Recurrent Nerve Paresis Research Articles

A critical analysis of 33 patients with substernal goiter surgically treated by neck incision

SummaryThe possibility of needing a combined access, with neck and chest incisions makes the treatment of substernal goiter a challenge both in the pre-op and the intraoperative. We hereby, discuss a standardization of the surgical technique to minimize the need for a chest approach, making the substernal goiter a surgically treatable disease, through a single neck incision, and with low indices of complication.Aimto assess the substernal goiter surgically approach through a neck incision and to analyze the surgical complications.Materials and methodswe carried out a historical cohort by retrospective analysis of the charts of patients submitted to thyroidectomy, and 33 of them (10.4%) had substernal goiter.Resultsall 33 patients were surgically treated through a neck incision without the need for sternotomy. We did not observe definitive lesions in the inferior laryngeal nerve or definitive hypoparathyroidism. Only 2 patients had recurrent nerve paresis; and 2 patients were re-operated because of a neck hematoma.Conclusionpatients with substernal goiter can be safely treated surgically through a single neck incision, bearing low complication rates.

Lehren aus Re-Operationen bei 55 Patienten mit primärem Hyperparathyreoidismus

On the basis of 70 re-operations in 55 patients (34 women, 21 men, median age 58 [43-83] years) suffering from primary hyperparathyroidism the reasons for failure of the first operations were analysed. The main reasons were inadequate exploration of the neck (failure to identify all four glands), failure to recognize multiple gland involvement, or inadequate resection in cases where more than one gland was affected. An abnormally situated gland was a less common cause, as shown by the fact that 41 out of the 73 glands removed at the last re-operation were situated in the normal position or in its immediate vicinity; in 20 cases the surgeon had failed to recognise multiple gland disease. Next in order of importance were anatomical variations in the location (32 out of 73 tumours) or the number of the glands (9 patients with hyperplasia of 5 glands). At the re-operations 89% of the parathyroid tumours were found in the neck region or would have been accessible from the neck at the time of the first operation. Overall, the hypercalcaemia was permanently rectified in 96.6% of the patients. During the last 10 years 94% of patients have been normocalcaemic postoperatively, thanks mainly to the re-implantation of autologous parathyroid tissue, preserved by low-temperature storage. The incidence of permanent unilateral recurrent nerve paresis attributable to the re-operations was 6%.

Postępowanie w przerzutach do węzłów chłonnych w przebiegu raka tarczycy

We would like to present the specificity, technique and efficiency of neck surgery in patients with lymph node recurrence in the course of thyroid cancer treatment. In the ENT Department of Medical University in Poznań, Poland, 16 patients were operated for diagnosed neck relapse of thyroid cancer in the years 2000-2005. All of them were directed from endocrinology or general surgery units, where were previously treated by means of total/partial thyroidectomy: in 7 cases high grade folliculary cancer, in 6 medullary, in 2 oxyphilic and 1 anaplastic cancer. In 5 patients bilateral (one site radical, one site selective), in 11 unilateral neck dissection were performed. The thyroid gland cancer metastases were predominantly localized in the level IV (in 15 of 16 cases) and in anterior neck compartment, i.e. level VI (7 of 16 cases). In 6 patients the remnant of thyroid tissue were excised. Complication - recurrent nerve paresis occured in one case. The time of observation ranged from 5 to 57 months. The neck relapse was observed in one patient with undiffeentiated thyroid cancer in 8 month time after selective neck dissection. The rest of the group is free of disease.

Longstanding recurrent paresis of the left false vocal cord secondary to a schwannoma relieved with laryngoscopic tumor removal

A rare case of schwannoma of the larynx with recurrent nerve paresis is presented. Clinical findings are presented together with those of magnetic resonance imaging (MRI). The tumor was located in the left false vocal cord and measured 3 cm in diameter, enhancing the movement of the vocal cord and involving also the fossa piriformis. The MRI showed a well defined and hypodense mass extending from the left false vocal cord, the aryepiglottic fold to the left vocal cord. The patient underwent an excision of the mass through a laryngoscope and the tumor was completely removed; the recurrent nerve paresis then subsided. The diagnosis and treatment of this tumor are discussed.

