Unilateral Recurrent Nerve Paralysis Research Articles

Thyroidectomy for Euthyroid Patients with Hashimoto Disease and Persistent Symptoms: An Observational, Postrandomization Study.

Despite adequate hormone substitution in Hashimoto disease, some patients may have persistent symptoms with a possible autoimmune pathophysiology. A recent randomized trial (RCT) using patient-reported outcome measures as the primary endpoint showed benefit in total thyroidectomy, but at a cost of high complication rates. To verify results from the RCT in an observational study including a wider range of patients and explore means of predicting who may benefit from such surgery. A total of 154 patients with Hashimoto disease, euthyroid with or without thyroid hormone substitution, and persistent Hashimoto-related symptoms were subjected to total thyroidectomy and followed for 18 months after surgery. The primary outcome was the General Health (GH) dimensional score in the Short Form-36 Health Survey (SF-36). Eighteen months after surgery, a clinically significant improvement in GH was seen, similar to the findings in the previous RCT. Anti-TPO antibody titers were markedly reduced after surgery, but preoperative titers or other preoperative parameters could not predict the outcome of surgery. Three (1.9%) of 154 patients experienced permanent unilateral recurrent nerve palsy and six (3.9%) experienced hypoparathyroidism after surgery. Thyroidectomy had a beneficial symptom-reducing effect in euthyroid patients with Hashimoto disease and persistent symptoms. The pathophysiology of residual symptoms remains unclear, and surgical complication rates are high. If thyroidectomy is considered as a treatment option, it should be performed in dedicated centers with experienced endocrine surgeons and as part of further studies on persistent symptoms. This trial is registered with NCT-02319538.

A Case of Unilateral Recurrent Nerve Palsy Improved by Chemotherapy for Esophageal Cancer

A Case of Unilateral Recurrent Nerve Palsy Improved by Chemotherapy for Esophageal Cancer

Surgical management of intrathoracic goiters: 20 years experience

Background: Surgery is necessary for intrathoracic goiters (ITG) even in asymptomatic forms considering the risks of compression and malignancy. The major problem is the adequate approach. Intrathoracic goiter’s removal can be performed via a cervical approach, whereas sternotomy might be required intraoperatively in some cases.Methods: A retrospective analysis of twenty years on 122 cases of intrathoracic goiters in a referral centre for thoracic surgery was carried out. We included secondary substernal goiters and ectopic thoracic goiters.Our aim was to define the specifities of this surgery and its outcomes. Postoperative data were examined as well as morbidity and mortality factors.Results: The most common symptoms included dyspnea, cough and dysphagia. Whereas Twenty-two patients were asymptomatic. One hundred sixteen patients underwent a successful transcervical incision without thoracic approach. Six cases of primary goiters were noted, of whom 3 were extracted via a cervical approach. Two cases showed unilateral recurrent nerve paralysis and two cases a hypoparathyroidism.Conclusions: Surgical management of intrathoracic goiter was correlated with low morbidity and mortality The cervical approach was performed in the vast majority of cases without an extra cervical procedure. Intrathoracic approaches were restricted to some selected indications.

Single-stage tracheal and cricotracheal segmental resection with end-to-end anastomosis: Outcome, complications, and risk factors

ObjectiveManagement of tracheal stenosis remains controversial. Endoscopic interventions commonly provide immediate relief of symptoms, but are associated with high recurrence rates. In contrast, high success rates have been reported in patients undergoing tracheal resection. However, well-defined indications and contraindications for tracheal resection are lacking and previous studies commonly ignore patient-related outcomes (e.g. dyspnoea). We aimed to evaluate the outcome of tracheal resection at our institution and identify risk factors for complications. MethodsAll adult patients undergoing tracheal resection at Aarhus University Hospital between January 2009 and September 2016 were included ResultsTwenty-seven patients were included. The most frequent aetiologies for tracheal stenosis were previous tracheostomy (n=8), prolonged intubation (n=3), a combination of the two (n=5), and intraluminal tumour (n=7). Sixteen patients underwent high tracheal resection, seven patients low tracheal resection, and four patients partial cricotracheal resection. Surgical success (no dyspnoea and no need for additional intervention) was achieved in 74% of patients. Four of six patients undergoing resection because of malignant disease were recurrence-free during the follow-up period. Fifteen (56%) patients suffered complications (transient or permanent). Four (15%) patients had recurrent stenosis and underwent reintervention. Other permanent complications included idiopathic hoarseness (15%), unilateral recurrent nerve palsy (11%), and dysphagia (7%). Previous treatment (endoscopic and open surgery) (OR=5.5, p=0.06) and chronic diseases (OR=8.3, p=0.02) were associated with increased risk for complications. ConclusionsTracheal resection was efficient treatment for the alleviation of dyspnoea in adults with tracheal stenosis. However, complications were frequent and careful preoperative patient selection and information are crucial.

