Background: Thyroid operations are performed by general surgeons, otolaryngologists, endocrine surgeons, and surgical oncologists. While thyroidectomy techniques are well described, differences persist among surgeons. A stepwise approach to thyroidectomy may promote standards of care and improve outcomes and training. Methods: A total of 177 patients underwent thyroid operations in The Center for the Scientific and Clinical Research of Endocrinology, Department of Endocrine Surgery of Uzbekistan, during 2017–2018, with a stepwise technique for thyroidectomy. The series included 155 women and 12 men, with a mean age of 41.4 ± 12.8 years. Evaluations included thyroid-stimulating hormone (TSH) and free T4 levels, fine needle aspiration cytology, ultrasonography of the thyroid gland, cervical lymph nodes and adjacent structures, and vocal cord assessment. We designated five steps of thyroidectomy: (1) Medial mobilization of the gland and division of the middle thyroid vein; (2) Dissection of the anterior suspensory ligament between the superomedial lobe and cricoid/thyroid cartilage, with the division of the superior pole vessel branches, (3) Division of the branches of the inferior thyroid artery (ITA) with preservation of the recurrent laryngeal nerve (RLN) and both parathyroid glands (PTGs); (4) Division of the posterior suspensory ligament (of Berry) that connects the lobe to the cricoid cartilage and first and second tracheal rings; and (5) Central and/or lateral lymph node dissection, if indicated. Results: A total of 134 patients (75.7%) had nodular goiter, 29 had Graves’ disease (GD) (16.4%), and 14 had thyroid carcinoma (7.9%). A total of 107 patients (60.5%) were euthyroid, 37 (20.9%) had controlled hyperthyroidism, and 33 (18.6%) had already been treated for hypothyroidism before surgery. Operations included total or near-total thyroidectomy (98, 55.4%), lobectomy (60, 33.9%), or lesser resections (19, 10.7%). There were two (1.1%) temporary and no permanent RLN palsies. Temporary hypoparathyroidism (lasting <11 days) occurred in 37 (20.9%) patients, but no patients suffered permanent hypoparathyroidism. Conclusion: Comprehension of thyroid anatomy and systematization of technical steps may improve outcomes and enhance training in thyroid surgery.

Aim: Determine the operative benefits of subcapsular infiltration of adrenaline in terms of blood loss and operative time in open and endoscopic thyroid surgery. Materials and methods: Between June 2020 and May 2021, this prospective, randomized study was carried out. All patients underwent total or hemithyroidectomy via an open or endoscopic approach, depending upon the characteristics of the thyroid lesion. During thyroidectomy, approximately 50–60 mL solution of adrenaline with saline was instilled in the subcapsular plane in a dose of 1:150,000 in 30 patients of group I. Only standard thyroidectomy was performed in the other 30 patients in group II. The pathological characteristics, intraoperative (intra-op) factors, clinical effects, and postoperative blood parameters were analyzed. Results: Of the 93 patients who underwent thyroidectomy over the aforementioned time frame, 60 patients—30 from group I and 30 from group II—were included in the study. The mean time taken for total thyroidectomy was 99.14 ± 7.02 minutes (n = 15), group I 94.00 ± 6.52 minutes (n = 8) vs group II 104.29 ± 7.52 minutes (n = 7) (p-value = 0.001). A complete thyroidectomy caused a mean blood loss of 62.06 ± 5.03 mL (n = 15) and group I 56.25 ± 5.18 mL (n = 8) vs group II 67.86 ± 4.88 (n = 7) (p-value = 0.001). The mean time taken for hemi thyroidectomy was 92.84 ± 6.08 minutes (n = 45), group I 87.73 ± 6.40 minutes (n = 22) vs group B 97.96 ± 5.77 minutes (n = 23) (p-value = 0.001). A hemi thyroidectomy resulted in a mean blood loss of 48.64 ± 5.65 mL (n = 45) and group I 42.50 ± 4.82 (n = 22) vs group B 54.78 ± 6.48 (n = 23) (p-value = 0.001). Conclusion: Results from this prospective study suggest that adrenaline infiltration significantly minimizes bleeding and reduces operative time in patients who undergo thyroidectomy. Clinical significance: Adrenaline infiltration makes the handling of the thyroid gland easier for the surgeon. This effective surgical hemostasis ends up in lesser blood transfusions, decreased operative time, and reduced morbidity and mortality for patients. It would help us to use adrenaline regularly during thyroid surgery.

