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Background Predicting definitive outcomes of post-thyroidectomy vocal fold paralysis (VFP) is challenging. We aimed to identify reliable predictors based on intraoperative neuromonitoring (IONM) and flexible fiberoptic laryngostroboscopy (FFL) findings. Methods Among 1172 thyroid operations performed from April to December 2021, all patients who exhibited vocal fold paralysis (VFP) at post-operative laryngoscopy were included. IONM data, including type of loss of signal (LOS), were collected. Patients underwent FFL, with arytenoid motility assessment, at 15, 45 and 120 days post-operatively. Patients were divided into two groups: those who recovered vocal fold motility (VFM) by the 120th post-operative day (recovery group) and those who did not (non-recovery group). Results Fifty-nine VFP cases (5.0% of total patients) met the inclusion criteria. Eight patients were lost at follow-up and were excluded. Overall, 9 patients were included in the non-recovery group (0.8% of total patients) and 42 in the recovery group. Among various predictive factors, only arytenoid fixation (AF) at the 15th post-operative day and Type I LOS were significant predictors for no VFM recovery (p = 0.007, RR = 9.739, CI:1.3-72.3 and p = 0.001, RR = 9.25, CI:2.2-39.3 for AF and Type I injury, respectively). The combination of type of LOS and arytenoid motility at the 15th post-op day yielded satisfactory predictive values for the progression of transient VFP to permanent. Conclusions Arytenoid motility at the 15th post-op day and type II LOS are associated with recovery of VFM. Type of LOS and FFL could be included in the follow-up protocols of patients with VFP to reliably predict clinical outcomes.

Background Predicting definitive outcomes of post-thyroidectomy vocal fold paralysis (VFP) is challenging. We aimed to identify reliable predictors based on intraoperative neuromonitoring (IONM) and flexible fiberoptic laryngostroboscopy (FFL) findings. Methods Among 1172 thyroid operations performed from April to December 2021, all patients who exhibited vocal fold paralysis (VFP) at post-operative laryngoscopy were included. IONM data, including type of loss of signal (LOS), were collected. Patients underwent FFL, with arytenoid motility assessment, at 15, 45 and 120 days post-operatively. Patients were divided into two groups: those who recovered vocal fold motility (VFM) by the 120th post-operative day (recovery group) and those who did not (non-recovery group). Results Fifty-nine VFP cases (5.0% of total patients) met the inclusion criteria. Eight patients were lost at follow-up and were excluded. Overall, 9 patients were included in the non-recovery group (0.8% of total patients) and 42 in the recovery group. Among various predictive factors, only arytenoid fixation (AF) at the 15th post-operative day and Type I LOS were significant predictors for no VFM recovery (p = 0.007, RR = 9.739, CI:1.3-72.3 and p = 0.001, RR = 9.25, CI:2.2-39.3 for AF and Type I injury, respectively). The combination of type of LOS and arytenoid motility at the 15th post-op day yielded satisfactory predictive values for the progression of transient VFP to permanent. Conclusions Arytenoid motility at the 15th post-op day and type II LOS are associated with recovery of VFM. Type of LOS and FFL could be included in the follow-up protocols of patients with VFP to reliably predict clinical outcomes.

Background: Comparative studies among protocols for the management of post-total thyroidectomy (TT) hypocalcemia are lacking. We compared the effectiveness of PTH-driven selective supplementation (PD-SS) and routine calcium and calcitriol supplementation with preoperative calcitriol administration in preventing symptomatic hypocalcemia (SH) and readmission. Methods: Three-hundred consecutive patients undergoing TT were assigned to 3 groups: the PD-SS group, the high-dose routine supplementation (HD-RS) group and the low-dose routine supplementation (LD-RS) group. Results: Mean post-operative stay was shorter in HD-RS patients when compared to PD-SS and LD-RS (p < 0.001). Significantly more patients in the PD-SS group experienced SH (p = 0.042). The rate of post-operative hypocalcemia was not significantly different among the groups (p = 0.063). No readmission for SH or hypercalcemia occurred. Conclusions: HD-RS emerged as the most effective treatment to prevent SH, without increasing the risk of readmission for calcitriol-related hypercalcemia. Basing on the present results, HD-RS should be recommended as the preferable protocol.

