Bilateral Nerve Palsy Research Articles

A Case Report on the Occurrence of Bilateral Nerve Palsy and Hypercalcemia in Sarcoidosis

A Case Report on the Occurrence of Bilateral Nerve Palsy and Hypercalcemia in Sarcoidosis

Single Dose Steroid Injection After Loss of Signal (LOS) During Thyroid Surgery is Effective to Recover Electric Signal Avoiding Vocal Cord Palsy and the Need of Staged Thyroidectomy: Prospective Evaluation on 702 Patients.

Steroids are often used for the management of vocal cord palsy after thyroid surgery. There are no reports in the current literature of their intraoperative use, immediately after a loss of signal during neuromonitoring (LOS). We evaluate the impact of a single dose of 4mg of dexamethasone on laryngeal nerve function, administrated at the time of a LOS during a nerve-monitored thyroidectomy. A prospective not randomized study was performed, dividing patients in two groups, when a LOS was detected. LOS was defined as an electromyographic signal (EMG) inferior to 100μV when stimulating the inferior laryngeal nerve, according to international guidelines. In group 1 (G1), surgeon waits for signal's recovery up to 20min. Absence of a detectable signal after 20min was predictive of vocal cord palsy; if it affected the first side of surgery the procedure was interrupted to avoid the risk of bilateral nerve palsy. In group 2 (G2), 4mg of dexamethasone were injected within 10min from a detected LOS, waiting 10min for its effects. An EMG value > to 200μV within 20' after steroid administration was predictive of full recovery and normal post-operatory vocal cord function. Vocal cords motility was checked at postoperative day 1 in all patients by an experienced ENT. Between January 2017 and December 2018, 702 patients underwent thyroid surgery under intermittent intraoperative nerve monitoring by two expert surgeons. A LOS was found in 22 patients in G1 and 16 in G2. Four patients in G1 spontaneously recovered electric signal (18.2%), while in G2 a signal was recovered in 14/16 patients (87.5%) (p < 0.001). This immediate effect was monitored by EMG, showing the increase in potentials at 10, 15 and 20min after injection. ENT evaluation found vocal cord palsy, respectively, in 18/22 and 1/16 patients (G1 vs G2, p < 0.001). One of the patients in G2 who recovered electric signal presented transient palsy, fully recovered at 2months, while the two patients who had a signal < 200μV did not present postoperative cord palsy. In G1, 10/18 palsy were definitive. No permanent palsies were presents in G2. A single 4mg iv dexamethasone injection within 10min form a LOS during thyroid surgery exerts a therapeutic action, measurable by EMG modifications. It avoids vocal nerve palsy and the need of a staged thyroidectomy. It may also protect from permanent cord palsy, but the mechanism is unknown.

Thyroidectomy Then and Now: A 50‐Year Australian Perspective

Since the mid-1800s, thyroidectomy has transformed from a procedure associated with high to near-zero mortality. Nonetheless, surgeons must continue to strive to improve patient care. Using historical records and contemporary data, this study compares the practice and outcomes of thyroid surgery at a tertiary institution during two periods, 50years apart. 'The Alfred Hospital Clinical Reports' recorded all cases of surgically managed thyroid disease from 1946 to 1959. These historical cases were compared to contemporary thyroidectomy cases at the Alfred Hospital from 2007 to 2016. Cases were compared for surgical indication and post-operative outcomes. There were 746 patients in the historical group (mean age 53years; 87% female) and 787 patients in the contemporary group (mean age 52years; 80% female). The most common indication for thyroidectomy in both groups was non-toxic nodular goitre. A greater proportion of the contemporary group were diagnosed with thyroid malignancy (27% vs. 8%; p < 0.001). The contemporary group recorded significantly fewer cases of thyrotoxic crisis (2.1% vs. 0%; p = 0.001), permanent nerve palsy (4.6% vs. 0.4%; p < 0.001) and bilateral nerve palsy (1.2% vs. 0%; p = 0.01). There were no mortalities in the contemporary group, while the historical data recorded three deaths (0.44%). This study compared thyroid surgery in two cohorts separated by a 50-year period. While it is not surprising that outcomes of thyroidectomy have improved, this study uniquely demonstrates trends of thyroid surgery over time and areas in which further improvements may be made.

