Recurrent Laryngeal Nerve Palsy Research Articles

Analysis of vocal fold movement characteristics in patients with laryngeal neurogenic injury

Objective:To analyze the characteristics of vocal fold movement and glottic closure in patients with laryngeal neurogenic injury. Methods:A total of 185 patients with vocal fold paralysis diagnosed by laryngeal electromyography as neurogenic damage to cricothyroid muscle, thyreoarytenoid muscle and posterior cricoarytenoid muscle were enrolled, they were divided into unilateral vocal fold paralysis group and bilateral vocal fold paralysis group, respectively, and superior laryngeal paralysis group, recurrent laryngeal nerve paralysis group and vagal nerve paralysis group according to nerve injury. The characteristics of vocal fold movement and glottic closure were analyzed under strobe laryngoscope. The qualitative evaluation of vocal fold movement was fixed vocal fold, reduced vocal fold movement and normal vocal fold movement, and the qualitative evaluation of glottic closure was glottic closure and glottic imperfection. The results were analyzed statistically. Results:The proportion of normal, reduced and fixed vocal fold motion in bilateral vocal fold paralysis group was significantly different from that in unilateral vocal fold paralysis group（P<0.05）, the composition of normal and reduced vocal fold motion in bilateral vocal fold paralysis group（47.70%） was significantly greater than that in unilateral vocal fold paralysis group（12.27%）. There was no significant difference between the proportion of glottic closure and glottic imperfecta in bilateral vocal fold paralysis group and unilateral vocal fold paralysis group（P<0.05）. The proportion of decreased vocal fold motion in superior laryngeal nerve paralysis group（50.00%） was higher than that in recurrent laryngeal nerve paralysis group（9.32%） and vagal nerve paralysis group（9.00%）. The proportion of decreased and fixed vocal fold motion in superior laryngeal nerve paralysis group, recurrent laryngeal nerve paralysis group and vagal nerve paralysis group was statistically significant（P<0.05）.There was no significant difference in glottic closure among the three groups（P<0.05）. Conclusion:Vocal fold movement characteristics of patients with laryngeal neurogenic injury were mainly vocal fold fixation, or normal or weakened vocal fold movement. There may be missed diagnosis of unilateral vocal fold paralysis in clinical practice. In half of the patients with superior laryngeal nerve palsy, vocal fold movement is characterized by vocal fold fixation.

Association of perioperative oral swallowing function with post-esophagectomy outcomes and nutritional statuses in patients with esophageal cancer.

Dysphagia after esophagectomy is a serious complication; however, no method has been established to accurately assess swallowing function. We evaluated the association of swallowing function tests with patients' post-esophagectomy complications and nutritional statuses. We retrospectively reviewed the data of 95 patients with esophageal cancer who underwent esophagectomy between 2016 and 2021. We performed perioperative swallowing function tests, including the repetitive saliva swallowing test (RSST), maximum phonation time (MPT), and laryngeal elevation (LE). Patients with recurrent laryngeal nerve palsy (RLNP) and respiratory complications (RC) had significantly lower postoperative RSST scores than patients without them; the scores in patients with or without anastomotic leakage (AL) were similar. Postoperative MPT in patients with RLNP was shorter than that in patients without RLNP; however, it was similar to that in patients with or without AL and RC. LE was not associated with any complications. Patients with an RSST score ≤2 at 2weeks post-esophagectomy had significant weight loss at 1, 6, and 12months postoperatively compared with patients with an RSST score ≥3. The proportion of patients with severe weight loss (≥20% weight loss) within 1year of esophagectomy was significantly greater in patients with RSST scores ≤2 than in those with RSST scores ≥3. Multivariate analysis showed that an RSST score ≤2 was the only predictor of severe post-esophagectomy weight loss. RSST scoring is a simple tool for evaluating post-esophagectomy swallowing function. A lower RSST score is associated with postoperative RLNP, RC, and poor nutritional status.

Impact of Intermittent Intraoperative Neuromonitoring (IONM) on the Learning Curve for Total Thyroidectomy by Residents in General Surgery.

