Recurrent Nerve Damage Research Articles

The Fate of the Aorta after Coarctation Repair: Open Surgical Replacement of Descending Aorta in a High-Volume Unit.

Objectives: Complications after aortic coarctation repair are associated with high mortality and require surgical or endovascular reintervention. For patients unsuitable for endovascular therapies, reoperation remains the only therapeutic option. However, surgical experience and up-to-date follow-up data concerning this overall rare entity in the spectrum of aortic reoperations are still highly limited. Thus, the aim of this study was to analyze the short-term outcomes and long-term survival of patients undergoing surgical descending aorta repair after previous coarctation repair in a high-volume unit. Methods: We present a retrospective single-center analysis of 25 patients who underwent open descending aorta replacement after initial coarctation repair. The surgical history, concomitant cardiovascular malformations, and preoperative characteristics as well as postoperative complications and long-term survival were analyzed. Results: The mean age at operation was 45.4 ± 12.8 years. A proportion of 68% (n = 17) of the patients were male. The most common complication necessitating reoperation after coarctation repair was aneurysm formation (68%) and re-stenosis (16%). The average time between initial repair and reoperation was 26.3 ± 9.9 years. Technical success was achieved in all the operations, while recurrent nerve damage (24%) and bleeding requiring rethoracotomy (20%) were identified as the most common perioperative complications. The one-year mortality was 0% and the overall long-term survival was 88% at 15 years. Conclusions: Open surgical descending aorta replacement can be performed safely and with excellent survival outcomes even in the challenging subgroup of patients after previous coarctation repair. Thus, reoperation should be considered a feasible approach for patients who are unsuitable for endovascular therapies. Nonetheless, concomitant cardiovascular anomalies and frequent preoperations may complicate the redo operation in this patient population.

431. DISSECTION OF THE SUPRACARINAL MESOESOPHAGUS RECURRENTIAL LYMPHADENECTOMY AND RECURRENT NERVE DAMAGE

Abstract Background Currently, an extended mediastinal lymphadenectomy is considered paramount for an accurate cancer staging as well as to improve the oncologic outcomes of patients with locally advanced esophageal cancer. Following the recently described supracarinal mesoesophagus (Cuesta et. al. 2023) allows a complete lymphadenectomy, including the left recurrential area. However, this dissection represents a considerable challenge and could be associated with significant complications. The aim of this study is to analyse if the extended lymphadenectomy guided by the anatomy of the superior mesoesophagus enables a more careful dissection of the recurrent nerves in order to avoid an injury of these structures. Methods We prospectively studied all patients in our centre with advanced esophageal cancer, from 2018 to 2023, who underwent esophagectomy and recurrent lymphadenectomy following the surgical plane of the supracarinal mesoesophagus (both unilateral and bilateral). All procedures were performed as curative intent by the same surgeon. We analysed all patients with recurrent nerve lesions and their severity, as well as their implication through the postoperative period and the treatment needed for their repair. In addition, we also studied the number of adenopathies included in the specimen, specifying those that belonged to the recurrential area and its positivity for tumoral cells. Results We included 40 patients in our study, 30 men and 10 women with an average age of 65 years. All of them received neoadyuvant therapy previous to the surgery (mostly CROSS and FLOT schemes). There were only 2 patients (5%) who suffered from permanent recurrent palsy, both needing surgical treatment for its correction. Two other patients had mild dysphonia that could be resolved with phoniatric rehabilitation. No fatal outcome occurred secondary to recurrent nerve injury. The median number of adenopathies resected in total was 35, while the median number of adenopathies corresponding to the recurrential area was 5. Conclusions In this study we have observed that, following the landmarks of the supracarinal mesoesophagus allows us to perform an extended mediastinal lymphadenectomy reducing the recurrent nerves injury down to only 5%. Even though a lesion of the recurrent nerves could imply a major influence on the quality of life, performing this dissection meticulously could improve the quality of cancer staging, overall and disease-free survival without significantly increasing the risk of recurrent nerve damage. For this reason, the proper knowledge of these anatomical planes of dissection may help improve lymphadenectomies without increasing or even reducing the rate of recurrent nerve injury.

Recurrent nerve damage following thyroid surgery: What can I do?

Recurrent nerve damage following thyroid surgery: What can I do?

