Unilateral Recurrent Laryngeal Nerve Paralysis Research Articles

Evaluation of Thyroidectomy Results Performed at a Tertiary Academic Center.

The aim of the study was to retrospectively analyze the patients who underwent thyroidectomy at a tertiary academic center regarding their surgical indications, histopathological diagnosis, and surgical complications. The study included a total of 739 consecutive patients who underwent lobectomy, total thyroidectomy, or completion thyroidectomy performed under intraoperative nerve monitoring (IONM) at the Department of Otorhinolaryngology-Head and Neck Surgery of Dokuz Eylül University between January 2009 and December 2019. Demographic data of the patients, preoperative clinicopathological characteristics, postoperative complications, characteristics of surgery and histopathological results were evaluated. There were 619 patients in the primary surgery and 120 patients in the revision surgery groups. Indications for surgery were suspicion of malignancy in 486, multinodular goiter in 214, and hyperthyroidism in 39 patients. Final histopathological evaluation of specimens revealed malignancy in a total of 507 (68.6%) patients. Rates of transient and permanent hypocalcemia were 7.3% (54/739) and 2.2% (16/739) in the whole group, while this was 6.6% (41/619) and 1.5% (9/619), respectively, among primary total thyroidectomy patients. There were 61 (8.3%) patients with transient recurrent laryngeal nerve (RLN) paralysis (unilateral in 60 patients, bilateral in one patient) and five (0.7%) patients with permanent unilateral RLN paralysis as postoperative complications. Rates for postoperative hematoma, seroma, wound infection and chylous fistula were 2.2%, 3.7%, 0.1%, and 0.5%, respectively. Our results support the safety of thyroid surgery performed under IONM in tertiary academic centers. Every institution should document and share its own results to properly inform its patients preoperatively.

Re-operative surgery for differentiated thyroid cancer: A single institutional experience of 182 cases

IntroductionRe-operative thyroid surgery (RTS) is performed in patients of differentiated thyroid cancer (DTC) with residual or recurrent disease. However, there is a paucity of literature discussing experience and technique of RTS. This study aims to address this gap by providing a comprehensive review of RTS for DTC, utilizing experiences from a dedicated complex thyroid surgical oncology program at the apex hospital in a developing country. MethodsA retrospective analysis was conducted using data from the Department of Surgical Oncology's thyroid cancer database. The study period spanned from 2006 to 2022. Clinical presentation, prior surgical history, operative details of RTS, and post-operative outcomes were assessed. Descriptive analysis was performed. ResultsDuring the study period, a total of 182 patients underwent re-operative thyroid surgery (RTS). The primary surgeries performed prior to RTS included near-total or total thyroidectomy in most cases (69.2%), and approximately half of the patients (48.4%) had prior neck node interventions. The RTS procedures consisted of completion total thyroidectomy in 30.8% of cases and surgery for thyroid bed recurrence in 9.9% of cases, while central node dissection was performed in 46.2% of patients and unilateral or bilateral template neck dissection was performed in 41.8% of cases. Extended resections were required in 9.3% of patients. Post-operative complications included permanent hypoparathyroidism (2.7%) and unilateral recurrent laryngeal nerve palsy (1.6%). ConclusionsRTS is a complex procedure with high rates of post-operative morbidity reported in literature. Optimal outcomes require a multidisciplinary approach, thorough assessment, and skilled surgeons.

Prospective study on the outcomes of harmonic scalpel assisted thyroidectomy in a tertiary care centre in South Kerala

