• Onset & Duration

  • Acute: < 2 wks
  • Subacute: 2–6 wks
  • Chronic: > 6 wks (≥ 4 wks in adults → malignancy workup)

• Growth Rate

  • Rapid → consider lymphoma, Riedel’s thyroiditis

• Associated Symptoms

  • Local: dysphagia, dyspnea, hoarseness (RLN), pain (subacute thyroiditis)
  • Systemic: fever, weight loss, night sweats (lymphoma, TB)

• Thyroid Function Symptoms

  • Palpitations, tremor, heat intolerance — absent here

• Risk Factors & Exposures

  • Prior neck irradiation, family history of thyroid cancer

• Social Hx

  • Tobacco, alcohol (↑ head & neck malignancy risk)

• Pulse

  • Supine: 98 bpm
  • Standing: 102 bpm (no orthostasis)
  • Persistent tachycardia in euthyroid → consider anxiety, anemia, POTS

• Thyroid Function Tests

  • TSH & Free T₄: normal → euthyroid

• CBC

  • Rule out anemia (tachycardia cause)

• Inspection

  • Midline swelling, smooth, ~3 cm
  • Moves with swallowing → thyroid origin

• Palpation

  • Firm, non-tender
  • Mobile except on deglutition
  • No pulsatility or bruit (rules out vascular)

• Special Tests

  • Transillumination: negative (solid vs cystic)

• Thyroid enclosed in pretracheal fascia → attaches to larynx/trachea
• Elevation of larynx/trachea during deglutition transmits movement to gland

• Remnant tract from foramen cecum to thyroid
• Attached to hyoid/tongue base → protrusion pulls cyst upward

• Nodular goitre
• Subacute or Riedel’s thyroiditis
• Thyroid carcinoma

• Thyroglossal duct cyst (moves on tongue protrusion)
• Dermoid cyst

• Infectious
• Tubercular
• Malignant

• Lipoma
• Carotid body tumor (pulsatile, bruit)

• Size, echotexture, vascularity
• Suspicious features: microcalcifications, irregular margins

• Indications:
  • Nodules > 1 cm with high-risk U/S features
  • Clinical suspicion of malignancy

• TFTs (already done)
• CBC (rule out anemia)
• Consider tilt-table if POTS suspected

• Indication: suspected retrosternal extension or complex neck anatomy

• AP view
• Lateral view
• Thoracic inlet view (for anesthetist → assess retrosternal extension & intubation difficulty)

• Indication: suspected hyperfunctioning nodules (not performed in euthyroid cases)

• Delay between radial and femoral pulse upstrokes → suggests coarctation or aortic compression

• Large retrosternal goitre compresses aortic isthmus → mimics coarctation physiology

Radio announcer (radial) sprints ahead, farmer (femoral) lags → “radio before femoral.”

58-year-old with long-standing multinodular goitre, intermittent leg cramps. Radial 80 bpm, femoral lag 0.4 s at 76 bpm. CT confirms retrosternal extension compressing aortic isthmus.

• Loss of palpable carotid pulse when compressed between thumb & fingers over thyroid lobe

• Tumour infiltration/encasement of carotid sheath → obliteration of arterial upstroke

Squeezing a jar of berry jam so tight it crushes its neck → no pulse felt.

62-year-old man, 6-week rapidly enlarging right neck mass. Compression abolishes right carotid pulse. FNAC confirms anaplastic thyroid carcinoma.

• Palpate & auscultate over superior border of thyroid cartilage, lateral to trachea in carotid triangle

• Thrill: palpable vibration over gland
• Bruit: continuous/systolic murmur on auscultation
• Mechanism: diffuse hypervascularity & high-flow shunting

Red goitre as mini volcano, rumbling vibration heard and felt.

30-year-old woman with weight loss, heat intolerance, smooth diffuse goitre. Thrill & bruit present bilaterally. Labs: suppressed TSH, high Free T₄.

• Warm, pulsatile, erythematous nodules → rare cutaneous metastases

• Hematogenous spread of follicular/papillary carcinoma to vascular scalp skin

“Scalp volcano” erupting metastatic nodules.

65-year-old man, 2 years post-thyroidectomy for follicular carcinoma, presents with 3 tender, hyperemic scalp nodules. Biopsy confirms metastatic thyroid carcinoma.

