Laryngeal Nerve Research Articles

Intraoperative Probe-Based Confocal Endomicroscopy to Histologically Differentiate Thyroid From Parathyroid Tissue Before Resection.

Frozen section is the standard method to histologically distinguish parathyroid tissue from thyroid tissue during endocrine neck surgery. Frozen section can be time-consuming and costly. Its drawback is that it is to be performed only after the removal of a suspected pathological tissue. This study demonstrates the use of probe-based confocal laser endomicroscopy (pCLE) to confirm histology prior to tissue resection. A prospective, single-institution, nonrandomized study was conducted. No sample size calculation was performed for this observational trial. The primary objective was the description of histological rendering of normal and pathological tissues through pCLE. Real-time in vivo fluorescence microscopy imaging was performed with the CystoFlex UHD probe after intravenous injection of 2.5 mL of 10% fluorescein sodium. Eleven patients with hyperparathyroidism and thyroid conditions were included. A total of 104 videos showing thyroid, parathyroid, adipose tissue, muscle, laryngeal nerve, and lymph nodes were recorded. Videos were compared with visual information and pathological samples (when sampling was indicated). Thyroid tissue could be identified based on the presence of colloid follicles (intensely fluorescent area surrounded by a small ridge of low-fluorescence epithelial cells) including the pathognomonic aspect of resorption vacuole. Parathyroid tissue could be identified based on a regular, "diamond-shaped" capillary network encompassing parathyroid chief cells. Blinded reinterpretation of pCLE videos demonstrated an 89.3% sensitivity and a 90% specificity as compared with histology in tissue recognition. This pilot study describes representative renderings of intraoperative pCLE to nontraumatically differentiate thyroid, parathyroid, and lymph nodes before surgical removal.

The efficacy of ansa cervicalis anterior root for unilateral recurrent laryngeal nerve injury

Objective: To discuss the long-term efficacy of laryngeal reinnervation using the anterior root of the ansa cervicalis in the treatment of unilateral vocal fold paralysis (UVFP) caused by thyroid surgery. Method: From January 2010 to January 2016, a total of 39 UVFP patients who underwent ansa cervicalis anterior root-to-recurrent laryngeal nerve (RLN) anastomosis and who had suffered nerve disfunction for 6 to 24 months were enrolled as UVFP group.Another 39 age and gender matched normal subjects served as control group. Videostroboscopy, vocal function assessment (acoustic analysis, perceptual evaluation and maximum phonation time), and laryngeal electromyography were performed preoperatively and postoperatively for assessing surgery efficacy. Paired sample t test was used for statistical analysis. Result: Videostroboscopic reports indicated that the glottic closure, vocal fold edge, vocal fold position, phase symmetry and regularity were significantly improved in the UVFP group (P<0.01, respectively, postoperative vs. preoperative)and showed no statistical differences compared to the control group (P>0.05, respectively). Both the postoperative GRBAS assessment and acoustic parameters were also significantly improved in the UVFP group, Pre-operative acoustic parameters/Post-operative acoustic parameters were 1.68±0.82/0.39±0.27, 10.08±2.56/4.58±2.96, 0.203±0.216/0.018±0.038, 5.96±1.92/17.42±4.11(P<0.01, respectively) and Pre-operative acoustic parameters/Post-operative acoustic parameters were 0.39±0.27/0.32±0.19, 4.58±2.96/3.32±1.27, 0.018±0.038/0.014±0.027, 17.42±4.11/18.76±5.29, which showed no statistical differences compared to the control group (P>0.05, respectively). Conclusion: Delayed laryngeal reinnervation with the anterior root of ansa cervicalis, it can restore the physiological laryngeal phonatory function to the normal or a nearly normal voice quality, which is a feasible and effective approach for the treatment of thyroid surgery-related UVFP.

