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To study the rate of postoperative hypocalcemia following completion thyroidectomy (CT), in comparison with the hypocalcemia rate following total thyroidectomy (TT).A retrospective study, performed at the McGill University Thyroid Cancer Center, Montreal, Quebec, Canada, from 2007 to 2012.Medical records of adult patients undergoing CT and TT operated by a single surgeon were reviewed. Data were extracted for demographics, postoperative calcium levels, surgical logs, and final surgical pathology. Hypocalcemia was defined as corrected serum calcium level ≤ 1.90 mmol/L, with concurrent serum parathyroid hormone8 ng/L, and/or any signs or symptoms of hypocalcemia.There were 68 CTs and 146 TTs. Transient hypocalcemia occurred in 1 of 68 (1.5%) and 18 of 146 (12.5%) patients in the CT and TT groups, respectively. The rate of hypocalcemia was significantly lower in the CT compared with the TT group (P = .02). In both groups, there were no cases of permanent hypocalcemia.The risk of transient of hypocalcemia in patients undergoing CT is significantly lower than the rate of hypocalcemia in patients undergoing TT.

The aim of this study is to retrospectively assess the specific perils associated with conducting sentinel lymph node biopsies to determine whether a central compartment neck dissection (CCND) is necessary in well-differentiated thyroid cancer. The goal was to assess the specific reasons for a false negative in 3 specific patients among a large population of thyroidectomy patients.Case series with chart review.Three McGill University teaching hospitals that are part of the McGill University Thyroid Cancer Center in Montreal, Quebec, Canada.Patients undergoing thyroidectomy and CCND for nodules suspicious for thyroid cancer (June 2009 to May 2010).Retrospective analysis of 157 patients who underwent thyroidectomy and analysis of CCND as a function of sentinel lymph node status on frozen section as determined by a pathologist at one of the participating centers.Three patients were considered true failures or false negatives of the original protocol. These 3 patients were deemed to have benign lymph node status intraoperatively but were found postoperatively to harbor malignancy and therefore should have undergone CCND. The critical reasons for the imperfect false-negative rate are believed to be secondary to samples falsely deemed benign as well as multinodular disease.The value of sentinel lymph node biopsy in thyroid cancer, although largely debated, appears to be strong. If caution is taken in using dedicated head and neck pathologists for sentinel lymph node cases, as well as properly addressing multinodular malignancy, clinical decision making can be rendered more objective.

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.A retrospective case series with chart review of 270 consecutive total thyroidectomy patients was conducted.Jewish General Hospital, a McGill University-affiliated hospital in Montreal, Canada.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.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%).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.

Objectives. The goal of the present study is to determine whether a decline in the 1-hour postoperative parathyroid hormone (PTH) level relative to the preoperative level is predictive of hypocalcemia. Methods. This is a retrospective study involving 142 consecutive patients who underwent total thyroidectomy. Changes in preoperative PTH levels were then compared with the 1-hour levels. Results. Thirty-four of 142 patients (23.9%) who underwent total thyroidectomy developed hypocalcemia. Thirty-one of the 34 patients who became hypocalcemic had a 1-hour postoperative PTH drop of 70% or more when compared with the preoperative value (sensitivity = 91%, specificity = 98%, positive predictive value = 94%, and negative predictive value = 97%). Conclusion. A decline in the preoperative PTH level of 70% or greater at 1 hour following total thyroidectomy appears to be a reliable predictor of patients at risk of developing hypocalcemia. By allowing thyroid surgeons to identify these patients in the early postoperative period, calcium supplementation can be initiated sooner.

