1. External branch of superior laryngeal supplies cricothryroid, the muscle that pulls down the thyroid cartilage and stretches the vocal cords, increasing the pitch of the voice. Damage to this will result in an inability to make high pitched sounds, speech or song.
2. Papillary thyroid cancer: assoc with radiation; if there is a hx of radiation and a nodule, resection of entire thyroid is warranted. If its small <1cm, lobectomy may be appropriate, if not, thyroidectomy. Suppress thyroid function with exogenous thryoxine, consider I-131 ablation.
Follicular thyroid cancer: same management as papillary.
3. Medullary thyroid: measure calcitonin, test for MEN neoplasms (pheo, pituitary, pancreatic, neuromas, parathyroid) and mutations. These tumors are more aggressive and tend to spread-- total thyroidectomy +/- LN dissection. These tumors cannot be treated with thyroxine suppression or I-131 ablation because they do not take up iodine.
4. Anaplastic: survival is poor. Radical excision + chemotherapy and radiation are indicated.
5. Pheochromocytoma: incidence of 1 in 3 million. In addition to blood and urine VMA/HVA metanephrines, do octreotide scan (neuroendocrine tumors/chromaffin cells have increased expression of receptors that take up octreotide/somatostatin) or MBIG scan, which couples a marker to a precursor of epinephrine. Treat with phenoxybenzamine for a week before surgery, add a b-blocker in people with tachycardia or a history of heart disease who may not be able to tolerate the increased catecholamines acting on b-receptors. When operating, be very careful not to manipulate the tumor to avoid catecholamine release. Be wary of extra-adrenal tumors, which will present along the sympathetic chain.
6. Most common cause of primary hyperparathyroidism is adenoma. Can do a sestamibi scan to assess locations of parathyroid adeoma. Dissect out the adenoma, and 2 of the other glands. If you can't find 4, look in the thymus, and between the esophagus and trachea. Symptoms: hypercalcemia causes kidney stones and myalgias and arthralgias from deposition of Ca in tissues. Treating the hypercalcemia: increased Ca leads to osmotic diuresis, which worsens the hyperCa. First IV rehydrate, then give a lot of lasix to diurese off the Ca.
7. Secondary hyperparathyroid: often due to ESRD, inability to excrete phos => increased phos binds all Ca => Ca-sensing cells in parathyroid sense low Ca and secrete excessive amounts of PTH. Also renal failure may lead to decreased 25 hydroxylase activity and less uptake of Ca from gut. This leads to bone lesions (osteitis fibrosis cystica, fractures) as well as possibly Ca deposition in tissues. Treat by removing 3.5 parathyroid glands, +/- implanting last one in arm for easier future access.
8. Carcinomas that metastasize hematogenously: HCC, RCC, chorio, follicular thyroid
9. Sarcomas that are likely to spread to lymph nodes: embryonal rhabdoscarcoma, epithelioid, lymphangiosarcoma, malignant fibrous histiocytoma, synovial cell sarcoma)
10. High grade sarcomas: radical excision + radiation (63 gy); local recurrence is frequent. Lower grade: complete compartmental resection, limb-sparing surgery.