Surgical Management of Hyperparathyroidism

Educational objectives: To discuss the diagnostic workup of hyperparathyroidism including localization studies and current controversial issues related to the management of hyperparathyroidism including unilateral versus bilateral exploration.

Supraomohyoid neck dissection as a staging procedure for squamous cell carcinomas of the oral cavity and oropharynx

BACKGROUND

A multi-institutional retrospective study was performed to evaluate the efficacy of the supraomohyoid neck dissection (SOHND) for detection of occult cervical metastasis in squamous cell carcinoma of the oral cavity and oropharynx.

METHODS

Seventy-five previously untreated patients with clinically negative necks were studied. Seventeen (23%) neck specimens revealed occult metastatic disease, and 58 (77%) were histologically negative. Postoperative irradiation was received by 94% of the patients with positive specimens and 22% with negative specimens. Patients were followed until recurrence of neck disease, or for a period of 2 years or longer.

RESULTS

Cervical metastasis subsequently developed in 25% of treated positive specimen patients, none of the untreated positive specimen patients, 8% of the treated negative specimen patients, and 11% of the untreated negative specimen patients. The sensitivity of SOHND for cervical metastasis was 82%, negative predictive value 91%, and accuracy 94%.

CONCLUSIONS

The authors conclude that SOHND is a useful procedure for detection of occult cervical metastatic disease in cancer of the oral cavity and oropharynx.

Biopsy techniques in head and neck

The establishment of an accurate histologic diagnosis is extremely important in the management of patients with head and neck lesions. This article describes various biopsy techniques and discusses the clinical implications in relation to common lesions involving thyroid and salivary glands and cervical lymphadenopathy. The diagnostic pitfalls and pros and cons of needle biopsy are also discussed in detail.

Intermediate-risk group for differentiated carcinoma of thyroid

BACKGROUND

We have previously described prognostic factors in differentiated carcinoma of the thyroid gland relating to age, size and extrathyroid extension of the tumor, histologic grade, gender, and distant metastasis. These factors have identified patients in the low-risk group with excellent prognosis and the high-risk group with significant mortality. However, some patients fall within the intermediate-risk category where due deliberation in decision making is required for selection of appropriate treatment.

METHODS

A retrospective review of a consecutive series of 1038 previously untreated patients with differentiated carcinoma of thyroid treated during a period of 55 years was undertaken. Data gathered from review of the charts were subjected to univariate and multivariate analysis to assess prognostic factors. On the basis of the patient's age, presence of distant metastasis, and size, grade, and histologic characteristics of the tumor they could be classified into low-, intermediate-, and high-risk categories. Thus 403 (39%) patients were in the low-risk group, 232 (22%) patients in the high-risk category, and 403 (39%) patients in the intermediate-risk category.

RESULTS

With a median follow-up of 20 years, 99% survival was achieved in the low-risk group, whereas only 57% survived in the high-risk group. Interestingly, in the intermediate-risk category of 403 patients, the 20-year survival was only 85%. Our results clearly identify a distinct intermediate-risk category that includes low-risk patients with high-risk tumor or high-risk patients with low-risk tumor.

CONCLUSION

Patients in the intermediate-risk category should be considered for an aggressive treatment approach based on individual prognostic factors.

Practical management of post-thyroidectomy hematoma

Thyroid diseases and surgery for thyroid neoplasms are both very common. Several complications of thyroidectomy are well known. Some of these are quite disturbing, such as recurrent laryngeal nerve injury and permanent hypoparathyroidism. However, postoperative hematoma often in the recovery room may be fatal. Close observation and early intervention are of utmost necessity in the post-thyroidectomy period. In a series of 600 thyroidectomies performed over a period of 11 years, eight patients developed postoperative hematoma. Seven of them underwent re-exploration, while one patient was treated conservatively. Two patients had second re-exploration for hematoma reaccumulation. All patients recovered very well after re-exploration except one elderly patient who required ventilatory support due to poor pulmonary reserve; after a week of ventilatory support and a tracheostomy, she too recovered well. One patient had the hematoma re-explored as late as 24 hours after the operation, while the remainder were re-explored within 4-6 hours after the initial procedure. Because of the extent of edema of the larynx and pharyngeal wall, it is very important that a senior, experienced person perform intubation in these patients. It is also very important to recognize that when the patients lie down flat, they may develop acute airway distress; hence, one must be prepared to intubate them emergently. We recommend close recovery room observation after thyroidectomy and early exploration and evacuation of hematoma in all patients who develop postoperative hematoma. A conservative approach may be considered in selected patients with minimal hematoma and no progression. However, it generally takes a long time for the hematoma to resorb. A better understanding of the complications of thyroidectomy will minimize morbidity and make thyroidectomy a safer procedure and a surgical triumph.