Objectives To determine the value of fine-needle aspiration biopsies (FNABs) of the thyroid and stratify the risk of malignancy within the indeterminate FNAB diagnostic category at our institution. Study design Case series with chart review of preoperative FNABs of consecutive patients who underwent total thyroidectomy between 2005 and 2007. Subjects and Methods A total of 115 cases were reviewed, and FNABs were categorized into four groups: benign, positive or suspicious for malignancy, indeterminate (follicular or Hurthle cell lesions), and nondiagnostic. Cytohistologic correlation was then established. Results The accuracy of FNAB in detecting thyroid malignancy was 88 percent with false-negative and false-positive rates of 13 percent and 7 percent, respectively. Overall, 52 percent of the indeterminate cases were carcinomas (48 percent of follicular lesions and 62 percent of Hurthle cell lesions). In the presence of cytologic atypia, the rate of malignancy increased to 75 percent and 83 percent for the follicular and Hurthle cell lesions, respectively. Conclusions FNAB is an accurate and helpful method for the evaluation of thyroid nodules with results directly correlating with management. Surgery should be considered for FNABs categorized as indeterminate, especially in the presence of cytologic atypia. Because of the high false-negative rate, benign FNABs require close follow-up with ultrasound examination and periodic biopsies.

1) Review the incidence of thyroid gland invasion by squamous cell laryngeal carcinoma reported in the literature. 2) Assess the association between thyroid gland invasion and anatomical characteristics of the laryngeal tumor.MEDLINE (1967-2007) and EMBASE (1980-2007). These databases were supplemented with 61 patients from McGill University who underwent total laryngectomy with hemi- or total thyroidectomy from 2001-2006.Systematic review for series of laryngeal carcinoma that commented on thyroid gland invasion according to tumor subsite and pathological characteristics. Total laryngectomy specimens for primary laryngeal squamous cell carcinoma with concomitant thyroid resection were included in the analysis.In total, eight series (n = 399) were included in the meta-analysis. Thyroid gland invasion was present in 33 laryngectomy specimens (8%); the principal method of invasion of the gland was by direct extralaryngeal extension. Subglottic extension10 mm (OR 7.22 [2.05 to 25.46]; P = 0.002), transglottic tumors (OR 3.23 [1.16 to 9.00]; P = 0.025), and subglottic subsite (OR 5.66 [1.34 to 23.87]; P = 0.018) were all significantly associated with thyroid gland invasion. Cartilaginous invasion by tumor was not a significant predictor of thyroid gland invasion (P0.05).Thyroid gland invasion is not a general feature of squamous cell laryngeal carcinoma. When present, it is strongly associated with anteroinferior spread of advanced laryngeal tumors. Thyroidectomy may only be required during total laryngectomy for transglottic tumors, subglottic tumors, and tumors with subglottic extension10 mm.

Objective We aim to present papillary microcarcinoma (PMC) incidence at a university teaching hospital, to compare characteristics of PMC in relation to size, and to assess for significant difference in PMC incidence among patients with non-PMC thyroid malignancies. Materials and Methods Pathology results were reviewed for consecutive total thyroidectomies between 2002 and 2007 (n = 860). Statistical significance was calculated using χ 2 or, when unavailable, Fisher exact test. Results PMC was found in 429 cases, which is 49.9 percent of all total thyroidectomies. In PMC ≥5 mm, 25.1 percent had extrathyroidal extension vs 9.1 percent for P P value was 300-fold smaller. Incidence in patients with any non-PMC thyroid malignancy was 51.6 percent against 47.2 percent in all other patients ( P = 0.203). Conclusions In this study, PMC was found in 49.9 percent of patients, which, to our knowledge, is higher than any other reported incidence. A threshold of ≥4 mm was more significant than 5 mm for carrying increased risk for extrathyroidal spread. There was no significant difference in PMC incidence in patients with malignant vs benign disease.

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.

Previous studies have established the efficacy of post-thyroidectomy hypocalcemia monitoring using parathyroid hormone (PTH) and corrected calcium levels at 1 and 6 hours. The goal of this study was to measure the impact of managing patients based on the above findings with respect to: duration of hospital stays, rates of transient hypocalcemia, number of blood tests, cost savings, and discharge from the hospital as early as 8 hours post-thyroidectomy without compromising safety.This is a prospective study involving 95 total thyroidectomy patients using historical data as controls. The previous protocol was modified in that all blood tests ceased for patients meeting the 6-hour critical level of PTHor = 28 ng/L and simultaneous corrected calciumor = 2.14 mmol/L (8.56 mg/dL). Furthermore, patients with 1-hour PTH levelsor = 8 ng/L were prophylactically treated with calcium and vitamin D supplementation.This study demonstrates lower rates of transient hypocalcemia from 28% to 9% (OR = 4.13, P = 0.016), a 10-hour reduction in mean hospital stay, and fewer blood tests (23 vs 15) for patients undergoing total thyroidectomy since the implementation of the new protocol. Furthermore, the experimental protocol resulted in an average cost savings of 766 Canadian dollars per patient.The new algorithm resulting from PTH and corrected calcium monitoring at 1 and 6 hours post-thyroidectomy has led to significant cost savings for our institution. It has also translated into greater patient satisfaction as a result of fewer blood tests, a lower incidence of transient hypocalcemia, and significantly shorter hospital stays.

