The need for prophylactic central compartment lymph node dissection in patients with papillary thyroid carcinoma continues to be a subject of ongoing debate. Regional lymph node metastases are a common finding with papillary thyroid carcinoma, with an incidence as high as 50% or more. With the widespread use of high resolution ultrasound and sensitive thyroglobulin assays, lymph node metastases, not appreciated at the time of surgery, are showing up in the follow-up period, creating significant angst amongst patients, endocrinologists, and their surgeons. It was previously thought that lymph node metastases in papillary thyroid carcinoma had little bearing on survival, but this has more recently been challenged. Opponents of prophylactic central compartment node dissection cite high perioperative morbidity as a word of caution in performing prophylactic central neck dissections. The following review will look at the most up-to-date literature and best evidence for arriving at logical and sensible recommendations. This review will also look at specific definitions of what is a central compartment lymph node dissection. In the hands of experienced thyroid surgeons, prophylactic central compartment lymph node dissection, performed in a meticulous manner, can limit persistent or recurrent disease in the central compartment, and can diminish the need for routine administration of radioactive iodine, with acceptable perioperative morbidit

Goiter or thyroid swelling in neck has been known to be a risk factor for difficulty in airway management during anesthesia and surgery. The factors associated with difficult direct laryngoscopy and intubations in any patient are also the factors to predict difficult intubation in goiter patients. The huge goiter and long standing goiter especially with intrathoracic extension predispose for tracheomalacia. The tracheomalacia can be diagnosed during surgery but the airway obstruction usually develops after the extubation. Tracheostomy may be required in the event of loss of airway. A better understanding by surgeons and the anesthesiologists about the airway problems in goiter shall improve the outcome

Hypocalcemia and permanent hypoparathyroidism are important outcome measures after total thyroidectomy. The aim of this article is to identify and highlight the wide variation in the adequacy/definition of these complications as reported in the surgical literature.

Nineteen journal articles (2008) on complications of thyroidectomy and 17 journal articles (2002) on ‘prediction’ of postthyroidectomy hypocalcemia derived from a PubMed search were reviewed.

Only 21% of studies of describing outcome and complications of thyroidectomy defined hypocalcemia, temporary/permanent hypoparathyroidism. 47% of studies on the early prediction of hypocalcemia failed to quote their normal range of serum calcium. When stated, the biochemical definition of hypocalcemia varied from 1.8 to 2.12 mmol/l. There is no consistent definition of post-thyroidectomy hypoparathyroidism.

There is no consensus apparent on literature review as to what constitutes post-thyroidectomy hypocalcemia and hypoparathyroidism. The need to benchmark and define appropriate outcome measures of thyroid surgery demands that this deficit is addressed.

Effective strategies that improve the inclusion of older persons in clinical trials are needed to better characterize and treat chronic conditions that affect elderly patients. Especially challenging is the recruitment of the elderly into treatment trials for chronic conditions with vague symptoms, as is the case for primary hyperparathyroidism. The incidence of primary hyperparathyroidism increases with age, and the disease may present with symptoms that are difficult to objectively measure but contribute to decline of function and quality of life. Understanding the optimal treatment of primary hyperparathyroidism necessitates inclusion of greater numbers of older persons in treatment trials. As a part of our study of asymptomatic hyperparathyroidism, we also devised a strategy to recruit and retain older persons in a randomized surgical trial for primary hyperparathyroidism.

Individuals greater than 60 years of age who did not meet established criteria for surgical intervention for primary hyperparathyroidism were offered the opportunity to participate in a clinical study evaluating the benefits of immediate minimally invasive parathyroidectomy (MIP) vs medical observation.

Strategies to encourage participation and compliance included compensation for incidental expenses of lodging, meals, and travel for clinic visits related to the study as well as regular interaction with an experienced study coordinator.

Study participation included formal neurocognitive evaluations, functional magnetic resonance brain imaging, functional performance batteries, and sleep studies over a 6-month period.

