Transcervical Approach Research Articles

Ectopic Mediastinal Thyroid: A Crossroad Between a Multi-Layered Endocrine Perspective and a Contemporary Approach in Thoracic Surgery

An ectopic thyroid (ET) involves numerous scenarios of detection and outcomes, while its current management is not standardised. A mediastinal ET (MET) represents a low index of suspicion. In this paper, we introduce a 47-year-old female who was accidentally identified with an MET, and a modern surgical approach was provided. An anterior mediastinal mass of 3.2 cm was found at CT upon a prior COVID-19 infection. Previous to the infection, she experienced non-specific complaints for a few months (intermittent night sweats, facial erythema, chest pressure, and dyspnoea). Also, CT identified a thymus-like mass and a left adrenal incidentaloma of 3 cm. The endocrine panel was normal, and the subject declined further investigations. She was re-admitted 12 months later: the MET had increased +1 cm (+45% volume) and was confirmed at a 99mTc pertechnetate scintigraphy. Noting the symptoms, mediastinal anatomy, and size change, the MET was removed via a minimally invasive trans-cervical approach (eutopic gland preservation) with the help of a Cooper thymectomy retractor (which also allowed for a synchronous thymus mass resection). No post-operatory complications were registered, the thyroid function remained normal, and the mentioned symptoms were remitted. A histological exam confirmed a benign MET and thymus hyperplasia, respectively. To conclude, this case pinpoints important aspects, such as the clinical picture became clear only upon thoracic surgery due to the complete remission of the complaints that initially seemed widely non-specific. The incidental MET finding was associated with a second (adrenal) incidentaloma, a scenario that might not be so rare, following multiple imaging scans amid the COVID-19 era (no common pathogenic traits have been identified so far). The co-presence of a thymus mass represented one more argument for surgery. Minimally invasive cervicotomy associated with eutopic gland conservation and the use of a Cooper thymectomy retractor highlight modern aspects in video-assisted thoracic surgery, which provided an excellent outcome, involving one of the lowest mediastinal thyroids to be removed by this specific procedure. Awareness of such unusual entities helps inform individualised, multidisciplinary decisions for optimum prognoses.

Endoscope-Assisted Transcervical Resection of Parapharyngeal Space Tumors.

We describe a novel technique for endoscope-assisted (EA) transcervical (TC) approach for resection of parapharyngeal space (PPS) tumors and compare perioperative outcomes of this approach to standard TC approaches. Retrospective chart review. Single tertiary care center. This was a single-institution, retrospective analysis of all patients undergoing TC approach for resection of PPS tumors over a 10-year period. We describe unique advantages of our surgical approach utilizing a 0° endoscope for improved surgical access, visualization, and efficiency. χ2 and Student's t test were used to compare perioperative outcomes between cases in which an endoscope was utilized EA for resection versus standard TC approach. Our cohort included 77 patients (n = 40 EA, n = 37 TC). There was no difference in patient age, sex, tumor laterality, tumor size, or tumor location between groups. The EA approach was associated with significantly shorter operative times (median [range] for EA 73 [33-270] minutes vs TC 112 [56-362] minutes, P < .01) and reduced rates of immediate postoperative marginal mandibular nerve paresis (EA: n = 5 [12.5%] vs TC: n = 16 [43.2%], P < 0.01). EA TC approach for resection of PPS tumors offers improved surgical access and is associated with reduced surgical time and rates of marginal mandibular nerve paresis compared to standard transcervical approaches.

Minimal Invasive Resection of Large Retrosternal Thyroid Goiter.