Objective: The study goals were to predict postoperative normocalcemia and hypocalcemia after total thyroidectomy using calcium levels and to assess the value of a standardized protocol in managing the total thyroidectomy patient. Study Design: We conducted a prospective study encompassing 68 patients undergoing a total thyroidectomy using a standardized protocol. Blood to measure postoperative calcium levels was drawn at 6, 12, and 20 hours and then twice daily thereafter. Calcium slope was calculated from the 6- and 12-hour serum corrected calcium levels. Results: Logistic regression analysis allowed the comparison of the 6- and 12-hour calcium slope versus proportion of normocalcemic patients postoperatively. A slope of +0.02 had a 97% chance of remaining normocalcemic (p = 0.0007). Conclusion: Successful prediction of calcium status post total thyroidectomy can be achieved using the slope of the 6- and 12-hour calcium levels. The risk of developing severe hypocalcemia can also be predicted with these slope values. Implementation of the protocol resulted in a significant reduction in the duration of hospital stay for patients who remain normocalcemic. (Otolaryngol Head Neck Surg 2002;127:289-93.)

Objectives:Study hypocalcemia incidence and trends over time following completion thyroidectomy (CT) versus total thyroidectomy (TT).Methods:A retrospective study comparing hypocalcemia and hypoparathyroidism incidence rates in all patients who underwent CT and in a random control group of TT at the McGill University Thyroid Cancer Centre, during the period of 2007 through 2012. Data were collected for demographic, clinical, and pathological characteristics.Results:There were 68 CT patients and 146 TT patients. Transient hypocalcemia occurred in 1 out of 68 (2%) and 18 out of 146 (12%) inpatients in the CT and TT groups, respectively. The rate of hypocalcemia was significantly lower in the CT group when compared with the TT group (P = .02). In both groups, there were no cases of permanent hypocalcemia. In the CT group there were 12 (18%) patients with parathyroid gland or parathyroid tissue found in the surgical specimen, compared with 47 (32%) of patients in the TT group. There were no correlations betwe...

Objectives:Evaluate whether the presence of preoperative thyroglobulin antibody (TgAb) levels can help predict the final pathology of thyroid nodules. Assess whether higher levels of preoperative TgAb increase the likelihood that a thyroid nodule is malignant.Methods:A retrospective chart review of patients who underwent thyroidectomy in 3 McGill University-affiliated hospitals between January 2012 and 2014 was conducted. Demographic data, TgAb levels, and final histopathology were recorded. Patients were divided into 2 groups: TgAb positive (defined as TgAb ≥30 IU/mL) and TgAb low/negative (defined as TgAb

Objectives:(1) Examine the added value of galectin-3 to HBME-1 staining on fine-needle aspiration (FNA) of thyroid nodules. (2) Correlate galectin-3 on FNA with pathology results both on FNA and final surgical pathology.Methods:A retrospective review of the charts of 53 patients undergoing FNA at the Jewish General Hospital in Montreal, Canada, in 2013 for the investigation of thyroid nodules whose FNA samples underwent HBME-1 and galectin-3 staining in addition to pathological examination.Results:Of 53 FNABs, 20 (37%) were galectin-3 positive, 24 (45%) were galectin-3 negative, and 9 (17%) were equivocal. With regard to HBME-1, 15 (28%) samples were positive, 32 (60%) were negative, and 6 (11%) were equivocal. Both stains correlated strongly with each other (P < .001) as well as with pathologist examinations of the FNA samples (P < .001 for both galectin-3 and HBME-1). Eleven patients underwent total or partial thyroidectomy. In correlation with surgical pathology, galectin-3 was correctly positive in 5 ...