• Indication: retrosternal extension or complex anatomy

• AP view
• Lateral view
• Thoracic inlet view (for anesthetist: assess retrosternal extension & intubation difficulty)

• Indication: suspected hyperfunctioning nodule (not used in euthyroid patients)

• Delay between radial & femoral pulse upstrokes → suggests aortic obstruction

• Large retrosternal goitre compresses aortic isthmus → mimics coarctation physiology

Radio announcer (radial) sprints ahead, farmer (femoral) lags → “radio before femoral.”

• Carotid pulse disappears when compressed between thumb & fingers over thyroid lobe

• Tumour encases/compresses carotid sheath → obliterates arterial pulsation

Squeezing a jar of “berry jam” too tight → no pulse felt.

• Superior border of thyroid cartilage, lateral to trachea in carotid triangle

• Thrill: palpable vibration
• Bruit: continuous/systolic murmur
• Mechanism: diffuse hypervascularity & high-flow shunts

Mini volcano goitre, rumbling vibration heard/felt.

• Warm, pulsatile, erythematous nodules → rare thyroid metastases

• Hematogenous spread of follicular/papillary carcinoma to scalp skin

“Scalp volcano” erupting metastatic nodules.

• Genetics: AD RET mutation
• MEN2A: MTC + pheochromocytoma + parathyroid hyperplasia
• MEN2B: MTC + pheochromocytoma + mucosal neuromas + marfanoid habitus

28-year-old woman, family history MTC, 2 cm thyroid nodule, calcitonin 350 pg/mL, 2× ↑ metanephrines, Ca 2.8 mmol/L + ↑PTH → bilateral adrenalectomy → total thyroidectomy + central neck dissection → parathyroidectomy if needed → RET genetic screening in family.

“RET-ro elevator” stuck between C-cells, adrenals, parathyroids.

• Genetics: MEN1 (menin) mutation
• 3 Ps: Parathyroid adenomas, Pancreatic NETs, Pituitary adenomas

40-year-old man with kidney stones, peptic ulcers, headache, galactorrhea; Ca 2.9 mmol/L + ↑PTH → parathyroidectomy; gastrin 800 pg/mL → enucleation of duodenal gastrinoma; prolactin 200 ng/mL + 8 mm pituitary microadenoma → consider TSS; lifelong surveillance.

Three partygoers at a piano reciting “P-P-P.”

• Rare extrathyroidal sign in Graves’ disease (<1%)
• Digital clubbing + periosteal new bone formation + soft-tissue swelling

52-year-old man with chronic Graves’, painless clubbing & shin edema, X-ray shows periosteal reaction on metacarpals/metatarsals, TRAb+, manage with NSAIDs/corticosteroids + treat Graves’.

Acrobats balancing on clubbing logs sprouting bone spikes.

• GAG deposition in dermis → nonpitting edema + “orange-peel” skin
• Follows ophthalmopathy by 6–12 months (5% Graves’)

45-year-old with Graves’, reddish plaques on shins, “orange-peel” texture, dermal thickening on ultrasound → topical steroids + control thyrotoxicosis.

• Delayed relaxation of Achilles reflex → hypothyroidism

60-year-old post-thyroidectomy noncompliant with levothyroxine, fatigue/cold intolerance, delayed ankle jerk relaxation, labs: ↑TSH, ↓T₄ → restart levothyroxine → reflex normalizes in 4 weeks.

• Thyroid myopathy: type II fiber atrophy in hyperthyroid; slowed kinetics in hypo

50-year-old with Graves’, 3 weeks difficulty climbing stairs, 4/5 proximal strength, CK 300 U/L → methimazole + beta-blocker → full recovery in 8 weeks.

• Diffuse Goitre

  • Uniform, smooth enlargement
  • Euthyroid
  • ↑ iodine deficiency (endemic)

• Solitary Nodular Goitre

  • Single palpable nodule
  • Colloid cyst, adenoma, or carcinoma

• Multinodular Goitre (MNG)

  • Multiple discrete nodules
  • Asymmetric, heterogeneous

1. Diffuse Goitre

   22-year-old from iodine-deficient region; 2-year painless bilateral swelling; euthyroid; treated with iodized salt → regression in 6 months.

