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Resumen El hiperparatiroidismo primario (HPP) se define como un trastorno endocrinológico caracterizado por hipercalcemia y niveles de hormona paratiroidea (PTH) elevados o inadecuadamente normales resultado de la secreción excesiva de PTH de una o más glándulas paratiroides. Con respecto a la causa, en un 85% se debe a un adenoma paratiroideo único y un 95% de los casos son esporádicos, sin un factor etiológico identificable. La presentación clásica en la mayoría de los casos es de forma asintomática, sin embargo, sus síntomas o signos clásicos incluyen los derivados de la afectación renal, donde la nefrolitiasis es la manifestación clínica más frecuente de la afectación ósea y de la hipercalcemia. El diagnóstico es bioquímico, sin necesidad de estudio imagenológico, el cual se realiza únicamente como pruebas localizadoras prequirúrgicas. El tratamiento definitivo es quirúrgico, siendo la paratiroidectomía con abordaje cervical el procedimiento de elección.

Primary hyperparathyroidism (PHP) is defined as an endocrine disorder characterized by hypercalcemia and elevated or inadequately normal parathyroid hormone (PTH) levels resulting from the excessive secretion of PTH from one or more parathyroid glands. The cause of this disorder is due, in 85%, to a single parathyroid adenoma and most cases (95%) are sporadic, without an identifiable etiologic factor. PHP is asymptomatic in most patients, however, classic symptoms or signs include those derived from renal involvement, where nephrolithiasis is the most frequent clinical manifestation, and those derived from bone affectation and hypercalcemia. The diagnosis is biochemical, without the need for an imaging study, which is performed only as pre-surgical locator tests. The definitive treatment is surgical, being the parathyroidectomy with cervical approach the procedure of choice.

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Skin cancer is usually classified into melanoma (SCM) and non-melanoma (SCNM), with different cell origins; being the SCM responsible for the highest mortality. In Chile, an incidence (2008) of 434 new cases is estimated, obtaining a standardized rate of 2.2 cases per 100,000 habitants. There are multiple associated risk factors, the main ones being exposure to UV radiation and sunburn. The strategies to prevent this pathology fall on these same factors. The clinical evaluation of the lesions with ABCD mnemonics added to the use of dermoscopy increases the diagnostic sensitivity and specificity; however, the definitive confirmation is through biopsy, which must include the necessary parameters to define prognosis of disease. The definitive treatment is Surgical. There are alternatives such as the use of the sentinel lymph node to define lymph node dissections. Regarding systemic therapies, the use of immunotherapy has shown results that improve survival in these patients.

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It is described that salivary gland tumors account for up to 3-6% of head and neck tumors, 80% of these being located in the parotid gland. Broadly speaking, the smaller the gland, the greater the probability of malignancy. The most common clinical manifestation in tumor pathology is the appearance of a painless mass. Indicators of malignancy should be considered: chronic volume increase or rapid growth, facial paralysis, cranial nerve involvement, ulceration, and cervical lymphadenopathy. Ultrasonography should be the first imaging study, however, it provides limited information. MRI is the exam of choice for salivary gland tumors, whereas CT and PET-CT allow the study of local and remote invasion. FNA is controversial, it is not indicated for all patients, in parotid tumors a cytological examination is usually not necessary prior to surgery. Excisional biopsy is not recommended due to the risk of tumor seeding, neural damage, and salivary fistula. The goal of treatment in gland tumors is the removal of the glands, associated with lymph node dissection and adjuvant radiation therapy in indicated cases. The general practitioner must comprehensively address these pathologies to achieve a timely referral to the specialist. (AU)

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Resumen Introducción: Los quistes dermoides son lesiones de origen ectodérmico poco frecuentes. Solo un 1,6% de ellos, se presenta en el piso de la boca y de éstos, solo un 6% lateralmente en el espacio submandibular. Objetivo: Reporte de caso y revisión de la literatura. Caso clínico: Se presenta un caso de una paciente de 32 años, con un cuadro de 1 año de evolución caracterizado por una lesión de crecimiento lento pero sostenido. Se le realizó la resección de la lesión junto con una submandibulectomía ipsilateral resultando compatible con un quiste dermoide. Discusión: La localización de esta lesión es muy infrecuente. En el estudio histopatológico son lesiones con epitelio pluriestratificado cornificado y anexos cutáneos. El estudio de imágenes orienta a una lesión quística, siendo la resonancia nuclear hoy en día el mejor examen para caracterizar esta lesión. Es una lesión benigna, sin recidivas reportadas cuando la resección ha sido completa.

Introduction: Dermoid cysts are uncommon lesions from ectodermic origin. Only 1.6% arise in the floor of the mouth, and at this site only 6% arise laterally in the submandibular region. Aim: Case report and review of the literature. Clinical Case: 32 years old patient, with a slow growing lesion during 1 year. Complete resection with an ipisilateral submandibulectomy was performed. The pathologic report showed a dermoid cyst. Discussion: The localization of this lesion is very uncommon. In the pathologic report are lesion with pluri stratified cornified epthitelium with skin attachments. Image studies show a cystic lesion being the magnetic resonance the best study to characterize this lesions. Are benign lesions, without recurrence reported when the lesion has been fully excised.

