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Objectives: The incidence of papillary thyroid cancer (PTC) is increasing, and due to the favorable postoperative survival rates, the extent of surgery should be carefully determined, and complications during the operation should be avoided. The recurrent laryngeal nerve (RLN) divides the right paratracheal lymph node (RPTLN) into anteromedial and posterolateral compartments due to its anatomical course on the right and left sides of the neck, and the posterolateral lymph nodes are in close proximity to the RLN. Due to the risk of this complication, in this study, we aimed to determine the risk factors for the development of right paratracheal posterolateral lymph node (RPTPLLN) metastasis in PTC. Methods: Between 2013 and 2022, patients who underwent central neck dissection (CLND) or central and lateral neck dissection due to the presence of PTC in the right lobe of the thyroid gland were included in the study. Descriptive data, along with preoperative imaging findings and postoperative pathology findings, were retrospectively evaluated. Results: The data of 55 patients who met the criteria were statistically analyzed. Of these patients, 24 (43.6%) were male and 31 (56.4%) were female. The mean age was 47.9±17.5 years (range: 16-81). The mean tumor size was 2.17±1.43 cm (range: 0.4-7.0). RPTPLLN was observed in 13 patients (23.6%). Univariate analysis revealed that extrathyroidal extension (p=0.008), lymphovascular invasion (p=0.044), presence of right paratracheal anteromedial (RPTAMLN) metastasis (p=0.001), and presence of left paratracheal metastasis (p=0.049) were statistically significant factors. However, in the multivariate analysis, only the presence of RPTAMLN was determined to be a significant variable (p=0.035). Conclusion: In patients undergoing surgery for PTC, the risk of metastasis in the RPTPLLN should be considered higher when there is metastasis in the RPTAMLN. We believe that formal dissection of the RPTLN should be considered for optimal evaluation in patients with tumors in the right lobe where central dissection is planned. Posterolateral dissection (PLD) should be routinely performed in the presence of clinical lymph nodes in the RPTAMLN. When a decision cannot be made, PLD may not be performed if the anteromedial tissue is examined with frozen pathology and the result is negative. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Our goal in this study is to analyze the correlation between papillary thyroid cancer (PTC) with elevated thyroid-stimulating hormone (TSH) levels and deficiency of vitamin D. METHODS: Patients who underwent thyroidectomy, also with available vitamin D test results preoperatively, were included in the study. The patients were separated into two different categories as having papillary thyroid carcinoma (Group 1), benign diseases (Group 2). According to the TSH (mUI/mL) level and vitamin D values, patients were categorized into four quarters. RESULTS: Preoperatively, TSH level (mean±SD mUI/mL) was higher in Group 1 (2.04±1.55) compared to Group 2 (1.82±1.94) significantly (p=0.029). Preoperatively, vitamin D levels (mean±SD) were higher in Group 1 (15.88±10.88) than in Group 2 (12.94±10.26) significantly (p=0.011). There was no significant difference between Group 1 and Group 2 according to the vitamin D deficiency (65.5%, 72.8%; respectively (p=0.472)). When categorized with reference to pre-operative vitamin D levels, the proportion of patients in Group 2 and Category 1 was higher significantly (p=0.031). CONCLUSION: Although the pre-operative TSH level was significantly higher in papillary thyroid carcinoma than benign thyroid diseases, the categorical distributions of the patients according to the TSH value were similar and the TSH values overlapped. Pre-operative mean vitamin D levels were similar in both PTC and benign thyroid disease groups so PTC was not associated with vitamin D deficiency. [ABSTRACT FROM AUTHOR]