<p class="abstract"><strong>Background:</strong> To estimate the outcomes of thyroidectomy using harmonic scalpel in terms of intra-operative and post-operative blood loss, operating time, incidence of post-operative hypocalcaemia, incidence of recurrent laryngeal nerve and superior laryngeal nerve palsy and post-operative pain.</p><p class="abstract"><strong>Methods:</strong> The patients are selected consecutively as and when they were presented during the study period. The study involved 23 patients out of which 17 underwent total thyroidectomy and 6 underwent hemithyroidectomy, all using harmonic scalpel. A complete history, physical examination and appropriate investigations were done to arrive at the correct diagnosis. Surgery was done and all the parameters were accurately assessed. </p><p class="abstract"><strong>Results:</strong> The mean intra-operative and post-operative blood loss in thyroidectomy by harmonic scalpel was 92.2 ml and 20.6 ml respectively. The mean operative time for thyroidectomy using harmonic scalpel was 58.2 minutes that includes 38 minutes for hemi thyroidectomy and 65.3 minutes for total thyroidectomy. Out of 23 patients, only 1 patient (4.3%) had transient hypocalcaemia in the post operative period. Three patients (13%) had transient unilateral recurrent laryngeal nerve palsy and none had superior laryngeal nerve palsy. The pain assessment by visual analog scale (VAS) score at 24 hours and 48 hours after harmonic scalpel assisted thyroidectomy were 3.87±0.97 and 2.35±1.30 respectively.</p><p class="abstract"><strong>Conclusions:</strong> Harmonic scalpel gives effective and reliable hemostasis, shortens the operative time, reduces the complications and improved pain control and hence may be considered as an effective tool in thyroidectomy.</p>

A Silent Thrombus and a Cord Palsy: A Sinister Combination

Background: A multitude of causes have been attributed to unilateral recurrent laryngeal nerve palsy. In the absence of a local or a regional cause for palsy, it is prudent to look into distant and rarer causes. Case Report: A 70-year-old male presented with the complaints of hoarseness of 3 months that was insidious in onset and progressive. Contrast enhanced computed tomography of neck and thorax showed left vocal cord palsy with silent thrombus in arch of aorta extending to ascending aorta. The results of cardiac auscultation and electrocardiography were normal. Conclusion: Cardiovascular causes have to be kept in mind, for they may lead to grave complications if missed when vocal cord palsy is the only presenting complaint. This underscores the importance of the knowledge of these rarer but sinister causes. Here we present a rare case of isolated left vocal cord palsy being the only presenting feature of a silent aortic arch thrombus.

A novel classification of tracheal defects and the reconstruction strategies: A retrospective study based on 106 cases.

The study aims to present a novel classification of tracheal defects and the corresponding reconstruction strategies. The retrospective study was designed to analyze patients with diagnosed primary or secondary tracheal tumors from 1991 to 2020. Surgical techniques, complications and prognosis were reviewed. Airway status and patient outcomes were the principal follow-up measures. Tracheal defects were classified into two plane sizes (vertical (V) and horizontal (H) planes). Vertical defects were further categorized into three groups based on their tracheal ring numbers (V1, ≤ 5 rings; V2, 6-10 rings; and V3, > 10 rings). Tracheal defects with horizontal plane size H1 and H2 represent defects less and more than one-half the circumference of trachea. Thus, suitable reconstruction strategies were planned primarily based on "V" and "H" classifications. The reconstruction strategies performed were sleeve resection followed by an end-to-end anastomosis, window resection with sternocleidomastoid myoperiosteal flap reconstruction, defects conversion with rotation anastomosis, and modified tracheostomy with secondary flap reconstruction. A total of 106 patients diagnosed with tracheal defects were enrolled in the study, of whom 59 patients underwent sleeve resection followed by end-to-end anastomosis; 40 patients received window resection alongside sternocleidomastoid (SCM) myoperiosteal flap reconstruction; five patients received converting defects with rotation anastomosis and two patients underwent modified tracheostomy with secondary stage flap reconstruction. Lumen stenosis occurred in three V2H1 defect cases and were treated by a second reconstruction surgery. Iatrogenic unilateral recurrent laryngeal nerve paralysis occurred in two patients with the V3H2 defect type, who were treated by temporary tracheotomy and partial vocal cord resection and extubated successfully during follow-up. All 106 patients achieved airway patency with adequate laryngeal function at the end of follow-up. No anastomotic dehiscence or bleeding occurred in any patient postoperatively. Though a significant number of multicenter studies concerning the reconstruction and classification of tracheal defects are needed, the study herein provides a novel classification of tracheal defects, which is primarily developed on the defect size. Therefore, the study might serve as a potential source for identifying suitable reconstruction strategies for practitioners.