Comparing the outcomes of total thyroidectomy using a harmonic scalpel versus the conventional ligation techniques in Iran

Background: Maintaining hemostasis is considered a remarkable challenge during total thyroidectomy. The use of thermal ultrasonic electrocoagulation (harmonic scalpel) for total thyroidectomy was recently introduced to substitute the conventional ligation methods. However, controversies exist on the efficacy of this technique compared to the classic method.
 Methods: The data regarding this prospective cohort study was gathered between March 2019 to March 2020. Ninety participants were enrolled in the study. Forty-five subjects received harmonic scalpel ligation and the other forty-five participants underwent conventional total thyroidectomy. Afterward, these two groups were statistically compared regarding surgical time, postoperative hypocalcemia, drainage volume, postoperative pain, hospital stay, and recurrent nerve damage.
 Results: No significant difference was detected in the group undergoing harmonic ligation concerning postoperative pain, postoperative hospital stay, drainage volume, and postoperative hypocalcemia in the first 48 hours post-operation. However, using a harmonic scalpel significantly reduced the surgical time (56 ± 2 minutes in the harmonic scalpel group versus 67 ± 9 in the conventional technique group, p < 0.001). Also, no recurrent nerve damage was detected in the study.
 Conclusions: Utilizing a harmonic scalpel has a remarkably higher time efficacy in total thyroidectomy. However, the study suggests no further advantage for this method compared to the conventional techniques in total thyroidectomy.

Energy Devices in Thyroidectomy: A Safe and Effective Alternative to Conventional Methods

Objective: The most feared complications of thyroid surgery, which is one of the most performed operations of endocrine surgery, are hoarseness due to recurrent nerve damage and hematoma formation in the neck. With the advancement of technology, the use of energy devices has increased during thyroid operations. However, there are different opinions about using energy devices during thyroid operations. Our study aimed to examine the reliability of energy use in thyroid operations. Material and Methods: The data of 144 patients who underwent thyroid surgery for various reasons were reviewed retrospectively. The patients were divided into 2 groups, those who used energy devices during the operation and those who were operated with the conventional method. Demographic data of the patients, duration of operation, complication rates were evaluated comparatively. Result: The majority of patients were women. It was observed that the operation time was shorter, and the amount of bleeding was less in the group in which the energy device was used (p≤0.001). It was determined that the duration of hospital stay of the patients was significantly longer in the conventional surgery group (p≤0.001). There was no significant difference between the two groups in terms of incision lengths. Likewise, there was no difference between the two groups in terms of complication development frequency. Postoperative verbal pain score was significantly higher in the group operated on by conventional method (p≤0.001). Conclusion: Energy devices can be used safely in thyroid surgery with less hospital stay, less postoperative pain levels, better bleeding control and complication rates similar to conventional surgery.

Electrical stimulation mapping of the pulmonary artery in swine: impact on pulmonary artery denervation procedure for pulmonary hypertension

Abstract Introduction Pulmonary artery denervation (PAD) has been recently shown to decrease pulmonary artery (PA) pressure. However, there is a lack of data related to target sites for ablation. Purpose To determine the optimal PA ablation sites based on response to high-frequency stimulation mapping and anatomical areas where radiofrequency ablation (RFA) should be avoided due to the risk of severe collateral damage. Methods A total of 17 Landrace swines were included into the study. PA angiography, hemodynamic measurements by right heart-sided catheterization and electrophysiological mapping (EM) using low (cycle length 330 ms) and high-frequency (33Hz) stimulation (HFS). Stimulation was performed at PA bifurcation and proximal parts of the main PA branches with a 5-mm distance between points; catheter manipulation was performed under fluoroscopic guidance in multiple projections. Points with evoked reactions were tagged on a 3-dimentional PA model in each case. In order to confirm reproducibility of reactions, HFS was performed at least twice at each point with a response. PA models obtained from all animals were combined in one for the final analysis. RFA using an open-irrigated catheter (40 Watts; 40 s; irrigation 30 ml/min) were performed at sites with evoked reactions. Repeated HFS was performed at ablation sites. After the procedure all animals were euthanized and underwent an autopsy study. Results Low-frequency stimulation (LFS) allowed to define areas of ventricular capture (VC) where HFS was avoided due to ventricular fibrillation induction risk. During HFS the following evoked responses were documented: sinus bradycardia, sinus rhythm (SR) acceleration, phrenic nerve capture (PNC), and laryngeal recurrent nerve capture. HFS captured left and right phrenic nerves in all animals at PA trunk, and its course was tagged (Figure 1). Laryngeal recurrent nerve capture was found in 4 (23%) of animals. Atrial capture was found in all cases while LFS at the anterior aspects of both PAs even at low output, and this precluded evaluation of neural autonomic reactions in these areas. Evoked bradycardia and SR acceleration were both found during HFS in 10 (59%) of cases each. Following RFA application evoked reactions were non-reproducible in all cases. RFA was applied in areas where no PNC or VC points were observed. An autopsy study confirmed the presence of RF-induced lesions of the PA wall. Conclusions There are two important findings of our study. First, stimulation-guided PA mapping is feasible and reveals several specific responses to HFS. Ablation at points with responses leads to non-reproducibility of the evoked reactions, confirming that transcatheter RFA may be an adequate approach for PA denervation. Second, previously proposed circular PA ablation might be associated with phrenic and laryngeal recurrent nerve damage. Stimulation-guided PA denervation can be proposed as a safer procedure, and should be evaluated in clinical settings. Figure 1. PA schematic representation Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Russian Foundation for Basic Research

