Thyro-Neck Clinic & Research Center

30/03/2026

Anatomy of Larynx

29/03/2026

Thyroid & Head-Neck Oncosurgeon

A specialized center for Thyroid, Parathyroid, Parotid and Head-neck cancer surgery by multidisciplinary team to achieve comprehensive cure.

22/03/2026

CASE SCENARIO -
♦️45 years old male patient diagnosed as a case of Medullary thyroid carcinoma. He was operated 1 year back.
Preoperative serum calcitonin was 120pg/mL
Postoperatively after 6 weeks Serum calcitonin level 10pg/mL
After 6 months Serum calcitonin - 35pg/mL
After 1 year Serum calcitonin -40pg/mL

What will be next steps of management? ♦️

🚩This patient most likely has biochemical persistent/recurrent medullary thyroid carcinoma (MTC) rather than “cure,” because post-op calcitonin never became undetectable and is rising (10 → 35 → 40 pg/mL). In MTC, a detectable/rising calcitonin after total thyroidectomy suggests residual or recurrent disease, and follow-up is guided by calcitonin + CEA , neck imaging, and resectability. Radioiodine is not useful in MTC. 

👉Interpretation of this case
• Pre-op calcitonin 120 pg/mL = relatively low tumor burden.
• 6 weeks post-op calcitonin 10 pg/mL = biochemical response, but not complete biochemical cure.
• 6 months 35 pg/mL, 1 year 40 pg/mL = persistent disease with mild rise.
• Because current calcitonin is 150 pg/mL or rising significantly. 

🚫Next steps of management-

📚1) Confirm biochemical test properly

• Repeat serum calcitonin in the same lab / same assay
• CEA (very important)
• Review the exact operative details:
Total thyroidectomy done?
Central neck dissection?
Lateral neck dissection?
• Final histopathology: tumor size, multifocality, LN status, margin status, extranodal extension
• RET mutation status if not already done

🎈WHY?

• Calcitonin assay variability exists.
• Management depends heavily on calcitonin and CEA doubling time (DT).
• ATA recommends using serial values to estimate doubling time; DT >2 years is more favorable, while 150 pg/mL (many use this threshold)
• Rapid calcitonin/CEA doubling time
• Suspicious symptoms (bone pain, cough, diarrhea, weight loss, neck mass)
• Abnormal neck imaging with concern for bulky disease

Possible later imaging if indicated:
• Contrast-enhanced CT neck/chest
• Liver CT or MRI
• Bone imaging (MRI / bone scan depending symptoms)
• Functional imaging (e.g., FDG PET or DOTATATE in selected advanced cases), but not routine first step at calcitonin 40

ATA follow-up algorithms particularly emphasize systemic localization when postoperative calcitonin is >150 pg/mL. 

⸻

📚4) If neck disease is localized and resectable → Re-operative compartment-oriented surgery

If ultrasound/FNA identifies:
• Persistent/recurrent central or lateral neck nodal disease
• Or thyroid bed recurrence

Then:
• Reoperation by experienced thyroid surgeon
• Prefer compartment-oriented dissection, not “berry picking”

Important caution:

Reoperation is indicated only if structurally identifiable disease is present and resectable.
Do not reoperate for biochemical disease alone (i.e., rising calcitonin without localized structural target).

⸻

📚5) If imaging is negative (most likely in this case) → Active surveillance

If neck US is negative and patient asymptomatic:

Management:
• Observation / surveillance
• Repeat:
• Calcitonin + CEA every 6 months
• Neck US every 6–12 months initially (or sooner if marker rise accelerates)

This is the likely best management for this patient, given:
• Low absolute calcitonin
• Slow rise
• No structural disease yet documented

⸻

📚6) No role for radioactive iodine
• RAI is NOT indicated in medullary thyroid carcinoma.
• MTC does not take up iodine. 

⸻

📚7) TSH management
• Continue levothyroxine replacement
• Do NOT suppress TSH like papillary thyroid cancer
• Keep TSH in normal range in MTC patients 

⸻

👉👉Consider hereditary workup (if not already done)

All MTC patients should have:
• RET proto-oncogene testing
• Screen for MEN2
• If RET positive, evaluate:
• Pheochromocytoma (plasma free metanephrines / urinary metanephrines)
• Hyperparathyroidism (calcium, PTH)

⸻
Summary of this case-

🟥🟥What I would do now in this exact patient??