A thyroid nodule can be radiologically detected in up to 60% of the population. No single ultrasound feature is sensitive or specific for malignancy. Aims: To assess the ultrasound features in thyroid nodules of the Northeast Indian population in a tertiary care hospital. Objective: To correlate ultrasonography (USG) with the histopathological examination (HPE) findings after surgery using the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS). Materials and methods: This retrospective cohort study involved the records of 40 patients with thyroid nodules who had visited the Department of ENT in the year 2019–2020. Case records were retrieved and out of which only 28 patients had both USG findings and HPE reports. Results: Ultrasonography (USG) findings of 28 patients were analyzed and correlated with HPE reports. ACR TI-RADS had sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 70, 87, 82, and 77%, respectively, in diagnosing thyroid malignancy. The risk of malignancy (ROM) for ACR TI-RADS, 1, 2, 3, 4, and 5 groups in our study was 0, 0, 25, 71, and 100%, respectively. Conclusion: A specificity of 87% and PPV of 82% of ACR TI-RADS USG is good for diagnosing thyroid malignancy and planning further management in our population. We recommend the routine use of ACR TI-RADS USG classification systems. Clinical significance: Routine use of any widely accepted USG classification system should be employed. We recommend institutional studies of large sample sizes or audits to study the ROM for each target population to plan for population-specific treatment protocols.

Aim: We aim to report a novel association of unilateral Graves’ disease with papillary thyroid carcinoma affecting the same lobe. Background: Graves’ disease is characterized by diffuse enlargement of the thyroid gland. Unilateral Graves’ disease is a rare clinical entity characterized by enlargement and hyperfunctioning of a single affected thyroid lobe. Case description: A 29-year-old female presented with thyrotoxic symptoms for the last 1 year. The patient underwent detailed clinical, hormonal, and imaging studies, which confirmed the presence of unilateral Graves’ disease. During this evaluation, she was also found to harbor papillary thyroid carcinoma in the same affected lobe. The patient underwent total thyroidectomy, followed by radioactive iodine ablation. Histopathological examination of excised tissue confirmed the presence of papillary thyroid carcinoma. Conclusion: A diffuse goiter is one of the classical and well-characterized manifestations of Graves’ disease. Unilateral Graves’ disease is a rare variant of Graves’ disease characterized by unilobar involvement. The exact underlying mechanism of unilateral lobar involvement is unknown. Clinical significance: The association of papillary thyroid cancer and unilateral Graves’ disease is unique and has not been described earlier. Due to its rarity, the diagnosis might be easily missed or misdiagnosed. We have also reviewed and summarized the relevant cases of unilateral Graves’ disease reported earlier in the literature.

Introduction: Adrenal myelolipomas are a rare benign tumor composed of mature adipose tissue and hematopoietic elements. The majority of cases are asymptomatic, most of them are diagnosed incidentally or as a result of developing complications due to the tumor. Case description: This report presents an unusual case of a 34-year male who suffered pain abdomen after colliding with a motorbike. Abdominal examination revealed distension in right hypochondrium. CECT abdomen confirmed the presence of right adrenal myelolipoma with possibility of hemorrhage. Hence, the patient was successfully managed with right adrenalectomy. Conclusion: After the initial diagnosis, management of myelolipoma should be done on case-to-case basis. Patients should be made aware of the various complications that could develop in future in case conservative management is chosen.

