Recurrent Laryngeal Nerve Dysfunction Research Articles

Dexamethasone for the Prevention of Recurrent Laryngeal Nerve Palsy and Other Complications After Thyroid Surgery

Recurrent laryngeal nerve dysfunction and hypoparathyroidism are well-recognized, important complications of thyroid surgery. The duration of convalescence after noncomplicated thyroid operation may depend on several factors, of which pain and fatigue are the most important. Nausea and vomiting occur mainly on the day of operation. Glucocorticoids are well known for their analgesic, anti-inflammatory, immune-modulating and antiemetic effects. However, there is little information in the literature on the use of steroids in thyroid surgery, and the information that is available is conflicting. To investigate whether preoperative dexamethasone could improve surgical outcome in patients undergoing thyroid surgery. A randomized double-blind placebo-controlled trial. A 30-day follow-up for morbidity was performed in all cases. All patients were hospitalized in a public hospital. From June 2008 through August 2011, 328 patients were randomized to receive either intravenous dexamethasone, 8 mg, administered 90 minutes before skin incision, or saline solution (placebo). Intravenous dexamethasone, 8 mg. The primary end points were temporary or permanent recurrent laryngeal nerve palsy. Transient and definitive hypoparathyroidism, pain and fatigue scores, nausea, and the number of vomiting episodes were also registered. Preoperatively and at several times during the first 24 postoperative hours, we measured C-reactive protein, interleukin 6, and interleukin 1β levels. In the dexamethasone group, the rate of temporary recurrent laryngeal nerve palsy (4.9%) was significantly lower compared with the placebo group (8.4%) (P = .04). Also, postoperative transient biochemical hypoparathyroidism occurred more frequently in the placebo group (37.0%) than in the dexamethasone group (12.8%). Dexamethasone use significantly reduced postoperative levels of C-reactive protein (P = .01) and interleukin 6 and interleukin 1β (P = .02), fatigue (P = .01), and overall pain during the first 24 postoperative hours (P = .04), as well as the total analgesic (ketorolac tromethamine) requirement (P = .04). Dexamethasone use also reduced nausea and vomiting on the day of operation (P = .045). Preoperative administration of dexamethasone, 8 mg, reduced postoperative temporary recurrent laryngeal nerve palsy and hypoparathyroidism rates and reduced pain, fatigue, nausea, and vomiting after thyroid surgery. However, these data require further analysis in randomized prospective studies. TRIAL REGISTRATION clinicaltrials.gov Identifier:NCT01690806.

Effect of patient Age on surgical outcomes for Graves’ disease: a case–control study of 100 consecutive patients at a high volume thyroid surgical center

ObjectiveTo compare outcomes between children (<18 yrs) and adults undergoing total thyroidectomy for Graves’ disease (GD) at a high volume, multidisciplinary thyroid center.Summary of background dataReported complication rates for children undergoing surgery for Graves’ disease are worse than for adults.Methods100 consecutive patients (32 children; 68 adults) who underwent total thyroidectomy for Graves’ disease (GD) by a high-volume endocrine surgery team from were compared.ResultsThe mean patient age was 9.7 yrs (range 3.4-17.9 yrs) in children versus 44.9 yrs (range 18.4-84.2 yrs) in adults. Operative times were longer in children (2.18 ± 0.08 hrs) than in adults (1.66 ± 0.03 hrs) (p = 0.003). Pediatric thyroid specimens averaged 38.6.0 ± 8.9 gm (range: 9–293 gm) and adult thyroid specimens averaged 48.0 ± 6.4 gm (range: 6.6-203 gm) (p = 0.34). Thyroid to body weight ratios were greater in children (0.94 ± 0.11 gm/kg) than adults (0.67 ± 0.8 gm/kg) (p = 0.05). In all patients, the hyperthyroid state resolved after surgery. There was no operative mortality, recurrence, or permanent hypoparathyroidism. Transient post-operative hypocalcemia requiring calcium infusion was greater in children than adults (6/32 vs. 1/68; p = 0.004). Transient recurrent laryngeal nerve dysfunction occurred in two children and in no adults (p = 0.32). Postoperative hematoma occurred in two adults and in no children (p = 0.46). The length of stay was longer for children (1.41 ± 0.12 days) than for adults (1.03 ±0.03 days) (p = 0.004).ConclusionSurgical management of GD is technically more challenging in children as evidenced by longer operative times. Whereas temporary hypocalcemia occurs more commonly in children than adults, the risks of major complications including disease recurrence, permanent hypoparathyroidism, recurrent laryngeal nerve injury, or neck hematoma were indistinguishable. These data suggest that excellent and equivalent outcomes can be achieved for GD surgery in children and adults when care is rendered by a high volume, endocrine surgery team.