Angiosarcoma of the head and neck

BACKGROUND

Angiosarcoma (AS) is an uncommon, highly aggressive tumor with a poor prognosis.

METHODS

To study the impact of various treatment modalities, namely surgery, radiation, and chemotherapy, we reviewed our experience with AS of the head and neck.

RESULTS

From 1978 through 1992, we treated 13 men and 5 women with AS (median age 67 years). Sixteen tumors occurred on the scalp and face and 2 in the oropharynx. Two patients presented with cervical metastases, and a third had subsequent nodal involvement. Primary surgery was used in 9 patients, including 1 who received adjunctive systemic doxorubicin hydrochloride, and 2 who received adjunctive radiotherapy. The tumors of 9 patients were unresectable: 4 were treated with intra-arterial doxorubicin hydrochloride; and 5, with systemic doxorubicin hydrochloride. Twelve patients (67%) died of disease an average of 25 months after diagnosis. Overall 5-year survival was 33%, but only 20% of the patients were disease free. Size of the tumor was an important predictor of survival, as all patients with a lesion > 10 cm died of disease, compared with 67% with a lesion < 10 cm. Four of 6 patients treated with wide local excision for lesions < 10 cm survived 5 years.

CONCLUSIONS

We recommend surgery for resectable lesions with postoperative radiation for unsatisfactory margins, large tumor size, deep extension, and multicentricity. Elective treatment of the neck does not appear warranted.

Substernal goiter: a clinical review

Thyroid disease is a very common problem, but indications for surgery are few. We have seen a large number of patients with multinodular goiter. The main indications for surgery in thyroid disease include fear of malignancy, tracheo-esophageal compression, and cosmetic reasons. Tracheo-esophageal compression is most commonly noted in patients with mediastinal goiters. Substernal goiter is defined as those situations in which at least 50% of the gland is in the mediastinal location. Although its incidence has decreased, it remains prevalent in almost every country in the world today. SSG is best diagnosed by a thorough history and physical examination, complemented by airway films, fiberoptic laryngoscopy, and computerized tomography. The most common presenting symptoms are those produced secondary to compression effects. SSG show a poor response to medical treatment. Moreover, given their propensity to cause acute airway symptoms, surgical treatment should be considered in most cases. Extirpation of the gland is best performed through a collar incision, with the addition of a median sternotomy in select few and difficult cases. Median sternotomy is necessary in only 1% to 2% of cases. Operative mortality is negligible, and the incidence of complication is minimized by following strict surgical principles.

Surgical management of accessory parotid tumors

Accessory parotid gland tumors are defined as masses within salivary gland tissue located adjacent to Stensen's duct, but separate from the main body of the parotid gland. These tumors usually present as asymptomatic cheek masses. There is a temptation to excise these masses locally; however, the likelihood of injury to branches of the facial nerve is high. The best surgical approach to tumors in the accessory parotid region is via a standard parotid incision and concomitant superficial parotidectomy. Eight patients have been surgically treated with accessory parotid gland masses. Six patients had mixed tumors, one had a low grade mucoepidermoid carcinoma, and one had a localized parotitis. Our approach included a standard parotid incision, raising an anterior flap beyond the mass, and exposing the main trunk of the facial nerve, with careful tracing of all its branches. This approach to accessory parotid gland tumors is superior in that it provides a better margin of resection and minimizes functional and cosmetic deformities. Most importantly, there is less danger of injury to branches of the facial nerve.

