Swallowing dysfunction following surgery for well-differentiated thyroid cancer with extrathyroid invasion

Pyriform sinus injury in thyroidectomy: the unknown complicating the known

Thyroidectomy is a common procedural skill in the armamentarium of an otolaryngologist but has its own set of complications. The more common complications are hypocalcaemia, recurrent laryngeal nerve palsy, injury to the external branch of the superior laryngeal nerve, postoperative bleeding, wound infection and, rarely, thyroid storm. High pyriform sinus injury during hemithyroidectomy is extremely rare, with this report being only the second reported case in the literature. A 61-year-old man presented with complaints of right-sided neck swelling. The patient had a 10cm × 8cm sized swelling in the anterior neck on examination. A contrast-enhanced computed tomography scan revealed a heterogeneously enhancing mass lesion involving the right lobe of the thyroid and isthmus with multiple nodules. The patient underwent right hemithyroidectomy with no intraoperative complications. The histopathology report describes a papillary thyroid carcinoma (cT3 N0 M0) with the presence of angioinvasion. On the fifth postoperative day, the patient complained of neck pain, suture site swelling and a change of voice. A volume of 50ml of whitish purulent fluid was evacuated. A laryngeal exam revealed restriction in mobility of the right vocal cord. The oesophagogram revealed the iatrogenic injury to the hypopharynx. The oesophageal leak gradually resolved after 6 weeks, as evidenced by multiple contrast oesophagogram, without any need for surgical intervention. We theorise that, while operating on long-standing monster thyroids, extra care should be given while dissecting in the tracheoesophageal groove as the stretched mucosa, an extracapsular extension of disease and lymphovascular invasion can all jeopardise the underlying structures.

Guideline for the Surgical Management of Locally Invasive Differentiated Thyroid Cancer From the Korean Society of Head and Neck Surgery

The aim of this study was to develop evidence-based recommendations for determining the surgical extent in patients with locally invasive differentiated thyroid cancer (DTC). