Permanent Vocal Cord Paralysis Research Articles

Association Between Annual Surgeon Total Thyroidectomy Volume and Transient and Permanent Complications

Although the association between annual surgeon total thyroidectomy volume and clinical outcomes is well established, published methods typically group surgeons into volume categories. The volume-outcomes association is likely continuous, but little is known about the point at which the annual surgeon procedure volumes begin to be associated with a decrease in complication rates. To model the volume-outcomes association as a continuous function and identify the point at which increasing surgeon volume begins yielding better outcomes. A retrospective cohort study was conducted in 2018 to 2019 on 10 546 patients from 2 Kaiser Permanente regions (Northern and Southern California), who underwent total thyroidectomy from January 1, 2008, through December 31, 2015, and were followed up through December 31, 2017. The association between annual surgeon procedure volume and outcomes was modeled with analyses that accounted for an association of unknown form and surgeon-specific effects, after adjusting for sociodemographics, prior-year utilization, and multiple comorbidities. Data were analyzed from October 2018 to April 2019. Total thyroidectomy. Presence or absence of transient and permanent hypoparathyroidism and vocal cord paralysis (VCP) in relation to surgeon volume of total thyroidectomies. Of 10 546 patients in this study, 8500 (81.0%) were male and 4877 (46.2%) aged 45 to 64 years. Surgeons with annual volumes of 1 to 9 total thyroidectomies operated on 2912 patients (27.7%), those with an annual volume of 10 to 19 operated on 3404 (32.6%), and those with an annual volume of 20 or more operated on the remaining 4232 (40.6%). During 2008-2015, a mean of 53.5 (range, 46-198) thyroidectomies were performed each year by surgeons with an annual volume of 40 or more procedures. A generalized additive model showed that the occurrence rates of VCP and hypoparathyroidism began to decrease at annual surgeon procedure volumes of 18.2 (95% CI, 15.0-21.5) and 18.1 (95% CI, 13.8-21.3) procedures per year, respectively. The model revealed a subsequent increase in complication rates for transient VCP. With the use of a refined model, statistically significant decreases were noted in the occurrence rates of complications as annual surgeon volumes increased. Among all 10 546 patients who underwent total thyroidectomy, 632 (6.0%) experienced transient hypoparathyroidism and 170 (1.6%) experienced permanent hypoparathyroidism, whereas 440 (4.2%) experienced transient VCP and 182 (1.7%) experienced permanent VCP. Absolute decreases in complication rates when all surgeons had modeled minimum annual procedure volumes greater than 40 were low, ranging from 0.6% for permanent VCP and hypoparathyroidism to 1.5% for transient hypoparathyroidism. In this study, occurrence rates of transient and permanent hypoparathyroidism and VCP appeared to decrease as the annual surgeon procedure volume increased, but the absolute decrease may be modest if the affected health system already has low complication rates. Shifting patients to higher-volume surgeons to realize these reductions may be of variable attractiveness in systems with low baseline complication rates.

Application of Continuous and Intermittent Intraoperative Nerve Monitoring in Thyroid Surgery

BackgroundWhether continuous intraoperative nerve monitoring (C-IONM) can further reduce the incidence of recurrent laryngeal nerve injury compared with intermittent intraoperative nerve monitoring (I-IONM) in high-risk thyroid surgery is still controversial. This observational study aimed to evaluate the incidence of vocal cord paralysis (VCP) in high-risk thyroid surgeries performed with I-IONM and C-IONM. Materials and methodsHigh-risk thyroid surgical patients operated with I-IONM or C-IONM by the same group of surgeons in the thyroid surgery department of our institution between January 2014 and February 2018 were analyzed. Differences in the incidence rates of temporary and permanent VCP between the two groups were compared. A P-value < 0.05 was considered statistically significant. ResultsA total of 344 patients who underwent high-risk thyroid surgery (550 nerves at risk [NARs]) were observed, with 238 patients (374 NARs) operated with I-IONM and 106 patients (173 NARs) operated with C-IONM. The incidence of temporary and permanent VCP was 1.9% (7/374) and 0.8% (3/374) in the I-IONM group and 1.2% (2/173) and 0% (0/173) in the C-IONM group, respectively, showing no statistical difference (P = 0.726 and P = 0.555). The incidence rate of impending recurrent laryngeal nerve injuries successfully prevented in the C-IONM group was 5.2% (9/173). ConclusionsBoth I-IONM and C-IONM are equally safe and effective in high-risk thyroid surgery. C-IONM can help predict impending recurrent laryngeal nerve injury in real time and has a good warning feature, thereby minimizing critical maneuvers in high-risk thyroid surgery.