Objectives:(1) Examine and meta-analyze the literature on galectin-3 staining on fine-needle aspiration (FNA) samples of thyroid nodules. (2) Summarize the diagnostic test accuracy of galectin-3 staining on FNA for well-differentiated thyroid cancer (WDTC).Methods:A systematic review of studies from 1990 to 2014 examining the diagnostic test properties of galectin-3 on thyroid nodule samples obtained by FNA with regard to WDTC. Data were meta-analyzed using DerSimonian-Laird random effect models for data pooling. Studies were weighted by inverse variance, and between-study variance was estimated using the Empirical Bayes method. Study heterogeneity and threshold effects were analyzed using the Cochrane Q and Spearman correlation coefficient, respectively.Results:Sixteen studies with 2076 cases were identified. The pooled sensitivity of galectin-3 for WDTC was 89.4% [confidence interval (CI): 87.2-91.4], and specificity was 91.9% (CI: 90.2-93.4). The positive likelihood ratio was 10.05 (CI: 8.24-12.26), an...

Objectives:Despite the rising prevalence of malignant papillary thyroid carcinoma, locoregional recurrence remains low. Clinico-pathological features associated with recurrence are not well defined. The objective of this study is to describe and evaluate the various pathological features found in patients with recurrent papillary thyroid carcinoma.Methods:A retrospective review was conducted identifying patients who were found to have recurrent papillary thyroid carcinoma between July 2006 and May 2013 at the McGill University Thyroid Cancer Centre.Results:There was a total of 552 patients with malignant papillary thyroid carcinoma. Over the study period, recurrent disease occurred in 2.0% of patients (n = 11), of whom 10 were pT3N1b and 1 was a pT4aN1. When these patients were compared with the 541 patients who did not have recurrence of their disease, there were significant differences for sex (P = .0271), size of primary tumor (P = .0355), positive margins ( =0 0002), lymphovascular invasion (P < .0001...

Objectives:Assess the rate of hypothyroidism following hemithyroidectomy.Methods:A retrospective study in adult patients undergoing hemithyroidectomy at the McGill University Thyroid Cancer Centre, during the years 2007 through 2012. Patients with preoperative hypothyroidism were excluded. Patients were followed 12 to 60 months after the primary surgery, and preoperative thyroid stimulating hormone (TSH) and free T4 levels were compared before and after the surgery. Hypothyroidism was defined as TSH levels >4.5 mU/L.Results:Of the 181 eligible patients in this study, 137 (75%) were females, with a mean age of 49.1 ± 14.3 years.The most common indication for surgery was follicular lesion. Hypothyroidism occurred in 65 (35%) of the patients, and was diagnosed at 1 to 36 months after surgery. Age and sex were not found to be risk factors for post-hemithyroidectomy hypothyroidism.Conclusions:In this study 35% of patients undergoing hemithyroidectomy develop postoperative hypothyroidism. Upon preoperative pati...

Objective: 1) Familiarize the audience with the new McGill Thyroid Nodule Score (MTNS) scoring system for thyroid nodules. 2) Present the statistics on the MTNS and why we feel this is a great adjunct in the management of thyroid nodules. 3) Describe a new tool at the clinician’s disposal that will help better manage patients with thyroid nodules.Method: This is a prospective study. A total of 245 consecutive patients were enrolled between July 2009 and March 2011. McGill Thyroid Nodule Score (MTNS), age, gender, and extent of surgery were recorded preoperatively. Final pathology was recorded postthyroidectomy. The percentage of malignancy was calculated for each MTNS score. Using Fisher exact test, the risk of malignancy for each group was compared to that anticipated based on the MTNS. We then used linear regression to plot a best fit curve for both the retrospective and prospective data and compared the 2.Results: We found no statistically significant difference when comparing the risk of malignancy be...