Current management and future prospects for papillary thyroid carcinoma with preoperative unilateral recurrent laryngeal nerve palsy

Current management and future prospects for papillary thyroid carcinoma with preoperative unilateral recurrent laryngeal nerve palsy

Medicolegal aspects of primary and renal hyperparathyroidism

Compared with malpractice claims in thyroid surgery, expert medico-legal reviews of surgery performed for hyperparathyroidism (HPT) that aim to prove or rebut surgical malpractice are rare. The aim of this analysis was to describe typical risk patterns for possible treatment errors and to generate recommendations for avoiding these treatment errors. A total of 12surgical expert medico-legal reviews, which were carried out by order of 9arbitration boards and 3courts between 1997 and 2020 were evaluated. If the indications for surgical treatment of hyperparathyroidism were present, the failure to identify aparathyroid adenoma or hyperplastic parathyroid glands was in the majority of cases not rated as a surgical treatment error, especially in atypical localizations. Unilateral recurrent laryngeal nerve palsy and postoperative bleeding cannot always be prevented, despite maximum diligence. In contrast, bilateral recurrent laryngeal nerve palsy can be prevented when intraoperative neuromonitoring is correctly applied. Alack of patient information regarding postoperatively persistent HPT, postoperative hypoparathyroidism following the removal of inconspicuous parathyroid glands and nonindicated lobectomy or total thyroidectomy, mostly performed under the assumption of an intrathyroid parathyroid adenoma, represented avoidable malpractice issues. Advanced knowledge of the pathophysiology of the disease and the anatomy of the parathyroid glands as well as the establishment of intraoperative and perioperative standards can prospectively greatly reduce avoidable errors in the surgical treatment and postoperative care of HPT.

Review of Injection Laryngoplasty for Unilateral Recurrent Laryngeal Nerve Paralysis: Transition and Features of Various Materials

Review of Injection Laryngoplasty for Unilateral Recurrent Laryngeal Nerve Paralysis: Transition and Features of Various Materials

Open Total Thyroidectomy with Continuous Intraoperative Nerve Monitoring

Introduction: Continuous intraoperative nerve monitoring (C-IONM) during thyroid surgery can be used to assess the recurrent laryngeal nerve (RLN) function and preventing unilateral and bilateral palsy. The main advantage of C-IONM using temporary implantable vagus electrode compared with the intermittent format (I-IONM) is the real-time monitoring of RLN integrity during thyroid mobilization and RLN dissection.1 Indeed, the I-IONM format using the handheld stimulation probe exposes the RLN to the risk of injury in between two stimulations. Therefore, the injury of the nerve can only be detected after the damage has already occurred, allowing to set to zero only bilateral RLN palsy by means of avoiding contralateral procedure (two-step surgery).2 In contrast, C-IONM provides the opportunity to perform the critical surgical actions necessary to avoid the impending RLN injury and enables to recover the RLN function after loss of signal, allowing to avoid even unilateral RLN palsy. Hereby we presented a video of a total thyroidectomy for a huge multinodular goiter performed with the help of C-IONM. Materials and Methods: A 54-year-old woman presented with a huge multinodular goiter. A total thyroidectomy performed with the help of C-IONM was planned. The surgical steps were illustrated and the anatomical structures identified. Results and Conclusions: C-IONM is a safe additional tool for thyroidectomy, which enables to perform the corrective maneuvers to avoid permanent nerve injury. If adequately used, it could prevent bilateral and unilateral RLN palsy. It results of great help in difficult cases, such as huge or recurrent multinodular goiter. No competing financial interests exist. Runtime of video: 7 mins 13 secs

Initial outcomes at a nascent tertiary pediatric thyroid surgical center

ObjectivesPrevious studies on pediatric thyroid surgical complications suggest that high-volume centers achieve improved outcomes. We hypothesize that initial outcomes from a nascent pediatric surgical practice may be comparable to higher volume centers. Furthermore, we determine whether a low-volume center can safely transition to an intermediate or high-volume center. MethodsA retrospective chart review was performed for all pediatric patients undergoing thyroid surgery at a single institution from 2014 to 2020. Surgeries were performed by two pediatric otolaryngologists. All patients were managed postoperatively by a multidisciplinary team of physicians that included pediatric otolaryngologists and endocrinologists. Data collection focused on patient demographics and postoperative complications, including rates of recurrent laryngeal nerve injury and permanent hypoparathyroidism. ResultsFrom 2014 to 2020, a total of 31 patients underwent thyroid surgery at our pediatric thyroid surgery center, 9 of whom underwent neck dissection. The mean age of our cohort was 14.4 ± 3.9 years (range 8 months–20 years). Postoperative pathology results revealed that 15 patients (46.9%) were diagnosed with PTC, 6 (18.8%) with follicular adenoma, and 4 (15.6%) with benign thyroid tissue. One (2.0%) patient had permanent unilateral recurrent laryngeal nerve paralysis and one patient experienced permanent hypoparathyroidism (2.7%). ConclusionsOur initial low complication rate as a nascent pediatric thyroid surgery center suggests that favorable outcomes can be achieved at lower volume surgery centers. In order to increase patient access to high-volume pediatric thyroid surgery centers, new centers must start with lower volumes before ultimately becoming high-volume centers. Our study shows that this can be safely achieved. Level of evidenceIV.