2. Solitary Nodule

   45-year-old man; 1.5 cm right thyroid nodule; US: hypoechoic; FNAC Bethesda II; periodic US follow-up.

3. MNG

   60-year-old woman; 20-year goitre, mild dysphagia; dominant 3 cm nodule FNAC benign; subtotal thyroidectomy for compression.

• Pathophysiology: TSH-R antibodies → diffuse hyperplasia
• Features: Smooth goitre, ophthalmopathy, pretibial myxedema, bruit/thrill
• Case: 28-year-old; palpitations, weight loss, warm goitre with thrill; TSH↓, T₄↑, TRAb+; methimazole + β-blockers + radioiodine

• Pathophysiology: Pituitary adenoma secretes TSH
• Features: ↑TSH & ↑T₄, pituitary mass, no ophthalmopathy
• Case: 50-year-old; TSH 8 mIU/L, ↑T₃/T₄; MRI pituitary adenoma; transsphenoidal resection

• Definition: Autonomous hyperfunctioning nodule(s)
• Case: 65-year-old; heat intolerance, 4 cm “hot” nodule on scintigraphy; lobectomy → resolves hyperthyroidism

• Autoimmune lymphocytic destruction → initial enlargement → atrophy; hypothyroid
• Case: 35-year-old; fatigue, weight gain, firm painless goitre; ↑TSH, anti-TPO+; levothyroxine

• Post-viral granulomatous inflammation; thyrotoxic → hypo → euthyroid
• Case: 40-year-old; tender thyroid, fever post-URI; ↑ESR, transient thyrotoxicosis; NSAIDs supportive

• Fibrosing inflammation extends beyond gland → “woody” thyroid
• Case: 50-year-old; hard fixed mass, dyspnea; biopsy fibrous; corticosteroids + surgical decompression

• Follicular adenoma subtypes: colloid, fetal, embryonal, Hurthle-cell
• Case: 52-year-old; 2 cm adenoma; FNAC suggests follicular; lobectomy confirms Hurthle-cell adenoma

1. Papillary Thyroid Carcinoma (PTC)

   • Lymphatic spread; excellent prognosis
   • Case: 30-year-old; 1 cm nodule, microcalcifications; FNAC PTC; thyroidectomy + node dissection

2. Follicular Carcinoma

   • Hematogenous spread; encapsulated invasion
   • Case: 55-year-old; 3 cm biopsy; hemithyroidectomy → invasion; completion thyroidectomy + RAI

3. Medullary Thyroid Carcinoma (MTC)

   • C-cell origin; MEN2 association
   • Case: 38-year-old MEN2A; ↑calcitonin, RET+; prophylactic thyroidectomy at age 10; monitor calcitonin

4. Anaplastic Carcinoma

   • Rapid, poor prognosis
   • Case: 70-year-old; painful enlarging mass, dysphagia; biopsy anaplastic; palliative radiotherapy

• Primary: Gland overproduces hormone (Graves’ or toxic nodules)
• Secondary: Pituitary TSH-oma drives normal gland

• Primary: TSH↓, T₄/T₃↑; eye signs; autoimmune markers
• Secondary: TSH ↗ or normal, T₄/T₃↑; pituitary mass

• TRH Test: Blunted TSH rise in primary; paradoxical in secondary
• RAI Scan: Homogeneous/focal uptake primary; diffuse non-suppressed in secondary
• MRI: Pituitary adenoma in secondary

• Primary: Methimazole/PTU → RAI or thyroidectomy for definitive
• Secondary: Transsphenoidal resection → octreotide if needed → antithyroids pre-op

• Graves’ (Primary): 32-year-old F, palpitations, smooth goitre + thrill, exophthalmos, TSH <0.01, RAI uptake 60%, treated with methimazole + RAI.
• TSH-oma (Secondary): 55-year-old M, mild goitre, TSH 5.5, T₄ ↑, MRI pituitary macroadenoma, transsphenoidal surgery.