F116. Correlation of laryngeal adductor reflex, vocal CoMEPs, and vagus nerve mapping during thyroid surgery with immediate and long-term outcome: Description of two cases

Introduction The implementation of intraoperative neuromonitoring (IONM) during thyroid surgery has proven to place more emphasis on preserving neurological function, decreasing considerably unfavorable outcomes. Our purpose is to correlate the Laryngeal adductor reflex (LAR), vocal-CoMEPs and vagus-RLN nerve mapping IONM changes throughout thyroid surgery, with immediate and long-term outcome in two representative cases. Methods LAR, a novel method for assessing laryngeal and vagus nerve integrity, vocal-CoMEPs, and nerve mapping, were used for IONM. CoMEPs were elicited by TES (short trains of 5 stimuli of 0.5-ms; ISI of 2-ms; intensity up to 120-mA), and LAR by a single electrical stimulus of the laryngeal mucosa using electrodes attached to the ETT (of 0.1–1-ms; intensity up to 8-mA) on the contralateral side of the operative field. ETT-based electrodes were used to record both LAR and CoMEPs responses from vocal fold muscles. Facial-CoMEPs were elicited as a control parameter. RLN-vagus mapping was done using a hand-held monopolar stimulation probe. Videolaryngoscopy was used for initial intubation with tube position verification prior surgery. Significant changes in LAR amplitude responses were the critical parameters for IONM interpretation. Both patients underwent pre and postoperative direct laryngoscopy and thyroarytenoid (TA) EMG assessments. Results Case 1. – A 43-year-old female presented with a history of multinodular goiter. Total thyroidectomy was scheduled. Preoperative evaluation was normal. Bilateral LAR and vocal-CoMEPs responses were elicited at the onset of surgery. During transecting of the left-thyroid-gland, left vocal-CoMEPs and LAR responses were lost. Left RLN and vagus mapping did not elicit any response after the event. Postoperatively the patient presented with hoarseness. Laryngoscopic examination confirmed paralysis of the left vocal cord and left TA-EMG performed 4 weeks after surgery showed abnormal spontaneous activity; low amplitudes-polyphasic MUPs; and mildly decreased interference pattern, consistent with moderate left RLN dysfunction. Case 2. – A 63-year-old female patient who underwent total thyroidectomy for an intrathoracic multinodular goiter. Preoperative assessment was normal. LAR and vocal-CoMEPs responses were bilaterally elicited at the onset of surgery. During resection of the left thyroid lobe, left vocal-CoMEPs and LAR responses completely disappeared. Left RLN and vagus mapping did not elicit any response after the event. Postoperatively the patient presented with cough and hoarseness. The laryngoscopic examination confirmed paralysis of the left vocal cord and post-op left TA-EMG results were also consistent with moderate left RLN dysfunction. Conclusion There is a good correlation between LAR, vocal-CoMEPs and RLN-vagus mapping changes with immediate and long-term outcome in patients during thyroid surgery. LAR is a novel method for assessing laryngeal and vagus nerve integrity that can be useful for IONM during thyroid surgery.

Insight into the neuroendocrine basis of signal evolution: a case study in foot-flagging frogs.

A hallmark of sexual selection is the evolution of elaborate male sexual signals. Yet, how the physiology of an animal changes to support a new or modified signal is a question that has remained largely unanswered. Androgens are important in regulating male reproductive behavior, therefore, selection for particular signals may drive the evolution of increased androgenic sensitivity in the neuro-motor systems underlying their production. Studies of the neuroendocrine mechanisms of anuran sexual signaling provide evidence to support this idea. Here, we highlight two such cases: first, a large body of work in Xenopus frogs demonstrates that sexually dimorphic androgen receptor (AR) expression in the laryngeal nerves and muscles underlies sexually dimorphic vocal behavior, and second, our own work showing that the recent evolution of a hind limb signal (known as the "foot flag") in Staurois parvus is accompanied by a dramatic increase in androgenic sensitivity of the thigh muscles that control limb movement. Together, these examples illustrate that the evolutionary modification or gain of a sexual signal is linked with a novel pattern of AR expression in the tissues that support it. We suggest that such co-evolution of AR expression and sex-specific or species-specific signaling behavior exists across vertebrates.

Lewis-Sumner Syndrome Manifesting as Unilateral Vocal Fold Paresis and Laryngeal Fasciculations

Lewis-Sumner syndrome (LSS) is a rare disease characterized by asymmetrical and multifocal mononeuropathy commonly located in the upper limbs. Some rare cases affecting cranial nerve have been described, but LSS is unknown to affect especially laryngeal nerves. This paper presents the first case of unilateral vocal fold paresis caused by an LSS in a 59-year-old man complaining of dysphonia, breathy voice, and vocal fatigue. Epidemiology, clinical features, diagnosis, and treatment will be described.