Paralysie faciale bilatérale au cours d’une infection à virus d’Epstein–Barr

Bilateral facial nerve palsy is a rare and sometimes difficult diagnosis. We describe a case of bilateral simultaneous facial nerve palsy associated with Epstein-Barr virus (EBV) infection in a 3-year-old boy. Several symptoms led to the diagnosis of EBV infection: the clinical situation (fever, stomachache, and throat infection), white blood cell count (5300/mm3 with 70% lymphocyte count), seroconversion with EBV-specific antibodies, lymphocytic meningitis, and a positive blood EBV polymerase chain reaction (9.3×103 copies of EBV-DNA). An MRI brain scan showed bilateral gadolinium enhancement of the facial nerve. A treatment plan with IV antibiotics (ceftriaxone) and corticosteroids was implemented. Antibiotics were stopped after the diagnosis of Lyme disease was ruled out. The patient's facial weakness improved within a few weeks. Bilateral facial nerve palsy is rare and, unlike unilateral facial palsy, it is idiopathic in only 20% of cases. Therefore, it requires further investigation and examination to search for the underlying etiology. Lyme disease is the first infectious disease that should be considered in children, especially in endemic areas. An antibiotic treatment effective against Borrelia burgdorferi should be set up until the diagnosis is negated or confirmed. Further examination should include a blood test (such as immunologic testing, and serologic testing for viruses and bacterium with neurological tropism), a cerebrospinal fluid test, and an MRI brain scan to exclude any serious or curable underlying etiology. Facial bilateral nerve palsy associated with EBV is rarely described in children. Neurological complications have been reported in 7% of all EBV infections. The facial nerve is the most frequently affected of all cranial nerves. Facial palsy described in EBV infections is bilateral in 35% of all cases. The physiopathology is currently unknown. Prognosis is good most of the time.

23-hour observation endocrine neck surgery: lessons learned from a case series of over 1700 patients.

Although the surgical procedures concerning the thyroid and the parathyroid glands are considered safe, the possible occurrence of complications (mainly hematoma and hypocalcemia) limit the short stay surgery. At our institution a 23-hour-surgery with overnight hospital stay for endocrine neck surgical procedures was introduced since 2004. The present case series analyses the institutional results. Over 1913 endocrine neck surgery procedures, 1730 patients (90,2%) were managed according to this model. Among these patients, 92 suffered from hypocalcemia, 12 from airways obstruction due to the hematoma, 5 from bilateral nerve palsy. 15 more patients had unpredictable general disease compromising the short-stay surgery management. The goal of the discharge after 23 hours was achieved in 92,8% of cases with a mean hospital stay of 1,1days. The 23-hour observation with an overnight surgery is feasible and safe if the correct indications are observed. A considerable volume of specific activity is needed.

Recurrent laryngeal nerve management in thyroid surgery: consequences of routine visualization, application of intermittent, standardized and continuous nerve monitoring.

The objective is to compare the consequences of routine visualization (RV) and the application of intermitted (I-IONM), standardized (S-IONM), and continuous monitoring (C-IONM) of recurrent laryngeal nerve (RLN) management. RV includes that 698 RLNs managed solely with visual identification. In a second period 777, RLNs were handled by the I-IONM. The third period 768 RLNs monitoring was performed according to the standards. C-IONM via VN stimulation included 626 RLNs. The following issues were analyzed and compared per each period study: RLN identification rate, branching detection, assessment of NRLN, intraoperative recognizable nerve damage, stage thyroidectomy rate, transient or definitive lesions, bilateral nerve palsy, and recovery time. Significance for nerve identification rate was achieved (p=0.03) when the statistical analysis was applied between RV vs. S-IONM and C-IONM. Extralaryngeal bifurcation was identified in 21, 44, 43, and 46 of RLN dissected, respectively, per period (p=0.005). The incidence of paralysis in identified and unidentified RLN was 3.8% (107/2806) and 82% (52/63), respectively. Rates of temporary/permanent RLNP were 16.7/1.7, 5/1.1, 4.5/1, and 3.1/0% per period study, respectively (p=0.07). Recognizable intraoperatively nerve damage was, respectively, 15, 45, 100, and 100% for period study (p=0.03). The recovery of injured nerves was significantly faster in C-IONM group. S-IONM and C-IONM cumulate 40-stage procedures. The standardized technique, guidelines adherences, and C-IONM allowed to (1) increase RLN identification; (2) reduce the severity of injuries in terms of (a) reset bilateral RLNP, (b) faster recovery time, and

