Nurcihan Aygun

Background: Graves' disease (GD) is associated with substantial impairment in health‐related quality of life (HRQoL) owing to a broad spectrum of systemic and neuropsychiatric symptoms. Although total thyroidectomy (TT) is an effective definitive treatment, the temporal pattern of postoperative symptom resolution and recovery of HRQoL has not been well characterized. This study aimed to evaluate the time course of symptom resolution and longitudinal changes in HRQoL following TT for GD. Methods: In this prospective observational study, 48 consecutive patients who underwent TT for GD between February 2025 and January 2026 were enrolled. All patients completed at least 6 months of postoperative follow‐up. Graves' disease–related symptoms were prospectively assessed before surgery and at scheduled postoperative visits using a standardized symptom assessment form. Time to symptom resolution was analyzed using Kaplan–Meier survival analysis. HRQoL was evaluated preoperatively and at 1 and 6 months postoperatively using the 36‐Item Short Form Health Survey (SF‐36). Results: The most common preoperative symptoms were irritability (72.9%), palpitations (70.8%), and heat/cold intolerance (70.8%). Kaplan–Meier analysis demonstrated that palpitations, tremor, heat/cold intolerance, diarrhea, and memory impairment resolved most rapidly, with a median time to resolution of 1 week. Anxiety, depression, ocular symptoms, pain, and irritability resolved more gradually, with a median time to resolution of 4 weeks. By the end of the 24‐week follow‐up, complete resolution was observed in all affected patients with palpitations, tremor, heat/cold intolerance, diarrhea, and pain. Significant improvements were observed across all SF‐36 domains over time (all p < 0.005). Improvements in physical functioning, bodily pain, vitality, role limitations due to physical health, and general health were evident early after surgery and continued through 6 months, whereas social functioning improved significantly only at the sixth postoperative month. Conclusions: TT was associated with rapid resolution of the classic manifestations of hyperthyroidism and significant, sustained improvements in both physical and psychosocial aspects of HRQoL. Defining the temporal pattern of postoperative recovery may improve patient counseling, optimize expectation management, and support shared decision‐making for patients with GD.

Objectives: The incidence of thyroid carcinoma in patients with Graves' disease (GD) has increased, with reported rates ranging from 1% to 21%. While thyroid nodules are a well‐established risk factor, the role of body mass index (BMI) in predicting malignancy in GD remains unclear. This study aimed to evaluate the prevalence of thyroid cancer in GD and identify independent predictors to improve preoperative risk stratification. Methods: We retrospectively analyzed 206 consecutive patients who underwent thyroidectomy for GD between 2016 and 2024. Demographic characteristics, preoperative biochemical parameters, and postoperative histopathological findings were reviewed. Patients were classified as malignant ( n = 42) or benign ( n = 164). All malignancies were papillary thyroid carcinoma. Results: The mean age was 42.3 ± 13.2 years, and 74.8% were female. Age was not associated with malignancy. Female sex was more prevalent in the malignant group (88.1% vs. 71.3%; p = 0.026). Patients with malignancy had significantly higher BMI (28.1 ± 4.2 vs. 25.5 ± 4.3 kg/m ² ; p = 0.001) and a higher rate of thyroid nodules (66.7% vs. 31.1%; p < 0.001). Biochemical parameters were not predictive. Multivariable analysis identified female sex (OR = 2.90, p = 0.045), thyroid nodules (OR = 3.27, p = 0.002), and BMI (OR = 1.13 per kg/m ² , p = 0.005) as independent predictors. BMI alone showed moderate discrimination (AUC = 0.67). Conclusion: Higher BMI is independently associated with thyroid malignancy in GD and may serve as a clinically relevant adjunctive risk marker. When combined with thyroid nodules and sex, BMI may enhance preoperative risk stratification and support more individualized surgical decision‐making in patients with GD. Level of Evidence: 3.

Background: The primary aim of this study was to characterize the prevalence of external branch of the superior laryngeal nerve (EBSLN) injury with and without the use of intraoperative neuromonitoring (IONM) and identify factors associated with injury. Methods: Patients referred to our clinic for thyroidectomy between June 2015 and June 2016 were prospectively randomized into two groups (single‐blinded): in Group 1, IONM was used during upper pole dissection only for the management of the recurrent laryngeal nerve (RLN); in Group 2, IONM was used for both RLN and EBSLN management. After thyroidectomy completion in all patients, cricothyroid muscle (CTM) EMG was performed. Results: EBSLN injury was significantly higher in Group 1 (15.4 vs. 2.1% of NAR, p < 0.001). EBSLN injury was detected in 23 (9.4%) of 245 Friedman type 1, in 7 (18.9%) of 37 Friedman type 2, and in 3 (3.2%) of 94 Friedman type 3 nerves. Conclusion: EBSLN injury is often a transection injury associated with permanent EBSLN dysfunction. Use of IONM facilitates the prevention of EBSLN injury.