Prognostic factors for recurrence of locally advanced differentiated thyroid cancer.

Retrospective review of 70 patients in a single, tertiary referral institution was done. Clinical pathology characteristics were analyzed to investigate prognosticators, based on primary endpoints; locoregional recurrence alone (LRR), total recurrence (LRR or distant metastasis (DM)), and recurrence-free survival. Recurrent laryngeal nerve (n = 31) and trachea (n = 30) were most commonly invaded organs by tumor. At the mean follow-up of 81.7 months, LRR occurred in 15 patients and/or DM was detected in 15 patients (10 developed LRR and DM). By multivariate analysis, R1 resection (positive margin) and pN1b stage increased risk of LRR with a fold of 3.16 [95%CI 1.08-9.24, P = 0.03] and 5.92 [1.61-21.7, P = 0.007], respectively. Also, they increased risk of total recurrence with a fold of 3.04 [95%CI 1.26-7.31, P = 0.01] and 3.42 [95%CI 1.16-10.0, P = 0.02], respectively. Patients with pN1b stage showed better LRR-free survival than pN0/N1a stage (P = 0.03). Conclusions Along with careful preoperative evaluation of the extent of primary and neck disease, obtaining negative resection margin and aggressive neck management is critical to improve oncologic outcomes of locally advanced DTC.

Vagus nerve stimulation: Surgical technique of implantation and revision and related morbidity

Indications for vagus nerve stimulation (VNS) therapy include focal, multifocal epilepsy, drop attacks (tonic/atonic seizures), Lennox-Gastaut syndrome, tuberous sclerosis complex (TSC)-related multifocal epilepsy, and unsuccessful resective surgery. Surgical outcome is about 50-60% for seizures control, and may also improve mood, cognition, and memory. On this basis, VNS has also been proposed for the treatment of major depression and Alzheimer's' disease. The vagus nerve stimulator must be implanted with blunt technique on the left side to avoid cardiac side effects through the classic approach for anterior cervical discectomy. The actual device is composed of a wire with three helical contacts (two active contacts, one anchoring) and a one-pin battery. VNS is usually started 2 weeks after implantation with recommended settings of stimulation (1.0-2.0mA; 500μs pulse width; 20-30Hz; 30s ON, 5min OFF). The complications of VNS therapy are early (related to surgery) and late (related to the device and to stimulation of the vagus nerve). Early complications include the following: intraoperative bradycardia and asystole during lead impedance testing, peritracheal hematoma, infections (3-8%), and vagus nerve injury followed by hoarseness, dyspnea, and dysphagia because of left vocal cord paralysis. Delayed morbidity due to the device includes late infections or problems in wound healing; other more rare events are due to late injury of the nerve. Late complications due to nerve stimulation include delayed arrhythmias, laryngopharyngeal dysfunction (hoarseness, dyspnea, and coughing), obstructive sleep apnea, stimulation of phrenic nerve, tonsillar pain mimicking glossopharyngeal neuralgia, and vocal cord damage during prolonged endotracheal intubation. The laryngopharyngeal dysfunction occurs in about 66% of patients and is usually transitory and due to the stimulation of the inferior (recurrent) laryngeal nerve. A true late paralysis of the left vocal cord is often partial and rare (1-2.7%), and usually transitory, and may be caused by previous surgical trauma (i.e., damage of nerve fibers and/or of their blood supply) or to a supposed chronic denervation during stimulation. Surgery for complete removal or revision and replacement of the device is to be considered in cases of device malfunction (4-16.8%), failure of VNS therapy, intolerable side effects, or because of patient's specific request. As described in the literature, the surgical techniques of lead revision and replacement are two: sharp and blunt dissection of helical electrodes and replacement; and blunt dissection combined with ultrasharp low-voltage cautery dissection. The incidence of left vocal cord palsy after vagus nerve stimulator replacement/revision is slightly higher than that of first implantation (4.9% vs. 3.8%). A de novo implantation in a naive segment of the left or right vagus nerve may be considered in specific cases; the use of the right vagus nerve is a rare exception that may be chosen with an acceptable result.

