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Postoperative parathyroid hormone levels in conjunction with corrected calcium values as a predictor of post-thyroidectomy hypocalcemia : Review of outcomes 1 year after the implementation of a new protocol

OBJECTIVES To determine the effectiveness of post-thyroidectomy parathyroid hormone (PTH) levels in conjunction with corrected calcium values as predictors of patients at risk of developing hypocalcemia. METHODS This is a follow-up study reviewing the results of a newly implemented post-thyroidectomy algorithm. The changes in management from the previous protocol involve decision making based on the 12-hour corrected calcium and PTH levels, as well as the 1-hour PTH value. The study involved 120 patients separated into two groups: 60 prior to implementation of the protocol and 60 following the implementation of the protocol. Patients having completion thyroidectomy, neck dissections, or parathyroidectomy were excluded. RESULTS Since the implementation of the new protocol, there has been a reduction in the rate of transient hypocalcemia (25% to 12%; p = .059), fewer blood tests (23 to 15 per patient), and earlier patient discharges. CONCLUSIONS The new algorithm is effective in detecting patients who are not at risk of developing hypocalcemia at 12 hours. This has led to significant cost savings at our institution. Moreover, calcium supplementation based on the 1-hour PTH level has coincided with a reduction in cases of transient hypocalcemia.

Cost savings associated with post-thyroidectomy parathyroid hormone levels

OBJECTIVES: A 1-hour post-thyroidectomy parathyroid hormone (PTH) level of ≤8 ng/L is predictive of patients who will develop hypocalcemia and guides early supplementation with calcium and vitamin D. However, most hypocalcemic patients fail to meet this criterion. The goal of this study was to determine whether PTH ≤ 15 ng/L could be used as a better predictor of hypocalcemia. STUDY DESIGN, SUBJECTS, AND METHODS: This retrospective study involved 270 thyroidectomy patients (2004-2006). PTH and calcium levels, length of admission, supplementation, and rates of hypocalcemia were recorded. RESULTS: Forty-three percent (26/60) of patients developing hypocalcemia met the PTH ≤ 8 ng/L cut-off. In contrast, 80% (48/60) of patients developing hypocalcemia had a PTH ≤ 15 ng/L. Two point two percent of patients had a 1-hour PTH ≤ 15 ng/L and failed to develop hypocalcemia, for a specificity of 97%. CONCLUSIONS: A 1-hour PTH cut-off of ≤15 ng/L for prophylactic supplementation should allow the prevention of the majority of cases of hypocalcemia, leading to significant cost savings by shortening hospital stays.

Female Gender as a Risk Factor for Transient Post-Thyroidectomy Hypocalcemia

Objectives. Transient post-thyroidectomy hypocalcemia is a common complication following thyroid surgery. Studies have identified risk factors and possible ways to help predict post-thyroidectomy hypocalcemia with the intent of ultimately limiting its incidence. This study evaluates the role of patient gender as a potential risk factor. Study Design. A retrospective case series with chart review of 270 consecutive total thyroidectomy patients was conducted. Setting. Jewish General Hospital, a McGill University–affiliated hospital in Montreal, Canada. Subjects and Methods. 219 women and 51 men were included. Postoperative hypocalcemia was defined as any 1 of the following: total serum calcium 1.90 mmol/L or less, or signs and symptoms of hypocalcemia. The following were evaluated as potential confounding factors in the study: age, menopause, preoperative calcium, parathyroid hormone, magnesium and phosphate levels, presence of carcinoma in the surgical specimen, number of parathyroid glands preserved in situ, thyroid gland volume, and nodule size. Results. Female patients experienced transient postoperative hypocalcemia in 24.7% (54/219) of cases, which was significantly greater than the 11.8% (6/51) incidence detected in men (P < .05). This represents a female/male relative risk ratio of 2.1 (confidence interval, 1.0-4.6). There was no significant difference in rates of hypocalcemia between premenopausal and postmenopausal women (22.7% vs 26.6%). Conclusion. These findings suggest that being female is likely a risk factor for transient post-thyroidectomy hypocalcemia. Although this association is statistically significant, its magnitude and clinical relevance are uncertain and may be trivial. Additional research is needed to ascertain the physiologic mechanisms underlying this gender difference.