Thyroid nodules are common and the prevalence varies between 4 and 7% by palpation and 19-68% by high-resolution USG. Most thyroid nodules are benign, and the malignancy rate varies between 7 and 15% of patients. Thyroid nodules are detected incidentally during clinical examination or, more often, during imaging studies performed for another reason. All detected thyroid nodules should be evaluated clinically. The main test in evaluating thyroid function is thyroid stimulating hormone (TSH). If the serum TSH level is below the normal reference range, a radionuclide thyroid scan should be performed to determine whether the nodule is hyperfunctioning. If the serum TSH level is normal or high, ultrasonography (US) should be performed to evaluate the nodule. US is the most sensitive imaging method in the evaluation of thyroid nodules. Computed tomography (CT) and magnetic resonance imaging are not routinely used in the initial evaluation of thyroid nodules. There are many risk classification systems according to the USG characteristics of thyroid nodules, and the most widely used in clinical practice are the American Thyroid Association guideline and the American College of Radiology Thyroid Imaging Reporting and Data System. Fine needle aspiration biopsy (FNAB) is the gold standard method in the evaluation of nodules with indication according to USG risk class. In the cytological evaluation of FNAB, the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is the most frequently applied cytological classification. TBSRTC is a simplified, 6-category reporting system and was updated in 2023. The application of molecular tests to FNAB specimens, especially those diagnosed with Bethesda III and IV, is increasing to reduce the need for diagnostic surgery. Especially in Bethesda III and IV nodules, different methods are applied in the treatment of nodules according to the malignancy risk of each category, these are follow-up, surgical treatment, radioactive iodine treatment, and non-surgical ablation methods. [ABSTRACT FROM AUTHOR]

Reoperative parathyroid surgery is challenging even for experienced surgeons. Cure rates are lower than primary surgery. Good anatomical and embryological knowledge is important. Preoperatively, a comprehensive surgical strategy should be planned. Pre-operative imaging modalities should be used extensively to find the overlooked gland to have a possibility to perform focused parathyroid surgery to avoid possible complications. One of the important developments is the new ancillary methods to find overlooked parathyroid glands. Orthotopic and possible ectopic locations should be known well by the surgeon to increase the surgical success rate. Reoperative parathyroid surgery needs a distinctive approach compared to primary parathyroid surgery. Basic principles include the selection of the incision and route for entering the thyroid region, use of ancillary methods, and intraoperative nerve monitoring and also require a meticulous dissection. Obtaining a surgical cure is difficult and high surgical caution is needed. Post-operative complication rates are higher compared to primary parathyroid surgery. Other treatment methods and medical treatment options may be evaluated in a patient who cannot undergo surgery. [ABSTRACT FROM AUTHOR]

Primary hyperparathyroidism (pHPT) is the most common cause of hypercalcemia and currently the only definitive treatment is surgery. Although the success rate of parathyroidectomy is over 95% in experienced centers, surgical failure is the most common complication today. Persistent HPT (perHPT) is defined as persistence of hypercalcemia after parathyroidectomy or recurrence of hypercalcemia within the first 6 months, and recurrence of hypercalcemia after a normocalcemic period of more than 6 months is defined as recurrent HPT (recHPT). In the literature, perHPT is reported to be 2--22%, and the rate of recHPT is 1--15%. perHPT is often associated with misdiagnosed pathology or inadequate resection of hyperfunctioning parathyroid tissue, recHPT is associated with newly developing pathology from potentially pathologically natural tissue left in situ at the initial surgery. In the preoperative evaluation, the initial diagnosis of pHPT and the diagnosis of perHPT or rec HPT should be confirmed in patients who are evaluated with a pre-diagnosis (suspect) of perHPT and recHPT. Surgery is recommended if it meets any of the recommendations in surgical guidelines, as in patients with pHPT, and there are no surgical contraindications. The first preoperative localization studies, surgical notes, operation drawings, if any, intraoperative PTH results, pathological results, and post-operative biochemical results of these patients should be examined. Localization studies with preoperative imaging methods should be performed in all patients with perHPT and recHPT with a confirmed diagnosis and surgical indication. The first-stage imaging methods are ultrasonography and Tc99m sestamibi single photon tomography Tc99mMIBI SPECT or hybrid imaging method, which is combined with both single-photon emission computed tomography and computed tomography (SPECT/CT). The combination of USG and sestamibi scintigraphy increases the localization of the pathological gland. In the secondary stage, Four-Dimensional computer tomography (4D-CT) or dynamic 4-dimensional Magnetic Resonance Imaging (4D-MRI) can be applied. It is focused on as a secondary stage imaging method, especially when the lesion cannot be detected by conventional methods. Positron Emission Tomography (PET) and PET/CT examinations with 11C-choline or 18F-fluorocholine are promising imaging modalities. Invasive examinations can rarely be performed in patients in whom suspicious, incompatible or pathological lesion cannot be detected in noninvasive imaging methods. Bilateral jugular vein sampling, selective venous sampling, parathyroid arteriography, imaging-guided fineneedle aspiration biopsy, and parathormone washout are invasive methods. [ABSTRACT FROM AUTHOR]

