# Clinical Cases: Thyroid and Parathyroid Surgery

## Case 1: Papillary Thyroid Carcinoma

### Patient Demographics
- **Age:** 35 years
- **Sex:** Female
- **Occupation:** Marketing executive

### Chief Complaint
"My doctor felt a lump in my neck during a routine physical."

### History of Present Illness
The patient presents for evaluation of a thyroid nodule discovered incidentally during an annual physical examination 2 weeks ago. She is asymptomatic and had not noticed the nodule herself. She denies dysphagia, voice changes, neck pain, or compressive symptoms. She has no history of radiation exposure to the head or neck. She reports feeling generally well with stable weight and normal energy levels.

### Past Medical History
- No significant medical history
- No prior neck surgery or radiation
- Regular menstrual cycles

### Family History
- No family history of thyroid cancer or thyroid disease
- No history of MEN syndrome

### Medications
- None

### Physical Examination
- **Vitals:** BP 118/74 mmHg, HR 70 bpm
- **General:** Well-appearing young woman in no distress
- **Neck examination:**
  - 1.5 cm firm, non-tender nodule in the right thyroid lobe
  - Nodule moves with swallowing
  - No cervical lymphadenopathy
  - Trachea midline
  - No thyromegaly
- **Voice:** Normal

### Laboratory Results
- TSH: 1.8 mIU/L (normal)
- Free T4: 1.2 ng/dL (normal)
- Calcium: 9.4 mg/dL (normal)

### Imaging and Cytology

**Thyroid Ultrasound:**
- Right lobe: 1.6 x 1.2 x 1.1 cm solid, hypoechoic nodule
- Irregular margins
- Microcalcifications present
- Taller than wide configuration
- No extrathyroidal extension
- TI-RADS Category 5 (high suspicion)
- Left lobe: Normal
- No suspicious cervical lymphadenopathy

**Fine Needle Aspiration (FNA):**
- Bethesda Category VI: Malignant
- Papillary thyroid carcinoma

### Preoperative Workup
- Laryngoscopy: Bilateral vocal cord mobility normal
- CT neck without contrast: Confirms nodule location, no lymphadenopathy, trachea not compromised

### Surgical Planning Discussion
Options presented to patient:
1. **Thyroid lobectomy:** For low-risk, unifocal PTC <4 cm
2. **Total thyroidectomy:** Allows RAI therapy, bilateral examination, lower recurrence

After discussion of risks, benefits, and her preferences, the patient opted for total thyroidectomy given desire for comprehensive treatment and avoiding potential second surgery.

### Operative Procedure
- Total thyroidectomy via collar incision
- Recurrent laryngeal nerves identified bilaterally and preserved
- Parathyroid glands identified and preserved with intact blood supply
- Central neck dissection not performed (no suspicious nodes)
- Intraoperative nerve monitoring used

### Pathology Results
- Right lobe: 1.5 cm papillary thyroid carcinoma, classical variant
- Negative margins
- No extrathyroidal extension
- No lymphovascular invasion
- Left lobe: Benign
- AJCC Stage: pT1bN0M0 (Stage I, given age <55)

### Postoperative Course
- Day 1: Serum calcium 8.2 mg/dL, PTH 18 pg/mL (normal)
- No hypocalcemia symptoms
- Voice normal
- Started on levothyroxine 125 mcg daily
- Discharged POD 1

### Adjuvant Therapy Decision
- Tumor board discussion
- ATA risk stratification: Low risk
- Radioactive iodine (RAI): Not recommended for low-risk T1bN0 disease
- TSH suppression: Maintain TSH 0.5-2.0 mIU/L

### Follow-up Plan
- Thyroglobulin levels every 6-12 months
- Neck ultrasound at 6-12 months, then periodically
- TSH monitoring for levothyroxine dose adjustment

### Teaching Points
1. Thyroid nodules are common; most are benign
2. TI-RADS guides FNA decision based on ultrasound features
3. Bethesda system classifies FNA cytology and guides management
4. Surgery is primary treatment for differentiated thyroid cancer
5. Extent of surgery (lobectomy vs. total) based on risk factors
6. Low-risk PTC has excellent prognosis (>98% survival)

### Clinical Image
![Thyroid Nodule Ultrasound](case_01_image.jpg)

**Image Description:** Thyroid ultrasound demonstrating a hypoechoic nodule with irregular margins and microcalcifications, features highly suspicious for malignancy (TI-RADS 5). The taller-than-wide configuration and punctate echogenic foci are characteristic of papillary thyroid carcinoma.