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic approach is linked to higher postoperative morbidity, reaching up to 30% when compared to the transcervical approach. Although alternative options like thoracoscopic resection have shown promising results, the morbidity of mediastinal dissection remains a concern. Thoracoscopic-assisted transcervical approach might be a feasible, less invasive alternative. This video outlines the steps and potential pitfalls of the procedure. The patient is positioned supine with an extended neck. Initially, the endocrine surgeon mobilizes the thyroid gland through cervical access. If a transcervical resection is not feasible, the patient is mobilized into a lateral decubitus position, and a second team thoracoscopically guides the mediastinal tumor through the thoracic inlet. This allows a stepwise controlled transcervical dissection of the retrosternal mass until complete resection is achieved, thus eliminating the need for mediastinal dissection. To demonstrate the procedure, we present the case of an 84-year-old male with lymph node-positive oncocytic thyroid carcinoma and a large retrosternal goiter extending posteriorly into the mediastinum up to the aortic arch. Thoracoscopic-assisted transcervical resection was performed. The recurrent laryngeal nerve was identified and monitored with a neurostimulation device during dissection. No palsy was noted in the postoperative evaluation. The patient had an uneventful postoperative course and was discharged on the second postoperative day. Thoracoscopic-assisted transcervical resection of large retrosternal goiter seems a feasible alternative to mitigate risks associated with thoracotomy, sternotomy, or thoracoscopic mediastinal dissection. Potential advantages include decreased postoperative morbidity and length of stay. This technique requires thoracoscopic expertise and may be limited depending on the goiter's size and mediastinal positioning.

Management of a Piriform Sinus Fistula With Chronic Neck Infection in an Adult.

A pyriform sinus fistula (PSF) is a rare congenital anomaly due to failed obliteration of the third or fourth pharyngeal pouch. Diagnosis and management of PSF remains controversial. We present a case of PSF and discuss its diagnosis and management. Case report and literature review. A 26-year-old female with a chronic left lateral neck abscess was diagnosed with a left PSF. She underwent surgery through a combined approach to close the openings of the PSF, internally and externally. We first placed a blunted ET tube into the internal opening of the PSF. We then performed an external transcervical approach to close the PSF at the cricothyroid membrane. Briefly, after a neck debridement and washout of the chronic neck infection, we identified the recurrent laryngeal nerve (RLN) in Lore's triangle. We performed left hemithyroidectomy to facilitate the dissection and protection of the RLN to its entrance into the larynx. A flexible laryngoscope was then inserted into the left piriform sinus through the ET tube to guide external dissection by transillumination. The scar tissue attached to the superior pole of the left thyroid lobe was then ligated and divided along the cricothyroid membrane. Lastly, we cauterized the internal opening of the PSF. The patient has remained recurrence-free for 1.5 years with normal vocal cord mobility. Histopathology revealed presence of a squamous-lined tract adjacent to the thyroid tissue. Surgical treatment for patients with PSF should be aimed at closing the internal and external openings of the PSF, debriding chronic neck infection, and protecting the laryngeal nerves, instead of removing the entire tract. A concurrent hemithyroidectomy facilitates the identification and protection of the RLN, as well as excision of the tract. Differentiation between third and fourth branchial cleft fistulae may not be clinically necessary, as it is unlikely to alter the therapeutic plan.

Knowledge and perception of medical students regarding remote-access thyroidectomy in Tabuk: the effects of extensive counseling-an interventional study.

Remote-access scarless thyroidectomies are relatively new surgical procedures, and their uptake for cosmetic concerns is rapidly evolving. However, demographic factors, previous thyroid surgery, and culture substantially influence the patient's choice. This is the first study to assess the extensive counseling effect on the patient's preference for remote-access thyroidectomies compared to conventional transcervical approaches. We aimed to assess the same among medical students at the University of Tabuk, Saudi Arabia. This interventional study was conducted from December 2023 to March 2024. A structured questionnaire was used to gather information about demographic factors, knowledge, and perception of the medical students regarding remote-access thyroidectomies before and after a slide presentation. Of 394 medical students (age 22.65 ± 1.62 years), 53.8% were women. Initially, the majority of the students preferred remote-access thyroidectomy over the conventional approach (85.3% vs. 14.7%, respectively); however, a substantial change toward the cervical approach was evident after extensive counseling [odds ratio, 2.59; 95% confidence interval (CI), 1.58-4.27; and P-value <0.00]. Knowledge regarding remote-access thyroidectomy was poor (26.9%). The students were anxious regarding postoperative complications (3.22 ± 1.59/5), thyroid scar appearance (3.28 ± 1.36/5), and postoperative pain (3.17 ± 1.38/5). Concerns regarding body satisfaction and cost were lower. Medical students at the University of Tabuk, Saudi Arabia, demonstrated low knowledge. The strong preference for remote-access thyroidectomy over transcervical thyroidectomy shifted substantially toward the conventional approach after counseling. The main factors were thyroid scar appearance, pain, and complications. Further larger-scale studies involving the general public and assessing the effect of extensive counseling on surgical choice are needed.