Adduction arytenopexy, hypopharyngoplasty, medialization laryngoplasty, and cricothyroid subluxation for the treatment of paralytic dysphonia and dysphagia

Vocal fold paralysis is a common disorder of variable etiology. The resultant dysphonia and dysphagia can result in significant morbidity and decreased quality of life for the afflicted patient. Numerous surgical procedures have been developed to improve voice and swallowing, each with its own set of advantages and disadvantages. Selection of the most appropriate procedure is determined in part an assessment of the position of the arytenoid cartilage, as proper realignment of vocal fold height and length may be critical to restoration of phonatory function. While arytenoid adduction has been employed traditionally to address arytenoid position, adduction arytenopexy coupled with cricothyroid subluxation may provide enhanced aerodynamic efficiency compared to arytenoid adduction. Hypopharyngoplasty can be easily performed concurrently, which through plication of the flaccid and non-functional ipsilateral pyriform sinus, can provide significant improvement in the salivary pooling and dysphagia which often accompanies recurrent laryngeal nerve dysfunction. This paper will address the indications, advantages, and surgical technique of adduction arytenopexy, cricothyroid subluxation, and hypopharyngoplasty.

Harmonic Scalpel Compared to Conventional Hemostasis in Thyroid Surgery: A Meta-Analysis of Randomized Clinical Trials

Background. The study's aim was to determine whether conventional hemostasis (CH) or the Harmonic Scalpel (HS) results in shorter operative times for thyroidectomy and to evaluate the incidence of postoperative complications with each approach. Methods. A literature search was conducted from study inception to September 30, 2008. Included studies randomized thyroidectomy patients to either CH or HS and reported the incidence of postoperative transient recurrent laryngeal nerve dysfunction (RLND) and hypocalcemia. Results. Nine RCTs were included. Use of the HS reduced operative time by 23.1 minutes (95% CI = 13.8, 32.33). There was no difference in the incidence of transient RLND (RR = 1.25, 95% CI = .56, 2.76), but a lower rate of transient hypocalcemia with the use of the HS (RR = .69, 95% CI = .51, .92). Conclusions. The use of HS in thyroidectomy significantly reduces operative time and is associated with a reduction in postoperative hypocalcemia compared to CH.

Video-Assisted Ductal Closure With New Modifications: Minimally Invasive, Maximally Effective, 1,300 Cases

Video-assisted thoracoscopic surgery (VATS) has been shown to be a safe and effective method of closing patent ductus arteriosus (PDA). We retrospectively studied our series of patients with PDA who underwent VATS closure with new modifications. From June 1997 to December 2004, 1,300 consecutive patients diagnosed with PDA (mean age, 6 years) were referred to us, and all of them met our inclusion criteria for the VATS procedure. Recently, we made some minor alterations to our routine methodology. After complete closure of PDA by two titanium clips, the extubated patient leaves the operating room without a chest tube. There were 3 cases of chylothorax, which were successfully treated by thoracotomy and ligation of the small lymphatic ducts after 1 week of close observation. The procedure was changed to thoracotomy in 7 patients. Meanwhile, 5 additional patients had transient recurrent laryngeal nerve dysfunction. All cases were reassessed immediately after the procedure, and followed for more than 7 years by control echocardiography. No significant complication or residual shunt was recorded during the follow-up period. Mean procedure time was about 10 +/- 2 minutes. All patients were discharged shortly after the procedure (about 20 hours). Based on this experience, VATS appears to be safer and more effective as well as having other advantages such as being simple to perform, quick, and comfortable for the patients. Furthermore, the cosmetic benefits also make it appropriate as an outpatient procedure.