**Attribution:** Image from Wikimedia Commons, Category:Thyroid nodules. Source: https://commons.wikimedia.org/wiki/Category:Thyroid_nodules

---

## Case 2: Primary Hyperparathyroidism

### Patient Demographics
- **Age:** 58 years
- **Sex:** Female
- **Occupation:** Retired nurse

### Chief Complaint
"I've been having kidney stones and my bones are getting weaker."

### History of Present Illness
The patient was found to have hypercalcemia (calcium 11.4 mg/dL) on routine bloodwork 3 months ago. Further workup revealed elevated PTH. She reports a history of two calcium oxalate kidney stones in the past 3 years, requiring lithotripsy for one. She also had a DEXA scan showing osteoporosis (T-score -2.8 at lumbar spine). She complains of fatigue, mild constipation, and difficulty concentrating ("brain fog") that she attributed to aging. She denies bone pain or fractures.

### Past Medical History
- Nephrolithiasis (2 episodes)
- Osteoporosis
- Hypertension
- GERD

### Family History
- Mother had "calcium problems" and kidney stones
- No known MEN syndrome

### Medications
- Lisinopril 10 mg daily
- Omeprazole 20 mg daily
- Calcium + Vitamin D (recently stopped after hypercalcemia diagnosis)

### Physical Examination
- **Vitals:** BP 142/88 mmHg, HR 76 bpm
- **General:** Well-appearing woman
- **Neck:** No palpable masses or nodules
- **Neurological:** Alert, oriented, no focal deficits
- **Musculoskeletal:** No bone tenderness

### Laboratory Results
- Calcium: 11.2 mg/dL (elevated, normal 8.5-10.5)
- Ionized calcium: 1.42 mmol/L (elevated)
- Phosphorus: 2.4 mg/dL (low-normal)
- PTH: 128 pg/mL (elevated, normal 15-65)
- 25-OH Vitamin D: 28 ng/mL (normal)
- Creatinine: 1.0 mg/dL
- 24-hour urine calcium: 380 mg/day (elevated, normal <250)
- Calcium/creatinine clearance ratio: 0.018 (>0.01 rules out FHH)

### Diagnosis
Primary hyperparathyroidism with end-organ manifestations (nephrolithiasis, osteoporosis)

### Localization Studies

**Sestamibi Parathyroid Scan with SPECT:**
- Focal uptake in the right inferior parathyroid region
- Consistent with parathyroid adenoma

**Neck Ultrasound:**
- 1.2 x 0.8 cm hypoechoic nodule posterior to right thyroid lobe
- Consistent with parathyroid adenoma
- Thyroid appears normal

**4D-CT Parathyroid (confirmatory):**
- Right inferior parathyroid adenoma confirmed
- Other parathyroid glands not enlarged

### Surgical Indications
Patient meets criteria for parathyroidectomy:
1. Symptomatic (kidney stones)
2. Osteoporosis (T-score <-2.5)
3. Age <70 with asymptomatic disease would also qualify
4. 24-hour urine calcium >400 mg (borderline)

### Preoperative Preparation
- Adequate hydration
- Avoid thiazide diuretics
- Hold calcium/vitamin D supplements
- Baseline laryngoscopy: Vocal cords mobile

### Operative Procedure
- Minimally invasive parathyroidectomy (MIP) via focused lateral approach
- Right inferior parathyroid adenoma identified and excised
- Intraoperative PTH monitoring:
  - Baseline: 135 pg/mL
  - 10 minutes post-excision: 38 pg/mL (>50% drop - Miami criterion met)
- Other parathyroid glands not explored given successful PTH drop

### Pathology
- Parathyroid adenoma, 480 mg
- Benign, no malignant features

### Postoperative Course
- POD 1 calcium: 8.8 mg/dL
- PTH: 22 pg/mL (normal)
- Mild perioral tingling (hungry bone syndrome) - treated with calcium supplementation
- Discharged POD 1 on calcium carbonate 500 mg TID and vitamin D

### Follow-up
- 2 weeks: Calcium 9.2 mg/dL, tolerating calcium taper
- 3 months: Calcium 9.4 mg/dL, PTH 35 pg/mL, off supplements
- 1 year: DEXA shows 5% improvement in BMD

### Teaching Points
1. Primary hyperparathyroidism: elevated calcium with inappropriately normal/elevated PTH
2. "Stones, bones, groans, and psychiatric overtones"
3. Localization studies identify adenoma location for focused surgery
4. Intraoperative PTH monitoring confirms successful adenoma removal
5. MIP reduces operative time, hospital stay, and complications
6. Hungry bone syndrome: postoperative hypocalcemia due to bone remineralization

### Clinical Image
![Parathyroid Sestamibi Scan](case_02_image.jpg)

**Image Description:** Sestamibi parathyroid scan demonstrating focal uptake in the right inferior parathyroid region consistent with a parathyroid adenoma. The delayed images show persistent uptake in the abnormal gland while thyroid uptake has washed out.