McGill Thyroid Nodule Score in Differentiating Benign and Malignant Pediatric Thyroid Nodules: A Pilot Study

Objective The McGill Thyroid Nodule Score (MTNS) is a preoperative tool used to predict the risk for well-differentiated thyroid cancer given a specific nodule in adults. We evaluated the clinical utility of a modified pediatric MTNS with children and adolescents. Study Design Case series with chart review. Setting Tertiary care children’s hospital. Subjects and Methods This is a retrospective chart review of 46 patients ≤18 years of age presenting with a solitary or dominant thyroid nodule treated with surgical resection between September 2008 and December 2015. The cumulative MTNS for each nodule was calculated and compared with the final pathology. Results Of 46 patients, 10 (21.7%) were diagnosed with well-differentiated thyroid cancer (80% papillary thyroid carcinoma, 10% follicular variant of papillary thyroid carcinoma, 10% follicular thyroid carcinoma). Malignant nodules were associated with a greater mean MTNS (benign, 5.72 ± 3.03; malignant, 16 ± 3.13; P < .05). The sensitivity, specificity, and positive predictive value of malignancy were 100%, 94.4%, and 83.3% for scores ≥10 and 80%, 100%, and 100% for scores ≥11, respectively. In nodules with indeterminate cytology (Bethesda III and IV), the pediatric MTNS showed good differentiation between benign and malignant disease, with mean scores of 7.95 and 12.5, respectively (P = .006). Conclusion This pilot study suggests that a comprehensive scoring system may help assess the risk of malignancy in pediatric thyroid nodules and differentiate nodules with indeterminate cytology into higher- and lower-risk categories. Given these findings, larger, multi-institutional studies are warranted.

Soft and Firm Alloplastic Implants in Rhinoplasty: Why, When and How to Use Them: A Review of 311 Cases

BackgroundModern rhinoplasty is not just a reduction procedure. An optimal nasal esthetic result occasionally requires augmenting the nasal tip, the dorsum or the lateral wall with autografts or alloplasts. A large number of nasal implant types have been reported in the medical literature.ObjectiveThe goal of this article is to demystify the role and indications of nasal implants in rhinoplasty. As well, it offers both the novice and experienced nasal surgeon a basic, simplified and organized approach to the use of soft and firm nasal implants in rhinoplasty.MethodsThis article presents the authors experience with 311 rhinoplasties using both soft and firm alloplastic implants. The indications for both types of alloplasts are discussed, the surgical technique detailed and the outcomes analyzed.ResultsA total of 311 nasal implant cases were reviewed. This series revealed a low incidence of postoperative infection (5.57% for soft implants and 0.1% for the firm ones). The revision rate was 2.7% for the soft implants group and 7.1% for the firm implants group.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Endoscopic Excision of an Intraosseous Forehead Dermoid Cyst in a Child

Abstract Purpose: Endoscopic excision of benign forehead masses in children aims to avoid conspicuous scarring and disfigurement. We present a video of an endoscopic-guided excision of an intraosseous dermoid cyst located in the mid-forehead. Case Presentation: A 10-month-old, dark-skinned boy was seen for an asymptomatic mid-forehead mass that was noted soon after birth. The mass was firm and fixed. Computed tomography scan demonstrated a 1-cm intraosseous mass in the mid-forehead consistent with a dermoid cyst. The mass did not penetrate the inner table of the cranium. The child was operated on at age 18 months by a team comprised of a pediatric general surgeon and a head and neck surgeon with extensive experience in facial plastics. The mass was removed through a single, vertical scar 2 cm above the hairline, using a combination of endoscopic and classic instruments. The procedure resulted in excellent cosmesis without any visible scar, and high parent satisfaction. Conclusions: Endoscopic excision of ...

