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Publication Open Access Anatomical, Functional, and Dynamic Evidences Obtained byIntraoperative Neuromonitoring Improving the Standards ofThyroidectomy(2021) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri ÜniversitesiThe use of intraoperative neuromonitoring (IONM) is getting more common in thyroidectomy. The data obtained by the usage ofIONM regarding the laryngeal nerves’ anatomy and function have provided important contributions for improving the standardsof the thyroidectomy. These evidences obtained through IONM increase the rate of detection and visual identification of recurrentlaryngeal nerve (RLN) as well as the detection rate of extralaryngeal branches which are the most common anatomic variations ofRLN. IONM helps early identification and preservation of the non-recurrent laryngeal nerve. Crucial knowledge has been acquiredregarding the complex innervation pattern of the larynx. Extralaryngeal branches of the RLN may contribute to the motor innerva tion of the cricothyroid muscle (CTM). Anterior branch of the extralaryngeal branching RLN has always motor function and givesmotor branches both to the abductor and adductor muscles. In addition, up to 18% of posterior branches may have adductor and/ or abductor motor fibers. In 70–80% of cases, external branch of superior laryngeal nerve (EBSLN) provides motor innervation tothe anterior 1/3 of the thyroarytenoid muscle which is the main adductor of the vocal cord through the human communicatingnerve. Furthermore, approximately 1/3 of the cases, EBSLN may contribute to the innervation of posterior cricoarytenoid musclewhich is the main abductor of ipsilateral vocal cord. RLN and/or EBSLN together with pharyngeal plexus usually contribute to themotor innervation of cricopharyngeal muscle that is the main component of upper esophageal sphincter. Traction trauma is themost common reason of RLN injuries and constitutes of 67–93% of cases. More than 50% of EBSLN injuries are caused by nervetransection. A specific point of injury on RLN can be detected in Type 1 (segmental) injury, however, Type 2 (global) injury is the lossof signal (LOS) throughout ipsilateral vagus-RLN axis and there is no electrophysiologically detectable point of injury. Vocal cordparalysis (VCP) develops in 70–80% of cases when LOS persists or incomplete recovery of signal occurs after waiting for 20 min.In case of complete recovery of signal, VCP is not expected. VCP is temporary in patients with incomplete recovery of signal andpermanent VCP is not anticipated. Visual changes may be seen in only 15% of RLN injuries, on the other hand, IONM detects 100%of RLN injuries. IONM can prevent bilateral VCP. Continuous IONM (C-IONM) is a method in which functional integrity of vagus-RLNaxis is evaluated in real time and C-IONM is superior to intermittent IONM (I-IONM). During upper pole dissection, IONM makessignificant contributions to the visual and functional identification of EBSLN. Routine use of IONM may minimalize the risk of nerveinjury. Reduction of amplitude more than 50% on CTM is related with poor voice outcome.Publication Open Access Effects of Central Neck Dissection on Complications in Differentiated Thyroid Cancer(2021) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Gül Demircioğlu, Zeynep; Ünlü, Mehmet Taner; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; T.C. Sağlık Bakanlığı; T.C. Sağlık BakanlığıObjective: It is still controversial whether performing central neck dissection (CND) in addition to total thyroidectomy (TT) increases the risk of complications. In the present study, we aimed to evaluate the effect of CND on the development of complications in differentiated thyroid cancer (DTC) compared to TT. Material and Methods: The data of 186 patients (136 females and 50 males) with a mean age of 48.73±14.78 (range, 17–82) whom were operated for DTC were evaluated retrospectively. The patients were divided into two groups, TT (Group 1) and CND±TT/ Completion thyroidectomy±lateral neck dissection (Group 2). Results: There were 117 (91 F, 26 M) patients in Group 1 and 69 (45 F, 24 M) patients in Group 2. Parathyroid auto transplantation (PA) was significantly higher in Group 2 compared to Group 1 (42% vs. 6%) (p=0.000). Total (58% vs. 21.4%, respectively, p=0.000) and transient hypoparathyroidism (52.2% vs. 20.5%, respectively, p=0.000) were significantly higher in Group 2 than in Group 1, but permanent hypoparathyroidism rates were statistically not significant (5.8% vs. 0.9%, respectively, p=0.064). In the multinomial logistic regression