• AP View:

  • Assess thyroid size, shape, tracheal deviation
  • Evaluate mediastinal widening

• Lateral View:

  • Visualize retrosternal extension
  • Assess tracheal compression/anterior displacement

• Thoracic Inlet View:

  • For anesthesia planning → identifies goitre extension below clavicles
  • Predicts difficult intubation or need for sternotomy

Hypothetical Case:

45-year-old woman treated for asthma, progressive dyspnea, MNG. Thoracic inlet view shows >50% gland below clavicles → fiberoptic intubation + cervical-sternal approach planned.

• Characterize Nodules:
  • Size, echotexture (solid vs. cystic), margins, microcalcifications, vascularity
• Risk Stratification:
  • Use TIRADS/ATA criteria → high-suspicion features (hypoechoic, irregular, “taller-than-wide”)
• Volume Assessment:
  • Estimate gland & substernal component → surgical approach

Hypothetical Case:

52-year-old man, 2.5 cm left nodule. US: hypoechoic, microcalcifications (TIRADS 5). No lymphadenopathy → FNAC indicated.

• Indirect (Mirror):
  • Quick, office-based; avoids sedation and laryngospasm
• Direct (Fiberoptic/Rigid):
  • Detailed view if mirror inadequate; risk of laryngospasm

Rationale:

• Baseline vocal cord function → detect pre-existing RLN palsy
• Medicolegal documentation → protects against postoperative nerve injury claims

Hypothetical Case:

60-year-old man, large left lobe, mild hoarseness. Indirect exam → left vocal fold paresis. Plan: intraoperative nerve monitoring + modified resection margins.

• FNAC Indications:

  • Nodules ≥ 1 cm with high-risk US features; ≥ 1.5–2 cm even if low-risk; suspicious nodes
  • Technique: US-guided, multiple passes; Bethesda reporting guides management

• Scintigraphy Indications:

  • Differentiate “hot” vs. “cold” nodules in thyrotoxicosis or multinodular goitre
  • Interpretation:
    • Hot → benign autonomous adenoma
    • Cold → ↑ carcinoma risk (5–15%)
    • Diffuse uptake → Graves’ disease

Hypothetical Case:

38-year-old woman, 1.2 cm irregular nodule; Bethesda V on FNAC → total thyroidectomy + central neck dissection.
66-year-old man, subclinical hyperthyroidism, MNG; scintigraphy shows “hot” 3 cm nodule → lobectomy resolves hyperthyroidism.

• Mechanism: Iodine deficiency → ↓T₃/T₄ → ↑TSH → diffuse follicular hyperplasia
• Reversibility:
  • Early/mild regresses with iodine (150 µg/day)
  • Longstanding endemic goitre → fibrosis, irreversible

Hypothetical Case:

22-year-old woman, 8 mo smooth 3 cm goitre; iodized salt → reduces to 1 cm by 6 mo, normal by 12 mo.

• MNG Pathogenesis: Focal hyperplasia/involution → asymmetric nodules; genetic heterogeneity → autonomous function
• Natural History:
  • ~4% adults > 30 yrs clinically; increases with age
  • Irreversible despite iodine repletion
• Toxic MNG: Decades of euthyroid → subclinical/overt hyperthyroidism

Hypothetical Case:

60-year-old man, 15-yr endemic goitre, persistent MNG despite iodine, 4 cm “hot” nodule → subtotal thyroidectomy for compressive and toxic symptoms.

• Rationale: Prevent thyroid storm, arrhythmias, hemodynamic instability
• Medications:
  • Methimazole (MMI): first-line in adults; titrate over 6–8 wks
  • Propylthiouracil (PTU): preferred in pregnancy/thyroid storm (blocks T₄→T₃)

Hypothetical Case:

35-year-old woman with Graves’, HR 110 → MMI 20 mg QD + propranolol. After 6 wks, free T₄ normal, HR 72 bpm → safe thyroidectomy.

• Mechanism: Wolff–Chaikoff effect → ↓hormone synthesis & vascularity in 5–10 days
• Regimen:
  • Lugol’s: 5–10 drops TID for 7–10 days
  • SSKI: 1 g/day in divided doses

Hypothetical Case:

28-year-old with agranulocytosis on MMI → KI 1 g QD + propranolol → HR 80 bpm, free T₄ ↓ → proceed to surgery.

• Purpose: Control tachycardia, tremor; inhibits peripheral T₄→T₃ conversion
• Agents:
  • Propranolol 20–40 mg q6h
  • Atenolol/metoprolol in asthma/cardiac disease

Hypothetical Case:

40-year-old with Graves’ + AF, ventricular rate 130 bpm → propranolol 40 mg QID → rate 80–90 bpm.