Surgical Complications After Thyroid Surgery: A 10-Year Experience at Jeddah, Saudi Arabia.

To evaluate the incidence and predictive risk factors of complications in patients who underwent thyroid surgery at our hospital with a residency training program. This retrospective cohort study analyzed the complications in all patients who underwent thyroid surgery between January 2008 and December 2017. Demographic data, preoperative diagnosis based on fine needle aspiration cytology, surgical approach, permanent pathology, postoperative complications, and factors associated with complications were recorded. At our hospital, 456 patients underwent thyroidectomy. The most common surgical complications were asymptomatic biochemical hypocalcemia and symptomatic hypocalcemia in 109 (23.9%) and 50 (11%) patients, respectively. Other surgical complications included permanent hypocalcemia, transient vocal cord palsy, permanent vocal cord palsy, hematoma, seroma, chyle fistula, and Horner's syndrome. Mean age > 45years and more extensive surgery were significantly associated with overall complications (P = 0.003; < 0.001). Mean age > 50years and vitamin D level < 25nmol/L (< 10ng/mL) were significantly associated with hypocalcemia (P = 0.008; < 0.001). Moreover, the extent of surgery and advanced thyroid carcinoma were significantly associated with vocal cord palsy (P < 0.001; 0.05). Hypocalcemia and vocal cord palsy are the most significant complications. Thyroid surgery can be performed safely by senior residents in the residency training program under the direct supervision of an experienced surgeon.

Gasless transoral robotic thyroidectomy using the DaVinci SP system: Feasibility, safety, and operative technique

BackgroundTransoral robotic thyroidectomy (TORT) is an ideal method for minimally invasive thyroidectomy, as there is less flap dissection during the procedure and no postoperative scars. However, this method also has the limitation of present DaVinci system and some technical problems related to CO2 gas insufflation that must be resolved. We investigated the feasibility and safety of gasless TORT using the latest version of the DaVinci system (SP). MethodsFrom October 2018 to January 2019, we performed 10 surgeries of gasless TORT using the DaVinci SP at Yonsei University Hospital. ResultsNine patients underwent unilateral thyroid lobectomy and one patient received total thyroidectomy. All operations were successfully completed. Nine cases had papillary thyroid carcinoma, and one had benign nodules. The mean surgical time was 177 min, and the mean hospital stay was 6.3 days. There were no reports of transient or permanent vocal cord palsy, recurrence, or mortality during the follow-up period. Temporary hypoesthesia of the chin due to mental nerve injury was observed in 3 of 10 patients, but it recovered spontaneously within 1 months in all cases. ConclusionsGasless TORT using the DaVinci SP system is feasible and safe for selected patients and is a potential alternative approach for scarless thyroid surgery.

Long-term quality of voice is usually acceptable after initial hoarseness caused by a thyroidectomy or a parathyroidectomy

Vocal cord (VC) palsy following a thyroidectomy or parathyroidectomy can result in significant morbidity for the patient. We aimed to investigate the incidence of VC palsy in a tertiary referral Institution, track the management of these cases and record the long-term outcomes and VC recovery rates. Retrospective review of all thyroidectomy/parathyroidectomy operations performed over 11 years. Patients with an unequivocal hoarse voice postoperatively were included. We analysed the patient's clinical characteristics and voice outcomes, operative, pathology and laryngoscopy reports during their follow-up. Ten patients fitted the inclusion criteria and were analysed. Median age at date of operation was 47.5 years (range, 16-81 years) and the M:F ratio was 1:2.3 (M:3, F:7). The median FU was 62.5 months (range, 12-144 months). The median hospital stay was 1.5 days (range, 1-87 days). There were 7 recurrent laryngeal nerve (RLN) injuries by manipulation, 1 case of RLN resection, 1 inadvertent division (with primary nerve repair) and 1 RLN was shaved off the thyroid. Long-term voice outcomes for the 7 patients with an RLN manipulation injury were: 3/7 patients had normal voice, 3/7 had moderate hoarseness and 1/7 had long-term hoarseness. The long-term voice outcome of the patient with RLN shaving off the thyroid gland was excellent while the 2 remaining patients (RLN resection and inadvertent division) needed 12 and 18 months respectively to achieve a normal quality of voice. Four out of the 10 patients had permanent VC palsy in the long-term and their voice outcomes varied: 1 patient had a normal voice, 2 patients had moderate hoarseness and 1 patient had persistent hoarseness. Only 1/10 patients did not show any voice improvement after 12 months. In the vast majority of cases post-operative hoarseness due to RLN palsy improves in the long-term, albeit voice may not return completely to normal.