A comparison of the quantitative evaluation of in situ parathyroid gland perfusion by indocyanine green fluorescence angiography and by visual examination in thyroid surgery.

Objective The most vital complications of thyroidectomy are recurrent nerve damage and hypocalcaemia. We aimed to compare the tissue perfusion scores (PS) of IG fluorescence angiography (IGFA) and visual examination by the surgeon after total thyroidectomy. Subjects and methods Forty-three patients were accepted into the study. Localisation of the parathyroid gland (PG) was determined by the naked eye and scored in terms of tissue perfusion. The averages of fluorescent light intensities for each IGFA were calculated, the perfusions were scored and compared with the PS given by the surgeon. Biochemical parameters were noted. Results 37.2% of patients had autotransplanted PGs, according to their visual scores. The means of IGFA-PS for PGs scored as 0, 1 or 2 on visual inspection were 48.58 ± 4.49 [30-70], 89.65 ± 8.93 [36-144] and 158.76 ± 8.93 [70-253], respectively, which correlated with the visual PSs in a statistically significant manner (P < 0.0001). The predictive cut-off value for IGFA-PS was determined to be 70, given a visual PS of 0 (95% CI [0.72-0.85]), and this was interpreted to be a candidate cut-off point for the autotransplantation of PGs. Conclusion IGFA scoring may be considered as an operative predictor, providing objective criteria to evaluate the tissue and blood perfusion of PGs after thyroidectomy. IGFA scoring may be considered to have value in minimising postoperative permanent hypoparathyroidism in patients.

Retrosternal Thyroid Goiter: Recurrent Laryngeal Nerve Dissection According to the Charles Proye's Toboggan Technique

Introduction: We present a case report supported by a video of a case of recurrent retrosternal thyroid goiter with superior identification of the recurrent laryngeal nerve (also called the Charles Proye's toboggan technique).1 Materials and Methods: In November 2012, we operated a 71-year-old patient for a recurrent unilateral retrosternal thyroid goiter. The patient underwent a subtotal thyroidectomy 20 years earlier; she showed symptoms of airway and esophageal compression. After a CT scan and a laryngoscopy, the patient underwent a right thyroid lobectomy. The surgery of retrosternal goiter is at increased risk for iatrogenic recurrent laryngeal nerve lesion.2 Charles Proye described a surgical technique to avoid this lesion. To have a better exposition, a section of the prethyroid muscles can be considered, particularly if it is a voluminous and/or recurrent goiter.3–4 The approach starts with the thyroid isthmus liberation that is dissected free from the anterior part of the trachea and transected. Then, the middle thyroid vein is divided and the superior pole vessels are divided. The superior pole is then mobilized laterally, and the recurrent laryngeal nerve is searched for at its entry point into the larynx. The nerve function can be verified by the neuromonitoring, which also helps to find it in this vessel-rich area. The dissection continues between the nerve and the posterior part of the thyroid, progressively from top to bottom, descending as on a toboggan. After the recurrent nerve dissection, the goiter can usually be extracted without difficulty, dividing the last vessels holding the goiter inside.1–4 Results: With the toboggan technique, it is often possible to do the thyroidectomy for mediastinal goiter without sternotomy and recurrent nerve damage.1 Using this technique, the recurrent nerve is never put under tension. The patient operated with this technique had a duration of hospitalization of 3 days without any postoperative complication. Conclusions: Whenever possible, we prefer to operate intrathoracic goiters using this technique because it allows us to better recognize and preserve the recurrent nerve without putting it under tension. The Source of Work or Study: In 1981, Charles Proye described a new surgical technique to operate intrathoracic goiters without sternotomy and with preservation of recurrent nerve; the surgery of mediastinal goiter is at increased risk for iatrogenic recurrent laryngeal nerve lesion. We utilize in our clinic this technique for intrathoracic goiters. This video describes the details of the Charles Proye's technique. The authors have not received any payment or support. The article is based on a videocommunication during the congress of the IAES in Helsinki, August 2013. Running time of video: 4 mins, 53 secs

