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      A delayed diagnosis: stridor secondary to hypocalcemia

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          Abstract

          Hypocalcemia with stridor is a well-known condition in the pediatric age group but has rarely been reported in the elderly. We report an elderly patient who presented with dyspnea and laryngeal stridor attack caused by hypocalcemia. The patient had been suffering from stridor and dyspnea episodes for 2 years, and the etiology had not been determined until the evaluation in our department. The cause of stridor was hypocalcemia secondary to thyroidectomy. Complete resolution of stridor was achieved by calcium replacement therapy.

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          Incidental parathyroidectomy during thyroid surgery: an underappreciated complication of thyroidectomy.

          The aim of this study was to investigate the incidence, risk factors, and clinical relevance of incidental parathyroidectomy during thyroid surgery. Prospective analysis of data in patients following thyroidectomy, specifically regarding the presence of parathyroid parenchyma in the thyroidectomy specimens, the underlying thyroid pathology, and the presence of postoperative hypocalcemia (biochemical/clinical). The clinical records of 158 patients who underwent thyroid surgery during a 2-year period were reviewed. Pathology reports were carefully reviewed for the nature of the underlying thyroid disease, the presence, number, and size of incidentally resected parathyroid gland(s), their location, and possible parathyroid pathology. Serum calcium levels were measured preoperatively, on the day of surgery, and on postoperative days 1, 2, and 7 or even later as needed. Two groups of patients were studied: a group with incidental parathyroidectomy following thyroidectomy (group A) and a group without incidental parathyroidectomy after thyroidectomy (group B). Total/near-total thyroidectomy was the procedure of choice and was performed in 154 patients; total lobectomy and contralateral subtotal lobectomy was performed in the other 4 patients. Elective central neck lymph node dissection was performed in four patients with neck lymphadenopathy. Inadvertently removed parathyroid tissue was found in 28 cases (17.7 %); in 6 of these patients (21%) the parathyroid tissue was intrathyroidal. The percentage of women in group A was significantly higher than in group B (93% vs. 58.5%, P = 0.0002). There was no statistically significant difference between the two groups (A and B) regarding the preoperative (presumed) diagnosis, the histologic diagnosis of thyroid disease (benign versus malignant), the type/extent of surgery, or the presence of thyroiditis. Biochemical and clinical hypocalcemia was observed in 6 (21%) and 2 (7%) patients in group A, respectively, and in 30 (23%) and 8 (6%) patients of group B, respectively. There was no statistically significant difference regarding the occurrence of postoperative hypocalcemia (clinical/biochemical) between the two groups (P = 0.33). Incidental parathyroidectomy is not uncommon following thyroidectomy and in a significant percentage of cases it may be due to the intrathyroidal location of the parathyroid glands. Incidental parathyroidectomy was not found to be associated with postoperative hypocalcemia (biochemical/clinical). Incidental parathyroidectomy may be considered as a potentially preventable but clinically minor complication of thyroid surgery.
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            Risk factors for postthyroidectomy hypocalcemia.

            Hypocalcemia is a common sequela of thyroidectomy; however, its causative factors have not been completely delineated. A prospective study of 60 patients who underwent unilateral (n = 15) or bilateral (n = 45) thyroidectomy between 1990 and 1993 was completed to determine the incidence and risk factors for hypocalcemia. Free thyroxine, thyrotropin, and alkaline phosphatase levels were obtained before operation in all patients, together with preoperative and postoperative ionized calcium, parathyroid hormone (PTH), calcitonin, and 1,25-dihydroxyvitamin D3 levels. All patients were examined for age, gender, extent of thyroidectomy, initial versus reoperative neck surgery, weight and pathologic characteristics of resected thyroid tissue, substernal thyroid extension, and parathyroid resection and autotransplantation. Hypocalcemia, defined by an ionized calcium level less than 4.5 mg/dl, occurred in 28 patients (47%), including nine (15%) symptomatic patients who required vitamin D and/or calcium for 2 to 6 weeks. In no patient did permanent hypoparathyroidism develop. With a multivariate logistic regression analysis, factors that were predictive of postoperative hypocalcemia included an elevated free thyroxine level (p = 0.003), cancer (p = 0.010), and substernal extension (p = 0.046). Postoperative decline in parathyroid hormone was not an independent risk factor for hypocalcemia, indicating that other factors besides parathyroid injury, ischemia, or removal are involved in the pathogenesis of postthyroidectomy hypocalcemia. An elevated free thyroxine level, substernal thyroid disease, and carcinoma are risk factors for postthyroidectomy hypocalcemia, and their presence should warrant routine postoperative calcium measurement. In the absence of these risk factors, routine postoperative measurement of serum calcium is unnecessary.
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              Prospective study of perioperative factors predicting hypocalcemia after thyroid and parathyroid surgery.