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Introducción: El cáncer diferenciado de tiroides (CDT), es actualmente la neoplasia endocrina más frecuente. Su tratamiento estándar es la resolución quirúrgica, asociado a ablación con radioyodo (RI) según la clasificación propuesta por la American Thyroid Association (ATA). Las indicaciones y dosis de este último, han ido variando en los últimos años según avanzan las investigaciones en este ámbito. Objetivo: En el siguiente estudio se compararon las dosis de RI utilizadas previo y posterior a la implementación de las últimas guías de la ATA. Materiales y métodos: Estudio retrospectivo observacional de 70 pacientes con diagnóstico de CDT del Hospital Clínico de la Universidad de Chile entre 2012 y 2017. Se agruparon los pacientes en dos cohortes, los operados entre los años 2012-2015 y los 2016-2017 clasificándolos según riesgo ATA, TNM y riesgo de recurrencia. Se consignaron las dosis de RI utilizadas y se compararon entre las cohortes. Análisis estadístico: Mann Whithney. Resultados: Al comparar la dosis de RI entre ambas cohortes, según TNM y riesgo ATA, se obtuvo los siguientes resultados: los pacientes T1b de la cohorte 2012-2015 presentaron dosis de RI significativamente mayores que los de la cohorte 2016-2017; también se evidenció que en pacientes N0 hubo una diferencia estadísticamente significativa, mostrando una tendencia a disminuir la dosis de RI; además, en los pacientes de la cohorte 2012-2015 con riesgo ATA intermedio, se obtuvo que las dosis de RI fueron significativamente mayores que las utilizadas en la cohorte 2016-2017. Conclusión: Se concluye que las variaciones de las dosis de RI utilizadas en pacientes con CDT en un hospital universitario van acorde a las recomendaciones internacionales actuales, particularmente la publicación de la guía ATA 2015, aplicándose radioablación con menor dosis de RI. Dado este cambio, se ha evidenciado igualdad de efectos con dosis menores de RI y consecuentemente menos efectos adversos.

Introduction: Differentiated thyroid cancer (CDT) is currently the most frequent endocrine neoplasia. Its standard of care is surgical treatment, associated with radioiodine ablation (IR) according to the classification proposed by the American Thyroid Association (ATA). The indications and doses of the latter have changed in recent years as research in this area advances. Objective: In the following study, the doses of IR used before and after the implementation of the latest ATA guidelines were compared. Materials and methods: Retrospective observational study of 70 patients with a diagnosis of CDT from the Clinical Hospital of the University of Chile between 2012 and 2017. Patients were grouped into two cohorts, those surgically intervened between the years 2012-2015 and 2016-2017, classifying them according to ATA risk, TNM and recurrence risk. The IR doses used were reported and compared between the cohorts. Statistical analysis: Mann Whithney. Results: When comparing the IR dose between both cohorts, according to TNM and ATA risk, the following results were obtained: T1b patients in the 2012-2015 cohort had significantly higher IR doses than those in the 2016-2017 cohort; It was also evidenced that N0 patients showed a statistically significant tendency to decrease the IR dose; In addition, the 2012-2015 cohort with intermediate ATA risk, revealed IR doses significantly higher than those used in the 2016-2017 cohort. Conclusion: It is concluded that the variations in IR doses, used in patients with CDT in a university hospital, are in accordance with current international recommendations, particularly the publication of the ATA 2015 guidelines, applying radioablation with a lower dose of IR. Given this change, equality of effects has been evidenced with lower doses of IR and consequently fewer adverse effects.

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The clinical approach to non-thyroid cervical masses in primary care has always been considered a diagnostic challenge. In the absence of specific diagnostic methods, the general practitioner must rely on clinic and general tests in order to achieve a suspected diagnosis and timely referral. On initial approach to cervical masses, one must first analyze each case according to patient age, associating an exhaustive anamnesis focused on the growth pattern and aggregate symptoms, along with a physical examination focused on signs of malignancy. Once completed, the etiology of the mass can be classified as probable congenital, inflammatory or tumoral origin. And also try to determine localization, temporality and discriminate between benign and malignant causes. Once the clinical interrogation has been completed, basic complementary tests and/or directed test according to suspicion can be requested. The foregoing allows the primary care physician a proper referral to specialist and/or initiation of appropriate treatment. (AU)

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Deep neck infections (DNIs) are special entities among infectious diseases for their versatility and potential for severe complications. Complex head and neck anatomy often makes early recognition of DNIs challenging, and a high index of suspicion is necessary to avoid any delay in treatment. The diagnosis is made by clinical history, physical examination findings and imaging studies. The treatment consists in securing the airway, intravenous antibiotics and surgical drainage, when needed. To make decisions the surgeon must understand the anatomy of the region, the etiology of infection, appropriate diagnostic tools, and medical and surgical management. This article provides a review of these pertinent topics. (AU)

