Riedel's Thyroiditis: Pitfalls in Diagnosis and Subsequent Complications

Riedel's thyroiditis is a rare disease of chronic inflammation with fibrotic infiltration of the thyroid gland and its surrounding vital structures. Due to its low incidence, there are often delays in diagnosis as it is commonly mistaken for other thyroid diseases. We report the case of a 34-year-old female patient who presented with a firm, enlarged mass in the neck, compression symptoms, and hypothyroidism. Lab tests showed elevated A-TG (thyroglobulin antibodies) and A-TPO (thyroid peroxidase antibodies) levels. Based on the disease presentation and supporting lab findings, the patient was misdiagnosed with Hashimoto's thyroiditis and treated accordingly. Yet the patient's symptoms grew progressively worse. She was discovered to have severe tracheal compression and bilateral RLN (recurrent laryngeal nerve) palsy. Tracheotomy became a necessary surgical intervention after the development of respiratory failure, but this procedure was complicated by the development of an intraoperative pneumothorax. After an open biopsy, histology revealed Riedel's thyroiditis. A new treatment was introduced, with which the patient's condition improved. However, she continued to suffer from the open tracheocutaneous fistula left by the tracheostomy, which adversely affected her everyday life. A follow-up operation was performed to close the fistula. In this case report, we discuss the consequences of misdiagnosing the patient and delaying the appropriate treatment for her disease.

Selective or radical surgical strategy in functional autonomy of the thyroid in endemic areas

BACKGROUND

The purpose of the research is to compare two surgical methods in the treatment of functional autonomy of the thyroid regarding postsurgical complications and functional results.

METHODS

212 patients were examined--divided into two groups. Group 1 (n = 148)--in which selective thyroid resection have been done and Group 2 (n = 64)--in which radical resection have been undertaken.

RESULTS

For both groups the following postoperative complications have been determined: In 4 (1.8%) patients transitory recurrent palsy is determined and in 1 (0.5%) patient-permanent recurrent palsy. The frequency of the transitory hypoparathyroidism is 7.5% (n = 16) and that of the permanent hypoparathyroidism is 0%. 148 patients from the two groups were followed up with respect to the functional results obtained at the eight postsurgical week and from 1 to 7 years after the operation. In the selective group (eight postsurgical week) 3 from the patients were with hyperthyroidism and 4 with hypothyroidism. From 1 to 7 years after the operation the following functional results have been determinated: in 7 patients relapse of the hyperthyroidism, in 8 patients new hypothyroidism and in 3 patients- morphological recurrence In radically operated patients the frequency of the postsurgical hypothyroidism during the 8 postsurgical week was 50% (n = 26). For the period from 1 to 7 years after the operation the following functional results were observed: 1 patient with relapse of hypothyroidism, 11 patients with new hypothyroidism. Not one morphological recurrence was observed.

CONCLUSIONS

The residual and recurrent hyperthyroidism are related to the insufficient extent of resection. A functionally confirmed surgical strategy has been imposed in the endemic areas striving to remove all nodular structures at the same preserving the normal thyroid tissue.

[Therapeutic approach to postoperative dysphonia following thyroid gland surgery]

The recurrent nerve palsy, which is frequently expressed clinically by postsurgical dysphonia is quite often a complication in the thyroid surgery. The choice of therapeutic behaviour is based on the assessment of the clinical condition of the patient, in other words, whether the dysphonia is accompanied by dyspnoea or not. 32 patients with postsurgical dysphonias are included in the survey. All patients were operated for thyroid disease in the Clinic of Endocrine Surgery between August 1996 until May 1998 and surveyed for a follow-up period of 3 to 21 months. The analysis of the results shows that the conservative treatment is appropriate for patients with functionally well compensated dysphonias, whereas the existence of high-level dyspnoea, whose morphologic substratum is most frequently a bilateral recurrent nerve palsy with median position of the vocal folds, necessitates surgical treatment.

Is medullary thyroid cancer predictable? A prospective study of 86 patients with abnormal pentagastrin tests

BACKGROUND

The aim of this prospective study was to distinguish biochemically between C-cell hyperplasia (CCH) and medullary thyroid cancer (MTC) before surgery.

METHODS

Eighty-six consecutive patients with an abnormal stimulated calcitonin level (> 100 pg/mL) underwent thyroidectomy and lymph node dissection. In sporadic MTC, histopathologic findings and postoperative biochemical outcomes were documented prospectively and correlated with preoperative basal and stimulated calcitonin levels.

RESULTS

Analysis of variance revealed a highly significant difference in basal/stimulated calcitonin levels (P < .0001), with a comparison of CCH (n = 39 patients) and sporadic MTC (n = 38 patients). With a comparison of sporadic MTC N0 M0 (n = 25 patients) and N1 M0/1 (n = 12 patients), the basal calcitonin level was significantly different (P < .05). There was a close correlation between the n-log of basal/stimulated calcitonin level and the n-log of the tumor volume; there were also different distributions of the n-log of basal/stimulated calcitonin level among CCH, MTC N0, and MTC N1. Assuming that a basal calcitonin level of more than 64 pg/mL and/or a stimulated calcitonin level of more than 560 pg/mL implies MTC, 31 of 38 patients with sporadic MTC were detected before surgery. Three patients were predicted false positive (neoplastic CCH). Patients with stimulated calcitonin levels of less than 129 pg/mL had CCH only. Patients with basal calcitonin levels of less than 22 pg/mL and sporadic MTC (7/38 patients) were node negative.

CONCLUSIONS

All patients with abnormal pentagastrin tests showed C-cell pathologic evidence. Sporadic MTC was predicted in 81% of the patients; CCH or N0 was predicted in 36% of the patients. Central neck dissection is recommended to avoid difficult reoperations. Lateral neck dissection is possible "on demand."

[The diagnostic and clinical aspects of postoperative dysphonias following operations on the thyroid]

Postoperative dysphonia is not rare and in some cases life-treating complication in the thyroid surgery. Its emerge, autonomous, or attended with dysphagia and dyspnea is an early symptom for intraoperative lesion of n. laryngeus recurrens. The investigation is carried out over 21 patients with postoperative dysphonias, operated for euthyroid or hyperthyroid strumas and followed-up for a period of 3-10 months. Analysis of the results indicated that the main reason for postoperative dysphonias in thyroid surgery is the lesion of n. laryngeus recurrens. Along with this one is impressed by the fact that in 30% of the cases dysphonic complaints may owe to nonsurgical reasons.