What's new in general surgery: endocrine.

There have been many advances in the field of endocrine surgery over the past year. We continue to gain a better understanding of the pathophysiology of endocrine dis- ease through the use of intraoperative hormone mea- surement. Standard surgical procedures have been mod- ified to allow a less invasive approach to surgically cure several endocrine problems. Videoscopic technology has also improved to allow safe operative resection of adre- nal, pancreatic, thyroid, and parathyroid pathology. These procedures have shortened hospital stays, time off work, and improved patient comfort after the proce- dure. A summary of some of these advances, resulting from thoughtful investigation by endocrine surgeons throughout the world, is presented below. solved in only 6% of patients 1 month after undergoing RAI ablation. Hyperthyroidism eventually resolved in 84% of RAI patients with a mean RAI treatment dose of 28 mCi and only 10 (6%) required a second treatment dose. More than half of the patients studied had local symptoms of compression, and size reduction of the goi- ter was seen in only 55 patients (38%) treated with RAI. Thyroidectomy resulted in no postoperative mortality and recurrent nerve paresis and hypoparathyroidism each occurred in three patients (2%). Surgical treatment of toxic multinodular goiter results in rapid and reliable correction of hyperthyroidism with low morbidity. RAI ablation is also safe and effective, usually with a single dose, but resolution of hyperthyroidism is delayed and thyroid goiter persists in many patients. Fine needle aspiration biopsy (FNAB) continues to play an important role in the characterization and treat- ment of thyroid nodules, but distinguishing benign from malignant follicular nodules remains difficult if not impossible. The accuracy of FNAB in detecting thy- roid malignancy is well known in both the academic and community healthcare environments. 2 Thyroid nodules containing follicular cytopathologic features, often de- scribed as follicular neoplasms, are almost always treated with thyroidectomy and are associated with a 20% to 30% malignancy rate. 3 Goldstein and colleagues 4 fur- ther characterized follicular thyroid nodules based on the presence or absence of cytologic atypia. Thyroid ma- lignancy was found by histopathologic examination in only 6.8% of patients without atypia in their FNAB sample, and all of these tumors were a follicular variant of papillary carcinoma. In contrast, 44% of patients with atypia in their FNAB samples harbored thyroid carci- noma, including two invasive follicular carcinomas. This observation may allow for a more conservative ap- proach for carefully selected patients with follicular thy- roid nodules without atypia. The thyroid malignancy

Video-assisted parathyroidectomy for primary hyperparathyroidism: a new approach involving a skin-lifting method.

Recent advances have allowed the performance of parathyroidectomy as an endoscopic procedure. Carbon dioxide (CO2) insufflation can be used to create a working space in the anterior neck, but it has been associated with a number of complications. We have devised a skin-lifting method to overcome these problems. Eleven consecutive patients underwent video-assisted parathyroidectomy. Preoperative imaging revealed a solitary adenoma in all 11 cases. A 3-cm oblique incision was made below the clavicle, and a 5-mm incision was made on the lateral neck. After the skin was lifted, video-assisted parathyroidectomy was performed. Surgery required 186 +/- 50 min. No conversions to conventional cervicotomy were needed. Levels of serum calcium and intact parathormone decreased significantly in all patients on postoperative day 1. Laryngeal recurrent nerve paresis and seroma were noted in one patient each. Our procedure eliminates any potential CO2 problems and offers the advantages of direct manipulation and improved cosmesis. Endoscopic parathyroidectomy should be considered a viable option for the surgical treatment of a solitary adenoma.