Benign lymphoepithelial lesions of the parotid

Persistent generalized lymphadenopathy has been well described in patients with seropositivity to the human immunodeficiency virus (HIV). Moreover, isolated enlargement of the parotid gland and parotid lymphadenopathy have been noted much more frequently over the past few years. Histologically, these lesions demonstrate follicular hyperplasia, cystic dilatation of the ducts lined by pseudo-stratified squamous epithelium, and lymphocytic infiltrates. They are generally considered to be benign lymphoepithelial lesions of the parotid or hyperplastic periparotid lymph nodes. The relationship of this entity to the AIDS-related complex (ARC) and the subsequent development of AIDS is not clear. Over the past 7 years, we have seen 50 patients with parotid enlargement in whom the diagnosis of benign lymphoepithelial lesion was made. Fine-needle aspiration was performed in 32 patients. Although not conclusively diagnostic, needle aspirates ruled out primary salivary glandular pathology. Most patients gave a history of intravenous drug abuse. HIV tests have been performed on a routine basis only in the last 2 years, and these were positive in the majority of the patients. Thirty-five patients underwent surgical excision. In the initial 20 patients, we routinely performed parotid exploration, identification of the facial nerve, and superficial parotidectomy. In the last 15 patients, we changed our surgical approach to parotid exploration and excision of the mass in the tail of the parotid. The exposure of the posterior belly of the digastric muscle, with identification and removal of the deep jugular node, has become routine. In each case, we found an enlarged lymph node in the deep jugular region, which was not clinically palpable preoperatively. The rate of surgical complications was minimal, and, after resection of the mass, patients improved symptomatically. If the patient shows obvious signs of AIDS, a nonsurgical approach with repeated aspirations should be considered, and treatment with zidovudine offered.

Transoral-transpharyngeal approach to the upper cervical vertebrae

The classical operative approaches to the cervical spine include the posterior one and the anterior exposure along the sternomastoid muscle. However, neither of these are helpful in exposing the upper cervical vertebrae, especially the odontoid process, atlas, and axis. We have used the transoral-transpharyngeal exposure for lesions of the odontoid process and upper (first to third) cervical vertebrae in six patients. The pathologic processes included rheumatoid disease and fracture of the cervical vertebrae, suspected tumor with compression of the spinal cord, basilar invagination, and compression of the medulla. In all six patients, the exposure was excellent, and postoperative morbidity was minimal. Tracheostomy was performed routinely in all these patients. In five patients, vertebral stabilization was performed as a secondary procedure a few days after the initial anterior decompressive surgery. The transoral-transpharyngeal approach appears to be relatively easy. It is associated with minimal complications and provides excellent exposure of the odontoid and upper cervical vertebrae for a microneurosurgical approach. Modifications of this approach include incision of the soft palate, excision of a portion of the hard palate, and, occasionally, transmandibular median labio-mandibulo-glossotomy (Trotter's) approach. Although the technique was described initially approximately 35 years ago, this neglected anatomic approach will facilitate cooperative efforts between head and neck surgeons and neurosurgeons.

Parathyroid localization prior to primary exploration

The success of parathyroid surgery is based on accurate localization of normal and abnormal parathyroid glands, knowledge of the pathologic conditions, and meticulous dissection during removal of the abnormal glands. Although parathyroid localization is essential in cases requiring re-exploration, there is considerable controversy regarding the indications for localization studies prior to primary exploration, since the success rate for surgery exceeds 90% to 95%. However, in specific circumstances, including diagnostic problems, technical considerations, and high-risk patient factors, preoperative parathyroid localization assists the operating surgeon even during the primary cervical exploration. The purpose of this paper is to define these specific circumstances and discuss the appropriate studies.

Selective use of drains in thyroid surgery

In the past, it was generally advised that every patient undergoing thyroid surgery have a drain placed because of the fear of post-operative hematoma. In the past 9 years, we have performed 400 thyroidectomies. For the first 6 years, we drained the operative site in most of thyroid procedures. However, it was apparent from our experience that drains had very little effect on the prevention of post-operative hematoma or of seroma. As a matter of fact, all four patients who required re-exploration in our initial series had drains in place. As a result of this experience over the past 3 years, during which time we have performed 150 thyroidectomies, we have used drains selectively. The indications for draining the thyroid bed have been the presence of a large dead space, operation for a large substernal goiter, and subtotal thyroidectomy for either large, multinodular goiter or for Graves' disease. Thus, among 150 recent thyroidectomies, we have drained only 35, and avoided drains in 115 patients. Though this is not a prospective study, we found no difference in the overall outcome whether drains were employed or not. Most patients who had no drains were ready for discharge within 24-48 hours of surgery. Since it may be difficult to perform a randomized prospective trial examining the use of drains in thyroid surgery, we propose that drains should be utilized only selectively for thyroid surgery.