Nessuno

Surgical manipulation of the cervical vascular bundle during neck surgery may promote a thromboembolic event. We evaluated if thyroid surgery is associated with any alterations in the carotid artery wall that would imply an augmented risk of cerebrovascular accident (CVA). A prospective evaluation of a consecutive series of patients who underwent total thyroidectomy was performed. High resolution Doppler ultrasonography (HR-DU) was performed the day before and three days after surgery in asymptomatic consenting patients scheduled for total thyroidectomy. Two hundred patients were recruited. Preoperatively, no hemodynamically significant stenosis (> 70%) was observed. Surgery was delayed in one patient because of asymptomatic subclavian steal syndrome. The remaining 199 patients underwent total thyroidectomy. No modification of preoperative findings was observed at the postoperative HR-DU evaluation. No CVA was observed. In the absence of any significant stenosis, thyroid surgery does not affect the presence and extent of arterial wall disease and the consequent risk of CVA. Thus, screening with HR-DU does not seem beneficial in a generally asymptomatic population without significant risk factors.

The Role of thyroid fine-needle aspiration cytology in the pediatric population

Erythropoiesis is affected during deep saturation dives. The mechanism should be related to a downregulation of serum Erythropoietin (s-EPO) concentration or to a toxic effect of the hyperbaric hyperoxia. We evaluated s-EPO and other haematological parameters in 6 scuba divers before, during and after a 14-days guinness saturation dive (8-10 m). Athletes were breathing air at 1.8-2 ATA, under the control of a team of physicians. Serum parameters were measured before diving (T0) and: 7 days (T1), 14 days (T2) after the beginning of the dive and 2 h (T3) and 24 h (T4) after resurfacing. Hgb, and many other haematological parameters did not change whereas Ht, s-EPO, the ratio between s-EPO predicted and that observed and reticulocytes (absolute, percent) declined progressively from T0 to T3. At T4 a significant rise in s-EPO was observed. Hgb did not vary but erythropoiesis seemed to be affected as s-EPO and reticulocyte counts showed. All these changes were statistically significant. The experiment, conducted in realistic conditions of dive length, oxygen concentration and pressure, allows us to formulate some hypotheses about the role of prolonged hyperbarism on erythropoiesis. The s-EPO rise, 24 h after resurfacing, is clearly documented and related to the "Normobaric Oxygen Paradox". This evidence suggests interesting hypotheses for new clinical applications such as modulation of s-EPO production and Hgb content triggered by appropriate O2 administration in pre-surgical patients or in some anemic disease.

We report a peculiar case of recurrent hyperparathyroidism caused by hyperplasia of a forearm graft implanted following a total parathyroidectomy in a 38-year-old patient with chronic renal failure. The forearm graft hyperplasia was detected using (99)Tc(m)-sestamibi scanning, which identified hyperplastic transplanted parathyroid tissue in the forearm of the patient. During the initial surgery, the surgeon failed to mark the parathyroid tissue with sutures or clips to facilitate locating it. Therefore, we referred the patient for radioguided surgery. This surgical procedure allowed us to locate and completely remove the hyperfunctioning transplanted parathyroid tissue.

Cribriform-Morular Variant of Papillary Thyroid Carcinoma in an 8-Year-Old Girl: A Case Report With Immunohistochemical and Molecular Testing.

Scuba diving is known to affect the rhino-pharyngo-tubaric district (RPT unit). The aim of the study was to document function modifications of the RPT unit in 6 Italian divers (3 men and 3 women) who lived for 14 days consecutively at a depth of 8-10 m, breathing air (21% oxygen) at a pressure ranging between 1.8 and 2 ATA. RPT and inner ear assessment were carried out before the dive (TIME 0) and 24 h (TIME 1) after resurfacing, in order to investigate diving-related RPT and inner ear alterations. Physical examination after resurfacing revealed: fungal external otitis, otoscopic findings consistent with middle ear barotraumas and rhinosinusitis. Rhino-manometry showed a remarkable increase in inspiratory nasal flow and a substantial decrease in nasal resistance. No epithelial cell disruption was retrieved comparing pre and post resurfacing samples. Post-diving tubaric dysfunction was found. Pure tone audiometry revealed a bilateral 40 dB HL hearing loss at 4 kHz in 1 diver. Relevant PTA functions did not seem to be affected by the experiment, no remarkable changes were found at the Sensory Organisation Test and at the Motor Control Test. The 14-day underwater period had a positive effect on nasal flows and resistances.