The most versatile and useful appendage on earth

At first glance, this paper by Shrestha et al. [1] is a standard analysis and evaluation of a single-centre experience using the elephant trunk technique for total arch replacement. About one-third of the operations were followed by a second-stage procedure, mostly a descending thoracic replacement, only in 11 cases by a thoracoabdominal repair. The focus of this paper clearly lies in the first surgical step. When studying this paper more thoroughly, it becomes obvious that it is not just an average description and common analysis of the surgical results as we can find almost monthly in all wellrespected cardiovascular journals. It is much more than that. It is a wonderful piece of history describing the evolution of the elephant trunk technique starting with its introduction three decades ago by its inventor Hans Borst. Needless to say that the idea of inserting a free-floating vascular prosthesis into the downstream aorta and that in doing so, avoid re-entering in a surgical field that is crowded with major vascular, bronchial, neurological, lymphatic and gastrointestinal structures almost merits the Nobel prize in cardiovascular surgery, if it existed. Technical modifications were later introduced by some outstanding pioneers in cardiovascular surgery (such as Crawford and Svensson) in order to facilitate the technique and to reduce complication rate. Very often, these modifications were just simplifications, which is of course characteristic of the influence of great surgeons. Of special importance are the alterations concerning cerebral protection: for 17 years, deep hypothermic circulatory arrest was the mainstay and in 1999 antegrade selective cerebral perfusion was introduced and is actually a main pillar to success. It is not a coincidence that this paper now originates from the cradle where the elephant trunk was born. If you do not possess an atlas of cardiovascular surgery, this paper will tell you the ins and outs based on the evolution of the surgical technique. For example, how you can avoid trunk impaction, how to deal with the dissection membrane in chronic situations, what should be the optimal length of the trunk, how to avoid left recurrent nerve damage .... These are all fundamental aspects that should be respected in order to obtain optimal results. Concerning these results, it should be stressed that 25% of the patients received the elephant trunk for an acute Type A dissection. Very few of us are able to perform this under these dangerous circumstances. Moreover, 30% were redos. It is obvious that these two items certainly have influenced the outcome in a negative way. Another important point that had a major impact on the results was the learning curve. As the evolution of the elephant and its trunk took millions of years, we may not expect that the surgical technique can be made perfect in 30. That is why the results should be interpreted with caution and be seen in perspective. For an elephant, its trunk is absolutely vital and indispensable; without the elephant trunk technique, no matter in which form, cardiovascular surgery certainly would loose tremendous allures and look massively different.

Sustained Enzymatic Correction by rAAV-Mediated Liver Gene Therapy Protects Against Induced Motor Neuropathy in Acute Porphyria Mice