Recurrent laryngeal nerve (RNL) identification constitutes the standard in thyroidectomy. Intraoperative nerve monitoring (IONM) has been introduced as a complementary tool for RLN functionality evaluation. The aim of this study is to establish how routine use of IONM can affect the learning curve (LC) in thyroidectomy. Patients undergoing total thyroidectomy performed by surgery residents in their learning curve course in 2 academic hospitals, were divided into 2 groups: Group A, including 150 thyroidectomies performed without IONM by 3 different residents, and Group B, including 150 procedures with routine use of intermittent IONM, by other 3 different residents. LC was measured by comparing operative time (OT), its stabilization during the development of the LC, perioperative complication rate. As previously demonstrated, the LC was achieved after 30 procedures, in both groups, with no differences due to the use of IONM. Similarly, there were no significant differences among the 2 groups, and between subgroups independently matched, for both OT and complications, even when comparing RLN palsy. Direct nerve visualization and IONM assessment rates were comparable in all groups, and no bilateral RLN palsy (transient or permanent) were reported. No case of interrupted procedure to unilateral lobectomy, due to evidence of RLN injury, was reported. The study demonstrates that the use of IONM thyroid surgery, despite requiring a specific training with experienced surgeons, does not particularly affect the learning curve of residents approaching this kind of surgery, and for this reason its routine use should be encouraged even for trainees.

Techniques of detecting recurrent laryngeal nerve palsy in patients undergoing thyroid surgery: Pearls and pitfalls

Abstract Though permanent vocal cord palsy consequent to recurrent laryngeal nerve (RLN) injury is rare following thyroidectomies, its consequences are grave enough for it to be the most feared complication postoperatively. Anesthesiologists and surgeons take various precautions to prevent its occurrence and employ various methods for its early detection. They include direct visualization of the nerve intraoperatively, use of intraoperative nerve monitoring, and post-extubation visualization of vocal cord mobility by use of direct or indirect methods. In the present narrative review, we aim to discuss the clinical evidence pertaining to the various methods adopted for the prevention and early detection of RLN palsy during thyroidectomy.

The anatomic repair of recurrent aortic arch obstruction in children and adolescents

ObjectiveSurgery for recurrent aortic arch obstruction is highly challenging and publications are rare. The aim of this retrospective, single-center study was to evaluate mortality, complications, and reintervention rate after an anatomic repair. MethodsBetween 1999 and 2022, in total 946 operations on the aortic arch were performed at the Children's Heart Center Linz. In 39 cases, the indication was a recurrent or residual aortic arch obstruction or coarctation in a patient aged 18 years or younger. This is our study cohort. The aorta was reconstructed by a direct anastomosis/autograft in 20 patients, patch in 17 patients, and interposition graft in 2 adolescents. In 32 procedures, cardiopulmonary bypass with whole body perfusion was employed, in 4, antegrade cerebral perfusion was employed, in 2, a left heart bypass was employed, and in 1 no cardiopulmonary bypass was used. ResultsMedian (Q1, Q3) age at operation was 253 days (100, 2198 days), weight 7.5 kg (4.5, 17.8 kg). Median cardiopulmonary bypass time was 177 minutes (115, 219 minutes), crossclamp time 73 minutes (49, 102 minutes). Three infants died during the hospital stay: 1 with Williams syndrome, 1 with hypoplastic left heart syndrome, and 1 with heterotaxia. There was no death due to an arch complication. The main complications were 1 neurologic injury after postoperative resuscitation (Williams syndrome) and 1 permanent recurrent laryngeal nerve paralysis. During the follow-up period of median 8.1 years (2.6, 12 years) 1 re-reintervention on the aortic arch was necessary. ConclusionsSophisticated reoperations on the aortic arch could be performed safely. In children, the growth potential of all segments of the aorta could be sustainably preserved by avoiding interposition or extra-anatomic bypass grafts.

Intraoperative nerve monitoring reduces recurrent laryngeal nerve palsy in endoscopic thyroid surgery: A trial sequential analysis.