The most appropriate treatment of substernal goiter (SG) is surgery. These patients should be evaluated carefully and multidisciplinary in pre-operative period and surgical management should be planned preoperatively. Although most of the SGs can be resected by the cervical approach, an extracervical approach may be required in a small proportion of patients. Surgical complications of SG related to thyroidectomy are higher than other thyroidectomies. In addition to the complications related to thyroidectomy, complications related to the type of surgical intervention may also occur in SG. The patients who may be needed extracervical approaches should be consulted with thorax surgeons, cardiovascular surgeons, and anesthesiologists preoperatively; the surgical management should be planned together. In this part, we aimed to evaluate the cervical approach methods, extracervical approach methods, technical details, and complications in detail. [ABSTRACT FROM AUTHOR]

Surgery is one of the most appropriate treatment options for many patients with substernal goiter (SG). However, SG surgery has some technical difficulties and a higher risk of complications compared to normal cervical thyroid surgery. Due to these technical difficulties and complication risks, which we also mentioned in our study, SG surgery should be performed by experienced and high-volume endocrine surgeons in centers with a large team and technical equipment. Pre-operative clinical and radiological evaluation and definitions in SG were evaluated in detail in our previous study. Detailed pre-operative evaluation, pre-operative risk assessment, surgical anatomy, anesthesia, appropriate surgical planning and estimation of surgical width are extremely important in SG surgery, where surgical technical difficulties and increased complication risks compared to cervical thyroid surgery come to the fore. In this study, we aimed to evaluate these preoperative and peroperative preparations in detail. [ABSTRACT FROM AUTHOR]

Intraoperative posterior cricoarytenoid muscle (PCAM) electromyography (EMG) may be useful for predicting postoperative vocal cord function (VCF) and prognosis of vocal cord palsy (VCP) in patients with intraoperative loss of signal (LOS). Thirty out of 395 patients having LOS detected by intraoperative neural monitoring (IONM), were applied intraoperative PCAM EMG. VCP was present in all Type 1 injury RLNs (16) (100%) and in 8 (57%) of 14 RLNs with Type 2 injury (p = 0.005). 14 out of 30 LOS patients (47%) had positive PCAM EMG amplitudes. The sensitivity, specificity, positive and negative predictive values and accuracy rates for predicting postoperative VCP via PCAM EMG, were calculated as 66.7%, 100%,100%, 42.86% and 73.33%. The negative PCAM EMG was related to VCP in both Type 1 and Type 2 LOS. VCP recovery time of Type 1 LOS patients was significantly longer than that of Type 2 LOS patients (p = 0.009). In Type 2 LOS, VCP recovery time was significantly longer in negative PCAM EMG patients compared to positive PCAM EMG patients (p = 0.046). Negative PCAM EMG is associated with the postoperative VCP. Type 1 injury results in VCP regardless of PCAM EMG results, and VCF recovers after a longer period compared to Type 2 LOS. In Type 2 LOS, positive PCAM EMG may result in VCP by 40%. However, the presence of negative PCAM EMG is related to the postoperative VCP in all patients and the recovery time is longer compared to positive PCAM EMG patients. [ABSTRACT FROM AUTHOR]