This is biochemical persistent/recurrent MTC.
Because postoperative calcitonin remained detectable and rose from 10 to 40 pg/mL over 1 year, the next step is:
1. Repeat calcitonin and measure CEA (prefer same assay)
2. Calculate calcitonin/CEA doubling time
3. Perform high-resolution neck US as first imaging (calcitonin

19/03/2026

Anatomy of Pharynx

01/03/2026

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23/02/2026

🎈🎈48 years old lady underwent left Hemithyroidectomy opertaion due to left sided nodular goitre (Bathesda-III).
Postoperative histopathology reveals
-Diffuse sclerosing type papillary thyroid carcinoma
-capsular invasion present
- multifocal
-psammoma bodies present
- surgical margin clear
- no perineural and perivascular invasion
- extensive fibrosis

what will be next plan of management? 🎈🎈

🚩🚩🚩Based on the histopathology, this is Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma (PTC) — an aggressive subtype.

High-Risk Features in This Case
• Diffuse sclerosing variant (more aggressive than classical PTC)
• Multifocal disease
• Capsular invasion
• Psammoma bodies (common in this variant)
• Hemithyroidectomy already done
• Margins clear
• No vascular/perineural invasion reported

This patient is in high risk group as per American Thyroid Association (ATA) risk stratification.

⸻

✅ Recommended Next Management Plan

📍📍Completion Thyroidectomy (Strongly Recommended)

Because:
• Aggressive histologic variant (Diffuse sclerosing type)
• Multifocal disease
• Capsular invasion
• High risk of bilateral and nodal involvement

👉 Remove the remaining right thyroid lobe

Allows:
• Better staging
• Facilitation of radioactive iodine therapy
• Thyroglobulin monitoring for recurrence

⸻

♦️♦️Neck Evaluation Before Completion Surgery
• High-resolution neck ultrasound
• Assess central & lateral cervical lymph nodes
• If suspicious → FNAC

Diffuse sclerosing variant has a high incidence of nodal metastasis.

If nodes positive → Therapeutic neck dissection

⸻

🎴🎴Post-Total Thyroidectomy Radioactive Iodine (RAI) Ablation

After completion thyroidectomy:

👉 RAI ablation is recommended

Indications in this case:
• Aggressive variant
• Multifocality
• Capsular invasion
• Age > 45
• Likely intermediate/high ATA risk

⸻

💹💹TSH Suppression Therapy

Start Levothyroxine with:
• TSH target:
•

18/02/2026

🎈🎈FOLLOW UP PROTOCOL AFTER HEMITHYROIDECTOMY FOLLOWING PAPILLARY THYROID CARCINOMA 🎈🎈

After a hemithyroidectomy (lobectomy) for papillary thyroid carcinoma (PTC), follow-up focuses on detecting recurrence, monitoring thyroid function, and deciding whether further treatment is needed.

⸻

🚩Initial Post-Operative Assessment (6–12 weeks after surgery)

📚Clinical Evaluation
• Wound healing
• Voice changes (recurrent laryngeal nerve)
• Palpation of the remaining lobe and neck nodes

📚Thyroid Function Tests
• TSH
• Free T4

Most patients will need levothyroxine to:
• Replace hormone (if hypothyroid)
• Mildly suppress TSH (goal depends on risk)

⸻

🚩TSH Target After Lobectomy

TSH suppression depends on recurrence risk:

Low risk (most lobectomy cases)
TSH Target- 0.5 – 2.0 mIU/L
Intermediate risk
TSH Target - 0.1 – 0.5 mIU/L
High risk
TSH Target-4 cm
• Gross extrathyroidal extension
• Positive margins
• Clinically significant lymph node metastases
• Aggressive histology
• Vascular invasion
• Multifocal disease in remaining lobe

⸻

🚩Radioactive Iodine (RAI)

After hemithyroidectomy alone:
• RAI is not routinely used
• Only considered if upgraded to high-risk disease and completion thyroidectomy performed

⸻

🚩Long-Term Follow-Up Schedule (Typical Low-Risk Patient)

👉Year 1
• TSH every 3–6 months
• Tg ± TgAb every 6–12 months
• Neck US at 6–12 months

👉Years 2–5
• Annual TSH
• Annual Tg
• Neck US every 1–2 years

👉After 5 years
• Individualized follow-up

⸻

🚩Recurrence Risk After Lobectomy

For properly selected low-risk patients:
• Structural recurrence: ~2–6%
• Disease-specific survival: >99%

Papillary thyroid carcinoma has an excellent prognosis.