Intraoperative nerve monitoring reduces recurrent laryngeal nerve palsy in endoscopic thyroid surgery: A trial sequential analysis.

Dysphagia in patients with severe COVID-19: a retrospective study

To investigate dysphagia after extubation in patients with severe coronavirus disease 2019 (COVID-19). We retrospectively examined patients with severe COVID-19 treated in our hospital between August 2021 and March 2022. Feeding outcomes were categorized into two groups—(1) total oral intake, and (2) difficulty in oral intake. To assess the feeding outcome, we used modified water-swallowing test (MWST) for all patients. However, in cases where aspiration or recurrent laryngeal nerve palsy was suspected, we conducted the fiberoptic endoscopic evaluation of swallowing after MWST. Patient data were collected from medical records. Forty-six patients with severe COVID-19 were included. Among the 46 patients, 14 (30.4%) experienced difficulties with oral intake. Older age, longer length of hospitalization, duration of mechanical ventilation, tracheostomy, diabetes, and higher serum levels of C-reactive protein (CRP) and procalcitonin (PCT) at the time of intubation were associated with difficulty in oral intake. The rate of difficulty with oral intake in patients with severe COVID-19 was 30.4%, which is not as high as reported in previous studies. Older age, longer duration of mechanical ventilation, tracheostomy, diabetes, and higher levels of CRP and PCT were associated with the prevalence of oral intake difficulty, suggesting that early attention should be paid to high-risk patients who have preexisting deterioration of swallowing function due to aging and comorbidities, or who have prolonged intubation or tracheostomy to prevent aspiration pneumonia.

Current Knowledge on the Use of Neuromonitoring in Thyroid Surgery.

Thyroid surgery rates have tripled over the past three decades, making it one of the most frequently performed procedures within general surgery. Thyroid surgery is associated with the possibility of serious postoperative complications which have a significant impact on the patient's quality of life. Recurrent laryngeal nerve (RLN) palsy and external branch of the superior laryngeal nerve (EBSLN) palsy are, next to hypoparathyroidism and postoperative bleeding, some of the most common complications. The introduction of neuromonitoring into thyroid surgery, which enabled both the confirmation of anatomical integrity and the assessment of laryngeal nerve function, was a milestone that began a new era in thyroid surgery. The International Neural Monitoring Study Group has produced a standardization of the technique of RLN and EBSLN monitoring during thyroid and parathyroid surgery, which in turn increased the prevalence of neural monitoring during thyroidectomy. The current status of IONM and the benefits of its use have been presented in this publication.

Assessment of pre-extubating recurrent laryngeal nerve palsy using ultrasound in postoperative patients with esophageal cancer: a prospective observational study.

Ultrasound performed after extubation has been suggested to be useful for the diagnosis of recurrent laryngeal nerve (RLN) paralysis. However, the use of ultrasound for this purpose before extubation has not been examined. The aim of this study was to examine the versatility (interrater reliability) and usefulness of ultrasound for evaluating the movement of vocal cords before extubation. The subjects were 30 patients who underwent radical surgery for esophageal cancer from August 2020 to December 2021. An experienced examiner performed an ultrasound examination before and after elective extubation on the day after surgery to evaluate RLN paralysis and record videos. Bronchoscopy was then performed to make a definite diagnosis. Three anesthetists blinded to the diagnosis also evaluated the cases using the videos, and the versatility of the examination was determined using a kappa test. The diagnostic accuracies of the examiner and three anesthetists were 76.7%, 50.0%, 53.3%, and 46.7%, respectively, and the kappa coefficients for the examiner with the anesthetists were 0.310, 0.502, and 0.169, respectively. The sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of RLN paralysis by the examiner using ultrasound before extubation were 0.57, 0.95, 0.80, and 0.87, respectively. These results indicate a lack of versatility of the ultrasound examination based on the low kappa coefficients. However, with an experienced examiner, ultrasound can serve as a non-invasive examination that can be performed before extubation with high accuracy and specificity for diagnosis of postoperative RLN paralysis.