The enlargement of multinodular goiter into the mediastinum through the thoracic inlet or ectopic thyroid tissues directly in the mediastinum is defined as Substernal Goiter (SG). However, there is no clear consensus in the literature on this definition. There are many definitions for SG in the literature. Most definitions are similar or overlapping. Since the thyroid is located in the neck above the thoracic inlet in its normal anatomical position, the simplest clinical definition should be preferred among the definitions regarding its descent below the thoracic inlet and adjacent to the mediastinal organs. In the American Thyroid Association guideline, SG is defined as clinical or radiological protrusion of the thyroid gland over the sternal notch or clavicle in a patient with a slightly extended neck in the supine position. SGs can be classified as primary or secondary according to their origins. In addition, there are combined SGs resulting from the enlargement of the primary SG, which is the growth of the cervical thyroid gland toward the mediastinum, and the secondary SG, which is defined as an ectopic mediastinal mass, together. We find it appropriate to define such SGs as mixed SGs. In this disease, which has the same etiology and etiopathogenesis as cervical goiter, the descent of the thyroid gland into the mediastinum due to some anatomical factors explains the physiopathology. Compression symptoms of mediastinal major vascular structures, trachea, and esophagus cause the symptoms and findings of SGs due to its localization. In addition, the relationship of SGs with possible malignancy risk and hyperthyroidism affecting the indications and methods of treatment has been discussed for a long time. In this study, we aimed to evaluate the definitions, classification, physiopathology, laboratory and imaging methods used for diagnosis, the relationship of SG with hyperthyroidism and malignancy, and briefly the treatment methods, according to the current studies from literature. [ABSTRACT FROM AUTHOR]

Objectives: We observed significant contractions in the cricothyroid muscle (CTM) after recurrent laryngeal nerve (RLN) stimulation in some patients. We aimed to evaluate whether these contractions resulted from the laryngeal-muscle movement due to the contraction of other intrinsic muscles or actual CTM contraction, with objective real-time intraoperative electromyography (EMG) recordings. Methods: This study was performed prospectively in 106 consecutive patients who underwent intraoperative neural monitoringguided primary thyroid surgery due to various thyroid diseases between February-2015 and February-2016. After completion of the thyroidectomy procedure; the RLN, vagus nerve (VN), external branch of the superior laryngeal nerve (EBSLN), plexus pharyngeus (PP), and contralateral EBSLN (CEBSLN) were stimulated and the responses from the CTM and CPM were recorded and evaluated by EMG through needle electrodes. Results: 182 CTMs of 106 patients, with the mean age of 45, were evaluated regarding their innervation patterns. Positive EMG waveforms were achieved from 181 CTMs with EBSLN stimulation. A total of 132 (74%) positive EMG responses were recorded after the stimulation of 179 RLNs. The mean amplitude obtained with CTM EMG with RLN stimulation was 5.5% of that with EBSLN stimulation. The CTM amplitude was 39% of the vocal cord amplitude with RLN stimulation. Positive EMG responses of 96 CTMs (55%) with VN stimulation were recorded. The mean amplitude through CTM EMG with VN stimulation was 6% of that with EBSLN stimulation. Positive EMG responses were achieved from 10 (0.6%) CTMs with the stimulation of 170 PPs. The mean amplitude obtained from CTMs with PP stimulation was 4.3% of that with EBSLN stimulation. Positive EMG amplitudes of 35 (67%) CTMs were obtained with stimulation of 52 CEBSLN. Temporary vocal cord paralysis was detected in six patients (5% of patients and 3.3% of the nerves) postoperatively. Conclusion: The RLN contributes significantly to the innervation of the CTM. Despite the findings associated with the contribution of the PP and CEBSLN to the CTM innervation, further studies are needed. We are of the opinion that these are among the significant factors that contribute to the differences in clinical findings between patients with EBSLN injuries. [ABSTRACT FROM AUTHOR]

Goiter term is generally used for defining the enlargement of thyroid gland. Thyroid nodules are very common and some of these nodules may harbor malignancy. Multinodular goiter (MNG) disease without thyroid dysfunction is defined as non-toxic MNG. There are many factors in etiology for development of MNG. They can be classified as iodine dependent and non-iodine dependent factors basically. Beyond this basic classification, the effect of many environmental and acquired factors is also effective on the development of goiter. Many methods have described for diagnosis and treatment for non-toxic MNG. Biochemical tests, imagining methods, invasive and non-invasive methods have been used for diagnosis for many years. Each method has advantages and disadvantages, separately. Although the best method for diagnosis is still debatable, distinguishing malignant nodules from benign nodules is the first and most important step for MNG. Biochemical tests such as serum thyroid stimulating hormone (TSH) measurement, thyroid hormone measurement; and thyroid ultrasonography are used for diagnosis of MNG, traditionally. Nowadays, there are some new techniques were developed like ultrasound-elastography. Furthermore, thyroid scintigraphy may be used if there is abnormal TSH measurement. Fine-needle aspiration biopsy and some cross-sectional imaging methods (computed tomography, magnetic resonance imaging, and positron emission tomography) could be used, too. After a certain diagnosis is made, treatment options should be evaluated. Many treatment methods have been used for goiter from ancient times upon today. From non-invasive methods such as medical follow-up to invasive methods such as lobectomy or thyroidectomy are options for treatment. Patients with compression symptoms due to an enlarged thyroid gland are usually candidates for surgery. In this study, it is aimed to determine the most appropriate treatment for the patient by discussing the advantages and disadvantages of all these methods. The present review discusses definition of goiter term, etiology, epidemiology, pathogenesis, diagnostic methods, and treatment methods for nontoxic MNG. [ABSTRACT FROM AUTHOR]