⸻

🚨 Red Flags During Follow-Up
• Rising thyroglobulin
• New neck mass
• Abnormal lymph node on ultrasound
• Persistent TSH elevation despite therapy

27/01/2026

26/01/2026

CASE SCENARIO -
🏩🏩15 years old boy presented with left sided neck swelling for 2 months which is mobile and non tender.
FNAC reveals metastatic carcinoma
Core biopsy reveals undifferentiated metastatic nasopharyngeal carcinoma.
Then nasoendoscopic biopsy taken from left sided fossa of rosenmuller but histopathology report was non conclusive.
📚1. what will be next plan of management?

📚2. Can we start chemoradiation without primary confirmation in this case?

SUMMARY-

• Cervical lymph node FNAC → metastatic carcinoma
• Core biopsy of node → undifferentiated metastatic nasopharyngeal carcinoma
• Targeted nasoendoscopic biopsy (left fossa of Rosenmüller) → non-conclusive

The diagnosis is strongly suspected but not histologically proven at the primary site.

Next Plan of Management-

Repeat and more aggressive biopsy of the nasopharynx

Preferably:
• Repeat nasoendoscopic biopsy under general anesthesia
• Multiple deep biopsies
• From:
• Both fossae of Rosenmüller
• Posterior nasopharyngeal wall
• Any suspicious mucosal or submucosal area

👉 A single superficial biopsy is often falsely negative in NPC.

⸻

Additional steps done alongside-

1. Imaging
• MRI of nasopharynx + neck (best for soft tissue and submucosal spread)
• ± PET-CT if available (helps localize occult primary)

2. EBV-related tests
• Molecular testing
• Plasma EBV DNA levels
These strongly support NPC when positive, especially in undifferentiated carcinoma.

⸻

What NOT to do

❌ Do not start chemoradiation without firm histological confirmation
❌ Do not assume lymphoma or TB given confirmed metastatic carcinoma
❌ Do not stop investigation after one negative nasopharyngeal biopsy

If repeated biopsies are still negative (rare but possible)
• Consider random nasopharyngeal biopsies
• Review pathology with immunohistochemistry
• Multidisciplinary tumor board discussion

🚩🚩🚩Can chemoradiation be started based only on neck node biopsy + IHC?🇧🇩🇧🇩🇧🇩

YES, it is acceptable IF all of the following are true:
🎈1. Neck node biopsy conclusively shows:
• Undifferentiated carcinoma
• IHC profile consistent with nasopharyngeal carcinoma
• Cytokeratin positive
• EBER (EBV) positive (very important)

🎈2. Imaging (MRI / PET-CT) shows:
• Lesion or asymmetry in the nasopharynx (especially fossa of Rosenmüller)
• No other primary site identified

🎈3. Repeated nasopharyngeal biopsies are non-diagnostic
• Despite adequate deep and multiple sampling

🎈4. Multidisciplinary tumor board consensus
• ENT + radiation oncology + pathology agree primary is NPC

⸻

Why this is acceptable
• Undifferentiated NPC is EBV-driven
• Cervical nodal metastasis is often the first and dominant presentation
• Primary tumor can be submucosal and occult
• Delaying treatment risks disease progression

So in this situation, the neck node essentially acts as the diagnostic tissue.

When it is NOT acceptable

❌ If IHC is non-specific
❌ If EBV studies are negative
❌ If another primary site is possible
❌ If biopsy was inadequate

In those cases → repeat nasopharyngeal biopsy is mandatory before treatment.

20/01/2026

CASE SCENARIO-

50 years old lady noticed a small nodular lesion in left lateral border of tongue for 6 month.
After excision histopathology report shows invasive squamous cell carcinoma but margins are not mentioned.
Review slide from another lab shows carcinoma in situ.
what will be next plan of management?

KEY FEATURES -

• 50-year-old woman
• Small nodular lesion, lateral border of tongue
• Present for 6 months
• Lesion already excised
• Initial histopath: Invasive squamous cell carcinoma
• Margins not mentioned ➡️(this is a big red flag)
• Second review: Carcinoma in situ

So now we have discordant pathology + unknown margins.

⸻

In this situation should NOT be done

• ❌ Simply observe
• ❌ Assume CIS and do nothing
• ❌ Give radiotherapy without proper staging
• ❌ Manage the neck blindly

⸻

NEXT STEPS-

Wide local re-excision (partial glossectomy) with adequate margins

Why?
• Margins are unknown
• Initial report says invasive SCC
• Tongue lateral border is high-risk
• CIS vs invasive discrepancy → treat cautiously

👉 Re-excision serves both diagnostic and therapeutic purposes.

