Introduction: Recurrent laryngeal nerve (RLN) identification is the gold standard in thyroidectomy. However, due to the anatomical variation of the RLN, it can be difficult to be identified especially by the less experienced surgeon. Meta-analysis showed that IONM did not significantly reduce the number of permanent RLN injuries but may be helpful in difficult or more complicated cases. Most of the studies were performed at the established centre with experienced surgeons. This study aims to find out whether the IONM will be helpful to junior, less experienced surgeons. Objective: This study aimed to demonstrate that the IONM system does help a junior surgeon in identifying RLN compared to visualization alone (VA). Methodology: A total of 40 nerve-at-risks from 25 patients who underwent thyroidectomies were randomized into IONM and VA group. Intraoperatively, the IONM system was set according to the guideline set by International Neural Monitoring Study Group, and standard thyroidectomy was performed. After medial rotation, the junior surgeon will start searching for the RLN with IONM or VA according to patient's group within 8 minutes. If the nerve was not found, a senior surgeon will proceed accordingly. Results: There was no difference in the demographic data (age, gender, ethnicity, and thyroid pathology) within both groups. The junior surgeon was able to find 90% of RLN using IONM compared to 60% by VA (p = 0.028). There was no RLN injury Conclusion: Intraoperative nerve monitoring does help junior surgeons to identify RLN compared to VA within the test duration. This can be used as a teaching tool without compromising the safety of the patient. Clinical significance: Intraoperative nerve monitoring is a useful tool not only to identify the RLN, hence reducing injury to it but also helps junior surgeons practicing to identify the nerve. It is more important when dealing with an anatomical variation of the nerve.

Introduction: Thyroid imaging reporting and data system (TIRADS) scoring is gaining popularity around the world among clinicians and radiologists. With any new practice, it is important to audit the results among different specialists and check concordance with the gold standard. We compared TIRADS scoring and thyroid nodule cytology data of two different surgeons to determine concordance and accuracy. Materials and methods: A retrospective analysis of records of patients with thyroid nodules managed under two specialist surgeons from 2016–2018 was performed comparing surgeon performed ultrasound (US) TIRADS grading with the Bethesda cytology classification. The TIRADS 2 and 3 lesions were corelated to Bethesda II (benign) results and TIRADS 5 was corelated to Bethesda V and VI (malignant) category. Data was also compared with our previously published audit in 2015. Results: A total of 254 thyroid nodules over a 3-year period, 208 cases (82%) were reported as benign disease and correlated to the TIRADS 2 and 3 grade given by the surgeon. Five were reported malignant which matched the TIRADS 5 score. Overall concordance rate for surgeon 1 and 2 were 79.7% and 87.2%, respectively. For each separate category, TIRADS 5 had the highest concordance at 100%, followed by TIRADS 3 at 91.9% and TIRADS 2 at 91.7%. None of the TIRADS 2 lesions were malignant. Sensitivity rates were similar at 71.1% compared to 70.6% in the previous audit. Conclusion: With proper training in TIRADS, we can achieve fairly good correlation between benign and malignant thyroid nodules among different surgeons and need for FNAC in TIRADS 2 lesions can be avoided. Clinical significance: This study shows importance of surgical audit. Good concordance rates can be achieved among different specialists with proper training.

Introduction: Retrosternal goiters requiring mediastinal access for thyroidectomy comprises less than one-third of thyroidectomies performed in major centers. This study aims to evaluate the outcomes of retrosternal goiters following thyroidectomies with mediastinal access. Methods: The study is a retrospective review of all patients with mediastinal retrosternal goiter who underwent surgery between 1st April 2011 and 1st March 2021 at a tertiary referral hospital. Demographic, clinicopathological data, radiological, and treatment outcomes data were analyzed. Results: A total of 13 patients underwent thyroidectomy with mediastinal access over a 10-year period from April 2011 to March 2021. Most of the goiters were in the posterior mediastinum, with eight out of 13 symptomatic at presentation, and the most common compressive symptom being that of dyspnea. Two-third of the resected retrosternal goiters were benign. The majority underwent a transcervical approach in combination with sternotomy, with two goiters in the mediastinum accessed by VATS. Whilst there were no mortalities, morbidities related to the complex surgery were mostly temporary hypocalcemia (30%) and laryngeal nerve injury (23%). Two patients presented with airway crises that required intervention with ECMO and tracheostomy. Discussion: Mediastinal goiters requiring surgery are uncommon and surgery can be challenging especially for those located in the posterior mediastinum. Complications of retrosternal goiter surgery are like that of standard thyroid surgery, however, the incidence of hypoparathyroidism and neuropraxia of the recurrent laryngeal nerve appears to be higher. Both ECMO and tracheostomy are strategies for difficult intubation.

