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By Ashleigh Elkins

The parathyroid glands are four small, pea-sized glands that are located behind the larger, butterfly-shaped thyroid gland. The parathyroid glands are named for their location. There are two superior thyroid glands, which are found behind the top part of the thyroid lobes; one behind the right thyroid lobe and one behind the left thyroid lobe. There are also two inferior parathyroid glands which can vary in their location. They are usually found behind the lower part of the right and left thyroid lobes. In some people, the inferior parathyroid glands may be located below the level of the thyroid gland, or may be found near the inferior thyroid veins. The parathyroid glands are usually 6mm in length and 3-4mm wide.

The parathyroid glands are involved in the regulation of blood calcium levels. This is important to ensure normal function of other organs and tissues, including the heart, kidneys, bones and nerves. The parathyroid glands produce a hormone called parathyroid hormone, or PTH, which controls the levels of calcium in the body. When the level of calcium in the blood drops, the parathyroid glands release PTH which works in a number of ways to increase the level of calcium in the blood.

Parathyroid hormone functions

rci.rutgers.edu

Parathyroid hormone – PTH

  • PTH acts on the bone to stimulate reabsorption of bone which results in the release of calcium stored in the bone
  • PTH acts on the kidney to increase the amount of calcium that is reabsorbed so that less calcium is lost through the urine
  • PTH also stimulates the activation of vitamin D in the kidney. Activated vitamin D is important because it helps the small intestine to reabsorb more calcium from the diet into the bloodstream

All of these actions work to increase the level of calcium. Once the calcium levels have returned to normal or become too high, the parathyroid glands become less active and do not secrete as much PTH.

Relationship between blood ionized calcium concentrations and plasma parathyroid hormone (PTH) levels in persons with normal renal and parathyroid gland function. American Journal of Physiology – Renal Physiology Published 6 May 2004 Vol. 286 no. 6.

What is hyperparathyroidism?

Hyperparathyroidism is a term used to describe increased activity in one or more of the parathyroid glands. There are three types of hyperparathyroidism:

Primary hyperparathyroidism, where the affected parathyroid gland produces too much PTH as a result of a problem within the parathyroid gland itself. The most common cause of primary hyperparathyroidism is a benign tumour within the gland called a parathyroid adenoma. Parathyroid adenomas are usually only found within one parathyroid gland, it is very uncommon to find a parathyroid adenoma in more than one gland. Less common causes of primary hyperparathyroidism include parathyroid hyperplasia, and very rarely, parathyroid carcinoma, a malignant parathyroid tumour.

Secondary hyperparathyroidism, where the underlying cause of the hyperparathyroidism is due to low levels of blood calcium, which is known as hypocalcaemia. Hypocalcaemia may be the result of poor calcium absorption in the intestines, or the result of severe dietary deficiency. Because vitamin D is necessary for calcium absorption, severe vitamin D deficiency can also cause hypocalcaemia and secondary hyperparathyroidism. People with chronic renal failure may also develop secondary hyperparathyroidism.

Tertiary hyperparathyroidism, which occurs after chronic secondary hyperparathyroidism. Once the underlying cause of the longstanding secondary hyperparathyroidism is addressed, the affected parathyroid gland or glands still continue to secrete too much PTH.

Parathyroid hormone testing

Parathyroid hormone levels are routinely measured by a blood test. Intact PTH (iPTH) is the biologically active form and is secreted when the calcium level is low. iPTH is the most frequently ordered parathyroid hormone test. iPTH is used to diagnose the cause of a high calcium level and to distinguish between parathyroid and non-parathyroid causes. A calcium test is almost always ordered along with an iPTH test. The key to diagnosis of a parathyroid gland disorder is the relationship between the calcium and iPTH and the response of the parathyroid glands to changing levels of calcium.

Symptoms

Symptoms of hyperparathyroidism can vary depending on whether the cause is primary, secondary or tertiary hyperparathyroidism. The symptoms of primary and tertiary hyperparathyroidism are similar, because both cause a high level of calcium in the bloodstream.