We report a peculiar case of recurrent hyperparathyroidism caused by hyperplasia of a forearm graft implanted following a total parathyroidectomy in a 38-year-old patient with chronic renal failure. The forearm graft hyperplasia was detected using (99)Tc(m)-sestamibi scanning, which identified hyperplastic transplanted parathyroid tissue in the forearm of the patient. During the initial surgery, the surgeon failed to mark the parathyroid tissue with sutures or clips to facilitate locating it. Therefore, we referred the patient for radioguided surgery. This surgical procedure allowed us to locate and completely remove the hyperfunctioning transplanted parathyroid tissue.

AIM: The aesthetic results of thyroidectomy have been evaluated in a prospective single-blinded randomized study MATERIAL OF STUDY: 140 patients undergoing thyroid surgery were randomized for skin closure into 4 groups: (1) intradermal non-absorbable suture; (2) intradermal non-absorbable double layer suture; (3) staples; (4) tissue adhesive. 136 out of the 140 patients were followed up at 3 months postoperatively. Scars were evaluated by a blinded plastic surgeon using the mVSS tool (modified Vancouver Scar Scale). Patients completed the PSAS form (Patient Scar Assessment Scale). RESULTS: Assessment of wound cosmesis with the mVSS revealed no statistical difference between group (1), (2) and (3); a statistically significant difference in the results with the group (4) (p = 0.0020) was found. The analysis of the results of PSAS showed very good subjective outcomes in all groups. However, the median values of PSAS at 3 months are better (p = 0.0001) for the group (1): follow results of group (2), (3) and (4). In some cases, the subjective rating in the group of women has been even higher than that reported by the blinded specialist. DISCUSSION: (1) still represents the gold standard in thyroidectomy. Conceptually the ideal technique should be (2): removing the suture (after two weeks from surgery) all problems related to the stimulus from foreign body are eliminated. CONCLUSIONS: The choice of suture technique to use depends on the skill and experience of the single surgeon. All four types of suture, if performed correctly, have given very attractive subjective and objective results.

BACKGROUND. Differentiated thyroid carcinoma (DTC) in juvenile patients has a risk of recurrence higher than in the adults. The optimal treatment strategy is unclear. Defining risk factors for recurrence could help to identify patients who require a more aggressive approach. METHODS. The demographic, clinical, surgical, pathological and nuclear medicine data of 67 patients aged less than 20 years who underwent surgery for DTC were reviewed and a complete follow up was obtained. RESULTS. All the patients underwent total thyroidectomy, with central neck dissection in 28 and lateral neck dissection in 14. All patients received levothyroxine suppressive treatment. Fifty-three patients underwent radioiodine ablation. At a mean follow up of 138.3+/-100 months, the overall survival rate was 98.5%. The 10-year disease free survival rate was 72%. Twenty patients (30%) experienced recurrence. Patients < 15 years old showed a significant higher recurrence rate than the older ones (70 Vs 29.8%) (P<0.05). Three out of 7 (42.9%) patients <= 15 years old with small tumours localized to the thyroid (pT1N0) experienced recurrence, but none out of 7 older. Age <= 15 years, nodal and distant metastases at diagnosis, multifocality were identified as significant risk factors for recurrence. CONCLUSIONS. An univocal aggressive approach, including total thyroidectomy, selective lymph node dissection, levothyroxine suppressive treatment and radioiodine ablation is mandatory. In all the patients <=15 years old central neck dissection should be considered. Long term surveillance should be warranted since recurrence can develop late after the first treatment.

This study was designed to evaluate physiological and psychological stress parameters in 2 professional trained scuba divers, using a unique physiopathologic model, offered by the guinness 240 hours scuba dive. Two scuba dive masters have spent 240 hours at 6 - 8 meters depth (26.4 ft) in Ponza Island water (Italy). Blood samples were collected daily in the underwater bell; samples were carried out of water in waterproof bags. Breath samples were collected, measuring ethylene release. Psychological assessment was performed using the State and Trait Anxiety Inventory and the Zung self-rating depression scale. In the studied subjects, cortisol and prolactin showed physiological pulsatile secretion. Breath ethylene didn't exceed normal values. At the start of the study, no subjects showed high levels of state anxiety, trait anxiety and current depression. Psychometric scales scores remained steady during the diving period and no subjects showed anxiety and/or depression and/or panic symptoms during the time of observation. The present study shows that, although the long-time diving, well trained professional divers did not develop anxiety and/or depression. No subject discontinued the diving due to occurred psychological disorders or systemic events. The present report shows that the long-term diving permanence is possible, at least in well trained scuba divers.

Gli autori descrivono le indicazioni, la tecnica ed i risultati della tiroidectomia mini-invasiva video-assistita, con particolare riguardo al trattamento del gozzo iperfunzionante