Cervical exploration for primary hyperparathyroidism

The classical presentation of primary hyperparathyroidism, "moans, bones, groans," is no longer commonly seen since the diagnosis of hypercalcemia is now made much earlier with the routine use of the SMA 12. In the past 8 1/2 years, 85 patients underwent cervical exploration in our institution for primary hyperparathyroidism. There were 34 male and 51 female patients, ranging in age from 18-84 years. The specific symptoms included hypertension in 40 patients, generalized weakness in 25, renal stones in 14, psychiatric problems in 2, and bone changes on X-ray in 4. Forty-one patients were totally asymptomatic. The diagnosis was made mainly on the basis of history, serum calcium and phosphorous levels, parathormone assay, and 24-hour urinary calcium studies. Preoperative localization studies were performed in 38 patients. Thallium technetium subtraction scans, when positive, were very helpful. The surgical approach involved stepwise exploration of both sides of the neck with identification of all four parathyroid glands. In patients with uniglandular pathology (87%), the adenoma was removed with biopsy of at least one normal gland. In multiglandular disease, the abnormal glands were removed. Frozen section was routinely performed to confirm the presence of parathyroid tissue and no attempt was made to pathologically distinguish adenoma from hyperplasia. Two patients had parathyroid carcinoma. In three patients, serum calcium levels did not fall, resulting in an operative success rate of 96%. One patient treated by subtotal parathyroidectomy developed permanent hypoparathyroidism and one other patient developed temporary hypocalcemia. Only a single patient developed vocal cord palsy. Early exploration in patients with primary hyperparathyroidism is indicated. The basic diagnostic workup is sufficient for initial exploration. It is important to distinguish uniglandular from multiglandular pathology after careful bilateral exploration and identification of all four parathyroid glands.

Completion thyroidectomy: a critical appraisal

BACKGROUND

Completion thyroidectomy can most accurately be described as reexploration of the neck to remove the contralateral thyroid lobe. This procedure has commonly been performed when the histopathologic condition of the ipsilateral thyroid lobe reveals papillary or follicular carcinoma of the thyroid. Because of a definitely increased risk of complications with completion thyroidectomy, avoiding its routine use is important. The purpose of this paper is to define the specific indications for completion thyroidectomy.

METHODS

Over the past 9 years, we have performed 400 thyroidectomies; the patients ranged in age from 18 to 88 years. Although we have routinely used preoperative needle biopsy and intraoperative frozen section, decisions regarding the extent of thyroidectomy have been based on the gross findings at operation, taking into consideration such prognostic factors as patient age, tumor grade and size, the presence of extracapsular spread or distant metastasis, and associated risk factors. The minimal procedure for solitary thyroid nodule has been lobectomy with isthmusectomy. If the contralateral lobe is grossly normal, lobectomy with isthmusectomy has also been the maximal operation in most of patients. Very few specific indications exist for removal of the opposite lobe.

RESULTS

Only three patients underwent completion thyroidectomy. All three patients had aggressive follicular carcinoma requiring radioactive iodine ablation, and all were referred after the initial surgery. We have not performed completion thyroidectomy on any of the patients on whom we initially operated.

CONCLUSIONS

The most common indication considered for completion thyroidectomy is a frozen section diagnosis of a benign follicular adenoma that is subsequently changed on permanent pathologic condition to follicular carcinoma based on the presence of capsular and/or vascular invasion. However, if minimal invasion has occurred, no difference exists in survival related to the extent of the thyroidectomy. Local recurrence in the contralateral lobe occurs in less than 10% of the time. Because completion thyroidectomy carries more risks, it should be avoided in most patients when possible. The definitive decision should be made during the initial operation based on gross findings, prognostic factors, and frozen section, and this plan should only be changed to mandate completion thyroidectomy in select circumstances.