Symptoms of primary and tertiary hyperparathyroidism include:

  • Bone and joint pain due to the breakdown of bone to release calcium
  • Kidney stones
  • Frequent urination
  • Excessive thirst
  • Loss of appetite
  • Nausea
  • Constipation
  • Fractures
  • Gout

The symptoms of secondary hyperparathyroidism are different to the symptoms of primary and tertiary hyperparathyroidism because elevated levels of blood calcium cause many of the symptoms in primary and tertiary hyperparathyroidism; but high levels of blood calcium are not an issue with secondary hyperparathyroidism. Increased fracture risk is common to all forms of hyperparathyroidism. Underlying renal problems are the cause of many of the symptoms of secondary hyperparathyroidism.

Symptoms of secondary hyperparathyroidism include:

  • Fractures
  • Bone deformities
  • Changes to urinary habits
  • Ankle and leg swelling
  • Fatigue
  • Nausea
  • Vomiting
  • Itching

Treatment

Surgery is the most common treatment for primary hyperparathyroidism and provides a cure in about 95 percent of all cases. Your surgeon will remove only those glands that are enlarged or have a tumour (adenoma).

If all four glands are affected, your surgeon will likely remove only three glands and perhaps a portion of the fourth. This approach will leave some functioning parathyroid tissue.

Parathyroid surgery can be done through a very small neck incision which leaves a minimal scar.

Complications from parathyroid surgery are uncommon. Risks include damage to nerves controlling the vocal cords and long-term low calcium levels requiring the use of calcium and vitamin D supplements.

For more information about the parathyroid glands click here.

If you have questions about the parathyroid glands, contact your local doctor who will arrange for you to see a thyroid surgeon.

The post Symptoms of Hyperparathyroidism appeared first on Thyroid Clinic Sydney.

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Rhinoplasty summary

This lady requested several changes to her nose. The before and after pictures are displayed in the slideshow.

Patient concerns

Appearance

  • Nasal bump
  • Nasal length too long
  • Drooping nasal tip

Function

  • Breathing problems
  • Nasal congestion and obstruction

Surgical technique

To address her concerns this lady underwent open structure rhinoplasty, nasal septal reconstruction and bilateral inferior turbinoplasties.

After rhinoplasty surgery

The concerns in terms of appearance and function are addressed. After rhinoplasty the bump is removed. The tip is deprojected and uprotated. The columella retraction was addressed. Overall the nose has a natural appearance in keeping with the facial features. The nasal airway is improved and breathing is easier.

The post Phoebe’s Before and After Pictures appeared first on Rhinoplasty Clinic Sydney.

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Tonsillectomy and Adenoidectomy for Children

ENT specialists commonly see children for issues regarding their throat or tonsils. Often if a child’s tonsils are chronically infected, a tonsillectomy would be recommended. In addition, many children will require the removal of the adenoids – which improves breathing through the nose. In these instances, where the tonsils and adenoids are removed in one procedure, the surgery will be called an adenotonsillectomy.

For parents preparing for your child’s surgery, it is helpful to understand the process, then explain to your child what will be happening.

How to prepare your child for tonsillectomy and adenoidectomy

How do you your child that they are going to undergo a routine procedure. First of all, take a deep breath. Your child will be just fine. Remember that this is in fact a routine procedure, that is performed by experienced and capable ear nose and throat surgeons. Staying calm and mentally preparing for the situation will in turn keep your child calm.

Prepare Yourself

  • Read everything you can about other parents’ experiences with their children.
  • Make a list of all of the soft foods you’ll need to have around after the surgery.
  • Talk to your paediatrician about your child’s pain management, importantly, know when and how to administer pain medication.
  • Remember that you will be required to keep a close watch on your child’s hydration and food intake. They may be feeling sore and may not want to swallow, but it is important to ensure they are receiving adequate fluid intake in order to recover as best as possible.

You should also make sure that you know the expected recovery time. Recovery length can vary from 7-14 days and will depend on the age of the child.

Tell Them What to Expect in Kid Terms

You know that your child needs this procedure to feel better. Whether your son or daughter has had sleep apnoea, ear infections, chronic sore throat, or some combination of these ailments. Your ENT surgeon would only advise on the surgery if it were deemed necessary and medical management has not been effective. It is important to ensure your child understands the procedure and understand they may feel a little under the weather after surgery. Try to keep them calm and explain the procedure in a manner that is most suitable for their age. For example, “Once the doctor has fixed up your throat it won’t be sore anymore. You will feel a lot better, and you’ll be able to go play a lot more.”