analysis, CND alone was determined as an independent risk factor for increased both total and transient hypoparathyroidism. The relative risk (RR) of CND for total hypoparathyroidism was 5.2 times increased (odds ratio [OR]: 0.192) (p=0.007), while the RR for transient hypoparathyroidism was 3.5 times increased (OR: 0.285) (p=0.036). According to the number of nerves at risk, CND was performed in 119 neck side and only thyroidectomy was performed in 253 neck side. Total vocal cord paralysis (VCP) rate (9 [7.6%] vs. 6 [2.4%], respectively) (p=0.017) and transient VCP rate (7 [6%] vs. 4 [1.6%], respectively) (p=0.021) in patients who underwent CND were significantly higher compared to those who underwent only thyroidectomy. In multinomial logistic regression analysis performing only CND was an independent risk factor for total VCP, and increased the total VCP RR approximately 5.34 times (OR:0.184, p=0.007). Conclusion: Although CND can be applied without increasing the rates of permanent hypoparathyroidism and VCP compared to TT, it increases the risk of total and transient hypoparathyroidism, total, and transient VCP. Patients undergoing CND should be followed carefully in terms of transient hypoparathyroidism.Publication Open Access Parathyroidectomy Results in Primary Hyperparathyroidism:Analysis of the Results From a Single Center(2021) Yetkin, Gürkan; Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Akgün, İsmail Ethem; Ünlü, Mehmet Taner; Erol, Rümeysa Selvinaz; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri Üniversitesi; T.C. Sağlık Bakanlığı; Sağlık Bilimleri ÜniversitesiObjectives: The curative treatment of primary hyperparathyroidism (PHPT) is surgery. Persistent and recurrent disease may de velop after surgical treatment. In this study, we aimed to evaluate the surgical cure rate in patients who underwent surgery forPHPT in our clinic. Methods: The data of patients who underwent parathyroidectomy for PHPT by two experienced surgeons between 2000 and2015 in our clinic were retrospectively evaluated. Patients who were followed for at least 6 months after their first parathyroidec tomy were included in the study. Surgical cure and persistent and recurrent disease rates were evaluated in patients. Results: During this period, 368 interventions were performed in 357 patients (293 F and 64 M) who were operated for PHPT inour clinic, with a mean age of 54.9±13.1 years. In the first surgery, 116 patients (32.5%) had bilateral neck exploration, 251 patients(67.5%) had unilateral neck exploration (UNE) or focused parathyroid surgery (FPS). In the first operation, 343 patients (96.1%) hadcure, 14 patients (13 F and 1 M) remained persistent. Secondary surgical intervention was performed in 11 patients. UNE or FPS wasperformed to 10 patients (90.9%), partial sternotomy was performed to one patient. Ten of the patients had cure. Three of these pa tients had a solitary parathyroid adenoma that was not removed in the first surgery, and seven patients had a second adenoma. Fourpatients remained persistent (1.1%). Recurrent disease developed in four patients during follow-up (1.1%). Total cure rate was 97.8%. Conclusion: The only definitive treatment for PHPT is surgery. High surgical cure can be achieved by pre-operative evaluationand appropriate surgical planning. However, persistent PHPT may develop, especially due to double adenoma or ectopic location.Patients with persistent PHPT can be evaluated with repeat imaging methods and with appropriate surgical planning, a high curerate can be obtained in secondary surgery, which can increase the total surgical cure rate. Recurrence rate is rare.Publication Open Access Surgical Treatment of Substernal Goiter Part 1: Surgical Indications, Pre-Operative, and Peroperative Preparation(2022) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Ünlü, Mehmet Taner; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri ÜniversitesiSurgery is one of the most appropriate treatment options for many patients with substernal goiter (SG). However, SG surgery has some technical difficulties and a higher risk of complications compared to normal cervical thyroid surgery. Due to these technical difficulties and complication risks, which we also mentioned in our study, SG surgery should be performed by experienced and high-volume endocrine surgeons in centers with a large team and technical equipment. Pre-operative clinical and radiological evaluation and definitions in SG were evaluated in detail in our previous study. Detailed pre-operative evaluation, pre-operative risk assessment, surgical anatomy, anesthesia, appropriate