Purpose: Postoperative hypoparathyroidism is the most common complication after total thyroidectomy(TT). The clinical significance of incidental parathyroid glands(IP) detected in pathological examination of removed surgical material is still controversial. The aim of this study was to evaluate the clinical follow-up findings and risk factors of patients with IP. Methods: Postoperative pathology results and postoperative biochemical findings of patients who underwent TT±Central Neck Dissection(CND)/Lateral Neck Dissection(LND) between September,2020 and September,2023 in single institution were retrospectively evaluated. Patients with IP were divided into Group-1, and patients without IP were divided into Group-2. Patients of Group-1 were divided as Single IP and Double IP subgroups according to the number of IP. Results: The findings of a total of 412 patients were evaluated. IP was detected in 90(21.8%) of the patients. Postoperative hypoparathyroidism was more common in Group-1 at the 6th hour, 24th hour and 1st month postoperatively (69.7% vs. 31.7%, p < 0.0001; 61.1% vs. 27.7%, p < 0.0001, 26.2% vs. 12.2%, p = 0.002, respectively). Persistent hypoparathyroidism was observed at a rate of 5.3% in Group-2 and 11.5% in Group-1 (p = 0.041). Postoperative hypocalcemia was seen more frequently in Group-1 than in Group-2 at the 12th hour (34.4% vs. 23.2%, p = 0.031, respectively). There was no difference between Single IP vs. Double IP groups for the serum levels of Calcium and PTH. Among the risk factors evaluated for the detection of IP, in the univariance analysis, operation indications(p = 0.018), CND(p < 0.0001), surgeon experience(p = 0.016), thyroid gland volume(p = 0.02), preoperative serum TSH value(p = 0.031); in multivariance analysis, operation type ( ± CND) (OR:2.785; 95% CI: 1.175–6.605; p = 0.020) and operator experience between 10–20 years (OR: 0.117, 95% CI: 0.033–0.418, p = 0.001) and >20 years (OR: 0.254, 95%CI: 0.085–0.760, p = 0.014) were found significant compared to operators experienced <5 years. Conclusion: Patients with detected IP after total thyroidectomy have lower postoperative Calcium and PTH. Significant risk factors for the IP were low level of surgeon experience and undergoing CND.

Purpose: The anatomical variations of the recurrent laryngeal nerve (RLN) are common during thyroidectomy. We aimed to evaluate the risk of RLN paralysis in case of its anatomical variations, retrospectively. Methods: The patients with primary thyroidectomy between January 2016 and December 2019 were enrolled. The effect of age, gender, surgical intervention, neuromonitorisation type, central neck dissection, postoperative diagnosis, neck side, extralaryngeal branching, non-RLN, relation of RLN to inferior thyroid artery (ITA), grade of Zuckerkandl tubercle on vocal cord paralysis (VCP) were investigated. Results: This study enrolled 1070 neck sides. The extralaryngeal branching rate was 35.5%. 45.9% of RLNs were anterior and 44.5% were posterior to the ITA, and 9.6% were crossing between the branches of the ITA. The rate of total VCP was 4.8% (transient:4.5%, permanent: 0.3%). The rates of total and transient VCP were significantly higher in extralaryngeal branching nerves compared to nonbranching nerves (6.8% vs. 3.6%, p = 0.018; 6.8% vs. 3.2%, p = 0.006, respectively). Total VCP rates were 7.2%, 2.5%, and 2.9% in case of the RLN crossing anterior, posterior and between the branches of ITA, respectively (p = 0.003). The difference was also significant regarding the transient VCP rates (p = 0.004). Anterior crossing pattern increased the total and transient VCP rates 2.8 and 2.9 times, respectively. Conclusion: RLN crossing ITA anteriorly and RLN branching are frequent anatomical variations increasing the risk of VCP in thyroidectomy that cannot be predicted preoperatively. This study is the first one reporting that the relationship between RLN and ITA increased the risk of VCP.