Focus On the Positive

Let them know that their special doctor is going to take good care of them. Tell them that they will be asleep for the whole operation, and they will not feel anything during that time. It is important not to lie to them about their recovery, tell them that it will be painful. However, putting a light spin on the negatives will help them feel more at ease and maybe even excited! Tell them they can eat all of the ice cream and jelly they want for a whole week!

Remember, above all else, to stay positive for your child. If you can keep a gentle smile on your face, you will put their mind at ease, which will help their recovery. If you have any concerns before or after surgery, don’t hesitate to talk to your paediatrician or surgeon about them. If you have questions about tonsillectomy and adenoidectomy in children, contact your local doctor, who will arrange for you to see an ear nose and throat surgeon.

For more information

The post Tonsillectomy and Adenoidectomy – How To Prepare Your Child appeared first on ENT Clinic Sydney.

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Increased Thyroid Cancer Incidence

The incidence (i.e. the number of new cases) of thyroid cancer has seen an increase in the past few decades. However, during the same period of time, there has also been an increase in the utilisation of imaging and biopsy to help detect thyroid cancer. As a result, the increased incidence of thyroid cancer in the recent past may not actually be due to a true increase in the number of cases of thyroid cancer. Rather, that more cases of thyroid cancer are being detected with the increased use of ultrasound and fine needle aspiration.

Increased Use of Thyroid Ultrasound and Fine Needle Aspiration Biopsy

The study by Zevallos et al., aimed to determine if the increased thyroid cancer incidence observed corresponded with a similar increase in the use of diagnostic investigations. Thyroid ultrasound and fine needle aspiration. This was achieved by examining the Veteran’s Affairs health system records. The number of cases of thyroid cancer and the numbers of diagnostic investigations performed in the period between the years 2000 and 2012 were compared. At the commencement of the study in 2000, the incidence of thyroid cancer was 10.3 cases per 100,000 people. In comparison, at the study’s conclusion in 2012, the incidence of thyroid cancer was 21.5 cases per 100,000 people.

As with the incidence of thyroid cancer during the study period, the use of ultrasound and fine needle aspiration biopsy also exhibited an increase. In 2000, the rate of thyroid ultrasound was 125.6 per 100,000 people, which had increased to 572.1 per 100,000 people in 2012. Similarly, in 2000 the rate of fine needle aspiration biopsy was 7 per 100,000 people, but rose to 46.2 per 100,000 by 2012.

What this result really means is that due to better access to testing for thyroid cancer, the number of cases that are detected increases. This does not necessarily mean that thyroid cancer is becoming more common. Rather, we are becoming better at detecting it. This finding is also likely to be because patients with small thyroid nodules are being over-investigated. The American Thyroid Association (ATA) recommends that all patients with a thyroid nodule should have their thyroid stimulating hormone level tested. If this comes back with a low result, they recommend that the patient has a radionuclide thyroid scan. Additionally, the ATA also recommends that all patients with suspected or known thyroid nodules have an ultrasound assessment of the thyroid, and endorse that fine needle aspiration is the investigation of choice for a thyroid nodule.

References

Zevallos JP., et al. (2015). Increased thyroid cancer incidence corresponds to increased use of thyroid ultrasound and fine-needle aspiration: A study of the Veterans Affairs health care system. Cancer, 121(5), 741-746. http://www.ncbi.nlm.nih.gov/pubmed/25376872

Cooper DS, et al. (2009). Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid, 19(11), 1167-1214. http://online.liebertpub.com/doi/full/10.1089/thy.2009.0110

The post Increased Thyroid Cancer Incidence & Increased Use of Thyroid Ultrasound and Fine Needle Aspiration Biopsy appeared first on Thyroid Clinic Sydney.