Impact of fine-needle aspiration cytology in thyroidectomy extent and associated surgical morbidity in thyroid cancer

PurposeTo assess the impact of fine-needle aspiration cytology (FNAC) in the extent of surgery in patients with thyroid cancer (TC) and the associated surgical morbidity in primary and completion setting.MethodsA Swedish nationwide cohort of patients having surgery for TC (n = 2519) from the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal surgery between 2004 and 2013 was obtained. Data was validated through scrutinizing FNAC and histology reports.ResultsAmong the 2519 cases operated for TC, the diagnosis was substantiated and validated through the histology report in 2332 cases (92.6%). Among these, 1679 patients (72%) were female, and the median age at TC diagnosis was 52.3 years (range 18–94.6). Less than total thyroidectomy (LTT) was undertaken in 944 whereas total thyroidectomy (TT) in 1388 cases. The intermediate FNAC categories of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/ FLUS), as well as suspicion for follicular neoplasm (SFN) lesions were more often encountered in LTT (n = 314, 33.3%) than TT (n = 63, 4.6%), whereas FNACs suspicion for malignancy and/or malignancy were overrepresented in TT (n = 963, 69.4%). Completion thyroidectomies were undertaken in 553 patients out of 944 that initially had LTT. In 201 cases with cancer lesions > 1 cm, other than FTC (Follicular TC)/ HTC (Hürthle cell TC) subjected to primary LTT, inadequate procedures were undertaken in 81 due to absent, Bethesda I or II FNAC categories, preoperatively. Complications at completion of surgery in this particular setting were 0.5% for RLN palsy (n = 1) and 1% (n = 2) for hypoparathyroidism 6 months postoperatively. The overall postoperative complication rate was higher in primary TT vs. LTT for RLN palsy (4.8% [n = 67] vs. 2.4% [n = 23]; p = 0.003) and permanent hypoparathyroidism (6.8% [n = 95] vs. 0.8% [n = 8]; p < 0.0001).ConclusionsFNAC results appear to affect surgical planning in TC as intermediate FNAC categories lead more often to LTT. Overall, inadequate procedures necessitating completion surgery are encountered in up to 15% of TC patients subjected to LTT due to absent, inconclusive, or misleading FNAC, preoperatively. However, completion of thyroidectomy in this setting did not yield significant surgical morbidity. Primary LTT is a safer primary approach compared to TT in respect of RLN palsy and permanent hypoparathyroidism complication rates; therefore, primary TT should probably be reserved for lesions > 1 cm or even larger with suspicion for malignancy or malignant FNAC.

Complications after Thyroidectomy; a Comparison Among Seven Different Surgical Procedures and the Impact of Central Compartment Lymph Nodes Sampling: a Cohort Study

Introduction: Thyroid nodules are commonly encountered in medical practice. The relation between the magnitude of thyroid surgery and its complications is not settled.&#x0D; Objectives: Our aim is to examine the incidence of recurrent laryngeal nerve injury and hypoparathyroidism after thyroid surgery in different thyroid procedures including local lymph nodes control.&#x0D; Methods: The records of 345 patients who underwent thyroidectomy at the Jordan University Hospital from January 2010 to December 2016 were reviewed. They were divided into seven groups (total thyroidectomy, near-total thyroidectomy, hemithyroidectomy, completion thyroidectomy, redo surgery, hemithyroidectomy with completion, and near-total thyroidectomy with completion). A comparison among the groups was done. Ninety-one patients who underwent central lymph nodes biopsy were identified. They were divided into three groups (pre-tracheal lymph nodes excision, central neck dissection, and central neck sampling) and then compared.&#x0D; Results: Transient hypocalcemia was significantly higher with total thyroidectomy in comparison to near-total thyroidectomy and hemithyroidectomy with or without completion. All groups were comparable regarding permanent hypocalcemia and recurrent laryngeal nerve palsy. No significant relationship between the type of dissection and complication rate was found.&#x0D; Conclusion: Near-total thyroidectomy is a safe alternative to total thyroidectomy with a lower early complication rate. Redo surgery and central dissection are not associated with higher morbidity.