Reconstruction of internal carotid artery in the resection of paraganglioma of head and neck

Objective:This study aims to discuss the necessity，surgical method and effect of reconstruction of internal carotid artery （ICA） in the resection of paraganglioma of head and neck. Methods:We retrospectively analyzed the data of the patients who underwent head and neck paraganglioma resection and ICA reconstruction in Peking Union Medical College Hospital from May 2015 to August 2023. The demographic characteristics, preoperative examinations, diagnoses, surgical techniques, and follow-up information were collected. Results:Six patients were enrolled, including four females and two males, with an average age of（39.8±13.0） years. All the patients presented mainly complaining local masses with or without pain. Four cases underwent surgery through Fisch infratemporal fossa approach type A+B, and one through approach type A and one through transcervical approach. Five patients had vascular reconstruction using the great saphenous vein while one patient used an artificial vessel. The average follow-up period was（43.8±31.6） months. One patient had tumor recurrence after 3 years and underwent second surgery to remove the residual tumor, and the other 5 patients had no tumor recurrence. One patient had acute bridging vessel embolism, and the other was found to have occlusion of the bridging vessel at follow-up. Conclusion:Carotid revascularization during resection of paraganglioma of head and neck is an important technique to completely remove the tumor, cure the disease, ensure intracranial blood supply, and reduce cerebrovascular complications. The "pre-reconstruction technique " is an effective method to minimize the duration of brain blood flow interruption, compared to traditional carotid revascularization. Close observation is necessary, along with regular radiological examinations to assess the patency of transplanted vessels, and the residual or recurrent tumors.

Endoscopy-assisted high cervical anterolateral retropharyngeal approach to clivus: a cadaveric study.

The surgical management of pathologies involving the clivus and craniocervical junction has always been considered a complex procedure because of the deeply located surgical targets and the surrounding complex neural and vascular anatomical structures. The most commonly used approaches to reach this area are the transnasal, transoral, and transcervical approaches. This approach was performed unilaterally on five cadaver heads and bilaterally on one cadaver head. We described a modified endoscope-assisted high cervical anterolateral retropharyngeal approach in which each stage of the procedure was demonstrated on human cadavers in a step-by-step manner using endoscopic camera views. This approach was broken down into nine steps. The neurovascular structures encountered at each step and their relationships with each other are demonstrated. The advantages and disadvantages of our modified approach were compared to the conventional transcervical, transoral, and endoscopic endonasal approaches.

Novel approach for tracheal resection in Morquio a syndrome with end-stage critical airway obstruction: a UK case series