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By Ashleigh Elkins

Background

A thyroglossal duct cyst is a congenital abnormality that results from a persistent thyroglossal duct. Thyroglossal cysts present as a neck swelling, generally in the midline or slightly to one side. They are generally smooth and painless. However, thyroglossal cysts are prone to infection and an infected cyst will often be quite painful.[1] Some patients may also experience other symptoms related to the cyst, including dysphagia and hoarseness.[2] Approximately 2/3 of patients with thyroglossal cysts have ectopic thyroid tissue within the cyst.[1]

Upon physical examination, a thyroglossal cyst can be differentiated from other neck lumps by observing the movement of the cyst/lump when the patient is swallowing or protruding their tongue. If the lump is a thyroglossal cyst, it will move upwards with swallowing or tongue protrusion.[1] The majority of thyroglossal cysts are detected during childhood. The location of a thyroglossal duct cyst can vary. Some are located above the hyoid bone, others are between the hyoid bone and thyroid cartilage and others are below the sternum. Cysts may also occur within the tongue.[2] The majority of thyroglossal cysts are located below the level of the hyoid bone, with approximately 60-80% of thyroglossal cysts being infrahyoid.[1]

Embryology

The thyroid gland initially develops on the base of the tongue and migrates to its final anatomical position during later stages of development. At approximately gestational week four, the foramen cecum develops as a result of an invagination of the pharyngeal membrane. The primitive thyroid originates from the foramen cecum, and descends into the neck via the thyroglossal duct, a tract running from the base of the tongue to the neck. After the thyroid cells have migrated, the thyroglossal duct regresses at approximately week 10. However, in some people, the thyroglossal duct does not regress completely, and parts of or the entire duct remains, giving rise to a thyroglossal cyst.[2]

Patients routinely undergo ultrasound studies prior to undergoing the Sistrunk procedure to determine whether there is a normally functioning thyroid gland in its anatomical position. Thyroid function tests are generally also ordered pre-operatively to determine whether or not the patient is euthyroid. If the patient does not have a functioning thyroid gland, then surgery is not usually performed, in order to minimise the risk of developing hypothyroidism.

Surgical procedure

Thyroglossal cysts are managed by surgical removal. Surgical removal of the thyroglossal cyst is indicated because the cysts are prone to infection, and for cosmetic and aesthetic reasons. In rare instances, thyroglossal cysts may be malignant. This is thought to occur in less than 1% of all cases, and the underlying malignancy is usually papillary thyroid cancer.[2] Thyroglossal cysts are removed by a surgical procedure called the Sistrunk procedure. This operation is named for the surgeon who first described it. Prior to the development of the Sistrunk procedure, thyroglossal cysts were treated merely by incision and drainage, with recurrence being a key issue.

Due to the problems with recurrences, there was a move towards removing the cyst, along with part of the hyoid bone above it. Recurrence rates were lower with this type of operation compared to incision and drainage, but were still quite high. In 1920, Walter Sistrunk described an extended version of the previous operation. The Sistrunk procedure involved removing the cyst and part of the hyoid bone, as well as removing a small core of tissue from the hyoid bone all the way to the foramen cecum, resulting in a much lower rate of recurrence.[1]

How the Sistrunk Procedure is Performed

  1. A transverse incision is made along the neck is made at the level of the hyoid bone. The incision is approximately 5cm in length.
  2. The skin and the platysma muscle are reflected to expose the cyst, which is commonly found underneath the raphe which connects the sternohyoid muscles
  3. The cyst is then dissected away from the surrounding muscles and tissues up to the level of the hyoid bone
  4. At the hyoid bone, the muscles which attach to the centre of the bone are resected and separated, and then a section of the centre of the hyoid about 2cm is removed together with the cyst and tract.
  5. From the superior aspect of the hyoid bone up to the level of the foramen cecum, a core of tissue is then removed as needed. The diameter of the core of tissue surrounding the thyroglossal duct is approximately 1cm.
  6. In the original Sistrunk procedure the foramen cecum was removed, along with part of each genioglossus muscle and the raphe joining the mylohyoid muscles are also removed. This is now only performed as needed depending on the location of the cyst and path of the thyroglossal tract.
  7. If the tract extended to the tongue base and needed to be removed the opening into the mouth would be closed. Then the genioglossus muscles are sutured, and the tissues at the cut ends of the hyoid bone drawn together with sutures.
  8. A drain is inserted near the hyoid bone and the skin is closed over it.[3]