Functional assessment of glottal insufficiency treated by hyaluronic acid injection: Retrospective 20-case series

ObjectivesThe objectives of the present study were to describe hyaluronic acid injection to the vocal folds as treatment for glottal insufficiency, assess indications and report vocal results at 1 month and later than 6 months postoperatively. Patients and methodsA single-center retrospective study was performed for the period March 2012 to August 2015. Inclusion criteria comprised: unilateral recurrent nerve palsy or vocal fold closure defect with conserved mobility. Exclusion criteria comprised: previous thyroplasty, severe swallowing disorder, and cognitive disorder hindering subjective vocal assessment. Restylane® injection was performed under general or local anesthesia. The Vocal Handicap Index (VHI), maximum phonation time (MPT) and GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) score were assessed preoperatively and at 1 month and more than 6 months postoperatively. ResultsTwenty patients were included: 14 with unilateral recurrent nerve palsy and 6 with vocal fold closure defect. Restylane® injection was performed under general anesthesia in 16 patients and local anesthesia in 4 (20%). At 1-month assessment, there was significant reduction in VHI (by 36 points; P=0.0001) and GRBAS score (by 6.95 points; P=0.0001) and significant increase in MPT (by 4.95sec; P=0.0001). At 6 months, VHI, MPT and GRBAS scores remained significantly improved (respectively, P=0.0002, P=0.001 and P=0.0001), without significant difference from 1-month levels. Three patients had minor complications; two recovered normal vocal fold mobility. ConclusionHyaluronic acid injection was effective in treating glottal failure, improving objective and subjective vocal parameters, which remained satisfactory even 6 months postoperatively.

Surgical treatment of substernal goiter: An analysis of 44 cases.

Substernal goiters are classified as primary or secondary intrathoracic goiters. Here, we report the diagnosis, symptoms, treatment, and postoperative complications of 44 substernal goiters (2 primary mediastinal goiter and 42 secondary mediastinal goiters). A retrospective chart review of 351 patients undergoing thyroidectomy at the Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center. Between 2009 and 2015, 44 patients underwent surgery for substernal goiter. The frequency of primary and secondary mediastinal goiters was 0.5% and 11.9%, respectively. The preoperative symptoms were neck mass, dyspnea, and dysphagia. Eight patients were asymptomatic. Thirty-nine patients had benign masses and 5 patients had malignant masses. Most patients were operated on for adenomatous goiters (52.2%). In ten cases beyond the aortic arch, the tumors were benign and there were eight cases of adenomatous goiter. All patients underwent a successful transcervical incision without sternotomy. Even the primary intrathoracic goiters were extracted after total thyroidectomy via the cervical approach without complications. Although one case showed unilateral recurrent nerve paralysis as a postoperative complication, phonetic function improved in 6 postoperative months. No instances of postoperative bleeding or definitive hypoparathyroidism occurred, and tracheostomy was not performed in any of the cases. The cervical approach was safely performed in almost all substernal goiters without an extracervical procedure. Selected cases of primary mediastinal goiter may be excised via the cervical approach.

Total thyroidectomy as a method of choice in the treatment of Graves' disease - analysis of 1432 patients.