Inferior Approach: a Safe Method for Identification of Recurrent Laryngeal Nerve During Thyroidectomy

The recurrent laryngeal nerve (RLN) and external branch of superior laryngeal nerve (EBSLN) and parathyroids have to be deliberately identified and preserved during each and every thyroidectomy. The RLN is vulnerable to injury at three sites during surgery. Various approaches have been adopted by surgeons the world over to identify and preserve the RLN. Here, we have adopted the ‘inferior approach’ (IA), which is an easy and a fruitful one. To safely identify and preserve the RLN in the neck using the inferior approach, an intra-operative analysis of RLN were conducted in 393 patients who underwent thyroidectomy for various indications at a tertiary care centre in North Malabar, Kerala, from January 2004 to December 2011 prospectively. The RLN was identified and preserved by inferior approach. Three hundred ninety-three cases were assessed (343 total and 50 hemi thyroidectomy); 358 and 375 RLN on left and right and 1 NRLN were identified. 64.88% of RLN was underneath, 7.14% was superficial to the main trunk and 27.97% was in between the branches of ITA. RLN enters the larynx mainly as a single trunk in 624 cases (85.11%), while it had branches in 110 cases (14.89%). Eighty-four cases (76.3%) had two branches and 26 cases (23.7%) had three branches. All nerves were identified and preserved using the inferior approach. We were unable to identify 2 RLN due to extensive adhesions and fibrosis of thyroiditis and malignancy. Fourteen patients had temporary hoarseness and no permanent vocal cord palsy was reported. Every thyroid surgeon should be aware of the anatomical variations of the RLN. Inferior approach is a safe technique for its identification and preservation.

Transoral endoscopic thyroidectomy using vestibular approach: A single center experience.

Background:Thyroid Natural Orifice Transluminal Endoscopic Surgery (NOTES) or transoral endoscopic thyroidectomy using vestibular approach is a recent advance embraced by the surgical community because of its potential for a scar-free thyroidectomy. In this article, we present our initial experience with this technique.Materials and Methods:We used a three-port technique through the oral vestibule, one 10 mm port for the laparoscope and two additional 5 mm ports for the endoscopic instruments required. The carbon dioxide insufflation pressure was set at 12 mm of Hg. Anterior cervical subplatysmal space was created from the oral vestibule down to the sternal notch, and the thyroidectomy was done using conventional laparoscopic instruments and a harmonic scalpel.Results:From May 2016 to December 2017, we have performed ten such procedures in the Department of General Surgery in our hospital, which is a tertiary referral center. Six patients had solitary thyroid nodules, for which a hemi-thyroidectomy was done. Four patients had multi-nodular goiter and total thyroidectomy or near-total thyroidectomy was done. The preoperative fine-needle aspiration cytology (FNAC) was suggestive of Bethesda class 2 lesions in all the patients with multinodular goiter and in five of the six patients with solitary nodular goiter. Only one patient with solitary nodular goiter had a Bethesda class 3 lesion on FNAC. The final histopathological report of the specimen was benign, either colloid goiter, or degenerative nodule in all cases of multinodular goiter and in four cases of solitary thyroid nodule. In one Bethesda class 2 solitary nodule, the histopathological report was suggestive of follicular carcinoma; in the Bethesda class 3 solitary nodule, the histopathological report was suggestive of follicular variant of papillary carcinoma. No complication such as temporary or permanent vocal cord paralysis, hypoparathyroidism, subcutaneous emphysema, pneumomediastinum, tracheal injury, esophageal injury, mental nerve palsy, or surgical site infection was found postoperatively. However, two patients developed small hematomas in the midline.Conclusion:Transoral endoscopic thyroidectomy is a safe, feasible, and minimally invasive technique with excellent cosmetic results.