Extended Sistrunk Procedure

There are two main limitations of the Sistrunk procedure. Firstly, the procedure does not aim to resect the portion of the thyroglossal duct that lies below the hyoid bone. Secondly, the thyroglossal duct is not a simple, straight tube-like structure. It is often a tortuous structure, particularly between the tongue base and the hyoid bone. In some sections the duct may be incomplete. Furthermore, the duct has several side branches, which may not be resected by the standard Sistrunk procedure. Because the procedure originally described by Sistrunk may not result in complete resection of the entire thyroglossal duct, an extended Sistrunk procedure has been described which aims to surgically remove the entire thyroglossal duct.[4]

For the extended Sistrunk procedure, the skin incision is made lower, usually at the level of the thyroid isthmus. The site of the incision may vary if there are any neck swellings or fistulae that will also need to be resected. Starting at the superior aspect of the thyroid isthmus, a section of tissue which includes both the thyroglossal duct and part of the bordering strap muscles is dissected. The resection continues superiorly towards the hyoid bone, removing the thyroglossal duct and cyst. As with the original Sistrunk procedure, a section of the hyoid bone is removed in the extended procedure. Above the level of the hyoid, the thyroglossal duct and cyst are resected along with a wider core of normal tissue, to ensure that any branches of the thyroglossal duct are also removed. This resection continues until the level of the tongue base; however, the tongue base is ideally not breached by the surgeon. A drain is placed in the neck at the end of the procedure and the wound is closed.[4]

Complications

As with all surgical procedures, there are potential risks and complications associated with both the standard Sistrunk procedure and the extended Sistrunk procedure. Major complications associated with the Sistrunk procedure are rare. Potential major complications include nerve injury, airway injury, thyroglossal cyst recurrence, hypothyroidism, blood transfusion and the development of a haematoma or abscess which may require further surgical intervention.[5]

Minor complications are more common than major complications after surgery. Minor complications are usually related to the wound, including superficial surgical site infections, small abscesses around the sutures, seromas and dehiscence of the wound. These minor complications are associated with very low morbidity and can be easily managed in an outpatient setting.[5]

The risk of developing major complications following the Sistrunk procedure is low for several reasons. The placement of a drain helps to reduce the risk of developing a haematoma and aseptic technique and antibiotic prophylaxis minimises the risk of infection. Furthermore, risk of injury to the airway and major vessels and nerves of the neck can be minimised by employing a meticulous surgical technique and by identifying key anatomical landmarks in order to reduce the risk of inadvertent injury to surrounding structures.[5]

Recurrence

Reported recurrence rates following the Sistrunk procedure are low, between 0 and 8%. In comparison, recurrence rates following incision and drainage of thyroglossal cysts exceeded 50%.[1] One study which has described the use of the extended Sistrunk procedure for primary excision of thyroglossal duct cyst reported a 0% recurrence rate at 3 years follow-up. When the extended Sistrunk procedure is implemented in revision cases, the recurrence rate is 7%.[4]

For more information about thyroglossal duct cyst and Sistrunk procedure click here.

References

[1] Wagner G, Medina JE. Excision of thyroglossal duct cyst: the Sistrunk procedure. Operative Techniques in Otolaryngology (2004); 15: 220-223

[2] Goldsztein H, Khan A, Pereira KD. Thyroglossal duct cyst excision—The Sistrunk procedure. Operative Techniques in Otolaryngology (2009); 20: 256-259.

[3] Sistrunk WE. The surgical treatment of cysts of the thyroglossal duct. Annals of Surgery (1920); 71:121-124.

[4] Ahmed J, Leong A, Jonas N, Grainger J, Hartley B. The extended Sistrunk procedure for the management of thyroglossal duct cysts in children: how we do it. Clinical Otolaryngology (2011); 36:252-279.

[5] Maddalozzo J, Venkatesan TK, Gupta P. Complications associated with the Sistrunk procedure. The Laryngoscope (2001); 111: 119-123.

The post Sistrunk Procedure for Thyroglossal Duct Cyst appeared first on Thyroid Clinic Sydney.

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