BackgroundMucopolysaccharidosis (MPS) type IVA is a rare lysosomal storage disorder caused by aberrations of the N-acetyl-galactosamine-6-sulfatase (GALNS) enzyme. MPS IVA is associated with a wide gamut of respiratory and airway disorders that manifest in a continuum of severity. In individuals exhibiting severe phenotypic expression, terminal stages of the disease frequently culminate in life-threatening, critical airway obstruction. These manifestations of end-stage disease are engendered by an insidious progression of multi-level airway pathologies, comprising of tracheomalacia, stenosis, tortuosity and 'buckling'. Historically, the management of end-stage airway disease has predominantly leaned towards palliative modalities. However, contemporary literature has posited that the potential benefits of tracheal resection with aortopexy, performed under cardiopulmonary bypass (CPB), may offer a promising therapeutic option. In this context, we report on outcomes from patients undergoing a novel approach to tracheal resection that is combined with manubrial resection, leading to improved airway calibre, obviating the requisition for CPB.ResultsIn this study, seven patients with severe MPS IVA exhibited clinical symptoms and radiological evidence indicative of advanced airway obstruction. All patients had a tracheal resection with a partial upper manubriectomy via transcervical approach, which did not require CPB. The surgical cohort consisted of 5 females and 2 males, the median age was 16 years (range 11-19) and the median height was 105.6cm (range 96.4-113.4). Postoperatively, significant improvements were seen in forced expiratory volume in 1 second (FEV1), with a mean increase of 0.68 litres (95% CI: 0.45-0.91; SD: 0.20). Notably, other spirometry variables also showed meaningful improvements, providing evidence of positive treatment effects. Furthermore, there were no major long-term complications, and the procedure resulted in a significant enhancement in patient-reported domains using PedsQL (version 4.0).ConclusionsThis study represents the largest case series to date, on tracheal resection in patients with severe MPS IVA. Our findings demonstrate the effectiveness of the transcervical approach with partial manubriectomy for improving respiratory function and quality of life for individuals with advanced airway obstruction. Tracheal resection presents a promising treatment modality for severe cases of MPS IVA. Successful outcomes rely on meticulous multidisciplinary assessment, judicious decision-making, and appropriate timing of tracheal surgery. Further research and long-term follow-up studies are warranted to validate the long-term efficacy and safety of this approach.

Transoral Robotic Approach to Parapharyngeal Space Tumors: Changes in Paradigm of Surgery.

PPS space tumors are extremely rare, accounting for 0.5% of head and neck neoplasms. Trans-oral, Trans-cervical, Trans-parotid, Trans-cervical-trans-mandibular, and infratemporal are various surgical approaches that have been described for PPS tumors. Of late, with the advent of robotic surgery, Trans Oral Robotic Surgery (TORS) for PPS tumors is being increasingly advocated with promising results. To establish both efficacy and safety of Trans Oral Robotic Surgery, Five cases of pleomorphic adenoma of parapharyngeal space with sizes varying between 2.5 cm to 7.5 cm were evaluated and removed using Trans oral robotic approach using the Da Vinci system. Three were removed in toto and two in piecemeal fashion. There was capsule breach in 2 cases, no major complication was reported in any of the cases. Transoral Robotic Approach for PPS tumors can provide the much-required bridge between Transcervical and Trans mandibular Oral Approach. It provides a better direct approach. Carefully selected patients with well encapsulated tumors are more amenable to this approach.

Extracranial Head and Neck Schwannomas: A Single Centre Retrospective Experience of 97 Cases.

Schwannomas are rare benign neurogenic tumours. About 25-45% of extracranial schwannomas are found in the head and neck region. In the head and neck, they can arise from various cranial, peripheral and autonomic nerves. Due to this, they have varied clinical presentations. This retrospective cohort includes 97 patients diagnosed with extra cranial head and neck schwannoma, and operated in the Otolaryngology and Head & Neck Surgery department, from 2013 to 2022. The parameters observed were the age and gender distribution, location, nerve of origin, size, pressure symptoms, cranial palsies, post-operative symptoms, recurrence and complications. The data were collected from the institute's electronic records. The median age of the study population was 36years; among them, 51 were men and 46 were women. The most common tumour location was parapharynx. The patients had varied head and neck symptoms, of which 23.7% had nerve paresis at presentation. Transcervical surgical approaches was most used. New onset cranial nerve paresis immediately post-surgery was noted in 22.7%. Recurrence was noted in 2% of cases. Extra cranial schwannomas are uncommon neoplasms and have varied presentations. Comprehensive evaluation with appropriate imaging should be done in all cases. Though benign, patients can present with nerve paresis. Recurrence is uncommon after complete resection.

Rare case of Lingual Nerve Schwannoma Presenting as Submandibular Area Swelling with Parapharyngeal Extension.

