Beata Wojtczak

Prospective study of vocal fold function after loss of the neuromonitoring signal in thyroid surgery: The International Neural Monitoring Study Group's POLT study.

Intraoperative neuromonitoring identifies recurrent laryngeal nerve (RLN) injury and gives prognostic information regarding postoperative glottic function. Loss of the neuromonitoring signal (LOS) signifies segmental type 1 or global type 2 RLN injury. This study aimed at identifying risk factors for RLN injury and determining vocal fold (VF) function initially and 6 months after definitive LOS.

A functional assessment of anatomical variants of the recurrent laryngeal nerve during thyroidectomies using neuromonitoring

PurposeThe aim of the study was to assess the usefulness of intraoperative neuromonitoring (IONM) in identifying anatomical variants of the recurrent laryngeal nerve (RLN) during thyroidectomies, with emphasis on the nerve’s relationship to the inferior thyroid artery (ITA), Zuckerkandl’s tubercle, nonrecurrent laryngeal nerves (NRLNs), and extralaryngeal bifurcation.MethodsA total of 128 subjects undergoing surgery for thyroid disorders were enrolled in the study, and the course and anatomical variants of RLN were assessed with IONM application.ResultsThe standard relationship between RLN and ITA was that the artery and nerve intersect (100%). The right RLN was below the ITA in 76.67% of the patients, and the left RNL was below it in 75.81%. There were no statistically significant differences in the relationship between RLN and ITA on the two sides; and gender did not significantly influence the relationship between the RLN and ITA on either side. In one patient a nonrecurrent inferior laryngeal nerve was present on the right side (0.83%). RLN bifurcation was observed in 33.33% of the patients on the right and in 19.35% on the left side; the difference between sides was statistically significant (p < 0.05). Posterior tubercle (Zuckerkandl’s tubercle) was observed on the right in 83% of the subjects and on the left in 69%. The age, thyroid volume and body mass index (BMI) did not influence the size of the tumor.ConclusionsThe utilization of IONM of the RLN in thyroid surgery adds a new dimension to the standard of visual nerve identification allowing for functional nerve testing at the most vulnerable area of the dissection: at the level of Berry’s ligament, posterior tubercle (Zuckerkandl’s tubercle) and crossing of the RLN with the inferior thyroid artery.

Clinical and histopathological characteristics of patients with incidental and nonincidental thyroid cancer

Introduction Thyroid nodules (TNs) are a common pathology. Their prevalence increases with age. Some of them are suspected of malignancy and qualified for surgery. Sometimes their malignant nature is detected incidentally after a surgical procedure. The aim of the study is to analyze clinical and histopathological characteristics of patients with incidental and nonincidental thyroid carcinoma (ITC vs. NITC). Material and methods The case records of 3,241 patients with solitary and multiple TNs who were treated consecutively between 2008 and 2014 were analyzed retrospectively. After the final selection 235 (7.25%) patients were included in the study (202 females and 33 males, mean age: 52.9 +16.5 years). Seventy-five (31.91%) cases were incidentally diagnosed and 160 (68.09%) were diagnosed before surgery. Results We did not observe any differences in age, gender or stage of disease at the time of diagnosis between the patients with ITC and NITC (p = 0.366, p = 0.850, p = 0.226 respectively). The occurrence of solitary nodules in patients with NITC was significantly higher compared to patients with ITC (p < 0.0001). There were no differences in histopathological types of thyroid cancer (TC). The logistic regression analysis showed that solitary TC was an independent predictor of NITC (p < 0.0001). Conclusions There are no differences in gender, age or histopathological type of cancer in patients with ITC and NITC. Papillary TC is the predominant type in both groups. Incidence of TC in a solitary nodule is significantly higher in NITC than ITC. Solitary type of TC is an independent predictor of NITC. The prevalence of ITC is associated with multifocal type of TC.

Ultrasound Guided Fine-Needle Aspiration Biopsy of Thyroid Nodules: Does Radiologist Assistance Decrease the Rate of Unsatisfactory Biopsies?

BACKGROUND Ultrasound guided fine-needle aspiration biopsy (UG-FNAB) is the main presurgical, minimally invasive, accurate and generally safe procedure for the diagnosis of thyroid pathology. At present it is recommended as a valuable diagnostic tool for the management of thyroid nodules. OBJECTIVES This study aimed to evaluate if a radiologists assistance in the UG-FNAB procedure decreased the rate of unsatisfactory biopsies. MATERIAL AND METHODS Over a 3-year period, 385 (100%) patients were enrolled to the study. All individuals had UG-FNAB performed for the first time due to multiple nodules of the thyroid gland. Patients with a family history of thyroid cancer, receiving radioactive iodine and other predispositions for thyroid malignancy were excluded. 184 (47.79%) patients were examined using UG-FNAB with a radiologists assistance (group 1) and 201 (52.21%) without such support (group 2). All biopsies were performed by the same surgeon. All specimens obtained were examined by two cytologists experienced in thyroid pathology. RESULTS The specimens from the UG-FNAB were more frequently diagnostic when obtained from procedures performed with a radiologists assistance (77.8% vs. 56.8%, p < 0.0001). The cellularity of the specimens obtained from the UG-FNAB performed with a radiologists assistance was higher than those obtained without such support (66.7% vs. 56.9%, p < 0.0001). CONCLUSIONS UG-FNAB of the thyroid nodules performed with a radiologists assistance makes it possible to obtain more valuable specimens, which may improve diagnostic accuracy in the preoperative management of thyroid pathology.

