The primary goal is to progress toward entrustment in EPA: Management of Patients with Diseases of the Thyroid and Parathyroid.

• Ultrasound & FNA: Demonstrate the ability to identify thyroid and parathyroid anatomy under ultrasound guidance and perform an ultrasound-guided FNA.

  • Optional (pending rep support): practice radiofrequency ablation of thyroid tissue. 

• Primary surgical technique objectives: 

  • Perform a thyroid lobectomy and/or total thyroidectomy with meticulous nerve preservation.

    • Gain familiarity with advanced nerve monitoring technology and its use in thyroidectomy. 

  • Perform a parathyroidectomy with simulated intraoperative PTH testing with meticulous nerve preservation.

    • Gain familiarity with advanced Parathyroid Identification Technology and its use in parathyroidectomy. 

  • Anatomy: Identify key structures: Recurrent Laryngeal Nerve (RLN), Superior Laryngeal Nerve (SLN), and the ligament of Berry. 

• Secondary surgical technique objectives:

  • Perform an emergency cricothyroidotomy. 

  • Perform a tracheostomy between the 2nd and 3rd tracheal ring with closure of the previous cricothyroidotomy incision. 

Scenario C: Cricothyroidotomy and Tracheostomy

Patient: A 42-year-old woman lost her airway and had a hypoxic arrest after neck surgery and attempts at endotracheal intubation have failed. 

Anatomy and Physiology:

• https://operativereview.com/thyroid-anatomy-physiology

• https://operativereview.com/parathyroid-anatomy-physiology

Specific Conditions:

• https://operativereview.com/thyroiditis-hypothyroidism

• https://operativereview.com/hyperthyroidism

• https://operativereview.com/goiter

• https://operativereview.com/thyroid-nodule-management

• https://operativereview.com/thyroid-cancer

• https://operativereview.com/primary-hyperparathyroidism

• https://operativereview.com/secondary-tertiary-hyperparathyroidism

• https://operativereview.com/parathyroid-carcinoma/

• https://traumaicu.org/tracheostomy/ 

• https://traumaicu.org/accidental-decannulation/

• https://traumaicu.org/tracheostomy-bleeding-and-tracheoinnominate-fistula/ 

Operative Considerations:

• https://operativereview.com/thyroidectomy

• https://operativereview.com/parathyroidectomy

• https://traumaicu.org/cricothyroidotomy/

• https://traumaicu.org/open-tracheostomy/

• https://traumaicu.org/percutaneous-tracheostomy/

Ultrasound/FNA

• Correctly identifies trachea, carotid, and internal jugular on US

• Stabilizes the transducer while maintaining needle visualization

• Successfully "aspirates" the simulated lesion

• Correctly discusses the Bethesda criteria for thyroid pathology

Thyroidectomy

• Creates a symmetric transverse collar incision

• Elevates subplatysmal flaps to the thyroid notch and sternum

• Correctly identifies and divides the midline raphe  

• Identifies, ligates, and divides the middle thyroid vein

• Rotates the thyroid lobe medially to expose the TE groove

• Isolates the superior pole vessels

• Ligates superior vessels individually and close to the capsule

• Identifies the Recurrent Laryngeal Nerve (RLN)

• Identifies and preserves the parathyroid glands

• Meticulous division of the Ligament of Berry

• Divides the isthmus from the trachea with energy or ties

• Correctly re-approximates the strap muscles and platysma  

Parathyroidectomy

• Identifies the relationship of the RLN to the parathyroid glands

• Demonstrates careful dissection of the adenoma

• Verbalizes the Miami criteria for successful adenoma resection

• Discusses/Demonstrates use of advanced parathyroid detection technology in parathyroid surgery

Cricothyroidotomy

• Identifies the thyroid and cricoid cartilage externally

• Creates a longitudinal incision down to the thyroid cartilage and down to the trachea

• Incises the cricothyroid membrane and secures it with a trach hook or bougie

• Places a 6-0 ETT over the bougie into the airway with care to prevent right mainstem intubation

Tracheostomy

• Identifies the cricoid and 2nd/3rd tracheal rings

• Creates an appropriate tracheal window (Bjork flap or slit)

• Successfully places and secures the trach tube

• Closes the cricothyroid membrane defect with absorbable suture