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Introduction: The success and complications associated with interscalene brachial plexus block (IBPB) anesthesia for shoulder surgery have been reviewed in recent retrospective reports with wide variability in results and differing conclusions. Numerous prior case reports have documented significant complications related to IBPB anesthesia. Those same reports generally conclude that the success of IBPB is less than optimal. Further, those reports conclude that IBPB should not be performed on patients who are heavily sedated or under general anesthesia because of the risk of undetectable intraneural injection of local anesthetic. This prospective study was undertaken to study the safety and efficacy of IBPB performed on patients after induction of general anesthesia. Methods: Following IRB approval, 500 consecutive consenting patients undergoing a variety of open and arthroscopic shoulder surgeries were enrolled in this study. For inclusion, the IBPB had to be performed by an anesthesiologist skilled and experienced in IBPB after the patient had been administered general anesthesia. Blocks were performed with an insulated needle, and a nerve stimulator was utilized to determine appropriate needle placement. Stimulation of the biceps brachia muscle, without stimulation of the phrenic nerve, with the current produced by the nerve stimulator set below 0.5 milliamps was required. Bupivicaine 0.5% with epinephrine 1:200,000 (40 ml) was instilled. Aspiration was performed after every 5 ml of injected fluid to ensure the absence of blood in the aspirate. Corticosteroid (Kenalog 25 mg) was randomly added to the anesthetic injection in some patients, while others received anesthetic without steroid. Adverse events were noted and followed, and the success and duration of each block was documented. Results: Mean time required for the performance of the blocks (positioning and preparation of the head/neck, needle placement, and instillation of meds) was 5.5 minutes. Mean current for nerve stimulation was 0.30 milliamps. The block was successful in 490 (98%) of the 500 cases. Overall mean block duration for all patients was 26 hours. Mean duration of analgesia for blocks performed without steroid was 20 hours. Mean duration for blocks performed with steroid was 28 hours. Immediate post-operative adverse side effects occurred in 54 patients (11%), including: Horner’s syndrome in 37 patients, mild subjective dyspnea due to phrenic nerve dysfunction in 7, severe subjective dyspnea in 3, and hoarseness due to recurrent laryngeal nerve dysfunction in 7. No patient suffered a pneumothorax. No treatment was required for the side effects of the IBPB. One block was aborted after instillation of 20 ml of Bupivicaine (without steroid) due to aspiration of blood during the routine intrablock aspiration check. That patient experienced 19 hours of post-injection analgesia. Nine patients noted persistent hypesthesia and/or paresthesia in the distal portion of the upper extremity after resolution of the analgesic effect of the IBPB. These symptoms resolved in less than one week in 4 patients. The remaining 5 patients had hypesthesis/paresthesia lasting longer than 2 weeks, but all noted spontaneous resolution between 2 weeks and 3 months post-IBPB. No patient had lasting sensory symptoms and no patient experienced persistent motor deficits. Conclusion: IBPB performed on patients under general anesthesia was found to be safe (no serious or permanent complications) and effective (98% success). It provided a satisfactory duration of effective analgesia (26 hours). Minor short-lasting adverse side effects occurred in 11% of patients, and temporary minor neurologic adverse events occurred in 2%. If noted, the author indicates something of value received. The codes are identified as follows: a, research or institutional support; b, miscellaneous funding; c, royalties; d, stock options; e, consultant or employee. *The Food and Drug Administration has not cleared the drug and/or medical device for the use described in this presentation (ie, the drug or medical device is being discussed for an “off-label” use). If noted, the author indicates something of value received. The codes are identified as follows: a, research or institutional support; b, miscellaneous funding; c, royalties; d, stock options; e, consultant or employee. *The Food and Drug Administration has not cleared the drug and/or medical device for the use described in this presentation (ie, the drug or medical device is being discussed for an “off-label” use).

Video-assisted thoracoscopic clipping of patent ductus arteriosus: close to the gold standard and minimally invasive competitor of percutaneous techniques

To review our 12-year experience in video-assisted thoracoscopic surgery (VATS) for patent ductus arteriosus. VATS was performed in 743 patients. Three groups were compared: 24 low-birth-weight infants (LBWIs), 676 children between 2.5-25 kg and 43 boys > 25 kg. A diameter of > 8 mm was the main contraindication. For 85 consecutive patients, hospital stay underwent cost analysis. Median age was 1.6 years (range 5 days-33 years) and median weight 9.0 kg (range 1.2-65 kg). Mortality was nil. Median operative time was 20 min and hospital stay 2 days. Residual patency at discharge was 0% in LBWIs, 0.7% in children, and 4.7% in boys (P = NS) and 0, 0.3, and 4.7% at follow-up (P = 0.001). Persistent recurrent laryngeal nerve dysfunction was recorded in 4.2% of LBWIs, 0.3% of children and 0% of boys (P = 0.012). Total mean cost was Euro 5954 +/- 2110. The success rate of VATS clipping compares favorably with the thoracotomic approach but without chest wall trauma and it may have a very favorable cost-effective therapeutic balance compared to transcatheter techniques.