BackgroundCentral retinal artery occlusion (CRAO) is a rare ophthalmological emergency and also a unique complication after thyroid surgery.MethodsWe present the first case of CRAO following thyroid surgery in a patient with Hashimoto's thyroiditis, along with a variety of interventions to overcome this complication.ResultsA 42-year-old female patient suffering from sudden vision loss following total thyroidectomy was diagnosed with CRAO. Hyperbaric oxygen therapy was started within the postoperative first 6 hours.ConclusionAlthough it is extremely rare, it should be noted that patients may experience retinal artery occlusion following the thyroid surgery. Immediate evaluation of patients with visual impairment in the early postoperative period, and planning of emergent hyperbaric oxygen therapy for the management are critical.

Purpose The anatomical variations of the recurrent laryngeal nerve (RLN) are common during thyroidectomy. We aimed to evaluate the risk of RLN paralysis in case of its anatomical variations, retrospectively. Methods The patients with primary thyroidectomy between January 2016 and December 2019 were enrolled. The effect of age, gender, surgical intervention, neuromonitorisation type, central neck dissection, postoperative diagnosis, neck side, extralaryngeal branching, non-RLN, relation of RLN to inferior thyroid artery (ITA), grade of Zuckerkandl tubercle on vocal cord paralysis (VCP) were investigated. Results This study enrolled 1070 neck sides. The extralaryngeal branching rate was 35.5%. 45.9% of RLNs were anterior and 44.5% were posterior to the ITA, and 9.6% were crossing between the branches of the ITA. The rate of total VCP was 4.8% (transient:4.5%, permanent: 0.3%). The rates of total and transient VCP were significantly higher in extralaryngeal branching nerves compared to nonbranching nerves (6.8% vs 3.6%, p = 0.018; 6.8% vs 3.2%, p = 0.006, respectively). Total VCP rates were 7.2%, 2.5%, and 2.9% in case of the RLN crossing anterior, posterior and between the branches of ITA, respectively (p = 0.003). The difference was also significant regarding the transient VCP rates (p = 0.004). Anterior crossing pattern increased the total and transient VCP rates 2.8 and 2.9 times, respectively. Conclusion Anatomical variations of the RLN cannot be predicted preoperatively. This study is the first one reporting that the relationship between RLN and ITA increased the risk of VCP. Thus, RLN should be identified definitely till the entry of the larynx to preserve all its branches.

Background: In thyroid surgery, both the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN) should be preserved for maintaining the vocal cord functions. We aimed to evaluate whether EMG of the CTM applied after the superior pole dissection provided additional informative data to the IONM via ETT or not, regarding the EBSLN function.Methods: The prospectively collected data of the patients, who have undergone thyroidectomy with the use of IONM for the exploration of both the RLN and EBSLN between October 2016 and March 2017, were evaluated retrospectively. Patients over 18 years of age with primary thyroid surgery for malignant or benign thyroid disease, and whom were applied CTM EMG with a needle electrode after the completion of thyroidectomy were included in the study. In the study, each neck side was evaluated as a separate entity considering the EBSLN at risk.Results: The data of 41 patients (32 female, 9 male) (mean age, 46.7 + 9.1; range, 22-71) were evaluated. Sixty seven EBSLNs out of 26 bilateral and 15 unilateral interventions were evaluated. With EBSLN stimulation after the superior pole dissection, positive glottic EMG waveforms via ETT were obtained in 45 (67.2%) out of 67, and the mean glottic amplitude value was 261 + 191 μV (min‐max: 116‐1086 μV). Positive EMG responses via the CTM EMG were achieved from all of the 67 EBSLNs (100%) with stimulation using a monopolar probe at the most cranial portion above the area of divided superior pole vessels. The mean value of CTM amplitudes via CTM EMG obtained with EBSLN stimulation was 5268 + 3916 μV (min‐max:1215 ‐19726 μV). With EBSLN stimulation, the mean CTM EMG amplitude was detected significantly higher than the mean vocal cord amplitude (p<0.0001). The CTM EMG provided more objective quantifiable data regarding the EBSLN function (100% vs 67,2%, p<0.001).Conclusion: In addition to the IONM via ETT, intraoperative post-dissection CTM EMG via needle electrode is a safe, simple and applicable method that may provide significant additional informative data to IONM with ETT by obtaining and recording objective quantitative data related to the EBSLN function.

Iscan Y, et al. Ann Surg Treat Res. 2022 Oct;103(4):205-216. https://doi.org/10.4174/astr.2022.103.4.205