Application of LigaSure Technology in Thyroid Surgery

The incidence of nodular forms of goitre, compression syndrome in particular, as well as thyroid oncopathology is steadily growing. The number of patients with diffuse toxic goitre and functional autonomy of nodular forms of goitre exhibits no tendency toward reduction. Thyroid surgery remains one of the major and most effective methods of treatment. Parathyroid glands and laryngeal nerves are located close to large branches of the thyroid arteries; therefore, thyroid surgery should be performed in a dry operative field.The objective of the research was to assess the efficacy of the LigaSure technology in the formation of reliable homeostasis as well as to provide morphological basis for blood clot quality and morphofunctional state of the thyroid parenchyma after hemithyroidectomy.Materials and methods. The results of surgical treatment of 100 patients with nodular and toxic forms of goitre being treated in the surgical department of the Ternopil Municipal Emergency Hospital during 2011-2012 were compared with the results of surgical treatment of 200 patients with similar pathology who underwent surgical treatment during 2014-2016. According to the in-patient medical records, in patients operated on during 2011-2012 to achieve homeostasis the traditional ligature method was used; the length of surgical access was 6-8 cm. However, to achieve homeostasis in patients operated on during 2014-2016 the LigaSure device was used during surgery; the length of surgical access was 2.5-3 cm. The removed part of the thyroid gland was sent for morphological examination. The thyroid tissue was fixed in a 10% neutral formalin solution to be studied macro-and microscopically. A 1.0x0.5-cm fragment of the thyroid tissue was dissected out from three areas: the first fragment was dissected out from the area of the impact of radio-frequency current; the second fragment was dissected out in the perifocal area 0.5 cm from the electrocoagulation area, and the third one was dissected out 0.8-1.0 cm from the electrocoagulation area. Dewaxed sections were stained with haematoxylin, eosin as well as with Hart and Mallory’s fuchselin. Histological preparations were studied using the SEOSCAN and Lumam P-8 microscopes at different magnifications. Results. Histological study revealed local coagulative necrosis in the area of the impact of LigaSure radio-frequency current. The contours of the follicles without coloured structures, which were saturated with haemolytic erythrocytes, indicated necrosis. The thyrocyte cytoplasm and intercellular tissue were eosinophilic; the nuclei were not identified. In the lumen of intraorganic blood vessels, there was formed homogeneous agglutinative thrombus tightly adhering to the vascular wall indicating the formation of reliable and high-quality homeostasis in the area of direct effect of radio-frequency current. In the perifocal area there were the signs of the adaptive processes on the background of pronounced microcirculatory disturbances. Changes in thyrocytes manifested themselves as necrotic and dystrophic swelling and enlightenment of the cytoplasm. Clinically, these changes may manifest themselves as an increase in the secretory function of the thyroid gland in the particular area. Changes being typical to chronic manifestations of nodular goitre were found in the areas more distant from coagulative necrosis. The thyroid parenchyma was represented by clusters of large and small follicles separated by connective tissue interlayers.Conclusions. The application of the LigaSure technology in surgical treatment of the thyroid gland improves the quality of surgical interventions due to a decrease in intraoperative blood loss, duration of surgery as well as postoperative in-patient treatment. In addition, the LigaSure technology provides better surgical access, thereby improving cosmetic effect. Morphologic changes in the thyroid gland due to the effect of radio-frequency current were distance-dependent: in the area of direct effect of radio-frequency current coagulative necrosis developed; in the perifocal area intensified secretory response of the thyroid tissue to the extreme factor occurred; in distant areas the typical structure of the nodular goitre with the signs of disturbed microcirculation was found.

Total Endoscopic Thyroidectomy with Intraoperative Laryngeal Nerve Monitoring.

Objective. To evaluate the clinical efficacy of laryngeal nerve (LN) monitoring (LNM) during total endoscopic thyroidectomy via breast approach, with emphasis on the identification rates for RLN and EBSLN and the incidence of RLN paralysis. Materials and Methods. This retrospective study included 280 patients who underwent endoscopic thyroidectomy with or without LNM. RLN and EBSLN were identified using endoscopic magnification in the control group, while they were localized additionally by LNM in the LNM group. Demographic parameters and surgical outcomes were analyzed by statistical methods. Patients in the control group were also stratified by the side of thyroidectomy to determine difference in left and right RLN injury rates. Results. All procedures were successfully conducted without permanent LN damage. The identification rates for RLN and EBSLN were high in the LNM group compared to those of the control group, and the risk difference (RD) of temporary RLN injury between two groups was 6.3%. The risk of damage was slightly higher for the left RLN than for the right RLN in the control group, which was performed by a right-hand surgeon. Conclusion. The joint application of LNM and endoscopic magnified view endows total endoscopic thyroidectomy with ease, safety, and efficiency.