Multi- and Unifocal Thyroid Microcarcinoma: Are There Any Differences?

BACKGROUND Thyroid microcarcinoma (TMC) often occurs as two or more separate foci, therefore a completion of primary surgery might be necessary. OBJECTIVES To evaluate and compare the incidence, diagnostic accuracy, clinicopathological characteristics and surgical treatment of unifocal and multifocal thyroid microcarcinoma (UTMC vs. MTMC). MATERIAL AND METHODS We retrospectively analyzed 3,218 medical records of patients consecutively admitted and surgically treated in one center due to thyroid pathology. RESULTS In the end, we evaluated 246 (7.64%) patients with thyroid malignancy. Ninety-seven of them (39.43%) were diagnosed as TMC: 84 (86.59%) UTMC and 13 (13.41%) MTMC (p < 0.0001). All MTMC were unilateral tumors. The papillary type of cancer was found in 82 (97.62%) patients with UTMC and in 12 (92.31%) with MTMC (p = 0.8661). In the UTMC group, 1 (1.19%) patient had follicular and 1 (1.19%) the medullary type of TMC. 1 (7.69%) individual in the MTMC group had tumors composed of papillary and follicular cancer. The number of younger patients (age < 45) was comparable in both groups (p = 0.825). The trend was observed that ultrasound guided fine needle aspiration biopsy (UG-FNAB) revealed malignant processes before surgery in a greater number of patients with MTMC than UTMC (84.62% vs. 58.33%, p = 0.131). In the MTMC group, the number of larger tumors (> 5 mm) was greater (84.62% vs. 65.48%), however the difference was not statistically significant. Thirteen percent of patients with UTMC presented cervical lymph node involvement, compared to nearly 8% of patients with MTMC (p = 0.298). Disease-related mortality was not observed in either group. CONCLUSIONS The prevalence of UTMC was significantly higher than MTMC. The majority of UTMC and MTMC were composed of the papillary type of cancer. MTMC and UTMC were equally frequent in both age groups. The accuracy of UG-FNAB was higher in patients with MTMC. The dimensions of most UTMC and MTMC was above 5 mm. The involvement of the cervical lymph node at the time of diagnosis in both groups is comparable and not infrequent.

Nontoxic Multinodular Goitre and Incidental Thyroid Cancer: What Is the Best Surgical Strategy?—A Retrospective Study of 2032 Patients

Objectives A discussion with regard to the most optimal surgical procedure in nontoxic multinodular goitre (NTMNG). We assessed and compared three main types of operations in 2032 patients with NTMNG. Methods This is a retrospective study of 2032 patients operated on in one center due to NTMNG. The observation period was 48 to 120 months (mean and SD: 87 ± 20). Results The early complications included uni- and bilateral recurrent laryngeal nerve paralysis (URLNP, BRLNP), overt tetany (OT), and postoperative bleeding (POB). We observed after TT, STT, and DO URLNP: 15 (1.73%), 3 (0.64%), and 2 (0.28%), respectively (p < 0.05); BRLNP: 3 (0.34%), 2 (0.43%), and 0 (0.0%), respectively (p = 0.25); OT: 42 (4.84%), 6 (1.29%), and 9 (1.28%), respectively (p < 0.0001); and POB: 11 (1.26%), 4 (0.86%), and 3 (0.42%), respectively (p = 0.209). Persistent complications we observed after TT, STT, and DO are the following: URLNP: 9 (1.03%), 3 (0.64%), and 1 (0.14%), respectively (p = 0.086); BRLNP: 1 (0.11%), 1 (0.21%), and 0 (0.0%), respectively (p = 0.51); and OT: 11 (1.26%), 2 (0.43%), and 2 (0.28%), respectively (p = 0.052). Incidental thyroid cancer (ITC) was recognized after TT, STT, and DO in 18 (2.07%), 21 (4.52%), and 11 (1.56%), respectively (p = 0.039). Recurrent goitre (RG) was observed in 1 (0.11%) after TT, 3 (0.64%) after STT, and 2 (0.28%) after DO (p = 0.234). Conclusions Performing less radical surgery in NTMNG is associated with a significantly lower risk of early and late URLNP and OT. In the case of BRLNP (early and persistent) and POB, no statistically significant differences are seen. The occurrence of ITC is higher following more radical surgeries. Less radical surgery is connected with a higher risk of RG.