BackgroundGraves’ disease represents an autoimmune disease of the thyroid gland where surgery has an important role in its treatment. The aim of our paper was to analyze the results of surgical treatment, the frequency of microcarcinoma and carcinoma, as well as to compare surgical complications in relation to the various types of operations performed for Graves’ disease.MethodsWe analysed 1432 patients (221 male and 1211 female) who underwent surgery for Graves’ disease at the Centre for Endocrine Surgery in Belgrade during 15 years (1996–2010). Average age was 34.8 years. Frequency of surgical complications within the groups was analyzed with nonparametric Fisher’s test.ResultsTotal thyroidectomy (TT) was performed in 974 (68%) patients, and Dunhill operation (D) in 221 (15.4). Carcinoma of thyroid gland was found in 146 patients (10.2%), of which 129 (9%) were a microcarcinoma. Complication rates were higher in the TT group, where there were 31 (3.2%) patients with permanent hypoparathyroidism, 9 (0.9%) patients with unilateral recurrent nerve paralysis and 10 (1.0%) patients with postoperative bleeding. Combined complications, such as permanent hypoparathyroidism with bleeding were more common in the D group where there were 2 patients (0,9%), while unilateral recurrent nerve paralysis with bleeding was more common in the TT group where there were 3 cases (0,3%).ConclusionsFrequency of complications were not significantly statistically different in relation to the type of surgical procedure. Total thyroidectomy represents a safe and efficient method for treating patients with Graves’ disease, and it is not followed by a greater frequency of complications in relation to less extensive procedures.

Hydroxyapatite versus titanium implant: Comparison of the functional outcome after vocal fold medialization in unilateral recurrent nerve paralysis

Results of medialization thyroplasty for treatment of unilateral vocal fold paralysis are often unsatisfactory. This study compares glottal closure and voice quality after use of 2 different medialization implant types: VoCoM and TVFMI. In all, 26 patients with unilateral vocal fold paralysis following thoracic surgery underwent medialization thyroplasty. In 11 patients (group I), a hydroxyapatite implant (VoCoM) was used. In 15 patients (group II), a titanium implant (TVFMI) was used. Preoperative and postoperative glottal closure and voice function were assessed with videostroboscopy, perceptual and objective voice measures, and the Voice Dysfunction Index (VDI). Group II showed a higher rate of complete glottal closure and greater improvement in perceived hoarseness, maximal phonation time, and maximal voice intensity than those in group I. With the individually adjustable titanium implant, better glottal closure and better functional outcome (phonation time and voice quality) were achieved.

Surgical voice rehabilitation in unilateral vocal fold paralysis

Unilateral recurrent nerve paralysis leads to glottic insufficiency, significantly reducing vocal ability. Due to its unusually long course, the recurrent laryngeal nerve is prone to iatrogenic lesions involves many medical fields generally with little expertise in voice disorders. Whenever the etiology is uncertain, a complete diagnostic work-up is mandatory. Indirect laryngoscopy confirms the diagnosis. Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytenoid joint. Moreover in many cases laryngeal electromyography yields a reliable prognosis of clinical outcome. While unfavorable results can be predicted with high accuracy, correct prognosis of complete recovery is more difficult. Speech therapy is the treatment of choice in cases of unilateral recurrent nerve palsy. Patients with persistent glottal gap may express the wish for surgical voice rehabilitation. Nowadays a broad spectrum of endoscopic and open approaches are available for this purpose. This review describes advanced techniques of voice-improving surgery available in specialized centers today.

Cricotracheal Resection in Nontracheotomized Adults: A Prospective Case Series

Cricotracheal resection is a modern technique of airway reconstruction used in cases of subglottic stenosis. We report a case series of adult, nontracheotomized patients. Fifteen patients with significant subglottic stenosis were identified as presenting with dyspnea and stridor. The stenosis was grade III in 14 cases and grade II in 1 case, according to the Cotton classification. The causes were manifold, with intubation and tracheostomy being the predominant risk factors. Cricotracheal resection was performed in all cases with preoperative and postoperative videotracheoscopy. The mean postoperative intubation time was 41.7 hours (11 to 103 hours), and the mean length of stay in the intensive care unit was 2.6 days (3 to 9 days). Videotracheoscopy for reassessment was performed after 96 days (average). In 13 of the 15 patients the subglottic lumen was returned to a normal diameter. In 1 case a recurrent stenosis was managed with repeated endoscopic interventions. One patient died on postoperative day 4 because of a pulmonary embolism. Additional complications consisted of 1 axillary venous embolism, 4 cases of ventilator-associated pneumonia, and 1 case of transient unilateral recurrent nerve palsy that recovered completely. Cricotracheal resection is a reliable and versatile technique for the reconstruction of the subglottic airway, almost regardless of the underlying cause. Most complications observed have not been associated directly with the procedure, but reflect the significant comorbidity of the patient population. There seems to be an increased risk for thromboembolic events that may be a consequence of the preoperative immobilization of dyspneic patients.

