Endocrine Surgery

Question 1

Indications for surgery when a patient has primary hyperparathyroidism

Answer 1

Symptoms!
Age <50
Nephrolithiasis
Osteoporosis

Question 2

2 types of scans patients get before surgery

Answer 2

Nuclear imaging scan (sestamibi, CT)

Ultrasound

Question 3

Sestamibi scan

Answer 3

Uses Tc-99 sestamibi
Gets retained in a bad parathyroid gland
Tells you left or right side

Question 4

Ultrasound for parathyroid

Answer 4

Tells you more if it is the upper or lower gland

Best test to evaluate the thyroid gland and any nodules

Question 5

Intraoperative PTH

Answer 5

Surgery, take out the bad gland, then remeasure the PTH levels during the operation to find out if you are missing another bad gland
Use a foot vein

Question 6

What risks are there for a procedure?

Answer 6

Risks associated with anesthesia, bleeding, infection and risks specific to the procedure

Question 7

5 risks of parathyroidectomy

Answer 7

Hematoma (1%)
Recurrent laryngeal nerve injury (1%) - permanent and profound hoarseness
External branch of superior laryngeal nerve injury (2%) - wont be able to sing high notes or yell
Permanent hypoparathyroidism (1%)
Recurrent hyperparathyroidism (1%)

Question 8

5 risks for thyroidectomy

Answer 8

Hematoma (1%)
Recurrent laryngeal nerve injury (1%)
External branch of superior laryngeal nerve injury (2%)
Permanent hypoparathyroidism (1%)
Need for thyroid hormone

Question 9

4 surgical options for thyroidectomy

Answer 9

Total
Near total (in case you can’t remove it all without injuring the RLN/parathyroids)
Thyroid lobectomy + isthmusectomy
Rarely isthmuscectomy

Question 10

Management of hematoma

Answer 10

Most occur within 4-6 hours of surgery
Present with swelling, pain, pressure, dysphagia, resp distress, dysphonia
Need to assess for airway compromise
May need to open sutures at bedside to relieve airway obstruction
Urgent return to OR to evacuate the hematoma

Question 11

Management of hypocalcemia

Answer 11

No risk with unilateral surgery
Present with paresthesias, positive Chvostek's and Trousseau's signs
Check Ca levels postop
Supplement with oral Ca +/- vit D
IV Ca in severe cases

Question 12

Management of hoarseness

Answer 12

Many causes (RLN injry, laryngeal irritations from intubation, hematoma)
May also have vocal fatigue, dysphagia for liquids, loss of airway with bilateral RLN injury
Bilateral is worse
Refer to laryngologist
Surgical options to improve the quality of voice
Voice therapy

Question 13

Thyroid cancer treatment (7)

Answer 13

Active surveillance
Surgery
TSH suppression
Radioactice iodine ablation
External beam radiation/chemo
Ongoing surveillance with tumor markers and imaging