Female Gender: A Post-Thyroidectomy Hypocalcemia Risk Factor

Objective 1) To evaluate the role of patient gender as a potential risk factor for post-thyroidectomy hypocalcemia. 2)To elucidate, from previous studies, potential physiologic mechanisms underlying any identified gender disparity. 3)To help better predict post-thyroidectomy hypocalcemia and ultimately limit its incidence with prophylactic/early calcium supplementation. Methods A retrospective review of 270 consecutive total thyroidectomy patients (October 2004-December 2006) was conducted, consisting of 219 females and 51 males. Postoperative hypocalcemia was defined as any one of the following: total serum calcium of less than or equal to 1.90 mmol/L up to 1 month following surgery or symptoms of hypocalcemia. The following were evaluated as potential confounding factors in the study: age, menopause, pre-operative calcium and parathyroid hormone levels, magnesium and phosphate levels, pathology and number of parathyroid glands preserved in situ. Chisquared testing was used to evaluate for statistical significance. Results Female patients experienced transient postoperative hypocalcemia in 24.7% (54/219) of cases, which was significantly greater than the 11.8% (6/51) incidence detected in males (p less than 0.05). This represents a female:male relative risk ratio of 2.1 (C.I. 1.0–4.6). There was no significant difference in rates of hypocalcemia between pre-menopausal (age less than 50) and post-menopausal women (22.7% vs. 26.6%). Conclusions These findings suggest that being female is a significant risk factor for transient post-thyroidectomy hypocalcemia. Furthermore, females appear to experience this postoperative complication more than twice as frequently as males. Additional research is needed in order to ascertain the physiologic mechanisms underlying this identified gender difference.

08:54: T4:Tg Ratio as a Predictor of Thyroid Cancer Recurrence

ined in 3,500 patients cured following surgery for primary HPT. Operative findings were analyzed. RESULTS: Multigland disease (MGD) was present in 9.1% but decreased in frequency from 13% in patents with Ca levels less than 10.6 to 3.6% when Ca was higher than 12 (p 0.05). Kidney stones was the only symptom that correlated with operative findings, virtually guaranteeing a single (95%) or double (5%) adenoma (p 0.0001). The incidence of hyperplasia decreased as PTH levels rose and was not seen when PTH was 2.6 times upper normal. Multiple adenomas occur at all PTH and Ca levels. CONCLUSIONS: High Ca and PTH levels and the presence of stones are the only predictors of good candidates for unilateral exploration. As Ca and PTH levels rise, the incidence of hyperplasia decreases but multiple adenoma rates are unchanged. There are no other parameters that can help predict who is better suited for limited exploration.

11:06: Cost Savings Associated With Post-Thyroidectomy PTH Levels

OBJECTIVES: Evaluate the diagnostic value of rhinolaryngoscopy using the narrow band imaging (NBI) system, a novel optical technique that enhances endoscopic diagnostic capability, in detecting squamous cell carcinoma of the head and neck (SCCHN) in patients with esophageal cancer (EC), who are at a high risk for developing SCCHNs. METHODS: Between January 2006 and December 2006, 667 consecutive EC patients prospectively underwent rhinolaryngoscopy screening by using both conventional white light and NBI system. The Lugol staining and histological examinations were performed on superficial demarcated brownish lesions detected by NBI system and demarcated red lesions, elevated lesions, or depressive lesions detected by white light. Sensitivity, specificity, accuracy, and positive/negative predictive value for detecting SCCHNs by each method were calculated by the histological results and compared with the chi-square test. Difference was considered significant at p 0.05. RESULTS: Forty-five (6.7%) of 667 patients had SCCHNs, including those at the oral cavity (n 1), larynx (n 1), oropharynx (n 7), and hypopharynx (n 36). Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for detecting SCCHNs by white light system were 51.1%, 99.7, 96.4%, 92%, 96.6%. In contrast, those by the NBI system were 97.7%**, 98.9%, 98.8%*, 86.3%, 99.8%** (*p 0.01, **p 0.001 vs. white light). Notably, sensitivity for detecting small lesions of 10mm or less in diameter was 100% for NBI whereas 18% for the white light system (p 0.001). CONCLUSIONS: The NBI endoscope significantly improves diagnostic accuracy, sensitivity, and negative predictive value in detecting SCCHN in EC patients. The NBI endoscope would be highly beneficial in detecting superficial SCCHNs in high-risk patients.