Complications of thyroidectomy: Insights from a single-centre study in northeast India

To study and compare the frequency of post-operative complications associated with thyroid surgeries indicated for various benign and malignant pathologies and assess the outcome of management of such complications in a tertiary care hospital in Northeast India. An analytical study was done at a tertiary care hospital in Assam over a period of 1 year from May 2022 to June 2023. Data was collected from 53 patients who underwent surgery at this hospital. Hemithyroidectomy, subtotal, near-total, and total thyroidectomies were performed in 31(58.4%), 2 (3.7%), 6 (11.3%) and 14 (26.4%) cases respectively. The overall rate of complications was 39.6%. Permanent hypocalcaemia was observed to be the most common complication, followed by transient hypocalcaemia and transient recurrent laryngeal nerve palsy. The complications were found to be more frequent in surgery for malignant thyroid disease. There was no mortality in our study. A better understanding of thyroid gland anatomy, meticulous haemostasis and Identification of Recurrent laryngeal nerve and parathyroid glands lead to favourable post-operative outcomes. Appropriate post-operative care with early identification and management of complications plays an essential role in reducing the duration of postoperative hospital stay and limiting patient morbidity.

High cervical anastomosis reduces leakage-related complications after a McKeown esophagectomy.

Anastomotic leak (AL) is one of the most serious complications after oesophageal cancer surgery. A high cervical anastomosis using a narrow gastric tube based on optimized procedures has the potential to reduce the AL after a McKeown oesophagectomy. A narrow gastric tube was defined as 2-2.5 cm in diameter. Meanwhile, we defined a high anastomosis (HA) and a normal anastomosis (NA) based on the position of the intraoperative cervical anastomosis above or below the level of the inferior thyroid artery, respectively. A total of 533 patients who had a McKeown oesophagectomy from March 2018 to March 2023 were included in this study, including 281 patients in the NA group and 252 patients in the HA group. Potential confounding factors in baseline characteristics were balanced by propensity score matching. After matching, 190 patients remained in both groups. When comparing the pathological and surgical results, we found that more lymph nodes, both in total number (21.1 ± 10.0 vs 15.8 ± 7.7, P = 0.001) and thoracic part (13.5 ± 7.8 vs10.8 ± 6.1, P = 0.005), were harvested from the HA group . The pathological T and TNM stages of patients in the HA group were earlier than those in the NA group (P = 0.001). Overall postoperative complications (P = 0.001), including pulmonary infection (P = 0.001), AL (P < 0.001), leakage-related pyothorax (P < 0.001), recurrent laryngeal nerve palsy (P = 0.031) and pleural effusion (P < 0.001), were all significantly lower in the HA group. Finally, multivariable logistic regression analysis indicated that HA was an independent protective factor for AL (odds ratio = 0.331, 95% confidence interval: 0.166-0.658; P = 0.002). For patients undergoing a McKeown oesophagectomy, a high cervical anastomosis using a narrow gastric tube can effectively reduce leakage-related complications.