Unilateral Cervical Polyneuropathies following Concurrent Bortezomib, Cetuximab, and Radiotherapy for Head and Neck Cancer.

We report a constellation of cervical polyneuropathies in a patient treated with concurrent bortezomib, cetuximab, and cisplatin alongside intensity modulated radiotherapy for carcinoma of the tonsil with neck metastasis. The described deficits include brachial plexopathy, cervical sensory neuropathy, and oculosympathetic, recurrent laryngeal, and phrenic nerve palsies within the ipsilateral radiation field. Radiation neuropathy involving the brachial plexus is typically associated with treatment of breast or lung cancer; however, increased awareness of this entity in the context of investigational agents with potential neuropathic effects in head and neck cancer has recently emerged. With this report, we highlight radiation neuropathy in the setting of investigational therapy for head and neck cancer, particularly since these sequelae may present years after therapy and entail significant and often irreversible morbidity.

Intraoperative localization and protection of important structures of the neck in thyroid surgery

Nodular thyroid disease affects thousands of people in Poland. Tumors of the thyroid account for about 1% overall human cancers. Thyroidectomy is the most common surgical operation in endocrine tumors. Operative therapy for benign thyroid nodules is recommended for: progressive increase in nodule size, substernal extension, compressive symptoms of the neck, the development of thyrotoxicosis and patient therapeutic prevalence. In Poland thyroidectomy is the fifth surgical procedure and comprises about 25000 operations yearly. Reduction of surgical injury with simultaneous retention of current safety and radical nature of surgical intervention forces the work into a relatively small operating field. Electric devices enabling the achievement of full and lasting haemostasis during thyroidectomy supplant traditional surgical method (ligature, haemostatic sutures) with no impact on the incidence of perioperative complications, while at the same time allowing to shorten the duration of the procedure. The haemostatic effect is associated with generation of heat, which apart from the intended result may bring about thermal tissue injury. During the surgical procedure it is important to determine the thermal spread around the active tip of electric devices in the operating field during thyroidectomy, and the safe temperature range during the operation to protect important structures of the neck. The mean safe distance of the active tip of an electric device from important anatomic structures is 5mm minimally and depends on the device type, time of operation and its power settings. All the modern techniques of vessel sealing are associated with generation of heat and its spherical spread, which causes thermal injury to the surrounding tissues. Their mode of operation through, among others, structural changes in collagen and elastin, leads to durable connection of sealed vessel walls and tissue structures. These systems enable a safe sealing of vessels of up to 7 mm in diameter. In conclusions: In the cases analyzed by the author concerning the thyroidectomy techniques, it is recommended to replace electric devices with ligatures or clips or human fibrinogen in place near the laryngeal nerves, parathyroid glands and the trachea. The decision of the change of the method of haemostasis maintenance in the vicinity of crucial structures has been left to the surgeon.

Clinical analysis of 39 cases with reoperation for thyroid

Objective To explore the cause of the thyroid reoperation ,methods,surgical approach ,and the prevention of complications .Methods 39 cases of thyroid reoperation in patients with clinical data were reviewed and analyzed.Results Thyroid papillary carcinoma in 11 cases,follicular carcinoma in 2 cases,nodular 22 cases of thyroid,thyroid adenoma 1 case,3 cases of primary hyperthyroidism .The incidence of transient hypoparathyroidism ac-counted for 2 cases,temporary laryngeal recurrent nerve injury in 2 cases,chyle leakage in 1 case,in total of 12.8%of postoperative complications .Conclusion Improper operation method choice for the first time and the misdiagnosis was the main cause of reoperation , The reoperation of thyroid is difficult and has more complications .Preoperative evaluation and careful operation can prevent the occurrence of complications . Key words: Thyroid/Surgery; Reoperation; Complication