Bridging the Gap of Skilled Surgeons in Low and Middle Income Countries Using ICT Based Tools : A Case Study in Super-Speciality Training

Introduction: Over the last two decades, advancement of super specialised surgical disciplines has shown improved health outcome, in particular quality and safety. Although medical technology has developed to meet diagnostics and therapeutic needs, there is a scarcity of trained human resources in advanced specialities in low and middle income countries (LMICs). Innovative methods are needed to educate and train people at their workplaces using collaborative technologies and networks. Methods: Over the last 15 years, two general surgeons in Cuttack have been telementored from Lucknow 1,163 km away, using collaborative technologies to develop Endocrine Surgery. This study reviews the last 11 years of the service which includes a clinical decision support system and treatment planning advice using real time videoconferencing. Results: Over the last 11 years, 199 endocrine surgeries per annum were performed with most being thyroid cases as compared with 119 surgeries per annum during the previous five years. Parathyroid and adrenal cases increased significantly during this period (p &lt;0.001). Rates of temporary and permanent vocal cord palsy (1.7% and 0%), hypocalcaemia (5.9% and 1.1%) were comparable with high volume centres. Based on the quantum, safety and quality outcome of endocrine surgery the provincial government has approved creation of a super-speciality department of endocrine surgery in Cuttack. Conclusion: Sustained engagement using telementoring can transfer surgical skills to needy surgeons and enable them to match the expertise of mentors. This model can be replicated in other specialities in a cost effective way to develop specialised human resources for healthcare, in particular in LMICs.

Analysis of neuromonitoring signal loss during retroauricular versus conventional thyroidectomy.

Loss of signal (LOS) during intraoperative neuromonitoring (IONM) of robotic or endoscopic thyroidectomy via a retroauricular approach (RAT) and during conventional open thyroidectomy (COT) was investigated to compare the risk of recurrent laryngeal nerve (RLN) injury between the two groups. Original article. This is a retrospective case series study performed between May 2014 and September 2016. IONM using the NIM 3.0 system (Medtronic Xomed, Inc., Jacksonville, FL) was used for this study. Pre- and postoperative vocal cord functions were assessed using a flexible laryngoscope. LOS types noted intraoperatively and their associations with postoperative vocal cord palsy (VCP) were evaluated. LOS rate and temporary and permanent VCP rates were compared between the two groups. The surgical events associated with LOS were also documented and analyzed in this study. In total, 153 patients were recruited, and 111 patients were enrolled in the RAT group; the remaining 42 patients were enrolled in the COT group. No statistically significant differences in intraoperative LOS (P = 0.812) and postoperative VCP rates (early, permanent; P = 0.259 and P = 0.577, respectively) between the two groups were observed. IONM accuracy of predicting postoperative VCP was 99.1% in our case series. On the basis of IONM findings, the risks of injury to RLN were similar between the two groups. Comparison of LOS was an objective method for verifying the novel RAT approach. We applied our IONM protocol and troubleshooting algorithm during RAT with acceptable accuracy, but the international standardized method of IONM is applicable and recommended for reducing false results using vagal nerve stimulation. 3b Laryngoscope, 129:2199-2204, 2019.

Vocal Cord Palsies Missed by Transcutaneous Laryngeal Ultrasound (TLUSG): Do They Experience Worse Outcomes?

Transcutaneous laryngeal ultrasound (TLUSG) is an innovative, non-invasive tool in detecting post-thyroidectomy vocal cord palsy (VCP). However, TLUSG failed to detect about 6-15% laryngoscopic examination (LE)-confirmed VCP. It is unclear whether the outcome of patients with VCP missed by TLUSG [false negative (FN)] is different from those with VCP diagnosed by TLUSG [true positive (TP)]. Therefore, this study aimed to compare the clinical outcome and prognosis between patients with FN results and TP results. Over 46months, all consecutive patients undergoing thyroidectomy or endocrine-related neck procedure were recruited. They underwent pre-operative and post-operative voice assessments on symptoms, voice-specific questionnaire [voice handicap index questionnaire (VHI-30)], TLUSG and LE. For patients with post-operative vocal cord palsy, reassessment LE would be arranged at second, fourth, sixth and twelfthmonths post-operatively until VCP recovered. In total, 1196 patients, including 74 post-thyroidectomy VCP, were recruited. For those with assessable vocal cords (VC), 58 VCP were correctly diagnosed by TLUSG (TP) and 10 VCP were missed by TLUSG (FN). Sensitivity and specificity of detecting a VCP by TLUSG were 85.3% and 94.7%, respectively. VHI-30 score was significantly increased after operation in TP group [31 (range - 6-105), p < 0.001] but not in FN group [20 (14-99), p = 0.089]. Comparing to TP group, VCP recovered earlier (69 vs. 125days, p < 0.001) and less patients suffered from permanent VCP in patients with FN results. (34.5% vs. 0.0%, p = 0.027). The VCP missed by TLUSG had a milder course of disease. Early recovery of VC function and non-permanent palsy were expected.

Feasibility of Endoscopic Thyroidectomy via Axilla and Breast Approaches for Larger Goiters: Widening the Horizons.