14. “TEXTBOOK OUTCOMES” IN SURGICAL APPROACH OF DIFFERENTIATED THYROID CANCER

Abstract Introduction The textbook outcome (TO) is a composite quality measure used to define the achievement of multiple ideal surgical results. There is a lack of studies regarding TO in differentiated thyroid carcinoma (DTC). The aim of the study is to define the TO in DTC surgery and determine the factors that avoid its achievement. Methods Retrospective study of consecutive patients undergoing surgery for DTC between 01/01/2021 and 31/03/2023. The TO is defined by the absence of complications (hematoma, recurrent laryngeal nerve palsy, hypocalcemia, seroma, surgical site infection (SSI)), prolonged hospital stay (exceeding the 75th percentile), readmission, and 90-day mortality. Results Fifty-nine patients were included (median age 53 years (43-61), 43 women (72,9%)) with a median follow-up of 17 months (14-20). The majority presented with unilateral nodules (32; 54,2%), Bethesda VI (24; 44,4%), with a median size of 21mm (11,75-35,0). Thirty-one patients (52,5%) underwent total thyroidectomy, 28(47,5%) lobectomy, 15 unilateral CCL (25,4%), 10 bilateral CCL (16,9%) and 10 unilateral LCL (16,9%). The median hospital stay was 1 day (1-1). Fourteen patients (23,7%) had complications: 1 hematoma (1,7%), 5 hoarseness (8,5%), 4 transient recurrent nerve palsy (6,8%) and 2 permanent (3,4%), 7 transient hypocalcemia (11,9%) and 4 permanent (6,8%), 2 SSI (3,4%) and 3 seroma (5,1%). Two patients were readmitted because of SSI (one requiring emergency surgery). In total, 69,5% (41) patients achieved TO. Risk factors that avoided its consecution were: total thyroidectomy [OR7,81 IC95%(1,95-31,25); p=0,004)] and unilateral LCL [OR4,63 IC95%(1,12-19,20); p=0,035)]. Conclusion Most of the patients achieved TO. The predictors associated to the absence of TO achievement were total thyroidectomy and unilateral LCL, meaning that the more aggressive the surgery is, the greater the chances are of surgical complications.

Comparison of Robotic Versus Conventional Open Thyroidectomy for Recurrent Laryngeal Nerve Safety: A Systematic Review and Meta-Analysis.

This review aims to investigate the safety of recurrent laryngeal nerve (RLN) by comparing robotic thyroidectomy (RT) versus open thyroidectomy (OT) in Western and Asian populations. Two main outcomes of this review were (1) the safety of RLN comparing the robotic and OT assessingtransient and permanentlaryngeal nerve (PLN) palsy as a postoperative complication in each surgical procedureand (2)the safety of RLN comparing the robotic and OT assessingtransient and permanentlaryngeal nerve (PLN) palsy as a postoperative complication between studies conducted in USA/Europe andAsia.We searched relevant literature in electronic databases such as PubMed, MEDLINE, Cochrane CENTRAL, ScienceDirect, and Cumulative Index to Nursing & Allied Health(CINAHL)up to September 2022. Furtherresearch was performed duringJanuary 2024 in the Scopus database. Two primary outcomes were set:transient RLN palsyand permanent RLN palsy, comparing RT and OT. In this review, 18non-randomized studies were included. A statistically significant difference between robotic and conventional OT was not observed either in transient RLN or in permanent RLN palsy. The odds ratio (OR) for the overall comparison of transient RLN palsy was 1.18, and the 95% confidence interval (95% CI) was 0.80-1.74. The subgroup analysis for transient RLN palsy between USA/Europe studies was OR 1.28, and the95% CIwas 0.64-2.58. The subgroup analysis for transient RLN palsy between Asian studies was OR 1.14, and the 95%CIwas 0.72-1.82. The OR for the overall comparison of permanentRLN palsy was OR 0.90, and the 95% CIwas 0.38-2.15. The subgroup analysis for permanentRLN palsy between USA/Europe studies was OR0.45, and the 95% CIwas 0.07-2.97. The subgroup analysis for permanentRLN palsy between Asian studies was OR1.13, and the 95% CIwas 0.42-3.05. Heterogeneity I2was 0% in all outcomes. The Mantel-Haenszel method fixed effect was used.First, RT and open conventional thyroidectomy have comparable safety for RLN, although the analysis showed no statistically significant results. Second, no statistically significant results were found for RLN safety in either USA/Europe or Asian studies.Considering that there is not a statistically significant difference between the two approaches for RLN safety, and due to the limited number of studies from Western countries, the results should be considered with caution. Important factors such as the patient's body characteristics, the existing thyroid pathology, and the surgical approachshould be kept in mind. More comparable studies are needed on the Western population.