Thyroid surgery in children: our experience.

Thyroid surgery in children is arare operation. The aim of our paper is to point out the specifics of thyroid surgery in children. Retrospective analysis of patients hospitalized at the Department of Paediatric Surgery, Faculty of Medicine, Comenius University and National Institute of ChildrensDiseases in Bratislava during a10-year period (20072016) who underwent thyroid surgeries. The retrospective analysis included 81 patients: 66 (81%) girls and 15 (19%) boys. The mean age of the patients was 14 years ±8 months (range 418 years). The most common indications for thyroid surgery were: anodule in 36 (44.4%) patients, Graves Basedow thyrotoxicosis in 19 (23.5%) patients, and suspected thyroid carcinoma in 11 (13.6%) patients. Cervical lymph node metastases (mts) were diagnosed in 9 (11.1%) patients, and distant pulmonary metastases in 5 (6.17%) patients. Total thyroidectomy (TTE) was performed in 43 (53%) patients, total lobectomy (TL) in 20 (24.7%) patients. Extended surgery on regional lymph nodes was performed in 9 (11.1%) patients. Eight (9.9%) patients underwent reoperation. Atotal of 12 (14.8%) patients experienced postoperative complications. Unilateral transient recurrent laryngeal nerve (RLN) paralysis occurred in 2 patients, and permanent in one patient. Transient postoperative hypoparathyroidism with hypocalcaemia was reported in 8 (9.9%) patients; no permanent condition of this type was observed. Multidisciplinary collaboration ensures that optimal surgical results are achieved in the patients. Experience of the surgeon performing thyroid surgery in children remains crucial.

Effects of Arytenoid Adduction Suture Position on Voice Production and Quality.

Arytenoid adduction (AA) is performed to treat unilateral vocal fold paralysis with a large posterior glottal gap. However, the voice effects of AA suture position remain unclear. This study aimed to evaluate voice production and quality as a function of AA suture position on the thyroid ala in a neuromuscularly intact in vivo larynx. Animal model. Unilateral recurrent laryngeal nerve and vagal paralysis were modeled in two canines. AA suture position was varied across five equidistant positions on the anterior inferior thyroid ala, from a paramedian position anteriorly to the oblique line posteriorly. Phonation was performed over 8 × 8 graded level combinations of recurrent and superior laryngeal nerve stimulation per suture position. The primary outcome was percent successful phonatory conditions. Secondary outcomes included fundamental frequency (F0), phonation onset pressure (PTP), cepstral peak prominence (CPP), and laryngeal posture. Anterior suture positions resulted in a greater percentage of successful phonatory conditions compared to posterior sutures. Suture position 2, located at the anterior inferior thyroid ala, resulted in the highest percentage of successful phonatory conditions, lowest PTP, and lower muscle activation levels to achieve higher CPP. Posterior sutures resulted in wider glottal gap and more effective F0 and vocal fold strain increase with cricothyroid muscle contraction, but with fewer successful phonatory conditions and higher PTP. Trends were consistent across both paralysis types. AA suture placed in the anterior inferior thyroid ala resulted in the best acoustic, aerodynamic, and voice quality outcomes. This study provides scientific evidence for maintaining current clinical practice. NA Laryngoscope, 131:846-852, 2021.

Redo thyroid surgery without drains.