Scarless (in the neck) endoscopic thyroidectomy (SET) has evolved into a cosmetically preferred alternative to conventional thyroidectomy (ConT). Recently many of our patients are demanding SET; however their goitres are larger than the recommended size of 4–6 cm. Our aim was to compare the outcomes of ET for small (<6 cm) vs large (≥6 cm) goitres and determine its feasibility in such cases. This is a retrospective analysis of prospectively maintained database of patients undergoing ET. Patients were divided into 2 groups: I, small (<6 cm) and II, large goitres (≥6 cm). Their demographic and clinicopathological profiles, operation time, conversion and complication rates, and hospital stay were compared. 99 patients (101 procedures) were included: group I, 60 patients (61 procedures), and group II, 39 patients (40 procedures). Mean tumor size (± SD) was 4.4 ± 0.9 cm and 6.7 ± 1.1 cm in groups I and II, respectively. The groups were comparable with respect to demographic and clinical profile except for mean duration of goiter [30.1 ± 32.6 months (group I) vs 60.5 ± 102.4 months (group I), p = 0.03] and gland weight [21.5 ± 15.3 grams (group I) vs 62.3 ± 51.3 grams (group II), p = 0.001]. Although there was no significant difference between mean operating times, long term perioperative outcomes, and conversion rates, temporary hypocalcaemia and length of stay were longer in group II. One patient had permanent vocal cord palsy (~1%, 1/101); none had permanent hypoparathyroidism. Our results indicate that ET can be offered to a subset of patients with larger goitres desirous of SET with no significant difference in mean operation time, conversions, and long term postoperative complications in experienced hands.

A systematic approach to the recurrent laryngeal nerve dissection at the cricothyroid junction

BackgroundTo describe and evaluate a four step systematic approach to dissecting the recurrent laryngeal nerve (RLN) starting at the cricothyroid junction during thyroid surgery (subsequently referred to as the retrograde medial approach).MethodsAll thyroidectomies completed by the senior author between August 2014 and January 2016 were retrospectively reviewed. Patients were excluded if concurrent lateral or central neck dissection was performed. A follow up period of 1 year was included.ResultsSurgical photographs and illustrations demonstrate the four steps in the retrograde medial approach to dissection of the RLN in thyroid surgery.Three hundred forty-two consecutive thyroid surgeries were performed in 17 months, including 213 hemithyroidectomies, 91 total thyroidectomies, and 38 completion thyroidectomies. The rate of temporary and permanent hypocalcemia was 13% (95% confidence interval [CI]: 8–20%) and 3% (95% CI: 1–8%) respectively. The rate of temporary and permanent vocal cord palsy was 9% (95% CI: 6–12%) and 0.3% (95%CI: 0.01–2%) respectively. The median surgical times for hemithyroidectomy, total thyroidectomy, and completion thyroidectomy were 39 min (Interquartile range [IQR]: 33–47 min), 48 min (IQR: 40–60 min), and 40 min (IQR: 35–51 min) respectively. 1% of cases required conversion to an alternative surgical approach.ConclusionIn a tertiary endocrine head and neck practice, the routine use of the retrograde medial approach to RLN dissection is safe and results in a short operative time, and a low conversion rate to other RLN dissection approaches.

Speech therapy after thyroid gland operations in Germany: analysis of routine data from 50,676AOKpatients

This study investigated the frequency of postoperative speech therapy in the context of vocal cord palsy after thyroid surgery based on nationwide routine data. Additionally, volume-outcome relationships were examined. Nationwide routine data from insured patients of the Local Health Insurance Fund (AOK) who underwent thyroid surgery for a benign thyroid disease between 2013 and 2015 were analyzed. Postoperative speech therapy was determined based on prescription data. Transient and permanent vocal cord palsy were determined using indicators. The effect of hospital volumes (volume quintiles) on prescription of postoperative speech therapy was determined by multivariate logistic regression. A total of 50,676 thyroid gland operations were identified. The overall frequency of postoperative speech therapy prescription was 6.5%. In AOK patients with transient or permanent vocal cord palsy, the frequencies of postoperative speech therapy prescription were 56.1% and 75.2%, respectively. The prescription volume of the normal case (≥21units of speech therapy) was exceeded in 0.7% of the AOK patients. In the two lowest case volume categories the risk of postoperative speech therapy exceeding the prescription volume of the normal case was significantly higher compared to the highest case volume hospitals (odds ratios: 1.2 and 1.8, respectively). This study presents the reality of healthcare with respect to the frequency of speech therapy prescription after thyroid gland surgery in Germany. In addition, it was determined that the risk of postoperative speech therapy prescription exceeding the volume of the normal case after thyroid gland operations decreases with increasing case volumes of hospitals.