頬部脂肪体を用いた声帯内脂肪注入術

In recent years, autologous fat has been increasingly used for intracordal injection as a means of vocal rehabilitation in patients with deficient glottal closure, and the dipose tissue used has for the most part been harvested from the lower abdomen. However, patients differ considerably in the amount of fat available in the lower abdomen, and obtaining sufficient fat is often difficult in patents with a low body mass index (BMI). To overcome this problem we tried adopting a method that uses the buccal fat pad, as practiced in plastic surgery. The details of the method and the postoperative course are reported. The intracordal fat injection method for buccal fat pad tissue was performed in 10 cases during the 1-year from January 2005 to December 2005, and the patients' postoperative course was carefully monitored for more than 6 months after surgery. With the exception of one case, no signs of complications, such as swelling, infection, etc., were seen at the site of fat collection or in the vocal cord after the operation. Phonation was markedly improved after the injection, and the improvement was maintained throughout the observation period. Treatment of unilateral recurrent nerve paralysis by intracordal injection of autologous fat harvested from the buccal fat pad was successful.

Unilateral and bilateral recurrence of inferior laryngeal nerve paralysis

Unilateral recurrent nerve paralysis leads to glottic insufficiency, causing a significant lack of vocal ability. In contrast, bilateral palsies present with stridor on inspiration due to glottic stenosis. Most of the underlying lesions are iatrogenic, with thyroid surgery being the single most important causative factor. However, a variety of different reasons can lead to such a condition. Whenever aetiology is uncertain a complete diagnostic work-up is mandatory. Indirect laryngoscopy confirms the diagnosis. Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytaenoid joint. Moreover, in many cases laryngeal electromyography provides a reliable prognosis of clinical outcome. While unfavorable results can be predicted with high accuracy, correct prognosis of complete recovery is more difficult. Speech therapy is the treatment of choice in case of unilateral recurrent nerve palsy. Only if a significant glottal gap persists medialization procedures may become useful for voice improvement. Endoscopic as well as open approaches are available for this purpose. Bilateral recurrent nerve palsies need to be addressed surgically in the vast majority of cases. Today, a variety of endoscopic techniques for widening the glottic airway are available. Compared to permanent tracheostomy these procedures have much less impact on the patient's quality of life and should be preferred whenever possible. Inevitably, voice quality is traded for airway normalisation. However, modern surgical techniques accomplish very tolerable phonatory results.

Study of movements of individual structures of the larynx during swallowing

Objective: The purpose of this study was to reveal movements of individual structures of the larynx during swallowing. Methods: Subjects were 7 healthy adults, aged 24 to 32 years (average 27 years), who had no organic or functional disease of the pharynx and larynx and 2 adults with unilateral recurrent nerve palsy, aged 49 and 60 years, respectively. We used the Toshiba IIDR system, which is composed of an X-ray TV system and a digital image managing circuit. One-fifth diluted Omnipark 300 was used as contrast medium (lohexol), with 15 cc for each swallow. The mask image for subtraction was designated as the frame before laryngeal elevation during swallowing for subtraction. We obtained the images for observation and analysis after subtracting the mask image from continuously obtained images. These images were captured into a personal computer at 30 frames per s and thereafter frame-by-frame observation and analysis were performed by means of NIH image 1.56. Results: We observed that the vocal folds underwent a series of movements during swallowing. (1) They adduct slowly and do not ascend; (2) then begin to ascend and continue adducting; whereby (3) they abduct for a moment while ascending. (4) Again, they adduct and achieve closure. (5) While maintaining closure, vocal folds elevate further to reach their maximal elevation; and (6) begin to abduct rapidly while maintaining maximal elevation. Finally, (7) they begin to descend and undergo repeated irregular abduction and adduction while descending. In examining the relationship between closure and opening at levels of the vocal fold and false vocal fold, we found that closure at the false vocal fold level precedes that at the vocal fold level and that opening at the vocal fold level precedes that at the level of the false vocal fold. Conclusion: Closure of the false vocal fold level appears important in the protection of the lower respiratory tract during swallowing.