Differentiated thyroid cancers (DTC) consist of 95% of thyroid tumors and include papillary thyroid cancer (PTC), follicular thyroid cancer (FTC), and Hurthle cell thyroid cancer (HTC). Rates of lymph node metastases are different depending on histologic subtypes and <5% in FTC and between 5% and 13% in HTC. Lymph node metastasis is more frequent in PTC and while rate of clinical metastasis can be seen approximately 30% rate of routine micrometastasis can be seen up to 80%. Lymph node metastasis of DTC mostly develops first in the Level VI lymph nodes at the central compartment starting from the ipsilateral paratracheal lymph nodes and then spreading to the contralateral paratracheal lymph nodes. Spread to the Level VII is mostly after Level VI invasion. Subsequent spread is to the lateral neck compartments of Levels IV, III, IIA, and VB and sometimes to the Levels IIB and VA. Occasionally skip metastasis to the lateral neck compartments develop without spreading to the central compartments and this situation is more frequent in upper pole tumors. Although application of prophylactic central neck dissection (pCND) in DTC increases the rate of complication, due to its unclear effects on oncologic results and quality of life, the interest to the pCND is decreasing and debate on its surgical extent is increasing. pCND is not essential in DTC and characteristics of patient and tumor and experience of surgeon should be considered when deciding for pCND. Due to lower complication rate of one sided pCND compared to bilateral central neck dissection (CND), low possibility of contralateral central neck metastasis and low risk of recurrence, application of one-sided CND is logical. Although therapeutic CND (tCND) is the standart treatment when there is a clinically involved lymph node, extent of dissection is a matter of debate. A case-based decision for the extent of tCND can be made by considering patient and tumor characteristics and experience of the surgeon. Due to the higher complication risk of bilateral CND, unilateral tCND can be performed if there is no suspicious lymph node on the contralateral side and bilateral tCND can be applied when there is a suspicion for metastasis only on the contralateral side or there are features for risk of metastasis to the contralateral side. In patients with clinical central metastasis owing to intra-operative pathology results by frozen section procedure are compatible with post-operative pathology results, when there is a suspicion for contralateral metastasis, a decision for one- or two-sided dissection can be made using frozen section procedure. In DTC, it can be stated that there is a consensus in the literature about not performing prophylactic lateral neck dissection (LND), but performing therapeutic LND (tLND). In addition, there is a debate on the extent of tLND. In a meta-analysis about lateral metastasis, the rates of metastasis to the Levels IIA, IIB, III, IV, VA, and VB were 53.1%, 15.5%, 70.5%, 66.3%, 7.9%, and 21.5%, respectively. Ultrasonography (USG) is an effective procedure for detection of cervical nodal metastasis on lateral compartment. Pre-operative imaging with USG and/or combination with the fine needle aspiration biopsy (cytology/molecular test/Thyroglobulin test) can allow pre-operative detection and verification of lateral lymph node metastasis. [ABSTRACT FROM AUTHOR]