surgical planning and estimation of surgical width are extremely impor tant in SG surgery, where surgical technical difficulties and increased complication risks compared to cervical thyroid surgery come to the fore. In this study, we aimed to evaluate these preoperative and peroperative preparations in detail.Publication Open Access Influence of Recurrent Laryngeal Nerve Variations \ron Vocal Cord Paralysis(2022) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Demircioğlu, Mahmut Kaan; Demircioğlu, Zeynep Gül; Akgün, İsmail Ethem; Ünlü, Mehmet Taner; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; Sağlık Bilimleri Üniversitesi; T.C. Sağlık BakanlığıObjective: Vocal cord paralysis (VCP) due to recurrent laryngeal nerve (RLN) injury is a significant potential complication of \rthyroid and parathyroid surgery. The aim of this study was to investigate the influence on VCP of the anatomical relationship \rof the RLN to the inferior thyroid artery (ITA) and extralaryngeal branching of the RLN.\rMaterials and Methods: The data of 123 patients (95 female, 28 male, mean age: 46+13.6 years), a total of 204 neck \rsides, who underwent a thyroidectomy and/or a parathyroidectomy performed with intraoperative nerve monitoring between March and December 2015 were evaluated retrospectively. Preoperative and postoperative vocal cord examinations \rwere performed in all cases. RLN branching at a distance of >5 mm with both branches entering the larynx was considered \rextralaryngeal branching of the nerve. Age, gender, nerve side, RLN branching, and the relationship between the RLN and \rthe ITA were evaluated to assess the possible effect on VCP.\rResults: Of the 204 neck sides, 11 (5.4%) RLNs developed VCP. Ten cases were temporary (4.9%) and 1 (0.5%) was \rpermanent. There was no significant difference in age, gender, nerve side, or RLN-ITA relationship in the VCP cases. Extralaryngeal branching was detected in 42 (22.7%) of 185 nerves, and the rate of total and transient VCP was significantly \rhigher in branching nerves than in nonbranching nerves (11.9% vs 3.5%, p=0.034, 11.9% vs 2.8%, p=0.030, respectively).\rConclusion: RLN branching is a potential risk factor for total and transient VCP, awareness of this anatomical variation and \rcomplete exposure during thyroid surgery are crucial to the prevention of RLN injury.Publication Open Access Substernal Goiter: From Definitions to Treatment(2022) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Ünlü, Mehmet Taner; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri ÜniversitesiThe enlargement of multinodular goiter into the mediastinum through the thoracic inlet or ectopic thyroid tissues directly in the \rmediastinum is defined as Substernal Goiter (SG). However, there is no clear consensus in the literature on this definition. There \rare many definitions for SG in the literature. Most definitions are similar or overlapping. Since the thyroid is located in the neck \rabove the thoracic inlet in its normal anatomical position, the simplest clinical definition should be preferred among the definitions regarding its descent below the thoracic inlet and adjacent to the mediastinal organs. In the American Thyroid Association \rguideline, SG is defined as clinical or radiological protrusion of the thyroid gland over the sternal notch or clavicle in a patient with \ra slightly extended neck in the supine position. SGs can be classified as primary or secondary according to their origins. In addition, there are combined SGs resulting from the enlargement of the primary SG, which is the growth of the cervical thyroid gland \rtoward the mediastinum, and the secondary SG, which is defined as an ectopic mediastinal mass, together. We find it appropriate \rto define such SGs as mixed SGs. In this disease, which has the same etiology and etiopathogenesis as cervical goiter, the descent \rof the thyroid gland into the mediastinum due to some anatomical factors explains the physiopathology. Compression symptoms \rof mediastinal major vascular structures, trachea, and esophagus cause the symptoms and findings of SGs due to its localization. \rIn addition, the relationship of SGs with possible malignancy risk and hyperthyroidism affecting the indications and methods of \rtreatment has been discussed for a long time. In this study, we aimed to evaluate the definitions, classification, physiopathology, \rlaboratory and imaging methods used for diagnosis, the relationship of SG with hyperthyroidism and malignancy, and briefly the \rtreatment methods, according to the current studies from literature.