Mesurement of Basedow's Disease as Head and Neck Surgeons

Thirty two patients with Basedow's disease were operated in Yamada Red Cross Hospital for recent 14 years and 6 months. Total thyroidectomy were performed in 7 patients, and Subtotal thyroidectomy were in residual 25 patients. In 25 patients who were performed subtotal thyroidectomy, normalization of the thyroid function were observed in 11, and hypothyroid were in 6, but recurrence of hyperthyroidism were observed in 1 case. None of the 32 patients who were operated were observed postoperative recurrent nerve paresis and hypoparathyroidism. Thirteen patients were determined as surgical operation for poor controled thyroid function, and 5 patients were determined afraid of combined thyroid malignancy. Recently Medical measurement was adopted in our department, in short, slow reduction of methymazole and block and replacement. Furthermore, surgical indication is determined by our department. Thirty two patients who were operated in our department were reconsidered about the surgical indication, and 19 patients were determined that surgery were not hurried. It is important that head and neck surgeons aggressively perticipate for the measurement of Basedow's disease, and it is necessary that head and neck surgeons the take the initiative for the determination of surgical indication.

Intraoperative electromyographic recurrent laryngeal nerve identification as a routine measure

In recent years, two methods of intraoperative monitoring of the laryngeal nerve have mostly been used: evoked electromyographic responses via endscopically applied needle electrodes inserted into the adducting laryngeal muscles, and non-invasive electrodes like special tubes with integrated electrodes or separately insertable electrodes like the postcricoid electrode or disposable electrodes attached to the tube, as used in this study. The incidence of recurrent nerve paresis or paralysis during the IRM period was 1/174 nerves (0.6%). The advantage of the IRM is the quick and certain identification of the nerve; intraoperative monitoring cannot replace a proper surgical technique. We conclude that the IRM, using a laryngeal surface electrode attached to the tube, is a safe and reliable method.

Early relapse after operation for Graves[apos ] disease: Postoperative hormone kinetics and outcome after subtotal, near-total, and total thyroidectomy

Background: The relative merit of operation in the treatment of Graves' disease has been questioned, and the extent of surgical resection is still a matter of debate. Methods: We have analyzed retrospectively the incidence of recurrent hyperthyroidism (frequency and time point) in 215 consecutive patients subjected sequentially to subtotal thyroidectomy (n = 63; remnant mass 6 to 8 g, based on surgeons' estimates and dimensions measured during operation), extensive subtotal thyroidectomy (n = 106; remnant mass ~4 g), and near-total (n = 27; unilateral capsular remnant of <2 g) or total thyroidectomy (n = 19). In addition, we have evaluated the postoperative kinetics of thyroid hormone elimination (free triiodothyronine and free thyroxine) in 14 selected patients with hyperthyroidism who underwent operation under β-adrenergic blockade but without any thyrostatic pretreatment. Results: The size of the remnant significantly (P < .05) affected the relapse rate (23.8%, 9.4%, and 0% in subtotal, extensive subtotal, and near-total/total thyroidectomy, respectively). However, the time point at which the relapse occurred did not differ in subtotal and extensive subtotal thyroidectomy. All relapses occurred within the first 70 weeks. The incidence of complications (permanent recurrent nerve paresis and persistent hypocalcemia) was comparable in all groups. The elimination of fT3 was biphasic and rapid such that the levels were within the normal range on the second day. In contrast, 15 days were required until the fT4 level had declined below the upper limit in all patients. Conclusions: We propose that the therapeutic goal in thyroid operations is to avoid recurrent hyperthyroidism. This is not reliably achieved by subtotal thyroidectomy; in contrast, near-total and total thyroidectomy are effective and safe. On the basis of the postoperative elimination kinetics, hormone replacement is to be instituted within 2 weeks after operation. (Surgery 1998;124:894-900.)

Early relapse after operation for Graves' disease: Postoperative hormone kinetics and outcome after subtotal, near-total, and total thyroidectomy