Does the recurrent laryngeal nerve recover function after initial dysfunction in patients undergoing thyroidectomy?

ObjectiveTotal thyroidectomy with or without central compartment dissection is the treatment of choice for thyroid carcinoma. Extensive dissection along the recurrent laryngeal nerve (RLN) can lead to vocal cord fixity and hoarseness even without nerve sacrifice. Recovery rates after surgery for thyroid cancers have not been well documented. The aim of the study is to analyze the incidence of vocal cord palsy (VCP) and its recovery rates in patients operated for thyroid cancers. Methodology: We performed a retrospective study on prospectively collected data in 152 thyroidectomy patients with 254 RLNs at risk. All patients underwent a laryngoscopic examination to document vocal cord function in the immediate postoperative period and on subsequent follow‐up. Incidence of VCP, recovery rates, univariate and multivariate analysis to identify risk factors for permanent VCP were calculated using binary logistic regression.ResultsIn our study, 28% patients underwent redo surgeries and 74% patients had dissection of the central compartment. The immediate postoperative RLN palsy rate was 11.2%, with a palsy rate of 9% and 16.2% in the per primum and redo surgery cohorts. On follow‐up, there was complete recovery of VCP in 66.7% of these nerves. The incidence of permanent RLN palsy was 3.9%. The mean time to recovery was 9.6 months.ConclusionVocal cord dysfunction recovered in most patients in this high‐risk cohort. There was a significant recovery even in the redo surgery group and a policy of watchful waiting is recommended in the absence of severe symptoms.Level of EvidenceIII

Risk profile analysis and complications after surgery for autoimmune thyroid disease.

Surgical approaches to autoimmune thyroid disease are currently hampered by concerns over postoperative complications. Risk profiles and incidences of postoperative complications have not been investigated systematically, and studies with sufficient power to show valid data have not been performed. A prospective multicentre European study was conducted between July 2010 and December 2012. Questionnaires were used to collect data prospectively on patients who had surgery for autoimmune thyroid disease and the findings were compared with those of patients undergoing surgery for multinodular goitre. Logistic regression analysis was used to evaluate risk factors for thyroid surgery-specific complications, transient and permanent recurrent laryngeal nerve (RLN) palsy and hypoparathyroidism. Data were available for 22 011 patients, of whom 18 955 were eligible for analysis (2488 who had surgery for autoimmune thyroid disease and 16 467 for multinodular goitre). Surgery for multinodular goitre and that for autoimmune thyroid disease did not differ significantly with regard to general complications. With regard to thyroid surgery-specific complications, the rate of temporary and permanent vocal cord palsy ranged from 2·7 to 6·7 per cent (P = 0·623) and from 0·0 to 1·4 per cent (P = 0·600) respectively, whereas the range for temporary and permanent hypoparathyroidism was 12·9 to 20·0 per cent (P < 0·001) and 0·0 to 7·0 per cent (P < 0·001) respectively. In logistic regression analysis of transient and permanent vocal cord palsy, autoimmune thyroid disease was not an independent risk factor. Autoimmune thyroid disease, extent of thyroid resection, number of identified parathyroid glands and no autotransplantation were identified as independent risk factors for both transient and permanent hypoparathyroidism. Surgery for autoimmune thyroid disease is safe in comparison with surgery for multinodular goitre in terms of general complications and RLN palsy. To avoid the increased risk of postoperative hypoparathyroidism, special attention needs to be paid to the parathyroid glands.

Complication Risk in Secondary Thyroid Surgery.