Background: Hypercalcemia and associated primary hyperparathyroidism (pHPT) are relatively common but are likely to be under-recognized and undertreated. This study aimed to assess the prevalence of incidental hypercalcemia, investigation, and follow-up with definitive care for an acute surgical Australian metropolitan population. This was complemented by a systematic review of the literature. Materials and methods: A retrospective cohort study was conducted in a metropolitan, 172-bed general hospital within the Metro South Health service district of South-East Queensland, Australia. The electronic medical records of all acute general surgical admissions over a 6-month period (February–July 2019 inclusive) were reviewed and analyzed. This was supplemented by a systematic literature review of incidental hypercalcemia and hyperparathyroidism. Results: Of 486, eligible patients requiring acute surgical admission, two were identified to possess incidental hypercalcemia, equating to an incidence of 0.41%. Within this context, the systematic review revealed a reported hypercalcemia prevalence of between 0.1 and 3.3% and a pHPT prevalence of between 1.3 and 3.5%. The incidence of new pHPT was between 6 and 50 per 1,00,000. Discussion: This study is the first to investigate the incidence of incidental hypercalcemia and related hyperparathyroidism in an acute general surgical admission setting. Whilst the outcomes of this study have not shown expectedly high rates of hypercalcemia and hyperparathyroidism, this provides a platform for future clinical education, awareness, local protocol development, and improved patient care. Clinical significance: The first study to investigate the incidence of incidental hypercalcemia and hyperparathyroidism in an acute general surgical admission setting. Lower than expected rates of hypercalcemia and hyperparathyroidism (2 out of 486 eligible patients) based on literature review which sets the platform for future research directions.

Background: The endoscopic transsphenoidal approach to pituitary tumors has become popular and accepted, with minimal postoperative morbidity. Aim: To document the efficacy and the patients’ safety of endoscopic transsphenoid surgery. Patients and methods: Summary of 55 consecutive patients with pituitary tumors who underwent endoscopic transsphenoidal surgery at the Department of Neurosurgery, Ibn Sina Teaching Hospital from March 2018 to February 2021. Follow-up is between 6 months and 2 years. Results: Females represent 52.7% and males 47.3% of the patients. Non-functioning tumors represent 32.7%, while hormones-secreting tumors are 67.7%. In 29 patients (52.7%), the tumors were completely excised. Subtotal excision was performed in seven patients (12.8%), while partial removal was done in 19 patients (34.5%). Conclusion: Endoscopic transsphenoidal pituitary surgery is a safe approach to pituitary adenomas, avoiding external scars with minimal postoperative morbidity.

Aim: Limited literature from Southeast Asia (SEA) exists on anaplastic thyroid cancer (ATC). The aim of this study was to ascertain factors associated with the survival of ATC at Putrajaya Hospital which is the main referral center for endocrine cases in West Malaysia. Materials and methods: This is a retrospective analysis of all patients with ATC between January 2002 and December 2016. Data concerning comorbidities, stage of disease, and clinical course were collected via electronic medical records and analyzed with Kaplan-Meier survival and log-rank tests for univariate and Cox proportional hazards model for multivariate analysis. This study was approved by the Malaysian Medical Research Ethics Committee (MREC). Results: A total of 76 patients were treated for ATC at our center, however, 11 had missing data and were excluded from the analysis. Of the remaining 65 patients, the majority were women (44 cases), and the mean age at presentation was 62 years. Majority of patients presented with stage IV C (50.8%) whilst others presented with IV A (3.1%) and IV B (46.2%). Most patients were treated palliatively (36.9%) whilst 29.2% underwent surgery only, 16.9% radiotherapy only, and 16.9% had multimodal therapies. Median survival was 2 months (range 1–14 months) with survival rates of 7.7–1.5% at 6 months and 1-year, respectively. Univariate analysis demonstrated that stage of disease and combination therapy improved survival. When correction was made for sex, age, and stage of disease, the only type of treatment received significantly affected outcomes. Multimodal therapy, either surgery and radiotherapy (hazard ratio 0.29, confidence interval 0.091–0.939, p = 0.03) or surgery followed by radiotherapy and chemotherapy (hazard ratio 0.09, confidence interval 0.01–1.0, p = 0.05) conferred better outcomes. Conclusion: The findings in this study that multimodal therapy conferred improved outcomes were comparable to that of numerous other studies, however, more research is needed in assessing the best treatment for this deadly disease.

Aim: To manage a rare case of paraspinal paraganglioma in an 8-year-old female. Background: Functional paraspinal paragangliomas are exceptionally rare entities in both adult and pediatric age groups. These tumors are closely associated with major vascular structures like the aorta and are in close proximity to the spinal nerves and threatened with deadly vascular complications (e.g., hemorrhagic shock) and neurological complications (e.g., paralysis or paresis of the lower limb). So managing pediatric patients with safe outcomes is a challenge. Case description: An 8-year-old female child presented with a two years history of headache, palpitations, sweating, and high blood pressure with no neurological deficit. On evaluation, she was found to have elevated urinary normetanephrine levels and a left lateral paraspinal mass located at the level of T7–T11 vertebral bodies on imaging. She was managed with preoperative alpha-adrenergic blockade followed by complete tumor resection. Conclusion: Biochemical evaluation, perioperative care with adequate α-blockade, and timely follow-up is necessary for best outcomes in functional paraspinal paraganglioma. Clinical significance: High suspicion of an index and multidisciplinary teamwork were key in diagnosing and managing this rare tumor.