Bilateral common peroneal nerve injury after pediatric cardiothoracic surgery: A case report and review of the literature

Nerve injuries after thoracic and cardiovascular surgery have been reported but generally concern the brachial plexus, phrenic nerve, recurrent laryngeal, and facial nerve. Common peroneal nerve injury (CPNI) following cardiopulmonary bypass has been reported in adults (4); however bilateral injury is extremely uncommon. Age, low body weight, co-morbidities such as peripheral arteriosclerotic disease, diabetes mellitus, and arrhythmias were associated with CPNI following cardiothoracic surgery in adults. Common peroneal nerve injury (CPNI) following cardiopulmonary by-pass has been reported in adults; however, bilateral injury is extremely uncommon. The superficial course of CPN makes it vulnerable to traction or compression. We report a 5-year-old girl manifesting with bilateral CPNI following prolonged cardiopulmonary by-pass. To the best of our knowledge, she is the first pediatric patient presenting with bilateral CPNI following cardiothoracic surgery and cardiopulmonary by-pass.

Discussion on the strategies of common hepatic artery lymph node dissection for thoracic esophageal squamous cell carcinoma

Objective To analyze the metastatic rule of common hepatic artery lymph node of thoracic esophageal squamous cell carcinoma,and to investigate the strategies of common hepatic artery lymph node dissection.Methods The clinical data of 682 patients with esophageal squamous cell carcinoma who were admitted to the Cancer Hospital of Fudan University from May 2005 to December 2010 were retrospectively analyzed.The locoregional lymph node metastasis of thoracic esophageal squamous cell carcinoma,relationship between metastatic rates of common hepatic artery lymph node and clinicopathological factors and the postoperative complications were analyzed.The enumeration data were analyzed using the chi-square test.Results A total of 18 277 lymph nodes were dissected (27 lymph nodes per patient).The lymph node metastatic rate was 55.87％ (381/682),and the metastatic lymph node ratio was 7.87％ (1438/18 277).Lymph nodes adjacent to the cardia of stomach,laryngeal nerve,lesser curvature of stomach,cervical esophagus,left gastric artery had a higher metastatic rate,while common hepatic artery lymph node had a lower metastatic rate.All the common hepatic artery lymph node metastasis was accompanied with locoregional metastasis.A total of 1480 common hepatic artery lymph nodes were dissected (2 common hepatic artery lymph nodes per patient).Twenty-four patients had common hepatic artery lymph node metastasis,with the metastatic rate of 3.52％ (24/682) and the lymph node ratio of 2.16％ (32/1480).The common hepatic artery lymph node metastatic rates of upper,middle and lower esophageal squamous cell carcinoma were 2.33％ (1/43),3.76％ (16/425) and 3.27％ (7/217),with no significant difference (x2 =0.295,P ＞ 0.05).The common hepatic artery lymph node metastatic rates of patients in T1,T2 and T3 stages were 2.35％ (2/85),5.46％ (10/183) and 2.90％ (12/414),with no significant difference (x2 =2.850,P ＞ 0.05).The common hepatic artery lymph node metastatic rates of patients with high,moderate and poor differentiated esophageal squamous cell carcinoma were 0(0/63),3.50％ (16/457) and 4.94％ (8/162),with no significant difference (x2=3.259,P ＞ 0.05).The common hepatic artery lymph node metastatic rates of patients with diameter of tumor under 3 cm,3-5 cm and above 5 cm were 2.59％ (6/232),3.02％ (11/364) and 8.14％ (7/86),with significant difference (x2 =6.267,P ＜ 0.05).The common hepatic artery lymph node metastatic rates of patients in N0,N1,N2,N3 stages were 0(0/301),2.53％ (5/198),5.65％ (7/124) and 20.34％ (12/56),with significant difference (x2 =62.368,P ＜ 0.05).The common hepatic artery lymph node metastatic rates of patients in stage Ⅰ,Ⅱ,Ⅲ and Ⅳ were 0(0/62),1.78％ (6/337),5.06％ (13/257) and 19.23％ (5/26),with significant difference (x2=25.959,P ＜0.05).Two hundred and twenty-eight patients had postoperative complications with the complication rate of 33.43％ (228/682).The incidence of anastomotic fistula was the highest,which was 11.58％(79/682).Conclusions The metastatic rates of common hepatic artery lymph node in thoracic esophageal squamous cell carcinoma is the lowest.For patients suffered from esophageal cancer in stage I or the tumor diameter under 5 cm,the dissection of common hepatic lymph node can be ommitted in surgery. Key words: Esophageal neoplasms; Common hepatic artery lymph node; Lymph node dissection

