Background: The use of intraoperative neuromonitoring (IONM) provides surgeons with real time information about recurrent laryngeal nerves (RLN) functional integrity. Hence, allowing them to modify the initially scheduled bilateral procedure, to a two-stage thyroidectomy in cases of loss of signal (LOS) on the first side of resection resulting in minimization of bilateral RLN injury. The purpose of our study was to present our results since the implementation of the above mentioned process in both malignant and benign thyroid disease. Methods: We conducted a retrospective, observational cohort study of prospectively collected data from all patients who underwent a scheduled total thyroidectomy with or without neck dissection in our Department over the last 4 years [2013-2016]. From the 1,138 patients who received surgical treatment during that period, 284 were excluded since they did not meet the criteria. Exclusion criteria involved previous neck operation, parathyroid surgery, pre-existing vocal cord palsy (VCP) and unilateral surgery. A total of 854 patients were eligible for our study. All patients were subjected to pre-and postoperative indirect laryngoscopy by the same experienced ENT specialist team and all the surgeries were performed by the same experienced team. The whole procedure followed the International Neural Monitoring Study Group's (INMSG) Guideline Statement. Results: We experienced 70 cases (70/854, 8.2%) with postoperative VCP. Two of them (0.23%) had permanent VCP and the rest of those patients (7.97%) experienced transient VCP. Twenty-three (2.7%) patients were candidates for staged thyroidectomy after LOS on the first side of resection, including ten patients with papillary or medullary thyroid carcinoma and one with toxic multinodular goiter (MNG). Of those patients, 22 incidents of VCP (95.7%) have recovered within two months and one of them persisted for more than six months (permanent VCP). We did not experience any permanent bilateral RLN palsy after the implementation of the staged procedure. Conclusions: Staged thyroidectomy seems a very attractive and promising procedure for both patient and surgeon, since it nearly eliminates one of the most fearful complications in thyroid surgery. We suggest staged thyroidectomy in all cases with first side of resection signal loss, even in malignancies, since the benefits are much more than the disabilities in a patient's morbidity and quality of life.

The frequency of surgical site infections (SSIs) after clean neck surgery is low and antibiotic prophylaxis is not recommended. This retrospective study investigated the effect of perioperative prophylactic antimicrobial therapy on the development of infections. A total of 807 consecutive patients undergoing clean neck surgery were included in the study. Antimicrobial prophylaxis with intravenous cefuroxime was administered in 518 cases. Although patients who received prophylaxis had a lower rate of SSIs than those who did not receive antibiotics, this was not statistically significant (0.4% vs 1.4% respectively, p=0.19). Older age was the only variable associated with the development of SSIs (p=0.014). Clean neck operations (thyroidectomy, parathyroidectomy and lymph node resection) are among the most common operations performed worldwide. Most guidelines do not recommend the routine use of perioperative antimicrobial prophylaxis for these procedures 1,2 because the frequency of surgical site infections (SSIs) is generally low (<1%).3,4 However, prophylaxis is still often used in these cases as some surgeons and anaesthetists feel that this advice is not appropriate for a part of the globe in which multidrug resistant infections are endemic. In this context, we studied the frequency of postoperative infections after clean neck surgery and examined the effect of perioperative prophylactic antimicrobial therapy on the development of infections. MethodsThis was an observational, retrospective study performed in a 140-bed private clinic (Department of Endocrine Surgery, Central Clinic) in Athens, Greece, over a 5-year period (2010)(2011)(2012)(2013)(2014). The study was approved by the clinic's ethics committee. All patients undergoing clean neck surgery (regardless of age, sex and co-morbidity) were included. All operations were performed by the same primary surgeon and surgical team. Apart from the primary operator, there were also three assistants and one of two anaesthetists. Administration of perioperative prophylaxis was at the discretion of the anaesthetist. The first anaesthetist did not provide antibiotic prophylaxis in any patient while the second administered antibiotics to all patients. Selection of the anaesthetist was independent of patient characteristics and operation plan. All data were retrieved from patient files. The patients were divided into two groups based on whether antimicrobial prophylaxis was administered. Among the patients in the antibiotics cohort, only those who received intravenous cefuroxime were studied. The primary outcome was the rate of SSIs or remote infections. Statistical analysis ResultsDuring the study period, 849 patients underwent surgery. Of these, 34 were excluded because data were missing, 7410 Ann R Coll Surg Engl 2017; 99: 410-412

We report an unusual case of idiopathic unilateral adrenal haemorrhage (AH) in a 55-year-old patient. This rare case had two characteristics that made it worth of report. First, idiopathic adrenal haemorrhage is very uncommon, and second it was presented as a huge, 23 cm diameter and 2,123 gr weight, “silent” adrenal mass. It is important to distinguish a benign lesion like this from a neoplasm, although we were not able to identify it preoperatively and the diagnosis was only made after the excised specimen was examined by a group of experienced histopathologists. Only a few similar published cases, to our knowledge, are described in the worldwide literature and even fewer of this size.

Intrathyroidal lymphoepithelial (branchial) cysts are very rare, and only few cases have been previously reported worldwide.Here, we report on a case of a male patient with such a rare histological finding after a routine left hemithyroidectomy performed for a nearly 4 cm cystic left thyroid lobe lesion. The patient was an 80-year-old man, fact that makes, to our knowledge, our patient the oldest in the current literature. Through a review of the existing literature, we concluded that although some entities are extremely rare, they should also be taken under consideration in everyday clinical differential diagnosis of otherwise common medical cases, such as our presented case. Such cases pose a differential dilemma for the clinical doctor in order to make a correct diagnosis, if that is possible, and then proceed with the efficient treatment.

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