Background: The relative merit of operation in the treatment of Graves' disease has been questioned, and the extent of surgical resection is still a matter of debate. Methods: We have analyzed retrospectively the incidence of recurrent hyperthyroidism (frequency and time point) in 215 consecutive patients subjected sequentially to subtotal thyroidectomy (n = 63; remnant mass 6 to 8 g, based on surgeons' estimates and dimensions measured during operation), extensive subtotal thyroidectomy (n = 106; remnant mass ~4 g), and near-total (n = 27; unilateral capsular remnant of <2 g) or total thyroidectomy (n = 19). In addition, we have evaluated the postoperative kinetics of thyroid hormone elimination (free triiodothyronine and free thyroxine) in 14 selected patients with hyperthyroidism who underwent operation under β-adrenergic blockade but without any thyrostatic pretreatment. Results: The size of the remnant significantly ( P < .05) affected the relapse rate (23.8%, 9.4%, and 0% in subtotal, extensive subtotal, and near-total/total thyroidectomy, respectively). However, the time point at which the relapse occurred did not differ in subtotal and extensive subtotal thyroidectomy. All relapses occurred within the first 70 weeks. The incidence of complications (permanent recurrent nerve paresis and persistent hypocalcemia) was comparable in all groups. The elimination of fT3 was biphasic and rapid such that the levels were within the normal range on the second day. In contrast, 15 days were required until the fT4 level had declined below the upper limit in all patients. Conclusions: We propose that the therapeutic goal in thyroid operations is to avoid recurrent hyperthyroidism. This is not reliably achieved by subtotal thyroidectomy; in contrast, near-total and total thyroidectomy are effective and safe. On the basis of the postoperative elimination kinetics, hormone replacement is to be instituted within 2 weeks after operation. (Surgery 1998;124:894-900.)

Quality assurance in benign thyroid diseases surgery

Quality assurance (or quality management) in surgery is of topical interest. Together with the Institute of Biomedical Engineering and Informatics of the Ilmenau Technical University, we have developed the computer-assisted documentation system SCHILDDOK to improve quality assurance in benign thyroid surgery in our hospital. SCHILDDOK has been recognized as a new concept and has been integrated in the daily work routine. That way, documentation does no longer mean an additional workload, but constitutes a productive part of routine work. According to our previous experiences SCHILDDOK appears to be an exceedingly valuable tool in internal quality assurance particularly because of its standardized data recording. The databadse SCHILDDOK could also be employed as an instrument of external quality assurance in various hospitals. By interconnecting them in a computer-network a comparison of the complication rate in these hospitals would be possible. If the results are checked by a superordinate institution. This would be equivalent to an external audit. There have to be uniform definitions to guarantee comparability of the data. Our suggestion is to define the rate of recurrent nerve paresis as the rate of newly occurring recurrent nerve pareses related to the side operated on. As standardized definition for the recurrent goitre we suggest: a goitre recurring at the operated side. In our opinion you can enhance quality assurance with SCHILDDOK in benign thyroid, diseases surgery.

Hemorrhage from Spontaneous Rupture of a Parathyroid Adenoma (A Case Report)

A case of extracapsular hemorrhage from spontaneous rupture of a parathyroid adenoma is reported. In the case presented here, adenoma was revealed by a sudden onset of a huge ecchymosis and hematoma of the entire anterior neck and right chest, causing recurrent nerve paresis. These cases of hemorrhage from rupture of silent parathyroid adenoma mimicking a dissecting thoracic aortic aneurysm are discussed.

閉鎖性損傷による頚部気管完全断裂の１例

A 69 year-old male, driving a car, swerved and collided into a tree. He was sent to our hospital because of dyspea with extension of the neck. Although he had no subcutaneous emphysema nor open wound, he showed bilateral pneumothorax. Thoracic drainage was performed and his dyspnea improved. One day after admission his dyspnea recurred without emphysema. We tried tracheostomy because of bilateral recurrent nerve paresis. The cervical trachea was completely separated between the cricoid cartilage and the 1st tracheal ring. Under general anesthesia, tracheostomy was performed at the level of 3 rings distal from the separated part and tracheoplasty was carried out. Ten days after the operation, progressive necrosis occurred in the anterior wall of the trachea between the anastomosis and the tracheostomy. A silicon T-tube was inserted to keep the tracheal lumen open 50 days after the operation. The proximal end of the T-tube did not pass the vocal cord because slight movement of vocal cord appeared. Granulation tissue gradually replaced the necrotic tissue. After the silicon T-tube was removed 78 days after the operation, the T-tube wound was closed, then he was discharged with horseness but without dyspnea.

Some Cases of Recurrent Nerve Paresis in connection with Encephalitis

Some Cases of Recurrent Nerve Paresis in connection with Encephalitis