Introduction: Goiter (derived from the Latin word gutter-throat)¹ is a noncancerous palpable enlargement of the thyroid gland. The enlargement, if it exceeds the upper limit of the normal defined volume, is pathological. Goiter is a manifestation of deficient thyroid hormone production due to iodine (I) deficiency. Here we report a case of a very large endemic multinodular goiter and its management in a secondary care hospital. Case description: A 52-year-old female reported to the outpatient department with swelling in her neck for the past 30 years. On examination, there was a huge swelling in the neck extending superiorly up to the floor of the mouth, inferiorly up to the sternum and pendulous over the sternum with no intrathoracic extension. Ultrasound revealed a heterogeneous echotexture of the gland with multiple nodules. Computed tomography revealed a heterogeneously enhancing enlarged thyroid with no calcification with mild tracheal compression. Fine needle aspiration cytology revealed adenomatous hyperplasia in nodular goiter. Blood triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) levels are within normal limits. Upper gastrointestinal (GI) endoscopy was done, which revealed a postcricoid web. It was managed with bougie dilators under endoscopic guidance. A decision to do a total thyroidectomy was made in view of dysphagia and the chance of containing hidden malignancy. The intubation was smooth. A Gluck Sorenson incision was made, and dissection proceeded like a total thyroidectomy. The strap muscles were retracted laterally and not divided. Left lobe dissection was started, the gland was brought out of the wound, and the carotid artery and internal jugular vein were delineated. A recurrent laryngeal nerve was identified between the carotid artery and trachea and was traced up to the cricothyroid muscle on both sides. Parathyroid was identified and preserved on both sides. The thyroid gland was separated from the trachea dividing Berry's ligament, and removed in toto. There was minimal tracheomalacia. The wound was closed in layers with surgical drains. The patient was extubated the next day. Her voice was normal, and serum calcium was within normal limits on the next postoperative day. On postoperative day 2, patient developed transient hypocalcemia. The same was managed with oral calcium supplements and intravenous (IV) calcium boluses. The patient was discharged home on the 7th postoperative day. Discussion: Adequate blood reservation should be made if transfusion is necessary during or after surgery. Availability of ventilator facilities should be ensured before taking these patients for surgery. During intubation, a difficult airway should be anticipated, and an awake fiberoptic intubation facility should be ready in the operating room. Controlled hypotension during anaesthesia may be necessary for the reduction of overall blood loss and improved surgical field conditions.⁴ It would be ideal to have a nerve monitor in managing these cases, but we could demonstrate recurrent laryngeal nerve without it.⁷ The excess skin need not always be removed as it is stretched skin due to the swelling and returns to its original size after thyroid gland removal. The patient was extubated the next day in view of tracheomalacia. The patient was supplemented with a replacement dose of T4 the next day. The histopathological report was a colloid goiter. Conclusion: This huge goiter is preventable and could have been managed early. The intraoperative challenges with these huge goiters are distorted anatomy, bleeding and injury to vital structures, namely the trachea, esophagus, and great vessels. For huge goiters, we advocate Gluck Sorenson incision, no division of strap muscles, and no excision of the excess neck skin. Tracheomalacia and occult malignancy were the main concerns with this long-standing large goiter.⁸

Aim: Management of spasmodic torticollis after endoscopic thyroidectomy. Background: Spasmodic torticollis is a disorder of movement of neck musculature characterized by involuntary posturing of the head. This results in postural deviations of the head and intermittent or continuous diffuse pain (70–80%) in the area of the neck and shoulder region associated with stiffness. Numerous neck complaints are present in patients who have undergone thyroid surgery, and even after surgery, this discomfort may continue for a long time and become severe if there is a lack of movement of the neck and shoulders postsurgery. At present, the most used endoscopic thyroidectomy method is the bilateral axillo-breast approach endoscopic thyroidectomy (BABA-ET). Case description: We report a case of a 44-year-old female who underwent BABA-ET and 6 months later came with a complaint of pain over the right and front of the neck associated with the sensation of burning, pinpricking, and numbness. The patient was posted for trigger point injection of the right-side sternocleidomastoid and front of neck under ultrasonography and advised for neck stretching exercises along with physiotherapy. On follow-up patient weeks later, the patient reported improvement in pain scores, no neuropathic features, as well as stiffness, and profound improvement in range of motion, which continued for 6 months. Conclusion: Myofascial trigger point neutralization followed by physical therapy significantly alleviates symptoms; therefore, it is a safe, minimally invasive, and diagnostic as well as a therapeutic modality in torticollis. Clinical significance: Neck surgeries predispose patients to neck myofascial pain and the development of trigger points, which may manifest as disturbed motor function in the form of muscle stiffness, weakness, restricted range of motion, and pain. Identifying the culprit's muscle and, along with it, physical therapy and trigger point neutralization helps in a significant reduction in pain and motor activity and improve overall wellbeing.

Lenvatinib and other tyrosine kinase inhibitors (TKIs) are being used in locally advanced thyroid cancers like poorly differentiated and anaplastic, as well as in radiorefractory differentiated thyroid cancer (DTC). However, their role in the neoadjuvant setting for DTCs is being increasingly explored, but there are only anecdotal reports in the literature that too only for percutaneous transhepatic cholangiography (PTC). Our case seems to be the first case where it was used in follicular thyroid cancer in the neoadjuvant setting.