagnosis, radiotherapy is the main form of treatment which may induce reduction in the size of the tumor and decrease pain, radiotherapy may also be given on neoadjuvant bases which may render resection possible in some patients. The tumor is usually not responsive to chemotherapy. The overall survival is uniformly poor regardless of the primary form of treatment, the median survival of the patients from the time of diagnosis is few months in most cases.

Two Concomitant Right Nonrecurrent Laryngeal Nerves Encountered During Thyroidectomy (Type 4 Course): Reported for the First Time

INTRODUCTION

The recurrent laryngeal nerve gains its name because after branching from the vagus nerve, it turns superiorly (recur) around the subclavian artery on the right and around the ligamentum arteriosum on the left, the nonrecurrent nerve has a straight direct course to the larynx and doesn't follow this course. It presents mostly on the right side. The presence of this variation places the nerve at higher risk of injury during neck surgery especially thyroid operations.

CASE PRESENTATION

A 45-year-old lady presented with painless thyroid enlargement for 1 year. Thyroid examination showed a 3-cm firm nodule at the right thyroid lobe with normal thyroid function tests. Right thyroid lobectomy was done and the histopathology showed a benign follicular lesion. During surgery, we discovered 2 nonrecurrent laryngeal nerves at the right side which were arising from the vagus nerve and both were entering the larynx.

CONCLUSION

Failure in identification of the nerve or overlooking the possibility of the non-recurrent laryngeal nerve may result in a serious sequelae of nerve damage, ipsilateral injury may lead to permanent hoarseness and bilateral injury may result in severe dyspnea or aphonia. Currently, there are 3 types of nonrecurrent laryngeal nerve courses. Type 1 passes near to the superior thyroid vessels. Type 2 (2A) passes parallel to the inferior thyroid artery and has a transverse course above it. Type 3 (2B) passes parallel to the inferior thyroid artery and transversely between branches of or under the inferior thyroid artery, we can add to this classification type 4, which are 2 nonrecurrent laryngeal nerves (double nerves) passing above and parallel to the inferior thyroid artery.