Acute intermittent porphyria (AIP) is characterized by a hereditary deficiency of hepatic porphobilinogen deaminase (PBGD) activity. Clinical features are acute neurovisceral attacks accompanied by overproduction of porphyrin precursors in the liver. Recurrent life-threatening attacks can be cured only by liver transplantation. We developed recombinant adeno-associated virus (rAAV) vectors expressing human PBGD protein driven by a liver-specific promoter to provide sustained protection against induced attacks in a predictive model for AIP. Phenobarbital injections in AIP mice induced porphyrin precursor accumulation, functional block of nerve conduction, and progressive loss of large-caliber axons in the sciatic nerve. Hepatocyte transduction showed no gender variation after rAAV2/8 injection, while rAAV2/5 showed lower transduction efficiency in females than males. Full protection against induced phenobarbital-attacks was achieved in animals showing over 10% of hepatocytes expressing high amounts of PBGD. More importantly, sustained hepatic expression of hPBGD protected against loss of large-caliber axons in the sciatic nerve and disturbances in nerve conduction velocity as induced by recurrent phenobarbital administrations. These data show for the first time that porphyrin precursors generated in the liver interfere with motor function. rAAV2/5-hPBGD vector can be produced in sufficient quantity for an intended gene therapy trial in patients with recurrent life-threatening porphyria attacks.

Anatomical bases of left recurrent nerve lesions during mediastinoscopy

The mechanism of left recurrent laryngeal nerve palsy after cervical mediastinoscopy remains unclear. Our aim is to describe the anatomical bases of this complication. Video-assisted mediastinoscopy was performed on ten fresh human cadavers with simultaneous dissection of the left recurrent nerve. Three dissection areas could be described regarding the risk of left recurrent nerve damage: a low risk area, along the right wall and before the upper part of the anterior wall of the trachea; an area at high risk of indirect stretch-induced lesions, between the lower part of the anterior wall of the trachea and the aorta; -an area at high risk of direct injury, against the lower part of the left wall of the trachea. Dissection between the trachea and the aorta causes traction on the left recurrent nerve. Indirect stretch-induced injury is probably a frequent mechanism of left recurrent nerve palsy during mediastinoscopy.

Chronic symptoms after subtotal or partial oesophagectomy: diagnosis and treatment

In the great majority of patients, subtotal or partial oesophagectomy is performed because of malignancy, for which wide local excision and additional lymphadenectomy are indicated. Except in patients with early lesions, the vagal nerves have to be sacrificed bilaterally, which can induce a great variety of functional abnormalities. The continuity of the gastrointestinal tract is preferably restored by using a whole-stomach interposition or gastric tube. The oesophago-gastric anastomosis is critically vascularized and carries a significant risk of benign fibrotic stricturing, especially when it is located in the neck. Acid or biliary reflux may result in persistent oesophagitis and the development of Barrett's metaplasia in the remnant oesophagus. The reservoir capacity of the gastric tube is limited, whereas the emptying rate can vary considerably, leading to complaints of either gastric retention or intestinal dumping. It is not clear whether or not gastric drainage procedures are beneficial. Recurrent nerve damage with vocal cord paralysis may result in aspiration and recurrent pulmonary infection. The permanent threat of recurrent disease combined with the substantial physical impact of an extensive surgical procedure inducing a wide range of functional disturbances of the gastrointestinal tract has a great influence on quality of life, at least temporarily. The late complications of anastomotic stricturing and the functional consequences of bilateral vagotomy, gastric tubulization and gastric pull-up will be reviewed. Moreover, the general and specific changes in quality of life will be addressed.

Chronic symptoms after subtotal or partial oesophagectomy: diagnosis and treatment

In the great majority of patients, subtotal or partial oesophagectomy is performed because of malignancy, for which wide local excision and additional lymphadenectomy are indicated. Except in patients with early lesions, the vagal nerves have to be sacrificed bilaterally, which can induce a great variety of functional abnormalities. The continuity of the gastrointestinal tract is preferably restored by using a whole-stomach interposition or gastric tube. The oesophago-gastric anastomosis is critically vascularized and carries a significant risk of benign fibrotic stricturing, especially when it is located in the neck. Acid or biliary reflux may result in persistent oesophagitis and the development of Barrett's metaplasia in the remnant oesophagus. The reservoir capacity of the gastric tube is limited, whereas the emptying rate can vary considerably, leading to complaints of either gastric retention or intestinal dumping. It is not clear whether or not gastric drainage procedures are beneficial. Recurrent nerve damage with vocal cord paralysis may result in aspiration and recurrent pulmonary infection. The permanent threat of recurrent disease combined with the substantial physical impact of an extensive surgical procedure inducing a wide range of functional disturbances of the gastrointestinal tract has a great influence on quality of life, at least temporarily. The late complications of anastomotic stricturing and the functional consequences of bilateral vagotomy, gastric tubulization and gastric pull-up will be reviewed. Moreover, the general and specific changes in quality of life will be addressed.