An integrated approach for the surgical treatment of patients with primary hyperparathyroidism

This paper presents the treatment results of 75 patients with primary hyperparathyroidism (PHPT) caused by a solitary parathyroid adenoma (SPA). Patients in Group 1 had PHPT with concomitant diseases of the thy roid gland (TG). Group 2 consisted of patients with PHPT without thyroid disease. Group 3 included patients with PHPT and concurrent diseases of the parathyroid glands (PG) and thyroid gland, which were operated on without the use of the proposed integrated approach. Patients in groups 1 and 2 were operated on using the following techniques. Patients in group 1 underwent surgery usinga traditional incision with photodynamic visualization (PV) of the PG and exposure of the recur rent and superior laryngeal nerves (LN) (in some cases with the use of magnifying devices and neuromyog raphy). Patients in group 2 underwent surgery with minimally invasive access, utilizingendoscopic video devices and the universal retractor “Multifiks1”. During the intervention,PVof the PG and electrophysiolog ical monitoring (EM)of the recurrent LN were carried out. In groups 1 and 2, adequacy of the operationwas determined by the change in the level of intraoperative parathyroid hormone (PTH) and ionized calcium before and after the removal of the PG. Our proposed integrated method for the treatment of patients with PHPT allowed for a significant reduction in the risk of postoperative complications and consequently an improvement in quality of life.

Clinical analysis of 109 cases of recurrent papillary thyroid carcinoma

Objective: To explore the factors related to recurrence of PTC (papillary thyroid carcinoma) and the sites of recurrence, in order to seek for the proper treatment of these cases. Methods: The clinical and follow-up data of 109 cases of recurrent PTC in Tianjin Medical University Cancer Hospital from January 2008 to January 2012 were analyzed retrospec­tively, and 350 cases of PTC without recurrence in the same period were also collected as the controls. The univariate and multivariate analyses were performed to find out the recurrence-related factors. Results: The univariate analysis revealed that initial operative approach, TNM stage and pathological subtype were associated with recurrence (P 0.05). Multivariate analysis indicated that initial operative approach and pathological subtype were the dependent factors for recurrence (P < 0.05). Of 109 cases, 20 (18.3%) were confirmed as residual carcinoma by pathology. The involved sites of recurrence included regions of lymph nodes (34 in group Ⅱ, 54 in group Ⅲ, 58 in group Ⅳ, 12 in group Ⅴ, 68 in group Ⅵ), soft tissues (5 in group Ⅱ, 6 in group Ⅲ, 9 in group Ⅳ, 0 in group Ⅴ, 8 in group Ⅵ), muscles (2 in anterior cervical muscle, 1 in extrinsic laryngeal muscle, and 0 in sternocleidomastoid), parathyroid (n = 1), laryngeal recurrent nerve (n = 3), esophagus (n = 1) and trachea (n = 2). Five cases developed pulmonary metastasis, and 1 case developed liver and bone metastases. Conclusion: For the PTC patients who have the possibility of recurrence, the reinforced postoperative follow-up should be required. Furthermore, regular reexamination is also needed for possible recurrent regions. Once the recurrence occurres, active and standardized therapy is suggested for PTC. DOI:10.3781/j.issn.1000-7431.2013.08.012