Thirty-five individuals ranging in age from 61 to 79 years were screened for participation. Nine individuals were ineligible, and 14 of eligible individuals consented to participate in the study. Among the 12 eligible individuals who declined to participate, the most common reason identified was distance to study center.

We report an effective strategy to recruit a substantial proportion of eligible elderly individuals as subjects in a study of treatment strategies for a medical condition with few overt symptoms.

Parathyroid carcinoma is a rare entity that has diverse presentation and diverse treatments. This case-series highlights the atypical and diverse presentation of parathyroid carcinoma and stresses the importance of the diagnostic approach and intraoperative strategy.

We report three patients with parathyroid cancer.

In one patient, a parathyroid lesion was found to be a parathyroid carcinoma intraoperatively, resulting in a change of operative strategy. In another, parathyroid carcinoma was suspected preoperatively and was treated accordingly. A third patient presented with an already a metastasized parathyroid carcinoma.

The diagnostic approach and intraoperative strategy are instrumental to determining the best treatment and yielding the best outcome.

Adrenal lymphoma is a rare diagnosis in subject presenting with bilateral adrenal masses. Adrenal insufficiency is a common complication of this disease. Most cases of primary adrenal lymphoma (PAL) present with adrenal insufficiency and huge bilateral adrenal masses. These are very aggressive tumors with poor prognosis. We, hereby, report two subjects of adrenal lymphoma presenting with bilateral adrenal masses. First case is a 50 years old male presented with features of adrenal insufficiency like anorexia, weight loss, nausea, vomiting, and generalized hyperpigmentation. Routine investigations revealed hyponatremia, normal serum K; serum lactate dehydrogenase was moderately elevated. Primary adrenal insufficiency was confirmed by low basal and cosyntrophin stimulated cortisol. CT abdomen revealed huge bilateral heterogeneous enlargement of adrenal glands. Lymphoma was confirmed by histopathology and immunohistochemistry, diagnosis of PAL was made after further staging. He was treated with Rituximab-CHOP regimen. Second case, 50 years old lady presented with fever, anorexia, weight loss. She had generalized lymphadenopathy. On imaging found to have bilateral adrenal mass, and histopathology from lymph node, breast mass and adrenal mass was suggestive of non-Hodgkin's lymphoma.

To report two unusual cases of primary hyperparathyroidism (HPT) that initially manifested with a “ jaw tumor” and to discuss the clinical implications of a giant cell granuloma vs an ossifying fibroma of the jaw.

The history, physical examination, laboratory values and the imaging and pathologic findings are described in two patients who presented with a “jaw tumor” and were subsequently diagnosed with primary HPT. The diagnosis and management of osteitis fibrosa cystica and HPT-jaw tumor syndrome are reviewed.

Patient #1 was a 70-year-old male who presented with hypercalcemia, severe jaw pain, and an enlarging mass in his mandible. Biopsy of the mass revealed a giant cell tumor and he was subsequently diagnosed with primary HPT. A sestamibi scan demonstrated a single focus of abnormal radiotracer accumulation, corresponding to a 13,470 mg parathyroid adenoma, which was resected. Postoperatively, the serum calcium normalized and the giant cell granuloma regressed spontaneously.

Patient #2 was a 36-year-old male with four incidentally discovered tumors of the mandible and maxilla, who was diagnosed with normocalcemic HPT and vitamin D deficiency. Biopsy of one of the tumors revealed an ossifying fibroma. Bilateral neck exploration revealed a 2480 mg right inferior parathyroid adenoma, which was resected. Postoperative genetic testing revealed an HRPT2 gene mutation. He subsequently underwent resection of an enlarging ossifying fibroma of the mandible with secondary reconstruction.

A “jaw tumor” in a patient with primary HPT may be a manifestation of osteitis fibrosa cystica or HPT-jaw tumor syndrome underscoring the importance of biopsy and genetic testing for management and follow-up.