Objectives:Secondary thyroid surgery is rare, compared with primary thyroid surgery. However, secondary surgery has a greater risk of complications due to the formation of scar tissue as well as increased fragility of the tissues following the previous surgery. Several surgical techniques and strategies have been recommended to decrease the complication rate associated with secondary surgery. The aim of this study was to evaluate the complication rate in patients who underwent secondary thyroid surgery using a lateral approach and intraoperative nerve monitoring (IONM).Methods:The data of 44 patients who underwent secondary surgical intervention after thyroid surgery performed for benign or malignant thyroid disease (Group 1), and of 44 patients who underwent primary surgery (Group 2) were compared. Lobectomy patients with a histopathological result of malignant disease, whom were applied completion thyroidectomy were excluded from the study. Secondary surgery was performed using a lateral approach. Access was achieved between the anterior edge of the sternocleidomastoid muscle and the strap muscles. In primary surgery, the thyroid lodge was entered through the midline. Standard IONM was applied in all cases. Hypocalcemia was defined as a serum calcium level of ≤8 mg/dL within the first postoperative 48 hours, regardless of clinical symptoms. Transient and permanent recurrent laryngeal nerve paralysis was evaluated based on the number of nerves at risk. The lobectomy was considered to be high-risk with the presence of recurrence, Graves’ disease, substernal goiter, and application of central dissection.Results:The mean age of Group 1 and 2 was 49.9±14.1 years and 45±12.6 years , respectively (range: 22-90 years; p=0.69). Female patients constituted 90.9% (n=40) of the population in Group 1 and 75% (n=33) of the patient population in Group 2 (p=0.87). In Group 1, 11 (25%) patients, and 7 (15.9%) patients in Group 2 underwent surgical intervention due to the presence of a malignant disease (p=0.29). Bilateral intervention was applied in 26 (59.1%) patients in Group 1 and 28 (63.6%) patients in Group 2. The rate of transient and permanent hypocalcemia in Groups 1 and 2 was 34.1% (n=15) vs 22.5%, and 2.5% (n=1) vs 0%, respectively, without any significant intergroup difference (p=0.237, p=1). In Group 1, 71 lobes were operated on, and there were 72 in Group 2. All of the interventions in Group 1 (100%), and 31.9% (n=23) of those in Group 2 were high-risk, and there was a significant intergroup difference (p<0.0001). The rate of transient and permanent vocal cord paralysis were 4.2% (n=3) vs 2.8% (n=2) and 6.9 % (n=5) vs 0% in Groups 1 and 2, respectively (p=0.719; p=0.245).Conclusion:When performed with a meticulous and attentive technique, secondary surgical intervention can be applied without increasing the incidence of permanent complications. Though there is substantial risk associated with all of these procedures, the rate of vocal cord paralysis was similar to that seen after primary intervention, and was thought to be related to surgical experience and technique, as well as the use of IONM.

Robotic Neck Surgery in the Pediatric Population.

Introduction:Thyroid, parathyroid, and thymus surgeries are traditionally performed via a cervical approach. However, robot-assisted procedures can provide a safe alternative for neck surgeries. We report our experiences with robotic transaxillary and retroauricular approaches in pediatric patients.Case Presentation:We conducted a retrospective review of pediatric patients who underwent robot-assisted neck surgery by a single surgeon between April 2010 and May 2017. Patient demographics and surgical outcomes including operative time, incidence of complications, and length of hospital stay were evaluated.Management and Outcomes:Nine surgeries in 7 female patients were reviewed (mean age, 16.0 ± 1.58 years; mean body mass index, 22.5 ± 0.75). Two thyroid lobectomies, 2 complete thyroidectomies, 1 subtotal thyroidectomy, 1 thyroid lobectomy with thymectomy, 2 subtotal parathyroidectomies with thymectomy, and 1 dermoid cyst excision were performed. Two surgeries with the retroauricular approach had a mean surgical time of 142.0 ± 6.13 minutes. Seven surgeries with the transaxillary approach had a mean surgical time of 146.1 ± 21.01 minutes. There were no reported conversions, permanent vocal cord paralysis, permanent hypoparathyroidism, hematoma, or seroma. There was 1 case (11%) of temporary shoulder hypoesthesia and 2 cases of temporary vocal cord paresis (22%).Discussion:This series on robot-assisted neck surgeries in children describes procedures performed with robotic transaxillary and retroauricular approaches. In the hands of a high-volume surgeon the techniques are feasible and safe options for operations in the neck in a select group of pediatric patients.

Voice and swallowing outcomes following reoperative anterior cervical discectomy and fusion with a 2-team surgical approach.

