Vol 12, No 4 (2018)

Clinical practice
Anatomical landmarks of the external branch of the superior laryngeal nerve
Malyuga V.Y., Kuprin A.A.

Background. The external branch of the superior laryngeal nerve innervates a cricothyroid muscle, which provides tension in vocal cords and formation of high-frequency sounds. When the nerve is damaged during surgery, patients may notice hoarseness, inability to utter high pitched sounds, “rapid fatigue” of the voice, and dysphagia. According to literature, paresis of an external branch of the superior laryngeal nerve reaches up to 58% after thyroid surgery.

Aim: to identify permanent landmarks and topographic variations of the external branch of the superior laryngeal nerve.

Materials and methods. The study is based on the autopsy material (21 complexes organs of the neck) and on identification of variations of 40 external branches of the superior laryngeal nerve. We identified two permanent landmarks that are located at the minimum distance from nerve and we made metrical calculations relative to them: oblique line of thyroid cartilage and tendinous arch of the inferior pharyngeal constrictor muscle.

Results. The piercing point of the nerve is always located at the inferior pharyngeal constrictor muscle without protruding beyond the oblique line of thyroid cartilage superiorly and tendinous arch of the inferior pharyngeal constrictor muscle anteriorly. The nerve had the parallel direction in 92.8% of cases (angel less than 30 degrees) relative to the oblique line and in 85.7% cases it was in close proximity to this line (at distance up to 4 mm).

The proposed topographic classification of the location of the external branch of the superior laryngeal nerve is based on localization of the piercing point of the nerve relative to the length of the oblique line of thyroid cartilage and the risk of nerve damage. In 14.2% of cases, the piercing point was in the front third of the line (type I), and in 50% it was in the middle third of this line (type II). These variations of the external branch of the superior laryngeal nerve was in close proximity to the upper pole of the thyroid gland, which could have lead to its damage during surgery. In type III and IV (35.8%) – the piercing point in the muscle was located as far as possible from the upper pole of the thyroid gland and the greater part of the nerve was covered with the fibers of inferior pharyngeal constrictor muscle.

Conclusion. We identified the main orienteers for the search and proposed anatomical classification of the location of the external branch on the superior laryngeal nerve.

Endocrine Surgery. 2018;12(4):161-177
Review of literature
Parathyroid glands: the normal development, anatomy and histological structure
Mokrysheva N.G., Krupinova J.A., Voronkova I.A.

Parathyroid glands (PG) are endocrine glands, which are the most important humoral regulators of calcium and phosphorus metabolism in the body. They were first described by an Englishman Richard Owen in 1849. Most of patients have four PG – upper and lower. In 13% of cases there are more than four PG. The glands arise as diverticula from the endoderm of the third and fourth branchial pouches between the fifth and twelfth week of gestation. The IV branchial pouch forms the upper gland, and III pouch forms the inferior gland.

The parathyroid hormone production has been demonstrated as early as 83/7 weeks gestational age. The formation, migration, differentiation and functioning of the PGs are determined by a number of genes and changes in them could lead to disfunction in these processes. The ectopic of PG is possible when migration violation (up to 22% of cases). The most common location of the ectopic PG is parenchyma of the thymus and thyroid gland. Each PG is richly vascularized and it is surrounded by a thin connective tissue. In adults, there are two types of parenchymal cells: the chief cells (active and inactive forms) and the oxyphil cells. During the life, the ratio of types of parenchymal cells and their activity have been changing, as well as the characteristics of the stroma.

Endocrine Surgery. 2018;12(4):178-187
Clinical Case
Medullary thyroid cancer. Returning to the need to determine the preoperative basal calcitonin level in patients with thyroid nodular pathology
Stanyakina E.E., Romanov I.S., Kondratieva T.T., Krylov A.S., Ryzhkov A.D., Shiryaev S.V.

There are International and Russian guidelines for the diagnosis and treatment of medullary thyroid carcinoma. There is a recommendation to determine the basal level of calcitonin for all patients with nodular thyroid disease at the all of these documents. However, this test is not performed for this category of patients routinely even in large clinics for a number of reasons, the main one, which seems to be an economic issue. Six months ago a patient addressed to our clinic who underwent surgical treatment for a papillary carcinoma (follicular variant) of the thyroid gland in the volume of thyroidectomy with pre-tracheal lymphodissection and subsequent course of radioiodine therapy at the place of residence. A relapse of the disease was suspected on the control examination at the place of residence and the patient was sent for consultation to the polyclinic of the N.N. Blokhin National Medical Research Center of Oncology. In our clinic, diagnostic studies were carried out, including a revision of the finished cytological and histological preparations and a conclusion was obtained – medullary carcinoma of the thyroid. Determination of basal level of calcitonin in serum showed a value of 1292 pg/ml. The level of basal calcitonin significantly decreased after repeated surgical treatment. This case shows that in order to avoid such mistake, which is described in our clinical case, it seems necessary to follow the national recommendations, international standards to determine the level of basal calcitonin for all patients with thyroid nodal pathology who consulted and treated in medical institutions.

Endocrine Surgery. 2018;12(4):188-195
18F-FDG PET/CT in nonfunctioning adrenocortical carcinoma diagnostics: case report
Dolgushin M.B., Martinovich A.A., Meshcheriakova N.A., Tulin P.E.

Clinical observation of the patient with adrenocortical cancer recurrence after adrenalectomy and multiple treatment.

A 46 year old man was diagnosed with adrenal mass. Endocrine activity was excluded. Due to local cancer advancement, the patient was given a radical treatment. After 5 years after surgical treatment, a local recurrence of the disease was detected according to the results of CT. For further restaging the patient underwent PET/CT with 18F-FDG, according to the results no distant metastases were detected. After complex treatment and observation period metastases were diagnosed. This clinical observation demonstrates possibilities of PET/CT with 18F-FDG – PET/CT, helps to determine nature of adrenal mass formations, revealing signs of their malignancy and is a valuable tool in adrenocortical cancer in cases of recurrent disease and in cases of metastatic lesions.

Endocrine Surgery. 2018;12(4):196-201

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