Redo thyroid surgery is associated with higher risk of hematoma than the initial thyroid surgery. We report a single surgeon's experience of performing redo thyroid surgery without drains. This retrospective single-institutional study evaluates the safety and efficiency of redo thyroid surgery without drains by comparing three groups of patients: those who underwent primary bilateral thyroidectomy (Group 1), those who underwent completion thyroidectomy (Group 2); and those who underwent thyroidectomy for recurrent thyroid diseases (Group 3). The demographic characteristics did not differ among the groups. Substernal extension and hyperthyroidism were more frequent in group 1, whereas the weight of the resected thyroid gland was lower in groups 2 and 3. Hematoma occurred in 5%, 4%, and 4% of patients in Groups 1, 2, and 3, respectively. Postoperative transient hypocalcemia occurred in 19%, 16%, and 21% of patients in Groups 1, 2, and 3 respectively. The postoperative incidence of transient recurrent laryngeal nerve (RLN) paralysis in Groups 1, 2, and 3, was 6%, 7%, and 8%, respectively. The incidence of permanent unilateral RLN paralysis in Groups 2 and 3 was 1%. The postoperative length of stay was 1day in 92% of the patients from all groups. Avoiding the routine use of drains in redo thyroid surgery is safe and effective, it does not increase overall surgical morbidity, and it reduces the overall length of stay in hospital.

A case of unilateral recurrent laryngeal nerve palsy caused by neck extension injury

A 63-year-old man collided with a vehicle while riding a motorcycle. At an emergency hospital, he was diagnosed with cerebral concussion, incomplete cervical cord injury, C6 fracture, facial bone fractures, and lacerations. Radiographical findings indicated that his neck was forced into an extended position. At our rehabilitation hospital, we evaluated the patient’s hoarseness and dysphagia 1 month posttrauma and determined the diagnosis to be due to “traumatic right recurrent laryngeal nerve palsy (RLNP).” We followed the patient’s RLNP during admission and at our outpatient clinic. His right RLNP gradually recovered and finally disappeared 6 months after the accident. We describe this case within the context of a review of the literature.

Efficacy of Total Thyroidectomy for Treatment of Benign Thyroid Lesions

Background: Total thyroidectomy is currently the preferred treatment for thyroid cancer, multinodular goitre (MNG) and Graves' disease. However, many surgeons choose not to perform total thyroidectomy to treat benign thyroid diseases owing to the associated risk of postoperative hypoparathyroidism, recurrent laryngeal nerve damage and bleeding. We reviewed 100 total thyroidectomies performed for benign thyroid diseases, when surgery was indicated. Objective: Assessment whether total thyroidectomy is safe and can be considered as the optimal surgical approach for treating benign thyroid diseases. Patients and methods: This study was conducted on 100 patients presented by thyroid swellings and admitted to Mansoura University Hospitals, Endocrine Surgery Unit over one year during the period between November, 2017 and October, 2018. All patients were submitted to careful history taking, clinical examination and radiological and laboratory investigations. Total thyroidectomy was done to all patients. Patients were evaluated early postoperative at 1, 6 and 12 months by sr. TSH, total & ionized calcium, PTH and vocal cord assessment. Results: Preoperative diagnoses in our patients revealed that there were 74 cases MNG (74%), 2ry toxic 19 cases (19%) and 1ry toxic 7cases (7%). The incidence of permanent bilateral recurrent laryngeal nerve palsy was 0% and that of permanent unilateral recurrent laryngeal nerve palsy was 1%. Whereas the incidence of temporary unilateral recurrent laryngeal nerve palsy was 5%. Permanent hypocalcaemia occurred in 2% and overall temporary hypocalcaemia occurred in 8% of patients. Hemorrhage requiring repeat surgery occurred in 1% of patients. Conclusion: In our study, total thyroidectomy showed no significant operative and/or postoperative complications. Also, it was noticed that total thyroidectomy operation gave very good results in patients with benign thyroid diseases provided that they were done in qualified center and by experienced endocrine surgeons.

Transoral endoscopic selective lateral neck dissection for papillary thyroid carcinoma: a pilot study.