Complications of microwave ablation in patients with persistent/recurrent hyperparathyroidism after surgical or ablative treatment

Objective To evaluate the complications associated with microwave ablation (MWA) in treating persistent/recurrent hyperparathyroidism (HPT) post-surgical or ablative treatments. Materials and methods From January 2015 to December 2022, 87 persistent/recurrent HPT patients (primary HPT [PHPT]: secondary HPT [SHPT] = 13:74) who underwent MWA after surgical or ablative treatment were studied. Grouping was based on ablation order (initial vs. re-MWA), prior treatment (parathyroidectomy [PTX] vs. MWA), and etiology (PHPT vs. SHPT). The study focused on documenting and comparing treatment complications and analyzing major complication risk factors. Result Among the 87 patients, the overall complication rate was 17.6% (15/87), with major complications at 13.8% (12/87) and minor complications at 3.4% (3/87). Major complications included recurrent laryngeal nerve (RLN) palsy (12.6%) and Horner syndrome (1.1%), while minor complications were limited to hematoma (3.4%). Severe hypocalcemia noted in 21.6% of SHPT patients. No significant differences in major complication rates were observed between initial and re-MWA groups (10.7% vs. 13.8%, p = 0.455), PTX and MWA groups (12.5% vs. 15.4%, p = 0.770), or PHPT and SHPT groups (15.4% vs. 13.5%, p > 0.999). Risk factors for RLN palsy included ablation of superior and large parathyroid glands (>1.7 cm). All patients recovered spontaneously except for one with permanent RLN palsy in the PTX group (2.1%). Conclusion Complication rates for MWA post-surgical or ablative treatments were comparable to initial MWA rates. Most complications were transient, indicating MWA as a viable and safe treatment option for persistent/recurrent HPT patients.

18F-Fluorodeoxyglucose positron emission tomography [18F-FDG PET CT] in assessment of patients with vocal cord paralysis [VCP] secondary to extra laryngeal neoplastic causes: How is it reliable?

BackgroundThe main cause of voice hoarseness is vocal cord palsy (VCP) that may be induced by many diseases that could be due to local laryngeal or extra laryngeal causes, including neoplastic and non-neoplastic entities. Normal vocal cords 18F-fluorodeoxyglucose (FDG) activity should be symmetric and of low grade higher than the mediastinal background uptake. Vocal cords asymmetrical FDG uptake was a well-known finding in patients with VCP. When recurrent laryngeal nerve (RLN) palsy is suspected, FDG PET and computed tomography (CT) findings can give strong evidence of diagnosis, with ability to diagnose the underlying extra laryngeal neoplastic etiology. Our aim was to assess the sensitivity and accuracy of hybrid FDG PET CT scan in diagnosis of VCP secondary to an extra laryngeal neoplastic cause.MethodsA retrospective study for 50 patients, presented with hoarseness of voice, referred from Otorhinolaryngology department to outpatient clinical oncology units, with clinically suspected extra laryngeal neoplastic causes of VCP. Left lung cancer was detected in 52% of patients which was the most frequent cause, 10% had right lung cancer, 8% had thyroid cancer, 6% had mediastinal lymphoma, 6% had metastatic mediastinal lymph nodes from breast cancer, and 6% had esophageal carcinoma.ResultsPET CT scan versus CT scan showed true positive results in (44 vs. 29 patient), true negative results in 5 patients in both scans, and false negative in (1 vs. 16 patient), with no false positive in either. Thus, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for PET CT scan versus CT scan were 98% vs. 68%, 100% for both scans, 100% for both scans, 83.3% vs. 23.8%, and 86% vs. 56%, respectively.ConclusionsFDG PET CT scan plays an important role in diagnosis of oncology-related extra laryngeal causes of VCP, with higher sensitivity, negative predictive value, and accuracy than CT scan. FDG PET CT scan should be included in the workup of VCP if extra laryngeal oncological cause is suspected.

Critical swallowing functions contributing to dysphagia in patients with recurrent laryngeal nerve paralysis after esophagectomy.