Objective: It is still controversial whether performing central neck dissection (CND) in addition to total thyroidectomy (TT) increases the risk of complications. In the present study, we aimed to evaluate the effect of CND on the development of complications in differentiated thyroid cancer (DTC) compared to TT. Material and Methods: The data of 186 patients (136 females and 50 males) with a mean age of 48.73±14.78 (range, 17-82) whom were operated for DTC were evaluated retrospectively. The patients were divided into two groups; TT (Group 1) and CND±TT/Completion thyroidectomy±lateral neck dissection (Group 2). Results: There were 117 (91 F, 26 M) patients in Group 1 and 69 (45 F, 24 M) patients in Group 2. Parathyroid auto transplantation (PA) was significantly higher in Group 2 compared to Group 1 (42% vs. 6%) (p=0.000). Total (58% vs. 21.4%, respectively; p=0.000) and transient hypoparathyroidism (52.2% vs. 20.5%, respectively; p=0.000) were significantly higher in Group 2 than in Group 1, but permanent hypoparathyroidism rates were statistically not significant (5.8% vs. 0.9%, respectively; p=0.064). In the multinomial logistic regression analysis, CND alone was determined as an independent risk factor for increased both total and transient hypoparathyroidism. The relative risk (RR) of CND for total hypoparathyroidism was 5.2 times increased (odds ratio [OR]: 0.192) (p=0.007), while the RR for transient hypoparathyroidism was 3.5 times increased (OR: 0.285) (p=0.036). According to the number of nerves at risk, CND was performed in 119 neck side and only thyroidectomy was performed in 253 neck side. Total vocal cord paralysis (VCP) rate (9 [7.6%] vs. 6 [2.4%], respectively) (p=0.017) and transient VCP rate (7 [6%] vs. 4 [1.6%], respectively) (p=0.021) in patients who underwent CND were significantly higher compared to those who underwent only thyroidectomy. In multinomial logistic regression analysis performing only CND was an independent risk factor for total VCP, and increased the total VCP RR approximately 5.34 times (OR:0.184; p=0.007). Conclusion: Although CND can be applied without increasing the rates of permanent hypoparathyroidism and VCP compared to TT, it increases the risk of total and transient hypoparathyroidism, total, and transient VCP. Patients undergoing CND should be followed carefully in terms of transient hypoparathyroidism. [ABSTRACT FROM AUTHOR]

At present, intraoperative neuromonitorization (IONM) with surface electrode-based endotracheal tube (ETT) is a standard method in thyroidectomy and can be performed either intermittently IONM (I-IONM) or continuously IONM (C-IONM). Despite the valuable contribution of I-IONM to the thyroidectomy, it still has limitations regarding the recording electrodes and stimulation probe. New approaches for overcoming the limitations of I-IONM and developing the method are taking attention. Most of the technical issues of IONM with surface electrode-based ETT are related with inadequate contact of electrodes to the vocal cords. Nowadays, efficiency of various recording electrodes is under investigation. Recording electrodes such as needle electrodes applied to thyroarytenoid or posterior cricoarytenoid muscle (PCA), surface electrodes applied to the PCA, and needle or adhesive electrodes applied to the tracheal cartilage or skin, can make safe recordings similar to the ETT electrodes. Despite their invasiveness, needle electrodes record higher electromyography (EMG) amplitudes than tube electrodes do. Adhesive surface electrodes make safe EMG recordings, although amplitudes of these electrodes are usually lower than those of the tube electrodes. These different types of electrodes are less affected by tracheal manipulations and amplitude changes are lower compared to the tube electrodes. During C-IONM, an additional stimulation probe is applied to the vagus nerve after dissecting the nerve circumferentially. Recently, without applying a probe, a new continuous monitorization method called laryngeal adductor reflex CIONM (LAR-CIONM) using sensorial, central, and motor components of LAR arch which is an automatic, primitive brainstem reflex protecting the tracheoesophageal tree from foreign body aspiration, has been implemented. Afferent track of LAR communicates laryngeal mucosa to the brainstem by internal branch of the superior laryngeal nerve and efferent track reaches larynx through recurrent laryngeal nerve. Total outcome of LAR activation is the closure of laryngeal entry by bilateral vocal cord adduction. In LAR-CIONM, a stimulus is given by an electrode from one side of surface electrode-based ETT and amplitude response of the LAR at the vocal cord is followed on the operation side. Recently, it has been reported that real-time EMG response can be obtained with stimulation probe cables applied to dissectors or energy devices during the dissection through I-IONM. [ABSTRACT FROM AUTHOR]