Objective: 1) To retrospectively assess the usefulness of preoperative thyroglobulin (Tg) levels in predicting sentinel lymph node (SLN) biopsy (SLNB) status. 2) To evaluate the correlation between preoperative Tg levels and the overall number of positive SLNs. 3) To compare primary tumor (T) classification in patients according to SLNB outcome.Method: Data from patients operated for well-differentiated thyroid carcinoma (WDTC) at the McGill University Thyroid Cancer Center were collected from January 2007 to January 2012. Statistical analyses were performed using a Mann-Whitney-Wilcoxon test, a Pearson correlation coefficient and a Pearson χ2 test.Results: Preoperative Tg levels and SLNB results were available in 74 patients (51 negative and 23 positive SLNBs). Mean preoperative Tg levels for negative and positive SLNB groups were 105.2 and 85.9 ng/mL, respectively, yielding no statistically significant difference (P = .143). Moreover, no statistically significant correlation was found between Tg levels ...

ObjectiveAn increase in papillary thyroid carcinoma in patients with Hashimoto's thyroiditis has been described. We have yet to find literature discussing a relationship with micropapillary thyroid carcinoma(MPC). Our objective is (1) to assess the relationship between Papillary Microcarcinoma and Hashimoto's Thyroiditis in thyroids without malignant disease, (2) compare effect of the presence of Hashimoto's on prognostic factors in patients.MethodsPathology reports were reviewed for consecutive patients undergoing total thyroidectomy over a 6-year period from 2002 to 2007. Patients with benign pathologies were included. Patients with MPC and no other malignancy were also included. This lead to a cohort of 314 patients. Statistical significance was calculated using Fisher's exact test and a chi-squared analysis.ResultsOut of the 314 patients, 98 were positive for Hashimoto's thyroiditis on biopsy of the removed thyroid. 58% of the patients with Hashimoto's thyroiditis had an incidental MPC, as compared to...

ObjectiveTo clearly define what constitutes successful parathyroidectomy in patients with primary hyperparathyroidism and to review our institution's results.MethodsA retrospective chart review was conducted for consecutive patients who underwent parathyroidectomy at a university-affiliated tertiary care center between January 1998 and February 2006. Intraoperative pre- and post-excision PTH levels were recorded. PTH and calcium levels were recorded at 3 – 6 month intervals in the first 2 years and then yearly.Results84 patients were analyzed. 50 (60%) had normal calcium and normal PTH levels following surgery, 28 (33%) had normal calcium and elevated PTH following surgery, and 6 (7%) had both elevated calcium and PTH. The mean follow-up time was 2.23 years, with a range of 0.25 to 5 years.ConclusionsSurgery was successful, as indicated by normocalcemia, in 78 patients (93%). Of these 78 patients, 28 (33%) developed persistent PTH elevation without developing hypercalcemia. Other studies have studied this...

ObjectiveDetermine the value of fine-needle aspiration biopsies (FNAB), and stratify the risk of malignancy within the indeterminate FNAB diagnostic category at our institution.MethodsThe preoperative FNABs of 115 consecutive patients who underwent thyroidectomy at a teaching hospital between 2005 and 2007 were reviewed and categorized into 4 groups: negative for malignancy, positive or suspicious for malignancy, indeterminate, and nondiagnostic. The final histopathological diagnosis was then compared with the FNAB result. FNABs reported as follicular or Hurthle cell lesions were considered indeterminate diagnoses, and malignancy rates were calculated within this category.ResultsThe FNAB results were as follows: 17% negative for malignancy, 35% positive or suspicious for malignancy, 40% indeterminate, and 8% nondiagnostic. The sensitivity of FNAB in detecting thyroid malignancy was 83%, specificity 92% and accuracy 85%. There were 9 discrepant cases giving a false negative rate of 17% and a false positive...

Objective(1) Compare prognostic factors in thyroid micropapillary carcinoma (MPC) =5 mm. (2) To compare MPC characteristics in patients with pre-existing thyroid carcinoma to patients...