Recurrent laryngeal nerve paralysis (RLNP) after esophagectomy can cause aspiration because of incomplete glottis closure, leading to pneumonia. However, patients with RLNP often have preserved swallowing function. This study investigated factors that determine swallowing function in patients with RLNP. Patients with esophageal cancer who underwent esophagectomy and cervical esophagogastric anastomosis were enrolled between 2017 and 2020. Videofluoroscopic examination of swallowing study (VFSS) and acoustic voice analysis were performed on patients with suspected dysphagia including RLNP. Dysphagia in VFSS was defined as score ≥ 3 of the 8-point penetration-aspiration scale VFSS and acoustic analysis results related to dysphagia were compared between patients with and without RLNP. Among 312 patients who underwent esophagectomy, 74 developed RLNP. The incidence of late-onset pneumonia was significantly higher in the RLNP group than in the non-RLNP (18.9 vs. 8.0%, P = .008). Detailed swallowing function was assessed by VFSS in 84 patients, and patients with RLNP and dysphagia showed significantly shorter maximum diagonal hyoid bone elevation (10.62 vs. 16.75mm; P = .003), which was a specific finding not seen in patients without RLNP. For acoustic voice analysis, the degree of hoarseness was not closely related to dysphagia. The length of oral intake rehabilitation for patients with and without RLNP was comparable if they did not present with dysphagia (8.5 vs. 9.0days). Impaired hyoid bone elevation is a specific dysphagia factor in patients with RLNP, suggesting compensatory epiglottis inversion by hyoid bone elevation is important for incomplete glottis closure caused by RLNP.

Complications related to thyroidectomy among patients with hyperthyroidism: Exploring the potential for ambulatory surgery.

Total thyroidectomy for hyperthyroidism is typically followed by overnight admission to monitor for complications including thyrotoxicosis. Outpatient thyroid surgery is increasingly common, but its safety in patients with hyperthyroidism has not been well studied. This retrospective study reviewed 183 patients with hyperthyroidism who underwent total thyroidectomy from 2015 to 2022 at one urban, academic center. The main outcomes were rates of thyroid storm, surgical complications, and 30-day ED visits and readmissions. Among 183 patients with hyperthyroidism (mean age, 45 ± 14.5 years; 82.5% female), there were no cases of thyroid storm and complications included recurrent laryngeal nerve (RLN) palsy (7.0%), symptomatic hypocalcemia (4.4%), and hematoma (1.6%). ED visits were present in 1.1% and no patients were readmitted. Total thyroidectomy was not associated with thyroid storm and <6% of patients required inpatient management. Ambulatory total thyroidectomy for hyperthyroidism warrants further consideration through identification of predictive factors for postoperative complications.

Recovery of Recurrent Laryngeal Nerve Function With Neoadjuvant Treatment: Neural Characterization.

Neoadjuvant targeted therapy has emerged as a promising treatment strategy for locally aggressive thyroid cancer. Its impact on tumor and adjacent tissues remains a nascent area of study. Here we report on a series of six subjects with locally advanced thyroid cancer and recurrent laryngeal nerve (RLN) paralysis who experienced recovery of RLN function with neoadjuvant treatment and describe the morphologic and electrophysiologic characteristics of these recovered nerves. This is a multicenter retrospective review. Descriptive analysis was conducted to examine the following parameters for recovered nerves: (1) nerve morphology, characterized as Type A (involving epineurium only) versus Type B (extending beyond epineurium); (2) proximal stimulability (normal vs. abnormal vs. absent); and (3) surgical management (resection vs. preservation). Six subjects with unilateral VFP were identified. Median time to return of VF mobility was 3 months (range 2-13.5). All nerves (100%) were noted to have Type A morphology at surgery. Proximal stimulability was normal in four subjects (66.7%), abnormal in one (16.7%), and absent in one (16.7%). Nerves that had improvement of function through neoadjuvant therapy were able to be surgically preserved in five subjects (83.3%). This represents the first characterization of RLNs that have recovered function with neoadjuvant treatment of locally advanced thyroid cancer. Although much remains unknown, our findings indicate carcinomatous neural invasion is a reversible process and recovered nerves may demonstrate normal morphology and electrophysiologic activity. 4 Laryngoscope, 2024.