• Corticosteroids: Dexamethasone 2 mg IV QID for thyroid storm/ophthalmopathy
• Cholestyramine: Binds thyroid hormones → increases clearance in refractory cases

• Calcium & Vitamin D: Start oral calcium (1 g TID) ± vitamin D to prevent postop hypocalcemia
• Airway & Anesthesia Planning:
  • Review imaging for retrosternal extension
  • Arrange fiberoptic intubation if tracheal compression
• Documentation: Baseline vocal cord status for medicolegal protection

• Rationale: Large visible goitres → psychosocial distress
• Guideline: Patient preference valid if all workup benign

Case: 30-year-old woman, 5 cm asymptomatic euthyroid goitre → hemithyroidectomy → improved self-image, no deficits

• Bethesda V–VI cytology → surgery
• Nodule ≥ 4 cm even if benign cytology
• High‐risk US features + indeterminate FNAC (III–IV)

Case: 50-year-old man, 4.2 cm nodule, Bethesda II → lobectomy → follicular carcinoma → completion thyroidectomy + RAI

• Symptoms: Dysphagia, dyspnea, venous congestion
• Relative indication: Nodule ≥ 3 cm with mass effect or retrosternal extension

Case: 62-year-old woman, 20-year MNG, progressive dysphagia → near-total thyroidectomy → immediate relief

• Indications: Failure of ATDs or RAI; agranulocytosis on methimazole
• Targets: Toxic adenoma / toxic MNG

Case: 45-year-old man, toxic MNG, persistent thyrotoxicosis post-2 RAI + agranulocytosis → total thyroidectomy after KI prep

• Indication: RET-mutation carriers (MEN2A/B)
• Timing: Childhood, before MTC develops

Case: 7-year-old boy, RET codon 634 mutation → prophylactic thyroidectomy → C-cell hyperplasia only

• Indications:
  • PTC > 1 cm after lobectomy
  • Multifocal disease or high-risk histology (vascular invasion, ETE)

Case: 42-year-old woman, lobectomy for 1.2 cm PTC → completion thyroidectomy + RAI ablation

1. Difficult Airway & Tracheal Compression

• Large/retrosternal goitres → tracheal shift/compression → fiberoptic intubation

Case: 58-year-old MNG patient → failed direct laryngoscopy → fiberoptic bronchoscope used

2. Malignant Hyperthermia

• Trigger: succinylcholine/volatile agents → hypermetabolic crisis
• Tx: stop trigger, 100% O₂, dantrolene (2.5 mg/kg IV)

3. Medication Reactions

• Anaphylaxis to anesthetics; β-blocker bronchospasm → preop allergy history, use alternatives

A. Hemorrhage

• Primary (during), reactionary (< 24 h), secondary (> 24 h)
• Tx: meticulous hemostasis, Valsalva check, drains in high-risk

Case: Aberrant superior thyroid artery branch → figure-of-eight ligature + cautery

B. Nerve Injuries

• RLN: transient 5–11%, permanent 0.5–2%; hoarseness → neuromonitoring
• EBSLN: pitch control loss in singers → identify at superior pole, ligate vessels close to capsule

Case: Soprano with vocal fatigue → EBSLN injury → voice therapy

1. Airway Obstruction

• Causes: tension hematoma, tracheomalacia, bilateral RLN palsy
• Tx: cut sutures, evacuate clot at bedside or OR, prepare for reintubation/tracheostomy

Case: 60-year-old, neck tightness, stridor at 3 h → 200 mL clot evacuated → airway restored

2. Hypocalcemia (Hypoparathyroidism)

• Devacularization/removal of parathyroids → ↓PTH → perioral numbness, Chvostek’s/Trousseau’s
• Tx: oral Ca²⁺ 1–2 g TID; severe → IV calcium gluconate + calcitriol

Case: Ca²⁺ 1.9 mmol/L at 12 h → IV Ca²⁺ → oral Ca²⁺ + calcitriol → symptom resolution