Identificação e Preservação de Glândulas Paratiróides em Peças de Cadáver

It is essential to know the thyroid gland morphology and its anatomical relations in the anterior compartment of the neck in order to minimize the rate of thyroid surgery morbidity, especially the lesion of parathyroid glands and laryngeal nerves. The aim of this study was the identification of parathyroid glands in cadaver parts and their histological confirmation. Twenty cadaver parts were used to simulate thyroidectomies. During dissection, the thyroid glands and eventual parathyroid glands were isolated and then submitted to histological study. Twenty cadaver parts (anterior cervical organs) were used for macroscopic dissection during which 48 fragments that corresponded to eventual parathyroid glands were isolated, 35 of which were effectively confirmed through histological observation to be parathyroid glands. The 20 cadaver parts were then divided into three groups according to the number of histologically confirmed parathyroid glands. In the first group, composed of 11 cases, all eventual parathyroid glands were confirmed. In the second group, composed of six cases, only some glands were confirmed. In the third group, composed of three cases, none of the possible glands were confirmed. In seven of the 20 isolated thyroid glands, eight parathyroid glands were identified during histological study: four subcapsular, three extra-capsular, one intra-thyroidal. There was no statistical relation in the dimensions of the parathyroid glands. The knowledge of the anatomy of the central visceral compartment of the neck and its most frequent variations reduces but doesn't eliminate thyroid surgery morbidity, especially parathyroid iatrogenic excision, difficulty which has been demonstrated during the dissection of cadaver parts.

Non-Recurrent Laryngeal Nerve and Aberrant Vasculature

Background: The incidence of non-recurrent laryngeal (RLN) nerve is around 0.5%. Injury to the nerve results in significant morbidity. Methods and Results: A case of a 63-year old lady with a non-RLN and an aberrant subclavian artery was described. A successful thyroidectomy was performed with subcapsular dissection and identification of the RLN medially. Embryogenesis and anatomical variations of the nonRLN were reviewed, and their clinical importance was discussed. Conclusions: It is important for surgeons who regularly perform thyroidectomies to be aware of the association between aberrant subclavian artery and the presence of non-RLN.

Evidence for swallowing reflexes evoked by acid and mechanical stimulation of the vagal afferent nerves innervating the larynx in anesthetized guinea pigs

PurposeSwallowing protects the lungs from aspiration and is evoked from the upper airways (UA) by activation of pharyngeal afferent nerves. We have tested the hypothesis that laryngeal (LX) afferent nerve activation may also evoke swallowing.MethodsSternohyoid muscle EMGs and UA airflow were used to detect swallows in anesthetized guinea pigs (GPs). Citric acid (CA; 0.01M, 50μL), applied topically to the LX mucosa, and UA pressure distensions, both applied 5× repetitively in 5 min intervals and delivered rostrally via the trachea, were used to evoke swallows.ResultsRepetitive LX CA challenge evoked swallowing (13±5 swallows; n=7). Severing both the recurrent (RLN) and superior (SLN) laryngeal nerves nearly abolished LX CA evoked swallows (0.3±0.3; n=4). Severing just the RLNs also nearly abolished the LX acid‐evoked swallows (1.3±0.9; n=4). By contrast, swallows evoked by 30sec pressure distensions of the UA were not prevented by RLN transection, with all intact (50±5; n=4) and RLN transected (26±3; n=4) GPs swallowing in response to each of 5 distensions. RLN transection did, however, delay the onset of UA distension evoked swallows (4.0±1.3s and 13.6±1.4s in intact and RLN transected GPs; n=4 each). A single, subsequent LX CA challenge evoked swallows in all 4 of these control GPs (4±1) but in none of the GPs with RLNs cut (0±0).ConclusionsLaryngeal vagal afferent nerve activation initiates swallowing.

Observation of Vocal Fold and Pharyngeal Paralysis After Carotid Endarterectomy Using a Magnifying Laryngoscope

Injury to the vagus nerve or one of its branches during carotid endarterectomy (CEA) can result in vocal fold paralysis (VFP), but the exact mechanisms and site of injury responsible for VFP after CEA are unclear. The aim of this study was to identify the site of nerve injury in patients with VFP after CEA using magnifying laryngoscopy. We performed 96 consecutive CEA procedures in 87 patients over 5 years. After 56 CEA procedures, we examined vocal fold movements with a flexible nasolaryngoscope and detected VFP in 5 of 40 cases (9 %). At 6-8 weeks after CEA, these five patients also underwent magnifying laryngoscopy at another institution by a specialist in vocalization. We confirmed ipsilateral VFP and pharyngeal paralysis in three patients. The other two patients recovered from their nerve injuries spontaneously before the magnifying examination. VFP and pharyngeal paralysis were caused by damage to the recurrent laryngeal and pharyngeal nerves. Therefore, the probable site of nerve injury during CEA was near the inferior vagal ganglion of the vagus nerve trunk in our three patients.