Marginal mandibulectomy for carcinoma of the floor of the mouth

Resection of primary tumors of the floor of the mouth mandates consideration of the management of the mandible which may be either involved by direct invasion or by close proximity. Segmental mandibulectomy can usually be performed when the tumor is either massive or directly invading the mandible. However, the cosmetic and functional results of segmental mandibulectomy are unsatisfactory. Whenever the tumor is close to the mandible or adherent to the periosteum, consideration should be given to marginal mandibulectomy. Over a period of 8 years, we have treated 65 patients with carcinoma of the floor of the mouth. Of these, 22 underwent marginal mandibulectomy. The number of patients staged T1, T2, and T3 were 4, 13, and 5, respectively. Most had oblique marginal mandibulectomy including the resection of the upper rim and medial cortex of the mandible. Vertical or horizontal mandibulectomy was rarely used. In each patient the preoperative workup included dental X-rays, panoramic films, and computerized tomography (CT) scan of the head and neck. The decision as to the extent of mandibulectomy was made primarily based on the clinical judgement. Seven patients underwent marginal mandibulectomy through the open mouth. However, in the remaining 15 patients, the cheek flap approach was utilized. The defect following marginal mandibulectomy was reconstructed either with split thickness skin graft, tongue flap, or myocutaneous flap. Small defects were left open to heal by granulation and secondary intention. Split thickness skin grafts healed very well over the surface of resected mandibles. Good local tumor control was achieved at the primary site and the functional and cosmetic results were excellent.

An experimental model for the surgical correction of tracheomalacia

Tracheomalacia may result from large intrathoracic goiters. Due to the chronic compression, particularly within the confines of the thoracic inlet, the tracheal wall weakens, with disintegration of some of the cartilaginous rings. Tracheomalacia can cause acute airway distress, particularly during the post-operative period, and may occasionally result in death. The other major cause of tracheomalacia is related to either prolonged endotracheal intubation or over-inflation of the tracheostomy cuff. While various techniques such as internal stenting, external support devices, tracheostomy, and tracheal resection have been used based on individual circumstances, no one method appears to be perfect. To further study this difficult problem, an experimental model of tracheomalacia was created in eight dogs. Six to seven rings of the tracheal cartilages were dissected submucosally. More than half of the circumference of the tracheal rings was resected. The tracheal walls were reconstructed with polytetrafluoroethylene (PTFE) grafts. The grafts strengthened the tracheal wall without causing luminal constriction. Tracheostomy was not performed on any of the dogs. All dogs tolerated the procedure well and were extubated at the conclusion of the experiment. The dogs were followed for 4 to 6 months and then sacrificed so that the tracheal wall could be examined histologically. There was considerable fibrosis leading to stiff neotrachea. The results of this experimental technique for prosthetic reconstruction to counteract problems simulating tracheomalacia are very encouraging.

Preoperative evaluation of the mandible in patients with carcinoma of the floor of mouth

Preoperative evaluation of the mandible for invasion by tumor has always been a difficult problem. Various methods have been used, including clinical evaluation, panoramic x-rays, dental films, routine mandible films, bone scans, computed tomographic (CT) scans, and magnetic resonance imaging (MRI) scans. The diagnostic accuracy of these methods has not been totally satisfactory from the clinical standpoint. We compared the diagnostic effectiveness of clinical evaluation, panorex films, and CT scans in 60 patients with carcinoma of the floor of mouth. The relative value of these tests was studied in relation to marginal or segmental mandibulectomy. Our data showed that CT scanning was not very helpful, mainly because of the presence of irregular dental sockets and artifacts. Clinical evaluation was the most accurate, both to determine bone invasion and to decide the type of mandibular resection necessary in association with the primary tumor. Panoramic films were helpful in evaluating the gross extent of mandibular invasion. However, they were not of any help in determining minimal bony invasion or cortical invasion. Even though CT scanning has made a tremendous impact in other areas of head and neck surgery, it is not of much help in making the critical decisions in the type of mandible resection, marginal or segmental, in patients with carcinoma of the floor of mouth. Our experience demonstrates that clinical evaluation is superior in preoperative evaluation of the mandible, and especially in deciding the type of mandible resection.

Mandibulotomy and mandibulectomy in difficult tumors of the base of the tongue and oropharynx

Wide exposure of the tumors of the base of the tongue and oropharynx can be easily obtained via mandibulotomy, which provides equally good exposure for tumors of the posterior oral cavity and oropharynx. Segmental mandibulectomy can be avoided in patients where the tumor does not invade the mandible or is not in close proximity of the mandible. Preoperative work-up may include evaluation by means of the fiberoptic telescope to determine the extent of the tumor, examination under anesthesia, panoramic X-ray of the mandible, CT scan and MRI, as well as dental evaluation. Tracheostomy provides airway during the operation and tracheobronchial access for clearance of pulmonary secretions postoperatively. The technique for median labiomandibuloglossotomy is described, as well as the mandibular swing approach and mandibulectomy. Cosmetic deformity after segmental mandibulectomy is minimal but mandible reconstruction should nonetheless be considered based on the extent of the tumor, tumor control, and the need for postoperative radiation therapy.