Schwannoma is a rare benign encapsulated nerve sheath tumor which originates from Schwann cells. Generally, schwannoma arising from lingual nerve involves the oral tongue and tongue base in the oral cavity. We report a rare case of lingual nerve schwannoma in a 16-year-old girl with complaint of right-side submandibular swelling for last 4-5 years. A diagnosis was established based on computed tomography (CT scan) and fine needle aspiration cytology (FNAC). CT scan showed tumor involving right submandibular region and superiorly reaching up to parapharyngeal space without any intraoral swelling. She underwent excision under general anesthesia (transcervical approach) without any complication. Per operatively, the tumor was found eccentrically placed with relation to the lingual nerve and lingual nerve fibers were splayed over the tumor. The final histopathological results confirmed the diagnosis of schwannoma.

Dermoid Cysts on the Floor of the Mouth.

The authors analyzed the clinical features and treatment results of surgical patients with a final diagnosis of dermoid cyst on the floor of the mouth over 14 years at our hospital. A total of 5 patients with a final diagnosis of dermoid cyst of the floor of the mouth from January 2010 to December 2023 were enrolled. All patients complained of swelling in the submentum or floor of the mouth. The mean tumor size was 4.2±1.0cm. All patients underwent complete surgical resection. A transcervical approach was performed in 3 patients, and an intraoral approach was implemented in 2 patients. There were no major complications after surgery with either method. The follow-up period was 71.4±75.7 months. There was no disease recurrence during follow-up. Dermoid cysts rarely occur on the floor of the mouth but should be considered in the differential diagnosis of other oral cavity tumors. Dermoid cysts on the floor of the mouth can be safely removed using the current transoral approach without scarring or recurrence.

Minimally invasive management of parapharyngeal space tumors: Introducing a decision-making algorithm and radiologic tool

ObjectiveTraditionally tumors of the parapharyngeal space (PPS) are resected through transcervical approaches. More recent approaches include endoscopic approaches or transoral robotic surgery (TORS) without directions on when to use which approach. Our objective was to find objective parameters to choose the most suitable approach. MethodsIt is a retrospective study containing 6 patients from May 2019 to May 2021 with tumors of the PPS treated in the Department of Otolaryngology and Head-Neck Surgery at the Hospital of Lucerne, Switzerland. ResultsThe data was analysed in average 53 months after surgery. Tumor resection was completed with TORS in 3 patients and endoscopically in 3 patients. Mean operation time was 114 min. No major complications occurred. No evidence of tumor was found in magnetic resonance imaging studies postoperatively in all patients. ConclusionWe conclude that a resection via TORS or endoscopic technique is safe and effective. Furthermore, we postulate that the further a tumor is located in the upper lateral area of the PPS, an approach via TORS is less possible.

Navigated Anterior Full-Endoscopic Transcervical Approach Odontoidectomy for Traumatic Posterior Atlantoaxial Dislocation Without Odontoid Fracture.

Complete posterior atlantoaxial dislocation (PAAD) with an unfractured odontoid process is a rare condition where a dislocated but intact odontoid process is positioned ventrally to the anterior arch of C1. This lesion is related to transverse and alar ligament rupture secondary to hyperextension and rotatory traumatic injury and is often associated with neurological deficit. The treatment strategy remains controversial, and in many cases, odontoidectomy is required. Traditional approaches for odontoidectomy (transnasal and transoral) are technically demanding and are related to several complications. This article describes a 360° reduction and stabilization technique through a navigated anterior full-endoscopic transcervical approach (nAFETA) as a novel technique for odontoidectomy and C1-C2 anterior transarticular fixation supplemented with posterior fusion. A 21-year-old man presented to the emergency room by ambulance after a motorcycle accident. On evaluation, incomplete ASIA B spinal cord injury was documented. Imaging revealed a complete PAAD. We performed a two-staged procedure, a nAFETA odontoidectomy plus C1-C2 anterior transarticular fixation followed by posterior C1-C2 wired fusion. At a 2-year follow-up, the patient had a 10-point Oswestry Disability Index score and neurological improvement to ASIA E. PAAD can be successfully treated through minimally invasive nAFETA. Noteworthy, the risks of the transoral and endonasal routes were avoided through this approach. In addition, nAFETA allows anterior transarticular fixation during the same procedure providing spinal stability. Further studies are required to expand the use of nAFETA in this field.