1. Hypothyroidism

• Lifelong levothyroxine; 1.6 μg/kg/day, TSH target 0.5–2.0

Case: 35-year-old starts L-T₄; TSH stable at 6 wks

2. Recurrent Goitre

• Residual tissue regrowth after subtotal → US surveillance; consider completion

3. Permanent Hypoparathyroidism

• Hypocalcemia > 6 mo → lifelong Ca²⁺ + vitamin D

Case: 60-year-old on Ca²⁺ + calcitriol at 6 mo

4. Permanent RLN Palsy

• Chronic hoarseness, aspiration → therapy, medialization procedures, tracheostomy

5. Scar Complications

• Hypertrophic/keloid scars → silicone, steroids, laser

• Etiologies & Timeline

  • Physiologic inflammatory response (IL-1, TNF, IL-6) → up to 38.5 °C
  • Pneumonia/aspiration → consolidation by POD 2 (CXR, sputum culture)
  • PE → fever, tachycardia, hypoxia around POD 2–3

• Diagnostics

  • Exam: auscultation, incentive spirometry
  • CXR if respiratory signs
  • CBC, blood cultures if systemic

• Management

  • Incentive spirometry, early mobilization
  • Empiric antibiotics if radiographic pneumonia
  • NSAIDs, fluids for low-grade fever

Case: Day 1 post–thyroidectomy, 55 M spikes 38.3 °C, clear lungs, normal CXR → NSAIDs + breathing exercises → afebrile by evening.

• Etiology

  • UTI from Foley catheter → bacteriuria by POD 3–5
  • Rare: cholangitis, intra-abdominal collections

• Diagnostics

  • Dysuria, urgency, suprapubic pain
  • UA + culture; remove/replace catheter

• Management

  • Tailored antibiotics (e.g., FQ)
  • Catheter care, early removal

Case: Day 4 post-hemithyroidectomy, 62 F with suprapubic discomfort, UA pyuria, E. coli → catheter removal + TMP-SMX → fever resolves.

• Etiology

  • SSI (superficial/deep) presenting POD 5–7
  • Abscess formation

• Diagnostics

  • Erythema, warmth, purulence, tenderness
  • Wound culture, CBC; US/CT if deep

• Management

  • Superficial: I&D + oral cephalexin
  • Deep: surgical drainage + IV broad-spectrum antibiotics

Case: Day 6 post-subtotal thyroidectomy, 45 M with 38.7 °C, fluctuant wound → US → I&D + IV cefazolin → guided therapy.

• Etiology

  • DVT → low-grade fever
  • PE → fever + dyspnea, tachycardia

• Diagnostics

  • DVT: calf swelling, Doppler US
  • PE: CT-PA if indicated; D-dimer limited

• Management

  • LMWH or DOACs
  • Early ambulation, pneumatic devices, prophylaxis

Case: Day 7 post-thyroidectomy, 70 F with calf tenderness + 38.2 °C → popliteal DVT on US → LMWH → transitioned to warfarin.

• Etiology

  • Drug fever (β-lactams, heparin)
  • Transfusion reactions (FNHTR)

• Diagnostics

  • Correlate onset with new meds/transfusions
  • Exclude infection

• Management

  • Discontinue offending agent → fever resolves in 48–72 h
  • Supportive care; stop transfusion + hemolysis protocol if needed

Case: Day 10, 52 M develops 38.1 °C two days after IV vancomycin → switch to linezolid → afebrile in 48 h.

• Depolarizing

  • Succinylcholine: onset 30–60 s, duration ~6 min; metabolized by butyrylcholinesterase

• Non-Depolarizing

  • Short-acting: Mivacurium (15–20 min)
  • Intermediate-acting:
    • Atracurium/Cisatracurium (Hoffman elimination)
    • Rocuronium/Vecuronium (steroid-derived)
  • Long-acting: Pancuronium (60–90 min; vagolytic)

• Succinylcholine (1 mg/kg)

  • Pros: rapid onset/offset; ideal for full-stomach
  • Cons: MH trigger, hyperkalemia, masseter spasm

• High-dose Rocuronium (0.9–1.2 mg/kg)

  • Similar onset; longer duration (30–60 min)

Case: 50 M emergent RSI receives succinylcholine → masseter spasm → switch to high-dose rocuronium + prepare MH protocol.