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Introducción: El abordaje de elección de la glándula tiroides y paratiroides, desde su descripción, ha sido la cervicotomía transversal. En el hiperparatiroidismo, con la optimización de los métodos de localización preoperatoria de las glándulas anómalas, se han creado técnicas abiertas mínimamente invasivas, con un mejor resultado estético y un menor tiempo de recuperación. Con el objetivo de eliminar las cicatrices externas se ha implementado una nueva técnica quirúrgica que utiliza abordajes endoscópicos a través de orificios naturales (NOTES). En los últimos años se ha hecho conocida una técnica de tiroidectomía y paratiroidectomía transoral endoscópica a través de incisiones en el vestíbulo oral. Caso clínico: Paciente de 65 años con hiperparatiroidismo primario con nódulo hiperfuncionante superior derecho que se somete a una paratiroidectomía parcial transoral endoscópica por abordaje vestibular. Resultados: El procedimiento se realiza sin incidentes con buena evolución posoperatoria de la paciente. Discusión: La paratiroidectomía transoral endoscópica por abordaje vestibular (TOEPVA) ha demostrado ser una técnica bastante segura, con resultados similares a los de la técnica abierta, pero sin dejar cicatrices visibles.

Introduction: The approach of choice of the thyroid and parathyroid glands, since its description, has been the transverse cervicotomy. In hyperparathyroidism, with the optimization of the preoperative localization methods of the anomalous glands, minimally invasive open techniques have been created, with a better aesthetic result and a shorter recovery time. With the aim of eliminating external scars, a new surgical technique has been implemented that uses endoscopic approaches through natural orifices (NOTES). In recent years, a transoral endoscopic thyroidectomy and parathyroidectomy technique through incisions in the oral vestibule has been known. Clinical case: A 65-year-old patient with primary hyperparathyroidism with right upper hyperfunctioning nodule who underwent partial transoral endoscopic parathyroidectomy due to vestibular approach. Results: The procedure is performed without incidents with good postoperative evolution of the patient. Discussion: Transoral endoscopic parathyroidectomy by vestibular approach (TOEPVA) has proven to be a fairly safe technique, with results similar to open technique, but without leaving visible scars.

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Resumen Introducción: Las fístulas del seno piriforme, originadas desde el tercer o cuarto arco branquial, son entidades poco frecuentes. Se pueden presentar como aumento de volumen cervical, fístula cervical, absceso cervical, tiroiditis abscedada y/o disfonía. Objetivo: Reportar 4 casos tratados en nuestro hospital y revisión de la literatura. Discusión: Frente a un cuadro clínico compatible, se debe realizar estudio endos- cópico y de imágenes. El manejo quirúrgico sigue siendo el de mejores resultados, pero se han desarrollado terapias endoscópicas y combinaciones de estas con buenos resultados. Conclusión: El diagnóstico requiere un alto índice de sospecha clínica. La cirugía abierta se mantiene como el gold standard, sin embargo, en población pediátrica estaría indicada la resolución endoscópica debido a la alta morbilidad de la cirugía tradicional.

Introduction: Pyriform sinus fistula is a rare cervical branchial anomaly derived from the third and fourth branchial arch. Pyriform sinus fistula should be considered in children presenting enlarged neck mass, fistula, abscess, thyroid infection and/or dysphonia. Objective: We here report 4 cases treated in Hospital Clínico Universidad de Chile and review of the current literature on pyriform sinus fistula. Discussion: When clinical presentation is compatible with pyriform sinus fistula, endoscopic and imaging techniques are required. Surgical outcomes are better, although endoscopic therapies and combination of both surgery and endoscopy have also reported good outcomes. Conclusion: Diagnosis is made based on signs and symptoms and a high index of clinical suspicion. Open surgery is gold standard, however in pediatric population endoscopic resolution should be considered to reduce the high morbidity of traditional surgery.

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The thyroid nodule is a frequent cause of primary care consultation. The prevalence of a palpable thyroid nodule is approximately 4-7%, increasing up to 67% by the incidental detection of nodules on ultrasound. The vast majority are benign and asymptomatic, staying stable over time. The clinical importance of studying a thyroid nodule is to exclude thyroid cancer, which occurs in 5 to 10% of the nodules. The Board of SOCHED (Chilean Society of Endocrinology and Diabetes) asked the Thyroid Study Group to develop a consensus regarding the diagnostic management of the thyroid nodule in Chile, aimed at non-specialist physicians and adapted to the national reality. To this end, a multidisciplinary group of 31 experts was established among university academics, active researchers with publications on the subject and prominent members of scientific societies of endocrinology, head and neck surgery, pathology and radiology. A total of 14 questions were developed with key aspects for the diagnosis and subsequent referral of patients with thyroid nodules, which were addressed by the participants. In those areas where the evidence was insufficient or the national reality had to be considered, the consensus opinion of the experts was used through the Delphi methodology. The consensus was approved by the SOCHED board for publication.

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