Treatment of multinodular goiter by surgery.

Although this comment emphasizes surgical treatment of multinodular goiter, the Author affirms that he feels both surgery and radioactive iodide (RAI) therapy have a role in managing this common condition. Multinodular goiter is typically a slowly evolving process and most often presents for management in post-menopausal women. The reasons for seeking treatment range from adverse cosmetic appearance, to concern about malignancy or symptoms indicating partial obstruction of the esophagus, compression of the trachea, or venous return to the superior vena cava. Less commonly, hoarseness prompts attention. Occasionally episodes of pain and swelling may be present. Typically, benign, non-toxic multinodular goiters grow to considerable size before patients seek attention. It is unusual for the gland to be less than three times normal size (greater than 45-50 g) when symptoms arise. Diagnostic studies, in addition to FTI, TSH, and often antibodies, may include ultrasound for examination of nodules, sometimes isotope scanning, occasionally CAT scans or X-rays to evaluate tracheal compression, and FNA of dominant nodules. Problems that suggest need for a surgical approach include adenopathy, very large size, progressive growth of a nodule or concern about FNA cytology, hoarseness or continued pain, marked tracheal compression, or obstruction of venous return. Surgery is conventionally done without specific medical preparation, currently involves admission on the day of operation, and typically the patient is discharged the following day. Patients are usually back at full activity in 10-14 days. Surgery almost always offers a good cosmetic outcome, and provides a histologic diagnosis. A bilateral subtotal thyroidectomy is often done, attempting to remove nodular tissue but leaving the posterior capsule and “normal” tissue intact. This operation rarely causes recurrent nerve paralysis or hypoparathyroidism. There is a trend toward total thyroidectomy in some centers, in an attempt to avoid recurrences (1). Almost all goiters can be removed through a transcervical incision. When done by a capable surgeon, the incidence of hypoparathyroidism, after surgery for multinodular goiter, is approximately 1%, unilateral recurrent nerve damage is approximately 1%, bilateral recurrent nerve damage almost never occurs, and tracheostomy should almost never be a problem (2). The low incidence of side-effects described may not be representative of results in hospitals where surgeons infrequently perform this operation. Obviously permanent hypoparathyroidism is a major lifelong complication, but unilateral recurrent nerve damage is typically a minor problem. Patients may, or may not, be started on replacement T4 therapy after subtotal resection, since the residual tissue can usually recover enough to ensure euthyroidism. Administration of thyroid hor

Operative management of thyroid abnormalities in a general medical practice hospital in sub-Saharan Africa.

This is a retrospective analysis of 82 patients undergoing thyroid operations in a general medical practice hospital in sub-Saharan Africa. All patients complained of neck swelling, and in 75% of patients this was the only symptom. Indications for operation included cosmesis in 74%, suspected malignancy in 13%, hyperthyroidism in 7% and pressure symptoms in 5%. Operative complications included recurrent laryngeal nerve injury in two (2.4%), wound haematoma in two (2.4%), wound infection in three (3.6%) and hypoparathyroidism in one (1.2%). There were no deaths and no instances of thyroid storm. Thyromegaly can be operatively managed in a hospital such as ours with a relatively low morbidity rate using conservative gland extirpation techniques. This conservative approach may result in under treatment for thyroid malignancies but should result in a lower incidence of recurrent nerve damage and hypoparathyroidism in the majority of people who undergo thyroidectomy solely for cosmetic indications.

A prospective evaluation of recurrent laryngeal nerve paralysis during thyroidectomy.