              To identify whether perioperative 1,25-dihydroxyvitamin D or parathyroid hormone (PTH) levels will predict the development of hypocalcemia after thyroid and parathyroid surgery. Prospective study. University hospital. The study included 103 patients who underwent thyroid or parathyroid surgery between 2002 and 2004, with a comparison of the patients who underwent thyroid lobectomy (TL; n = 34), total thyroidectomy (TT; n = 27), parathyroid adenoma excision (PAE; n = 34), and subtotal parathyroidectomy for hyperplasia (SP; n = 8). Preoperative 1,25-dihydroxyvitamin D levels, number of patients requiring calcium replacement, and postoperative PTH and calcium levels. No patients in the TL or PAE group developed postoperative hypocalcemia that required calcium replacement. Six patients (22%) in the TT group and 3 patients (38%) in the SP group required calcium replacement for clinically significant hypocalcemia (P<.001). All patients who required calcium replacement had PTH levels of less than 15 pg/mL (1.6 pmol/L) 8 hours after surgery. Among the patients with postoperative PTH levels of less than 15 pg/mL (1.6 pmol/L) 8 hours after surgery, no patients in the PAE group required calcium replacement, compared with 75% of patients in the TT and SP groups (P<.001). The patients in the TT group had significantly lower postoperative calcium levels than those in the TL (P<.001) or the PAE (P<.005) group. The patients in the TL group reached stable calcium levels significantly earlier than those in the other groups (15.8 hours after surgery; P<.05). There was no relationship between preoperative 1,25-dihydroxyvitamin D levels and postoperative calcium levels. Preoperative 1,25-dihydroxyvitamin D levels were not predictive of postoperative calcium levels. Patients who undergo PAE or TL are at extremely low risk for requiring calcium replacement. Patients who undergo TT or SP with 8-hour postoperative PTH levels greater than or equal to 15 pg/mL (1.6 pmol/L) are at low risk for developing postoperative hypocalcemia, whereas those with PTH levels less than 15 pg/mL (1.6 pmol/L) have a high risk of developing hypocalcemia.
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                Author and article information

                Contributors
                +90-312-3432421 , +90-312-3186690 , fatihbuyukcam@gmail.com
                Journal
                Int J Emerg Med
                International Journal of Emergency Medicine
                Springer-Verlag (London )
                1865-1372
                1865-1380
                23 October 2010
                23 October 2010
                December 2010
                : 3
                : 4
                : 461-462
                Affiliations
                [1 ]Department of Emergency Medicine, Diskapi Yildirim Beyazit Training and Education Hospital, Ankara, Turkey
                [2 ]Yunus Emre Mahallesi, Nurlu Sokak 4/6, Yenimahalle, Ankara, Turkey
                [3 ]Department of Internal Medicine, Diskapi Yildirim Beyazit Training and Education Hospital, Ankara, Turkey
                Article
                228
                10.1007/s12245-010-0228-2
                3047863
                21373324
                ac443192-485a-4972-9d4f-ea210cce6678
                © The Author(s) 2010
                History
                : 19 June 2010
                : 9 August 2010
                Categories
                Case Report
                Custom metadata
                © Springer-Verlag London Ltd 2010

                Emergency medicine & Trauma
                hypocalcemia,stridor,laryngospasm,postoperative complications
                Emergency medicine & Trauma
                hypocalcemia, stridor, laryngospasm, postoperative complications

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