Video-Assisted Thoracoscopic Surgical Closure of Patent Ductus Arteriosus: 300 Cases

From June 1997 to October 2000, 300 consecutive patients (mean age, 6 years) with patent ductus arteriosus recognized by echocardiography and/or cardiac catheterization underwent video-assisted thoracoscopic surgery. Under general anesthesia, three 5-mm holes were made in the left thoracic wall. A video camera and specialized surgical devices were introduced. The ductus was dissected and 2 titanium clips were applied for complete closure of the ductus. Exclusion criteria were: diameter of the ductus &gt; 9 mm; complicated patent ductus arteriosus (aneurysm formation, endocarditis, or calcification); and pleural adhesion or a previous left-sided thoracic operation. All cases were reassessed immediately after the procedure, and followed up by echocardiography. No residual shunt was recorded. The procedure was changed to a thoracotomy in 3 adults due to inappropriately dilated canal (&gt; 9 mm); 2 others developed transient recurrent laryngeal nerve dysfunction. Mean procedure time was 20 ± 2 minutes. All patients were discharged shortly after the procedure (at approximately 20 hours). The results indicate that video-assisted thoracoscopic surgery was superior to other techniques of ductal closure.

Effect of training on the incidence of nerve damage in thyroid surgery.

In thyroid surgery early postoperative recurrent laryngeal nerve (RLN) dysfunction offers a sensitive measure of the quality of the operation. The aim of this study was to analyse the effect of training in thyroid surgery on the rate of early functional disturbances of the RLN after thyroid resection. In 617 patients (median age 48 years, female to male ratio 2.8:1) who underwent unilateral or bilateral thyroid resection, 1059 RLNs were subjected to operative risk. Laryngoscopy was performed before and after operation. The 45 surgeons were divided into three groups: group 1, specialist thyroid surgeons; group 2, experienced surgeons; and group 3, residents. Personal gain of experience was defined by the preceding number of thyroid operations. Within each group the complication profile was determined by adding the personal complication profiles of each surgeon. The complication rates were low during surgical residency (group 3). In group 2 complication rates increased up to the 50th operation. Group 1 showed the expected exponential decrease to under per cent after another 130 operations. Complication rates are affected considerably by the extent of surgical experience in a non-linear and complex logarithmic manner, starting with low rates in the beginner group, peaking after further experience and then decreasing exponentially.

Cranial and cervical nerve injuries after carotid endarterectomy: A prospective study

Background: The purpose of this study was to review the outcome of patients who had cranial and cervical nerve injuries after carotid endarterectomy (CEA). Methods: This prospective study reviewed 200 consecutive CEAs. Preoperative and postoperative cranial nerve assessment was completed on all patients. Neurologic evaluation included routine direct fiberoptic laryngoscopy. Patients found to have no neurologic injury had no further follow-up. Patients with postoperative peripheral neurologic dysfunction were enrolled for regular long-term follow-up to assess delayed recovery. Results: Overall, 25 (12.5%) nerve injuries were identified in 24 patients. There were 11 (5.5%) hypoglossal, 8 (4%) recurrent laryngeal, 2 (1%) superior laryngeal, 2 (1%) marginal mandibular, and 2 (1%) greater auricular nerve injuries. None of the patients were lost to follow-up. All nerve dysfunctions were transient, with all but 4 nerves recovering completely within 6 months. The recovery took from 1 week to 37 months, with a mean recovery time of 5.8 months. Two patients with recurrent laryngeal nerve dysfunction were found to have prolonged full recovery time (ie, 31 and 37 months, respectively). Two patients successfully underwent contralateral CEA, although movement of the opposite vocal cord was not fully restored. Conclusions: Cranial nerve injury after CEA is a common occurrence and can be classified as a “major” or “minor” complication, depending on the severity of the clinical consequences. Extended follow-up will identify the specific subset of patients with a late complete nerve recovery. (Surgery 1999;125:85-91.)

Video-thoracoscopic surgical interruption of patent ductus arteriosus. Routine experience in 332 pediatric cases.

Pediatric video-assisted thoracic surgery closure of patent ductus arteriosus can now be performed on a routine basis. We review here our entire experience with this technique. Three hundred and thirty two consecutive patients underwent video-assisted closure of patent ductus arteriosus from September 1991 to September 1996. Indications were symptomatic ductus or failure of closure in older children. All complications were carefully noted, as well as intensive care unit stay, and operating room time. Patients were divided in three age groups: less than 6 months (101 patients, 31%), 6-48 months (179 patients, 54%), greater than 48 months (52 patients, 16%). The mean weight was 12.6 kg (range 1.2-65 kg). Associated cardiac anomalies were atrial septal defect (3), ventricular septal defect (5), anomalous pulmonary venous return (1). Six patients had a residual shunt following video-assisted interruption. Five patients had successful immediate clip repositioning (three via video-assisted interruption, two via thoracotomy). One patient continued to have a small shunt, which is followed medically. Complications included recurrent laryngeal nerve dysfunction in six patients (1.8%) (five transient, one persistent). Mean operating time was 20 +/- 1.5 mn and hospital stay averaged 48 h (> 6 months), 72 h (< 6 months). Interruption of patent ductus can be safely performed by video-assisted technique with minimal morbidity and no mortality. It can be performed in all age group with minimal hospital stay.