Results Of Minimally Invasive Vats Thymectomy In Miastenia Gravis Patients Compared With More Invasive Approaches - 10-Year Experience In A Single Center.

Myasthenia gravis (MG) is an autoimmune, neurologic disease that causes a wide range of symptoms. While the transsternal, transcervical and thoracotomy approaches are accepted as effective, there is still debate regarding the VATS approach. We analyzed our center's surgical experience with thymectomy for myasthenia gravis, comparing the results of patients operated on using VATS and more invasive approaches, over a period of 10 years. A search of the department's surgical database for myasthenia gravis cases between January 2010 and January 2021, revealed a total of 40 cases. Twenty-four patients were included in the final analysis and were distributed into two groups: the VATS procedure group (group A) and the open procedure group (group B). The latter included sternotomy, thoracotomy, transcervical and hemiclamshell approaches. Only radical thymectomies were included. The established outcomes were clinical improvement defined as asymptomatic remission, reduction, or discontinuation of the medication necessary to achieve optimal symptom control. The median follow-up time was 27 months (ranging from 4 to 75 months). Videothoracoscopy radical thymectomy was performed on 12 patients. Complete remission with no medication was achieved in 1 case (8.3%), while 2 patients (16.7%) became asymptomatic with reduced medication. An improvement (reduced symptoms or decreased medication) was observed in 8 cases (66.6%). No change in clinical outcome was noted in 1 patient (8.3%). None of the patients reported worsening symptoms. Open thymectomy was performed on 12 patients. Complete remission with no medication was achieved in 1 case (8.3%), while 2 patients (16.7%) became asymptomatic with reduced medication. An improvement was noted in 6 cases (50%). No change in clinical outcome was observed in 3 patients (25%) whereas 2 of them (16.7%) experienced slightly better symptom control but with a significant increase in medication. One patient (8.3%) described the clinical results as without any significant change. None of the patients reported worsening symptoms. The videotoracoscopic approach in the treatment of myasthenia gravis is non-inferior compared to the open approach and effective in a long-term follow-up, offering all the additional benefits of less invasive surgery.

Surgical management of a midline submental neck mass in Zimbabwe: A case report

Introduction: Differential diagnoses of a pediatric neck mass are extensive, ranging across benign, malignant, congenital and infectious causes. Limited access to imaging in low-resource settings increases the complexity of narrowing this list to appropriately diagnose and treat neck masses. This occasionally allows neck masses to grow unchecked, increasing the morbidity of their presence and eventual excision. The goal of this report is to describe nuances in the diagnosis and treatment of pediatric neck masses in resource-limited settings through a case report of a neck mass in a pediatric patient.Patient presentation: A 10-year-old girl in Harare, Zimbabwe, presented for surgical management of a midline neck mass that appeared 4 years prior to presentation for definitive treatment. A myriad of barriers delayed her care, allowing the mass to grow into her floor of mouth, displacing her tongue and leading to speech and feeding difficulties.Management and outcome: At presentation to the tertiary care facility, she received a pre-operative ultrasound showing a well-circumscribed, echogenic mass. Her neck mass was surgically excised through a transoral approach. Permanent pathology was consistent with a dermoid cyst.Conclusion: At 1-month postoperative follow-up, the patient had experienced no complications and had a complete resolution of her functional symptoms and appearance.Contribution: We present a case that can illuminate the utility of ultrasound in the diagnosis of pediatric neck masses. Additionally, we facilitate an important discussion on transoral versus transcervical approach for midline neck masses with the decision hinging on size, location, surgeon preference and comfort and consideration of cosmesis.

Incorporating Microdebrider Use in a Community-Based Thyroidectomy Practice.