Surgical assessment of complications after thyroid gland operations

The extent, magnitude and technical equipment used for thyroid surgery has changed considerably in Germany during the last decade. The number of thyroidectomies due to benign goiter have decreased while the extent of thyroidectomy, nowadays preferentially total thyroidectomy, has increased. Due to an increased awareness of surgical complications the number of malpractice claims is increasing. In contrast to surgical databases the frequency of complications in malpractice claims reflects the individual impact of complications on the quality of life. In contrast to surgical databases unilateral and bilateral vocal fold palsy are therefore at the forefront of malpractice claims. As guidelines are often not applicable for the individual surgical expert review, the question arises which are the relevant criteria for the professional expert witness assessing the severity of the individual complication. While in surgical databases major complications after thyroidectomy, such as vocal fold palsy, hypoparathyroidism, hemorrhage and infections are equally frequent (1-3 %), in malpractice claims vocal fold palsy is significantly more frequent (50 %) compared to hypoparathyroidism (15 %), hemorrhage and infections (about 5 % each). To avoid bilateral nerve palsy intraoperative nerve monitoring has become of utmost importance for surgical strategy and malpractice suits alike. For surgical expert review documentation of individual risk-oriented indications, the surgical approach and postoperative management are highly important. Guidelines only define the treatment corridors of good clinical practice. Surgical expert reviews in malpractice suits concerning quality of care and causality between surgical management, complications and sequelae of complications are therefore highly dependent on the grounds and documentation of risk-oriented indications for thyroidectomy, intraoperative and postoperative surgical management.

Bilateral Femoral Neuropathy After Massive Toxic Ingestion in a Suicide Attempt

Bilateral femoral nerve injury can occur after various surgical and nonsurgical processes, but has rarely been reported. We describe a case of bilateral femoral neuropathy after a suicide attempt in a 41-year-old woman. We suggest a stretch mechanism to explain this observation. We also discuss the other causes of bilateral nerve palsy, usually secondary to a compressive injury, with a review of the medical literature. The patient reported is the first in the literature to have suffered from bilateral femoral nerve palsy after a suicide attempt. Half of the reported cases are secondary to a surgical process (particularly abdominopelvic surgery). If a compressive origin is most frequent, a stretch mechanism may at times explain a bilateral femoral neuropathy.

Vocal cord palsy as a complication of adult cardiac surgery: surgical correlations and analysis.

Vocal cord palsy after adult cardiac surgery is often attributed to non-surgical mechanisms as tracheal intubation and central venous catheterisation. It may also be caused by injury of the recurrent laryngeal nerves by surgical dissection. We hereby present a review of relevant clinical reports. The cumulative incidence was 1.1% (33 in 2980). Main reported surgical mechanisms of injury were harvesting of internal thoracic artery and topical cold cardioprotection. Bilateral nerve palsy has been lethal on at least one occasion. Where vocal cord injury followed harvesting of the left internal thoracic artery, it was reported ipsilateral to the conduit.

Neuromonitoring of the recurrent laryngeal nerve--a critical analysis of patients with postoperative nerve palsy

The transligamental intraoperative neuromonitoring of the recurrent nerve is established in many surgical clinics as an useful and reliable technique. It is especially suitable to identify the recurrent nerve and to monitor its function during thyroid operation. We have analysed 14 early postoperative recurrent nerve palsies between June 1997 and December 2000 (1,23 % related to nerves at risk). As a result of complete follow up we found 4 permanent nerve palsies (0,35 % related to nerves at risk). In 11 out of 14 cases the neuromonitoring revealed a dysfunction of the recurrent nerve. The following long distance microsurgical preparation showed no interruption of the continuity of the nerve. Knowing the fact of unilateral negative monitoring signal we adapted our operative strategy. Therefore we did not observe bilateral nerve palsies. In 3 patients we found a positive nerve signal but nevertheless these patients showed postoperative unilateral recurrent palsies. The possible reasons are discussed. We are convinced that the neuromonitoring of the recurrent laryngeal nerve is an important progress in thyroid surgery.

中耳炎を初発とした多発性脳神経障害例

A 63-year-old woman with multiple disturbances of the cranial nerves is reported. She initially complained of bilateral hearing loss and otorrhea, followed by right facial palsy and vertigo and was hospitalized on August 25, 1983. Despite steroid therapy, her condition deteriorated and finally complete bilateral deafness and complete bilateral facial palsy developed.Histologial examination of the mastoid mucosa, obtained by exploratory tympanotomies in both ears, showed non-specific inflammation. Noteworthy findings or laboratory examinations were extremely high levels of ESR and CRP, positive RA test, and negative tuberculin test.Tracheotomy was performed because of recurrent bilateral nerve palsy. Scleritis occurred in March, 1984, and the disturbances of eye movement, ptosis and atrophy of tongue developed in September, 1984. Long-term steroid therapy did not improve cranial palsy. There were no neurological signs such as pathological reflex in the limbs, involuntary movement or meningeal irritation symptom. There were no remarkable findings on CT or MRI.Although treatment by a local hospital continued, the III, IV, VI, VII, VIII, X and XII cranial nerves remained paralyzed. She finally died of systemic weakness in March, 1989.This was a rare case that began with bilateral otitis media and proceeding to paralysis of initially occurred and cranial nerves in order of VII, VIII, X, XII, III, IV and VI nerves. The background of this case included systemic vascular disease, especially Cogan's syndrome, because of otologic and ocular symptoms and multiple disturbances of the cranial nerves.