Objective1. Review the incidence of thyroid gland invasion by squamous cell laryngeal carcinoma in the literature. 2. Correlate thyroid gland invasion with anatomical characteristics of the laryngeal tumor. Do laryngeal tumors which invade the thyroid gland share certain characteristics which can aid in determing the management of the thyroid gland during total laryngectomy?MethodsSystematic review of MEDLINE (1967–2007) and EMBASE (1980–2007) for all total laryngectomy series which commented on thyroid gland invasion according to tumor subsite and pathological characteristics. These results were supplemented with 61 patients from our centers who underwent total laryngectomy with hemi- or total thyroidectomy. Eleven series in total (n = 535) were included in the meta-analysis (fixed effects model).ResultsThyroid gland invasion was present in 47 laryngectomy specimens (9%); the main method of invasion of the gland was by direct extralaryngeal extension. Subglottic extension > 10mm (OR 6.27 [2.16 to 18.19];...

Objectives: Previous studies have established the efficacy of postthyroidectomy hypocalcemia monitoring using parathyroid hormone (PTH) and corrected calcium levels at 1 and 6 hours. The goal of this study was to measure the impact of managing patients based on the above findings with respect to: duration of hospital stays, rates of transient hypocalcemia, number of blood tests, cost savings, and discharge from the hospital as early as 8 hours postthyroidectomy without compromising safety. Methods: This is a prospective study involving total thyroidectomy patients using historical data as controls. The previous protocol was modified in that all blood tests ceased for patients meeting the 6-hour critical level of PTH ≥ 28ng/L and simultaneous corrected calcium ≥ 2.14 mmol/L. Furthermore patients with 1 hour PTH levels

CASE REPORT In March 2002, a 75-year-old man was referred to the Otolaryngology–Head and Neck Surgery Department for evaluation of a slowly growing left neck mass. Physical examination revealed a large, indurated mass in the left posterior triangle that was tender and fixed to the underlying tissues. The remainder of the history and physical assessment did not reveal any other abnormalities. A computed tomography (CT) scan with contrast revealed a heterogeneously enhancing left neck mass associated with an irregularly contoured left thyroid. A fine needle aspiration biopsy (FNAB) was obtained from the left neck mass and showed papillary carcinoma. The patient subsequently underwent a total thyroidectomy and modified radical left neck dissection with sparing of the sternocleidomastoid muscle and spinal accessory nerve. The tumor was adherent to the left internal jugular vein and it was elected to remove the vessel in continuity with the mass. At the completion of the dissection, a small chyle leak was recognized and the thoracic duct was identified, ligated, and oversewn. Valsalva maneuvers repeatedly induced by the anesthetist on multiple occasions demonstrated that the thoracic duct leak was successfully closed. Further inspection before closure of the wound revealed adequate hemostasis and no drainage from the thoracic duct. A 1⁄2 inch drain was placed. The immediate postoperative course was unremarkable and by the third hospital day the patient was tolerating a full oral diet. On postoperative day 4, a moderate quantity of milky fluid appeared from the drain site, and 15 mL was sent to Biochemistry and Microbiology for analysis. A new pressure dressing was applied, but the drainage continued to progress. His diet was changed to a zero-fat diet consisting of clear fluids, fruit, and Vital Resource Fruit Beverage. Biochemical analysis revealed a triglyceride level of 9.64 mmol/L in the aspirate. The sample sent to the microbiology laboratory grew coagulase-negative Staphalococcus aureus. The infection was successfully treated with a 10-day course of cloxacillin. During the next 15 days, the patient continued to have soaking through his pressure dressings despite daily changes. On hospital day 18, subcutaneous Octreotide 100 g three times daily was started to decrease the chyle output before starting the patient on total parenternal nutrition (TPN). Within 24 hours, the chyle fistula stopped draining completely. After several days without drainage, the patient was started on a full oral diet with no recurrence of the chyle leak. He received a total of 8 days of Octreotide treatment before being discharged home in good condition.

Guillain-Barre syndrome (GBS), also known as acute idiopathic polyneuritis, is the most common acquired demyelinating neuropathy, characterized by muscular weakness and mild distal sensory loss. GBS presenting as bilateral vocal cord paralysis (BVCP) is extremely rare, with only 1 other case reported in the literature.1 The following is a case of BVCP as the presenting symptom of GBS in an elderly man.