• Atracurium: 0.4–0.5 mg/kg induction; 0.08–0.1 mg/kg q20–45 min (hepatic/renal safe)

• Pancuronium: 0.07–0.1 mg/kg induction; risk accumulation

• Monitoring: Train-of-four ≥ 0.9 before extubation

Case: 45 F prolonged thyroidectomy: pancuronium induction, atracurium maintenance → neostigmine reversal at TOF 2 twitches → timely extubation.

• Pathophysiology: AD RYR1 mutation → uncontrolled Ca²⁺ release with succinylcholine/volatile agents

• Signs:

  • Early: masseter spasm, tachycardia, hypercapnia
  • Late: rapid hyperthermia > 40 °C, rigidity, acidosis, rhabdomyolysis

• Management:

  1. Stop triggers + 100% O₂ hyperventilation
  2. Dantrolene 2.5 mg/kg IV q5–10 min (up to 10 mg/kg)
  3. Active cooling, sodium bicarbonate for acidosis, electrolyte correction, maintain UO > 2 mL/kg/h

• Prophylaxis: Dantrolene 2.5 mg/kg IV ~75 min pre-op in known MH susceptibility

Case: 35 F under GA develops end-tidal CO₂ spike + jaw rigidity → succinylcholine stopped, dantrolene 150 mg IV → rigidity resolves, temp normalizes with supportive care.

• Definition: Proximal end of colon brought out as single stoma; distal segment oversewn or resected
• Indication: Permanent diversion for unresectable distal disease (e.g., obstructive anorectal carcinoma)
• Case:

  72-year-old man with inoperable rectal cancer and complete obstruction → end colostomy for palliation

• Definition: Loop of colon (transverse or sigmoid) opened and matured as two lumens (proximal stool, distal mucus)
• Indications:
  • Temporary protection of distal anastomosis
  • Palliative diversion with planned future reversal
• Case:

  58-year-old woman post–low anterior resection receives protective loop sigmoid colostomy to allow anastomotic healing

• Definition: Colon completely divided; both ends matured as separate stomas (proximal stool, distal mucus)
• Indication: Decompression of distal bowel with future reconnection planned
• Case:

  45-year-old man with perforated diverticulitis and peritonitis → transverse double-barrel colostomy for source control

• Transverse Colon: More mobile, emergency accessibility → loop/double-barrel in acute obstruction
• Sigmoid Colon: Preferred for elective stomas → patient comfort, firmer stool output

• Mechanism: Liquid stool contacts skin → dermatitis
• Management:
  • Proper siting by WOC nurse
  • Barrier creams, adjust wafer/flange
• Case:

  60-year-old man develops erythematous rash around stoma → flange resized + barrier paste → irritation resolves

• Mechanism: Proximal stoma → large fluid losses → dehydration, electrolyte imbalance
• Management:
  • Oral rehydration solutions
  • Antimotility (loperamide)
  • Dietary modification
• Case:

  55-year-old woman with loop transverse stoma >2 L/day output → started on loperamide + oral rehydration → output ↓ to 1 L/day

• Mechanism: Excess mesenteric length allows bowel telescoping through stoma
• Management:
  • Conservative for small reducible prolapse
  • Surgical revision if irreducible/ischemic
• Case:

  70-year-old woman with irreducible 5 cm prolapse → elective stoma refashioning with mesenteric plication

• Mechanism: Abdominal wall defect around stoma → herniation of bowel
• Management:
  • Supportive belts for mild cases
  • Mesh repair or relocation for symptomatic hernias
• Case:

  65-year-old man with bulge next to stoma → CT confirms hernia → mesh-reinforced stoma relocation

• Retraction: Tension or weight loss → stoma sinks below skin → leakage, skin breakdown
• Stenosis: Fibrotic narrowing → obstruction, pain
• Management:
  • Dilation for stenosis
  • Revision for retraction
• Case:

  58-year-old man with post-cancer weight loss → stoma retraction + leakage → revision with fascial advancement

• Mechanism: Excess tension or compromised blood supply at creation
• Management:
  • Superficial necrosis → allow demarcation then revise
  • Full-thickness necrosis → immediate revision
• Case:

  Day 1 post–loop colostomy, 50-year-old exhibits dusky stoma → OR within hours for relocation due to necrosis