シリコンブロック挿入１８年後の喉頭病理所見

Thyroplasty type I is one of various surgical treatments for glottic insufficiency following unilateral recurrent nerve paralysis. However, the choice of materials for the prosthesis inserted into the thyroid cartilage is controversial with regard to stability and safety. We experienced a case of laryngeal palsy caused by syringomyelobulbia. Thyroplasty type I was performed with a silicone block 18 years ago to prevent aspiration pneumonia, but in accordance with progress of the laryngeal palsy, the patient developed severe pneumonia. We performed a total laryngectomy for the improvement of his dysphagia, and conducted a histopathological study of the larynx with the silicone prosthesis. We found slight fibrinogenesis around the silicone block, however, foreign body giant cells, inflammatory cells, or absorption of silicone were not observed. We tentatively concluded that these findings show the stability and safety of silicone as a prosthesis for thyroplasty type I.

The evaluation and treatment of swallowing disorders

The effects of laryngotracheoesophageal cleft, rheumatoid arthritis, gastroesophageal reflux disease, supracricoid partial laryngectomy with cricohyoidopexy, and postsurgical unilateral recurrent nerve paralysis on swallowing function are examined. Procedures for screening patients for symptoms of s

Prophylactic thyroidectomy in 75 children and adolescents with hereditary medullary thyroid carcinoma: German and Austrian experience.

When mutations of the RETproto-oncogene were found in 1993 to account for hereditary medullary thyroid carcinoma (MTC), surgeons obtained the opportunity to operate on patients prophylactically (i. e., at a clinically asymptomatic stage). Whether this approach is justified, and, if so, when and to which extent surgery should be performed remained to be clarified. A questionnaire was sent to all surgical departments in Germany and Austria. All of the patients who fulfilled the following criteria were enrolled: (1) preoperatively proved RET mutation; (2) age </= 20 years, (3) clinically asymptomatic thyroid C cell disease; and (4) TNM classification pT0-1/pNX/pN0-1/M0. Seventy-five patients were identified, and fifteen mutations were detected in six codons. Two adolescents had unilateral pheochromocytomas as part of the multiple endocrine neoplasia II (MEN-II) syndrome. No hyperparathyroidism was noted. All patients underwent total thyroidectomy, and 57 patients went on to have lymph node dissection. Parathyroid glands were removed in 34 patients and autografted in 11. Histopathology revealed MTC in 46 patients (61%, youngest 4 years); C cell hyperplasia (CCH) only was detected in the other 29 patients. Three patients had lymph node metastases (LNMs) the youngest being age 14 years. Calcitonin levels were not useful for differentiating between CCH and MTC, but in all patients with LNMs at least the stimulated calcitonin levels were assayed. After surgery, five patients (6.7%) sustained permanent hypoparathyroidism, and one patient (1.3%) had a permanent unilateral recurrent nerve palsy. All but three patients (96%) were biochemically cured. In conclusion, prophylactic total thyroidectomy can be performed safely in experienced centers. We recommend prophylactic total thyroidectomy at age 6. Cervicocentral lymph node dissection should be included when calcitonin levels are elevated or if patients are older than 10 years. Bilateral lymph node dissection should be performed if LNMs are suspected or when patients with elevated calcitonin are older than 15 years.