Voice quality preservation in thyroid surgery with neuromonitoring

PurposeVoice problems are common after thyroidectomy. The aim of this study was to assess the voice related quality of life after thyroidectomy with neuromonitoring. The sociodemographic and treatment factors influencing the quality of voice after the operation were investigated.MethodsA total of 40 patients after thyroidectomy with neuromonitoring were enrolled into the study. The voice outcome was analyzed pre and postoperatively by two validated self-assessment questionnaires: Voice Handicap Index and Voice-Related Quality of Life survey.ResultsAll external branches of the superior laryngeal nerve were identified during the operation. There were no recurrent laryngeal nerve palsies. The mean total VHIs before and after thyroid operation were 1.2 [SD 2.564] and 2.8 [SD 6.944], respectively (p = 0.5). Preoperatively, the mean overall score for the V-RQOL was 99.6; postoperatively 98.7 (p = 0.05). A strong correlation between the V-score of the V-RQOL and O-score of the VHI before and after thyroidectomy was observed (both p < 0.001).There was no correlation between V-RQOL or VHI and sex, the kind of thyroid operations, diagnosis, thyroid function, the mean volume of the goitre, the presence of retrosternal position and the extent of thyroid operations (p > 0.05). A small correlation between the mean age of the patients and postoperative O-Score of the VHI (p = 0.007650) and between the mean age and postoperative V-Score for the V-RQOL (p = 0.00648) was observed.ConclusionsThe use of neuromonitoring in thyroid surgery is beneficial for patients to improve voice quality. The identification and preservation of EBSLNs is crucial to eliminate altered voice after thyroidectomy.

Diagnostics of Thyroid Malignancy and Indications for Surgery in the Elderly and Younger Counterparts: Comparison of 3,749 Patients

Background It seems valuable for clinicians to know if diagnostics of thyroid malignancy (TM) and indications for surgery in the elderly patients differ from these in younger counterparts. Materials and Methods Retrospective analysis of the medical records of 3,749 patients surgically treated for thyroid tumor. Data of patients with histopathology confirmed TM (n = 309) were studied. Results The rate of cytological prediction to malignancy was more than three times higher in elderly women. Compression was a main reason for surgery in the elderly (p < 0.0001). The final diagnosis of malignancy was significantly higher in older women (p = 0.002). Clinical suspicion of malignancy was positively correlated with histopathological diagnosis in total group of women (r = 0.543, p < 0.001) and total group of men (r = 0.560, p < 0.001). The subgroup of the eldest TM patients included a significantly higher number of subjects with advanced cancer and primary tumor progression (p < 0.0001). Distant metastases were significantly more presented among the elderly patients (p = 0.032). Conclusions The rate of cytological prediction to malignancy in elderly women is high. Tracheal compression is a common surgical indication in the elderly patients. The final diagnoses of malignancy predominate in elderly women. The oldest TM patients present a higher number of advanced thyroid tumors and distant metastases.

The recurrent laryngeal nerve and the tubercle of Zuckerkandl

The tubercle of Zuckerkandl is the posterior and lateral projection of the thyroid gland. It was originally described by anatomists, and later became of interest to thyroid and parathyroid surgeons because of its close proximity to the recurrent laryngeal nerve and the superior parathyroid gland. It is more frequently found on the right side of the body, and when found bilaterally it is often larger on the right. It has been postulated that an enlarged tubercle of Zuckerkandl can cause symptoms of compression even in the absence of a large goiter, but it is clinically significant because of its use as a landmark for finding the recurrent laryngeal nerve and the superior parathyroid gland during surgery.

Recurrent Laryngeal Nerve Branching

Recurrent laryngeal nerve (RLN) dysfunction is among the most common and feared complications of thyroidectomy and is an increasingly common cause for malpractice suits against endocrine surgeons. Temporary or permanent vocal cord palsy may carry a significant burden of disease. Thorough knowledge of the normal anatomy and its variants, a meticulous surgical technique, and a gentle handling of tissues with routine identification of the RLN represent the standard of care for a safe thyroidectomy. Temporary palsy of the RLN occurs in up to 10 % of cases and permanent paralysis in <2 % of patients. Inadvertent injury to the nerve is directly influenced by the common anatomic variations of the RLN along its expected and unexpected cervical course. These variations include the extralaryngeal bifurcation of the RLN that constitutes a frequent event present in up to 30–40 % of cases. Branching of the nerve typically occurs at the level of the ligament of Berry along the distal 1 or 2 cm of the RLN cervical course before its entry into the larynx. Branching of the RLN represents a major risk factor for both transient and permanent nerve palsy. Thus, intraoperative recognition and verification of functional and anatomic integrity of premature division of the nerve is crucial during thyroid operations. Initial studies using intraoperative nerve monitoring suggest that the anterior branch of the bifid RLNs is the one supplying motor fibers to the posterior cricoarytenoid muscle and vocalis muscle. Identification, exposure, and preservation of extralaryngeal branches of the RLN are mandatory and represent basic surgical principles in thyroid surgery to prevent nerve injury and its associated morbidity.