Transoral endoscopic thyroid surgery via the vestibular approach (TOETVA) has been gradually accepted worldwide due to its scar-free effect on the neck. Even central cervical lymphadenectomy has been performed in some cases of papillary thyroid carcinoma (PTC). However, there are few reports involving lateral neck dissection with TOETVA. In this study, we attempted to perform selective lateral neck dissection (SLND) for PTC via a transoral vestibular approach. This prospective study was conducted from January 2016 to December 2018 in twenty PTC patients with unilateral T1 tumors without capsular invasion and patients with abnormal level III and IV lymph nodes who underwent SLND via a transoral vestibular approach. Endoscopic surgery was successfully accomplished in all 20 PTC patients. The mean age was 29.2 ± 5.5 (20-41) years. The mean operation time was 146.0 ± 18.7 (114-193) min. The average postoperative hospital stay was 6.8 ± 1.3 (5-10) days. The mean number of removed nodes was 7.4 ± 2.5 (4-12) in the central neck and 10.9 ± 2.8 (6-16) in the lateral neck, and the positive yield amounts were 2.0 ± 1.2 (0-4) and 2.7 ± 1.9 (0-6), respectively. No major complications occurred except for 1 case of transient unilateral recurrent laryngeal nerve palsy andtwo cases of effusionin theoperativearea. No evidence of persistent or recurrent disease was observed in these patients during a mean follow-up of 24.3 ± 9.1 (6-36) months. The cosmetic results and protection of personal privacy of this procedure were excellent. Endoscopic SLND via the transoral vestibular approach is feasible, safe, and effective for selected PTCs. A multicenter large comparative study is necessary.

Total thyroidectomy vs completion thyroidectomy for thyroid nodules with indeterminate cytology/follicular proliferation: a single-centre experience

BackgroundDespite total thyroidectomy (TT) is the most practiced procedure for a preoperatively diagnosed neoplastic lesion, according to the ATA guidelines, many surgeons perform completion thyroidectomy (CT) after hemithyroidectomy for patients with preoperative follicular proliferation/indeterminate cytology who are diagnosed with malignancy. CT has a higher complication rate than the primary procedure. The primary endpoint of our study is to compare the morbidity rate after CT with that after primary TT in patients with follicular proliferation/indeterminate cytology.MethodsWe retrospectively reviewed 237 patients who underwent thyroid surgery from 2009 to 2018 at our institution. We recruited only patients with follicular proliferation/indeterminate cytology and excluded those undergoing lymphadenectomies and thyroidectomies for benign pathology and staged thyroidectomies after intraoperative documentation of a RLN lesion. One hundred eighty-six of these patients underwent TT, and fifty-one underwent CT for the detection of differentiated thyroid cancer at the histological exam.ResultsNo differences were found in the total complication rates between the two groups (OR 0,76, 95% CI 0.35–1.65, P = 0.49). We did not find any significant differences in the subgroup analysis. In particular, no significant differences were identified for transient hypocalcaemia (OR 1.17, 95% CI 0.44–3.11; P = 0,74), permanent hypocalcaemia (OR 1.04, 95% CI 0.21–5.18; P = 0,95), transient unilateral recurrent laryngeal nerve palsy (OR 0.78, 95% CI 0.21–2.81; P = 0,16), permanent unilateral recurrent laryngeal nerve palsy (OR 1.48, 95% CI 0.28–7.85; P = 0,61), and haematoma (OR 1,84, 95% CI 0,16-20,71; P = 0,61).ConclusionsCT following hemithyroidectomy can be performed with acceptable morbidity in patients with thyroid nodules with preoperative indeterminate cytology/follicular proliferation.

Unilateral recurrent laryngeal nerve palsy post-thyroidectomy: Looking for hyperventilation syndrome

AimsUnilateral Recurrent Laryngeal Nerve (RLN) palsy is responsible for dysphonia and difficulties in swallowing. The role of unilateral RLN palsy on dyspnea is not fully elucidated. Our hypothesis is that air leak could be responsible for development of hyperventilation syndrome (HVS). ObjectiveThe objective of this study was to determine in patients with unilateral RLN palsy if dyspnea could be associated with HVS. Material and methodsOver a 12-month period, all patients with permanent unilateral RLN palsy after thyroidectomy complaining from the onset of unexplained dyspnea were tested. Measurement of Nijmegen score, an hyperventilation test, an arterial blood gas, lung function and cardiac tests were performed. The diagnosis of HVS was defined if at least two criteria were present among: Nijmegen score>23; reproduction of at least 2 usual symptoms during hyperventilation test; an expirated pressure of CO2 (EpCO2)<30mmHg or<90% of the initial EpCO2 after a 5minutes recovery period following a 3minutes voluntary hyperventilation. ResultsTen out of 366 patients with thyroidectomy for benign disease had permanent unilateral RLN palsy and dyspnea. Among 10 patients included, 8 were diagnosed having HVS on the hyperventilation test without cardiac/lung dysfunction. ConclusionIn summary, this study is a proof of concept that HVS might be involved in dyspnea associated with unilateral RLN palsy.