⸻

Details of the plan
1. Wide local excision of the primary site
• Aim for ≥1 cm clinical margin
• Send specimen with proper orientation

2. Histopathology review by experienced head & neck pathologist
• Confirm:
• Invasion vs CIS
• Depth of invasion
• Margins

3. Neck management
• If final report shows:
• Pure carcinoma in situ → NO neck treatment
• Micro-invasive / T1 SCC with minimal depth → observation of neck
• Significant invasion (>3–4 mm DOI) → consider elective neck dissection
4. No radiotherapy unless:
• Positive margins not salvageable
• High-risk features on final pathology

13/01/2026

27 years old lady presented with thyroid swelling.
Rt lobe -5cm nodule
Lt lobe- 2 tiny nodule 6mm and 8 mm with calcification.
FNAC reveals follicular neoplasm.
what will be next plan of management?

Key features-

• 27-year-old woman
• Right lobe: 5 cm nodule
• Left lobe: two small nodules (6 mm, 8 mm) with calcification
• FNAC: Follicular neoplasm (Bethesda IV)

What FNAC means here

FNAC cannot distinguish follicular adenoma from follicular carcinoma because capsular/vascular invasion can’t be assessed on cytology. So this is not a diagnosis, it’s an indication for surgery.

⸻

Next step in management → Surgery

The question is extent of surgery.

Options:
1. Diagnostic hemithyroidectomy (lobectomy)
2. Total thyroidectomy

⸻

Best choice in this patient → Total thyroidectomy

➡️Why?
• Large dominant nodule (5 cm) → higher risk of malignancy
• Bilateral nodules (even though small)
• Calcification in contralateral nodules → suspicious feature
• Young patient → avoids second surgery if carcinoma is confirmed
• Facilitates:
• Radioiodine therapy (if needed)
• Thyroglobulin surveillance

👉👉Most endocrine surgery guidelines favor total thyroidectomy when:
• Follicular neoplasm plus
• Large size (>4 cm) or
• Bilateral nodularity or
• Suspicious ultrasound features

⸻

So, the plan

👉 Total thyroidectomy, followed by:
• Final histopathology
• Further management based on results:
• If follicular carcinoma → staging ± radioiodine
• If benign → thyroxine replacement

09/01/2026

CASE SCENARIO -
15 years old girl undergoing Superficial parotidectomy for Pleomorphic Adenoma.
During surgery accidentally facial nerve cut..
what is the best management in this situation?

MANAGEMENT-

➡️Immediate primary repair of the facial nerve

If the facial nerve is accidentally cut during superficial parotidectomy, the best management is immediate microsurgical repair during the same operation.

Step-by-step approach
1. Identify both proximal and distal ends of the facial nerve clearly
2. Tension-free end-to-end anastomosis under an operating microscope
• Epineurial (or perineurial) repair
• Fine sutures (e.g., 8-0 or 9-0 nylon)

If direct end-to-end repair is NOT possible

(usually due to a nerve gap or tension)

➡️Interposition nerve graft
• Greater auricular nerve → best choice (readily available in parotid surgery)
• Alternatives: sural nerve, ansa cervicalis

What NOT to do
• 🚫Do not delay repair if it’s recognized intra-operatively
• 🚫Do not close and “wait and see”
Delayed repair gives much worse functional outcomes.

Post-operative considerations
• Facial physiotherapy
• Eye protection (if eye closure affected)
• Long-term follow-up for facial nerve function
• Secondary facial reanimation procedures only if primary repair fails

Why immediate repair matters (especially in kids)
• Better axonal regeneration
• Less muscle atrophy
• Much better long-term facial symmetry and function

When do you see results after immediate facial nerve repair?

Not immediately. Facial nerve recovery is slow and gradual.

Typical timeline
• 0–3 months:
❌ No visible movement
(this is normal — axons are regenerating)
• 3–6 months:
✅ First signs of recovery
– flicker of movement
– slight facial tone returning
• 6–12 months:
✅ Progressive improvement
– better symmetry
– voluntary facial movements
• 12–18 months (sometimes up to 24 months):
Maximal recovery achieved

Why it takes so long?

• Facial nerve regenerates at ~1 mm/day
• Muscles need time to re-innervate and strengthen
• Children/adolescents usually recover better than adults (big plus in a 15-year-old)

Expected outcome after immediate repair
• Good to excellent functional recovery (House–Brackmann grade II–III) in many cases
• Earlier repair = better outcome
• Clean cut > crush injury

Key reassurance for patients/family
• Lack of movement early on does NOT mean failure
• Improvement is gradual and continues for over a year
• Physiotherapy and eye care are essential during recovery