Objectives: Substernal goiters often require surgery, yet their location presents challenges. Most can be removed via transcervical approach, but extent and relationship to mediastinal structures can merit consideration of sternotomy and assistance of colleagues. Despite widespread use in sinus surgery and previous literature reports, microdebrider use to facilitate transcervical removal of substernal goiters has not been broadly adopted. Our objective was to report our experience with use of the soft tissue shaver to facilitate substernal goiter deliver through a cervical incision in a community-based thyroidectomy practice. Methods: We reviewed thyroidectomy cases performed by a general otolaryngologist (D.M.Y.) in a community setting from January 2017 through December 2019. Four patients required microdebrider use for intracapsular debulking of substernal goiter to allow for transcervical removal. We discuss pre- and perioperative considerations, present computed tomography (CT) and operative images, review surgical technique, and report estimated blood loss (EBL), surgical time (T), complications, and length of stay. Results: Average EBL was 237.5 ml (range 100-500 ml). Average T was 137 minutes (range 121-170 minutes). No patients required sternotomy. One patient developed postoperative hematoma requiring evacuation and cautery of a bleeding site. No other complications were encountered, all patients were discharged after overnight observation. Conclusions: The microdebrider can be safely utilized by general otolaryngologists to facilitate transcervical removal of substernal goiters. Adoption of this familiar tool for a different surgical application can reduce the need for sternotomy, assistance of colleagues, or referral to a tertiary care center, with associated decrease in risk, morbidity, surgical time, length of stay, and cost, and improved patient convenience and satisfaction.

Combined Transcervical and Median Sternotomy Approach for a Massive Substernal Goiter.

Herein, we describe a combined transcervical and median sternotomy approach for a massive substernal goiter causing tracheal stenosis. A goiter of this size, specifically weighing 630g, is rare. We advocate for a multidisciplinary approach for airway management and for consideration of awake fiberoptic intubation with tracheosomy avoidance for similar patients.

Trans-Cervical Approach To The Thoracic Outlet Syndrome.

Thoracic outlet syndrome is caused by compression of the neurovascular structures within the thoracic outlet leading to a collection of symptoms in the upper limb and shoulder. Identification of the causative factor is essential and thorough clinical examination using specific manoeuvres can aid in the diagnosis of this syndrome. Cervical rib is one of the causes for thoracic outlet syndrome and this manuscript will discuss the thoracic outlet syndrome, cervical rib, incidence, clinical presentation, diagnosis and management including surgical approaches with a focus on transcervical approach.

Long-term Quality of Life After Thyroidectomy: Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Transcervical Approach.

To compare long-term health-related quality of life (HRQOL) after Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) and transcervical approach (TCA) thyroidectomy. Prospective cohort study. Tertiary referral center. A web-based survey was distributed to patients at our institution who met the criteria for TOETVA and underwent thyroidectomy by TOETVA or TCA between August 2017 and October 2021. All survey participants were at least 6 months postsurgery. Minors, non-English speakers, and patients who received concomitant neck dissection or reoperative thyroidectomy were excluded from the study. The survey assessed quality of life through 4 standardized instruments: the Dermatology Life Quality Index (DLQI), the Eating Assessment Tool (EAT-10), the Voice Handicap Index (VHI-10), and the Short Form Health Survey (SF-36). A total of 108 TOETVA and 129 TCA patients were included in the study. The median age of respondents was 44 (36, 54; 25th, 75th percentile) years and median time from surgery to survey was 35 (22, 45; 25th, 75th percentile) months. TOETVA group DLQI (0.63 vs 0.99; P = .17), VHI-10 (1.94 vs 1.67; P = .35), EAT-10 (2.14 vs 2.32; P = .29), SF-36 physical component (52.25 vs 51.00; P = .25), and SF-36 mental component (47.74 vs 47.29; P = .87) scores were all similar to those of the TCA group. Scrutinizing specific DLQI questions, individuals in the TOETVA group were less self-conscious of their skin as compared to the TCA group (Q2; 0.08 vs 0.26, P = .03). Long-term HRQOL after TOETVA is similar to TCA, with significantly lower skin-related self-consciousness.