Cranial/cervical nerve dysfunction after carotid endarterectomy.

The purpose of this article is to review the results of patients who had cranial and cervical nerve dysfunction after undergoing carotid endarterectomy. The prospective study reviewed 183 consecutive carotid endarterectomies. Preoperative and postoperative cranial nerve assessments were accomplished on all patients. Neurologic evaluation included direct fiberoptic laryngoscopy. Patients found to be neurologically intact had no further follow-up. Patients with postoperative neuropraxia were entered into regular long-term follow-up to assess delayed recovery. Twenty-six (14.2%) nerve injuries were identified in 21 patients. There were 14 recurrent laryngeal, 8 hypoglossal, 2 marginal mandibular, and 2 greater auricular nerve dysfunctions. Two patients were lost to follow-up. Eighteen (9.8%) nerve injuries were transient, whereas two (1.1%) were permanent. Four patients are currently undergoing extended follow-up to assess delayed recovery. Two patients with recurrent laryngeal nerve dysfunction were found to have prolonged full recovery intervals: 20 months and 50 months, respectively. The incidence of focal neuropraxia after carotid endarterectomy is presented. Most injuries are transient. However, permanent injuries can lead to significant disability. Extended follow-up will identify the small subset of patients with delayed complete nerve recovery.

Video-assisted thoracoscopic surgical interruption: The technique of choice for patent ductus arteriosus: Routine experience in 230 pediatric cases

Video-assisted thoracoscopic surgical interruption for patent ductus arteriosus is a well-standardized procedure already described. We present our entire series of such cases, from the first case (performed on Sept. 5, 1991) to March 1, 1995. Two hundred thirty patients in a variety of age groups underwent video-assisted interruption: younger than 6 months (70 patients, 30%), 6 to 48 months (123 patients, 54%), and older than 48 months (37 patients, 16%). The mean weight was 12.6 kg (range 1.2 to 65 kg). Thirty-nine patients had symptomatic pulmonary hypertension. Associated intracardiac anomalies included atrial septal defect (three), ventricular septal defect (five), and anomalous pulmonary venous return (one). All patients underwent video-assisted interruption of the patent ductus arteriosus with two titanium clips. Closure was evaluated by postoperative echocardiography before extubation. Five patients had a persistent patent ductus after video-assisted interruption, all early in our experience and related to insufficient dissection resulting in inadequate clip placement. Four patients had successful immediate clip repositioning (three by video-assisted interruption and one by thoracotomy). Subsequent echocardiography revealed persistent closure in these patients. A persistent patent ductus arteriosus with minimal flow was discovered in one patient without symptoms after discharge. Recurrent laryngeal nerve dysfunction was noted in six patients (2.6%; five transient and one persistent). There were no deaths, hemorrhages, transfusions required, or chylothoraces in this series. Mean operative time was 20 ±15 minutes, and hospital stay averaged 48 hours for patients younger than 6 months and 72 hours for patients older than 6 months. This is a safe, rapid, cost-effective technique that results in excellent results and a shortened hospital stay. Video-assisted interruption represents the technique of choice for closure of a patent ductus arteriosus. (J THORAC CARDIOVASC SURG 1995;110:1681-5)

Cranial nerve injury during carotid arterial reconstruction.

In a series of 109 carotid arterial reconstructions cranial nerve injury was observed in 14 of 102 patients. Ipsilateral peripheral hypoglossal nerve injury occurred in nine patients with carotid occlusive disease. The marginal mandibular nerve was injured in three patients and recurrent laryngeal nerve dysfunction was noted in four patients. Two cranial nerves were injured in two patients. Full recovery of hypoglossal dysfunction was seen within 2-52 weeks (average 20 weeks). The nerves are injured by retraction to clear the operative field or by postoperative haematoma. Risk factors include crossing of the hypoglossal nerve close to the carotid bifurcation or procedures requiring long arteriotomy or skeletonization of the internal carotid artery. Unilateral cranial nerve injury is usually mild but will require delay of controlateral carotid reconstruction to avoid severe bilateral cranial nerve palsy.