Recurrent laryngeal nerve paralysis after thyroidectomy can be unrecognized without routine laryngoscopy, and patients have a good potential for recovery during follow-up. A prospective evaluation of vocal cord function before and after thyroidectomy. Periodic vocal cord assessment was performed until recovery of cord function. Persistent cord palsy for longer than 12 months after the operation was regarded as permanent. A university hospital with about 150 thyroid operations performed by 1 surgical team per year. From January 1, 1995, to April 30, 1998, 500 consecutive patients (84 males and 416 females) with documented normal cord function at the ipsilateral side of the thyroidectomy were studied. Vocal cord paralysis after thyroidectomy. There were 213 unilateral and 287 bilateral procedures, with 787 nerves at risk of injury. Thirty-three patients (6.6%) developed postoperative unilateral cord paralysis, and 5 (1.0%) had recognizable nerve damage during the operations. Complete recovery of vocal cord function was documented in 26 (93%) of 28 patients. The incidence of temporary and permanent cord palsy was 5.2% and 1.4% (3.3% and 0.9% of nerves at risk), respectively. Among factors analyzed, surgery for malignant neoplasm and recurrent substernal goiter was associated with an increased risk of permanent nerve palsy. Primary operations for benign goiter were associated with a 5.3% and 0.3% incidence (3.4% and 0.2% of nerves at risk) of transient and permanent nerve palsy, respectively. Unrecognized recurrent laryngeal nerve palsy occurred after thyroidectomy. Thyroid surgery for malignant neoplasms and recurrent substernal goiter was associated with an increased risk of permanent recurrent nerve damage. Postoperative vocal cord dysfunction recovered in most patients without documented nerve damage.

Results of reoperation for persistent and recurrent hyperparathyroidism.

Between August 1975 and January 1981, 106 patients thought to have persistent or recurrent hyperparathyroidism underwent a total of 108 parathyroid re-explorations at the National Institutes of Health. These 106 patients had a total of 175 previous operations for hyperparathyroidism (156 cervical and 19 mediastinal). Nephrolithiasis (54% of patients) and bone disease (24% o patients) were the predominant symptoms. Arteriographic examination and selective venous sampling provided highly accurate localizing results in 33% of the patients, and were of some help in 64%. The final diagnoses after reoperation and re-evaluation were: single-gland disease in 58 patients, primary nonfamilial hyperplasia in 19 patients, familial hyperplasia in three patients, multiple endocrine neoplasia (MEN) Type I in ten patients, MEN Type II in two, parathyroid carcinoma in four patients, secondary hyperplasia in three patients, and familial hypocalciuric hypercalcemia (FHH) in two patients. The diagnosis was in doubt in five patients. In the 95 patients with unequivocal hyperparathyroidism, not due to parathyroid carcinoma, surgery eliminated hypercalcemia in 91 (96%). Two patients died after operation, one of disseminated candidiasis, and one patient, with an immunodeficiency, of sepsis. Five patients developed temporary, and one permanent, recurrent nerve damage; 41% of the patients were hypocalcemic, at the time of discharge from the hospital.

Spontaneous laryngeal disease in the canine.

This report describes the type and incidence of spontaneous laryngeal disease in the dog. Signs of laryngeal disease are similar to those in other species. Dogs are usually presented with inspiratory obstructive dyspnea or stridor, since earlier signs are often missed. Severe, congenital abnormalities may occur unrecognized due to neonatal death. Subtle anomalies are seldom presented. Congenital paralysis of the laryngeal musculature has been seen in the Bouvier des Flandres and the Siberian Husky. Laryngeal obstruction occurs commonly in brachycephalic dogs (Bulldog, Boxer, Boston Terrier, Pug, Pikingese). The forshortened nasal cavity and pharynx result in reduced airway space. The result is inspiratory obstruction varying from noisy respiration to severe obstruction with cyanosis and syncope. Everted laryngeal ventricles are most common in these dogs. Mild degrees of ventricular edema are common in small breed dogs with lower respiratory disease and in field-trial Beagles due to voice abuse. Traumatic injuries to the larynx and hyoid apparatus are not rare. Bite wounds from dog fights are the most common cause. Compression fractures are rare, but injuries associated with shearing stresses, due to being shcken by the neck cause airway obstruction. These types of injuries include avulsion of the aryepiglottic folds, longitudinal tearing of the epiglottis, arytenoid displacement, hyo-laryngeal separation, and laryngotracheal separation. Delayed signs of recurrent nerve damage are common in severe laryngotracheal injuries.

Vocal cord paralysis following approaches to the anterior cervical spine.

AbstractThe charts of 85 patients who had undergone an approach to the anterior cervical spine between 1966 to 1970 were reviewed. Nine of them (11 percent) showed postoperative voice changes, three of those had permanent vocal cord paralysis. The possible causes of recurrent nerve damage are discussed.