Completion Total Thyroidectomy in Children With Thyroid Cancer Secondary to the Chernobyl Accident

To evaluate the usefulness of submitting children with thyroid cancer secondary to nuclear accidents to a completion total thyroidectomy. A case series consisting of patients living and operated on in Belarus whose parents had asked for a clinical evaluation in a western European center. A tertiary care referral center. The conditions of 47 children from Gomel, Belarus, with differentiated thyroid carcinoma following the nuclear accident at Chernobyl, Ukraine, were evaluated at the University of Pisa, Pisa, Italy. In approximately half of the cases, the treatment in Belarus consisted of a hemithyroidectomy. After a complete evaluation, the decision was made to reoperate on 19 of them by performing a completion total thyroidectomy. The preoperative evaluation revealed that 5 (26%) of the 19 patients who had undergone a hemithyroidectomy had unilateral recurrent nerve palsy and that 2 (10.5%) had hypoparathyroidism. Neck ultrasonography was used for the preoperative localization of thyroid residuals, thyroid nodules, suspicious lymph nodes, and a guided fine-needle aspiration biopsy specimen. The circulating thyroglobulin measurement was obtained before reoperation. An iodine 131 whole-body scan (WBS) was performed and circulating thyroglobulin levels were obtained after completion of the thyroidectomy during withdrawal of levothyroxine sodium therapy. The number of patients with a recurrence of thyroid cancer and lung or lymph node metastases after the completion total thyroidectomy. The results of the histologic examination were positive for papillary thyroid cancer in 6 (28.6%) of 21 patients, 3 with residual cancer in the remaining thyroid lobe and 3 with metastatic lymph node disease. A posttherapy WBS demonstrated lung metastases in 5 (28%) of 18 patients and lymph node metastases in 6 (33%) of 18 patients; the results of a posttherapy WBS were negative for metastases in 7 (39%) of 18 patients. Hypoparathyroidism developed in 4 (21%) of 19 patients who underwent a completion total thyroidectomy; unilateral laryngeal nerve palsy developed in 1 (5.2%) of these 19 patients. Among 22 children who previously underwent total thyroidectomy in Belarus, a diagnostic WBS showed lung metastases in 10 (45%) of the children and lymph node metastases alone in 3 (14%) of the children; the results of a diagnostic WBS were negative for metastases in 9 (41%) of the children. Statistical analysis showed a nonsignificant (P>.05) difference in the prevalence of lung and lymph node metastases in patients who previously underwent total thyroidectomy compared with patients who underwent completion total thyroidectomy. Completion total thyroidectomy allowed for the diagnosis and treatment of recurrent thyroid cancer and lung or lymph node metastases in 61% (11/18) of the patients in whom residual differentiated thyroid carcinoma was not previously recognized.

Percutaneous Collagen Injection for Postoperative Unilateral Recurrent Nerve Palsy

Percutaneous Collagen Injection for Postoperative Unilateral Recurrent Nerve Palsy

甲状軟骨形成術Ｉ型の一工夫

Isshiki Thyroplasty Type I, a surgical procedure to medialize a paralyzed vocal cord through a window made in the thyroid lamina, has been widely performed to improve hoarseness and misdeglutition in cases of unilateral recurrent nerve paralysis. The medialization of the vocal cord is usually obtained by the insertion of a silicone shim through the window, but the trimming of the silicone is troublesome, and the operation cannot be done without silicone. Thus, we recently devised a new method using a fragment of cartilage instead of silicone. In this method, a vertical portion of the rectangular cartilage removed from the window in the thyroid lamina was inserted between the thyroid cartilage and the endochondrium at the level of the window and was fixed with fibrin glue. This procedure is easy to perform and does not necessitate silicone. Two cases with good results using this method were reported.

Recurrent nerve/ansa cervicalis nerve anastomosis: a treatment alternative in unilateral recurrent nerve paralysis.

Sectioning of the right recurrent nerve was done in 5 mongrel dogs under general anaesthesia. The distal stump was anastomosed with the ansa cervicalis nerve branch to the sternothyroid muscle. Three to 5 months later the vocal cord movements during light and very light anaesthesia were videorecorded. Under light anaesthesia contraction and medial bulging of the reinnervated right vocal cord occurred in 4 of the dogs. Under very light anaesthesia there was also some adduction of the right vocal cord in these 4 dogs. The right recurrent nerve was then sectioned proximally to the anastomosis and stimulated electrically. In all 5 dogs we observed that electrical stimulation produced a strong adduction of the right vocal cord. Histochemistry of the right vocal and posterior cricoarytenoid muscles showed that reinnervation had taken place. The study indicates that in cases of unilateral vocal cord paralysis an anastomosis between the ansa cervalalis and the recurrent nerve will result in improved phonatory function of the affected vocal cord.