**Attribution:** Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Parathyroid_glands

---

## Case 3: Graves' Disease Requiring Surgery

### Patient Demographics
- **Age:** 32 years
- **Sex:** Female
- **Occupation:** Elementary school teacher

### Chief Complaint
"I can't control my thyroid with medications and I don't want radioactive iodine."

### History of Present Illness
The patient was diagnosed with Graves' disease 18 months ago after presenting with weight loss, palpitations, heat intolerance, and tremor. She was started on methimazole and initially achieved euthyroid state. However, she has had two relapses requiring dose escalation. She developed elevated liver enzymes (AST/ALT 3x normal) on higher dose methimazole, requiring dose reduction. She remains symptomatic with difficulty controlling heart rate. She desires definitive treatment and prefers surgery over radioactive iodine as she is planning pregnancy in the next year.

### Past Medical History
- Graves' disease (18 months)
- Graves' ophthalmopathy (mild - lid retraction, no proptosis)
- No other medical problems

### Family History
- Mother: Hypothyroidism
- Maternal grandmother: "Thyroid problems"

### Medications
- Methimazole 10 mg daily (reduced from 20 mg due to hepatotoxicity)
- Propranolol 20 mg TID

### Physical Examination
- **Vitals:** BP 128/70 mmHg, HR 98 bpm (on beta-blocker), fine tremor
- **Eyes:** Lid lag present, mild lid retraction, no proptosis, no diplopia
- **Neck:**
  - Diffusely enlarged thyroid (approximately 40g)
  - Smooth, non-tender
  - No nodules palpated
  - Audible bruit over thyroid
  - No lymphadenopathy
- **Cardiovascular:** Tachycardic, regular rhythm, no murmurs
- **Skin:** Warm, moist

### Laboratory Results
- TSH: 0.08 mIU/L (suppressed)
- Free T4: 2.8 ng/dL (elevated, normal 0.8-1.8)
- Free T3: 5.2 pg/mL (elevated)
- TSH receptor antibodies (TRAb): Positive
- Thyroid peroxidase antibodies: Positive
- AST: 68 U/L (elevated)
- ALT: 72 U/L (elevated)

### Imaging
**Thyroid Ultrasound:**
- Diffusely enlarged thyroid gland
- Increased vascularity ("thyroid inferno")
- No discrete nodules
- Total thyroid volume: 45 mL

**Radioiodine Uptake (if performed):**
- Elevated 24-hour uptake consistent with Graves' disease

### Treatment Options Discussed
1. **Continue ATDs:** Limited by hepatotoxicity, ongoing symptoms
2. **Radioactive iodine:** Effective but delays pregnancy 6-12 months, may worsen ophthalmopathy
3. **Total thyroidectomy:** Definitive, allows immediate pregnancy planning, appropriate for ophthalmopathy

Patient chose surgery given desire for pregnancy and concern about ophthalmopathy.

### Preoperative Preparation
- Goal: Achieve euthyroid state before surgery
- Continue low-dose methimazole (10 mg) with liver monitoring
- Add potassium iodide (SSKI) 5 drops TID starting 10 days before surgery to reduce vascularity
- Beta-blocker continued
- Preoperative labs: T4 normalized, liver enzymes stable

### Operative Procedure
- Total thyroidectomy
- Capsular dissection technique
- Bilateral recurrent laryngeal nerve identification and preservation
- All four parathyroid glands identified and preserved in situ
- One parathyroid inadvertently devascularized - autotransplanted to sternocleidomastoid muscle

### Pathology
- Diffuse thyroid hyperplasia consistent with Graves' disease
- No malignancy
- Total thyroid weight: 52 grams

### Postoperative Course
- Voice normal postoperatively
- POD 1 calcium: 7.8 mg/dL, PTH: 12 pg/mL (low)
- Symptomatic hypocalcemia (perioral tingling, Chvostek's sign positive)
- Started on IV calcium gluconate, then oral calcium carbonate 1g TID and calcitriol 0.5 mcg BID
- Calcium improved to 8.4 mg/dL
- Started levothyroxine 112 mcg daily
- Discharged POD 2

### Follow-up
- 2 weeks: Calcium 9.0 mg/dL on supplements, weaning
- 6 weeks: Off calcium supplements, PTH recovered to 28 pg/mL
- TSH normalized on levothyroxine
- Ophthalmopathy stable
- Cleared for pregnancy planning

### Teaching Points
1. Surgery is preferred for Graves' with ophthalmopathy, large goiter, or pregnancy planning
2. Preoperative preparation essential: euthyroid state, iodine to reduce vascularity
3. Total thyroidectomy preferred to lobectomy (lower recurrence)
4. Transient hypocalcemia common (20-30%); permanent hypoparathyroidism rare (<2%)
5. RLN injury risk ~1% with experienced surgeon
6. Lifetime levothyroxine replacement required

### Clinical Image
![Graves Disease Thyroid](case_03_image.jpg)

**Image Description:** Thyroid ultrasound with Doppler imaging demonstrating the "thyroid inferno" pattern characteristic of Graves' disease. The markedly increased blood flow throughout the diffusely enlarged gland creates the characteristic appearance of intense color Doppler signal.

**Attribution:** Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Thyroid_nodules