OBJECTIVE Dysphagia and vocal cord palsy (VCP) are common complications after anterior cervical discectomy and fusion (ACDF). The reported incidence rates for dysphagia and VCP are variable. When videolaryngostroboscopy (VLS) is performed to assess vocal cord function after ACDF procedures, the incidence of VCP is reported to be as high as 22%. The incidence of dysphagia ranges widely, with estimates up to 71%. However, to the authors' knowledge, there are no prospective studies that demonstrate the rates of VCP and dysphagia for reoperative ACDF. This study aimed to investigate the incidence of voice and swallowing disturbances before and after reoperative ACDF using a 2-team operative approach with comprehensive pre- and postoperative assessment of swallowing, direct vocal cord visualization, and clinical neurosurgical outcomes. METHODS A convenience sample of sequential patients who were identified as requiring reoperative ACDF by the senior spinal neurosurgeon at the University of Alabama at Birmingham were enrolled in a prospective, nonrandomized study during the period from May 2010 until July 2014. Sixty-seven patients undergoing revision ACDF were enrolled using a 2-team approach with neurosurgery and otolaryngology. Dysphagia was assessed both preoperatively and postoperatively using the MD Anderson Dysphagia Inventory (MDADI) and fiberoptic endoscopic evaluation of swallowing (FEES), whereas VCP was assessed using direct visualization with VLS. RESULTS Five patients (7.5%) developed a new postoperative temporary VCP after reoperative ACDF. All of these cases resolved by 2 months postoperatively. There were no new instances of permanent VCP. Twenty-five patients had a new swallowing disturbance detected on FEES compared with their baseline assessment, with most being mild and requiring no intervention. Nearly 60% of patients showed a decrease in their postoperative MDADI scores, particularly within the physical subset. CONCLUSIONS A 2-team approach to reoperative ACDF was safe and effective, with no new cases of VCP on postoperative VLS. Dysphagia rates as assessed through the MDADI scale and FEES were consistent with other published reports.

Robotic-assisted modified radical neck dissection using a bilateral axillo-breast approach (robotic BABA MRND) for papillary thyroid carcinoma with lateral lymph node metastasis.

Although safe in patients with papillary thyroid carcinoma (PTC), robotic thyroidectomy using a bilateral axillo-breast approach (BABA) has not been frequently performed in patients with advanced PTC. This study describes surgical outcomes in patients with PTC and lymph node metastasis (LNM) in lateral neck compartment who underwent robotic-assisted modified radical neck dissection with BABA (robotic BABA MRND). The medical records of patients with PTC and lateral LNM who underwent robotic BABA MRND from March 2010 to July 2016 were retrospectively reviewed. Fifteen patients, 14 women and 1 man, of mean age 37.1 ± 9.3 years, were enrolled. Mean operation time was 272.7 ± 33.8min. A mean 20.7 ± 7.2 lymph nodes were retrieved from the lateral neck compartment, with a mean 5.3 ± 4.4 lymph nodes being metastatic. The rates of transient and permanent hypocalcemia were 46.7 and 0%, respectively, and the rates of transient and permanent vocal cord palsy were 6.7 and 0%, respectively. Fourteen patients (93.3%) had stimulated thyroglobulin concentrations below 2ng/mL after the first treatment with radioactive iodine. Robotic BABA MRND could be safely performed and may be a good surgical option in selected patients with PTC and lateral LNM.

Two-stage thyroidectomy in the era of intraoperative neuromonitoring.

The use of intraoperative neuromonitoring (IONM) provides surgeons with real time information about recurrent laryngeal nerves (RLN) functional integrity. Hence, allowing them to modify the initially scheduled bilateral procedure, to a two-stage thyroidectomy in cases of loss of signal (LOS) on the first side of resection resulting in minimization of bilateral RLN injury. The purpose of our study was to present our results since the implementation of the above mentioned process in both malignant and benign thyroid disease. We conducted a retrospective, observational cohort study of prospectively collected data from all patients who underwent a scheduled total thyroidectomy with or without neck dissection in our Department over the last 4 years [2013-2016]. From the 1,138 patients who received surgical treatment during that period, 284 were excluded since they did not meet the criteria. Exclusion criteria involved previous neck operation, parathyroid surgery, pre-existing vocal cord palsy (VCP) and unilateral surgery. A total of 854 patients were eligible for our study. All patients were subjected to pre- and postoperative indirect laryngoscopy by the same experienced ENT specialist team and all the surgeries were performed by the same experienced team. The whole procedure followed the International Neural Monitoring Study Group's (INMSG) Guideline Statement. We experienced 70 cases (70/854, 8.2%) with postoperative VCP. Two of them (0.23%) had permanent VCP and the rest of those patients (7.97%) experienced transient VCP. Twenty-three (2.7%) patients were candidates for staged thyroidectomy after LOS on the first side of resection, including ten patients with papillary or medullary thyroid carcinoma and one with toxic multinodular goiter (MNG). Of those patients, 22 incidents of VCP (95.7%) have recovered within two months and one of them persisted for more than six months (permanent VCP). We did not experience any permanent bilateral RLN palsy after the implementation of the staged procedure. Staged thyroidectomy seems a very attractive and promising procedure for both patient and surgeon, since it nearly eliminates one of the most fearful complications in thyroid surgery. We suggest staged thyroidectomy in all cases with first side of resection signal loss, even in malignancies, since the benefits are much more than the disabilities in a patient's morbidity and quality of life.