This case involves a forty-year-old female who began to experience heat intolerance, tremors, heart palpitations, weight loss, sweating, anxiety, and diarrhea. Her physician ordered laboratory testing which revealed elevated thyroid hormone levels. An ultrasound of the neck showed multiple nodules in the left lobe of the thyroid gland. Fine needle aspiration with biopsy confirmed the diagnosis of stage I medullary carcinoma. The patient underwent a total thyroidectomy to treat her thyroid cancer. After surgery, the woman experienced symptoms of severe calcium depletion. Although she was taking daily calcium supplements, she experienced muscle tetany and numbness around her mouth. She was also found to have an abnormal EKG with QT prolongation. On physical examination, she experienced carpal spasms when the physician inflated the blood pressure cuff. Also, the patient’s facial muscles spasmed when the physician tapped her cheek. Further evaluation revealed that all of her parathyroid glands were dissected out during her total thyroidectomy. She was told that she developed hypoparathyroidism from surgery, which then caused calcium depletion. The patient required lifelong treatment with calcium chloride.
Question(s) For Expert Witness
1. Did this surgeon practice the standard of care when surgically treating thyroid cancer, and what should have been done to prevent these symptoms from occurring in this patient?
Expert Witness Response
This surgeon failed to properly preserve the parathyroid glands in this patient during a thyroidectomy. Additionally, the patient should have undergone a partial thyroidectomy given the location and stage of the cancer. It is not standard of care to perform a total thyroidectomy in a low stage cancer found within a single lobe of the thyroid gland. All of the parathyroid glands were dissected out as a result of the thyroidectomy causing hypoparathyroidism. One manifestation of hypoparathyroidism is hypocalcemia or calcium depletion. Symptoms of hypocalcemia include petechiae, paresthesias (oral, perioral, and acral), muscle tetany, and hyperactive tendon reflexes. Some clinical signs of hypocalcemia that can be elicited by a physician include Trousseau’s and Chvostek’s sign. Trousseau’s sign is when carpal spasms are elicited when a physician inflates the blood pressure cuff. Chvostek’s sign is when the facial muscles spasm when the patient’s cheek is tapped. Life-threatening complications of hypocalcemia include laryngospasms and cardiac arrhythmias. To prevent this from happening, a partial thyroidectomy should have been performed with preservation of the parathyroid glands and blood supply. If a patient is found to have hypocalcemia due to parathyroid dissection, you can either administer calcium gluconate or calcium chloride.
About the author
Jason Cohn
Jason is a 4th year medical student pursuing a career in Otolaryngology/Facial Plastic Surgery. His Interest include sports, fitness, chemistry, otolaryngology, plastic surgery, allergy/immunology, surgical oncology, human genetics, public health, preventative medicine, and rheumatology.