Laryngeal Nerves Monitoring Versus Non-monitoring in Thyroid Surgery

Background and objectives: Thyroid surgery is the most common cause of recurrent nerve (RLN) injury. Deliberate identification of the RLN minimizes the risk of injury. When the nerve is identified and dissected, the reported RLN injury rate during thyroidectomy is 0-2.1%. Continuous intra-operative nerve monitoring during surgery remains a controversial issue. The basic technique involves a skin surface electrode or muscle electrode used to make electromyography (EMG) recordings, which have an audible alarm to alert the surgeon if passive (e.g.stretch during traction) or active nerve stimulation has occurred. We aim to evaluate the use of intra-operative nerve monitoring (IONM) to preserve the laryngeal nerves that may be at risk for injury during thyroid surgery and show the merits of using electrophysiologic laryngeal nerve monitoring during thyroid surgery. Patients and methods: This study was conducted as a prospective study on 28 patients whom are thyroidectomy candidates; we elected 14 thyroidectomy candidates in whom we don’t use NIM during surgery (Control group_A). These patients were chosen to be evenly matched with another 14 thyroidectomy candidates to monitor the recurrent laryngeal (RLN) and external branch of superior laryngeal (EBSLN) throughout thyroidectomy procedures (NIM group_ B) to compare the laryngeal nerves risk of injury with and without the use of nerve monitor. Results: Four patients (2 patients in-group A and 2 patients in-group B) were dysphonic after operation. Laryngoscopy revealed unilateral recurrent laryngeal nerve palsy in all except one bilateral in group A. There were no significant differences in RLN paralysis, paresis, or total injury rates between both groups. The number of patients in the presented study was limited to draw a statistical conclusion for significance. Conclusions: The routine application of IONM cannot prevent or reduce recurrent laryngeal nerve injury. However the study signifies the trend towards the use of INOM in expectedly difficult cases and in revision surgery with distorted anatomical relationships and fibrous adhesions.

Outcome of Thyroid Surgeries at Patan Hospital

Objective: To assess the outcome of thyroid surgeries at Patan HospitalMaterials and Methods: It is a retrospective study of in-patient records of patients undergoing thyroid surgeries for various indications from April 2013 to January 2015 at Patan Hospital, Lalitpur.Results: During the period of 21 months, 75 patients underwent thyroid surgeries. Majority of patients underwent hemithyroidectomy (35) followed by total thyroidectomy (28), subtotal thyroidectomy (7) and completion thyroidectomy (5). Out of 28 patients undergoing total thyroidectomy (TT), 11 underwent central compartment clearance (CCC), 5 underwent CCC and lateral neck dissection. Among 5 patients undergoing completion thyroidectomy, CCC was performed in all cases and in one patient lateral neck dissection was also performed. A total of 13 patients developed unilateral recurrent laryngeal nerve palsy (RLN), among them 5 had permanent palsy. Tracheostomy had to be done in immediate postoperative period for stridor following total thyroidectomy (TT) in one case. Temporary hypocalcaemia was observed in 10 (10/28) cases following TT, out of which 8 had undergone CCC. Permanent hypocalcaemia was observed in 7 (7/28) cases following TT out of which 3 had undergone CCC. Chylous leak occurred in one of the patient undergoing left level II-IV neck dissection which was managed conservatively. None of the patient had to be transfused postoperatively.Conclusion: Complications to thyroid surgery are not uncommon. Visualization of recurrent laryngeal nerve alone in our context is adequate in experienced hands. Identification of parathyroid during thyroidectomy is recommended to avoid hypocalcaemia. Meticulous dissection can reduce the complications.Nepalese Journal of ENT Head and Neck Surgery, Vol. 6, No. 1, 2015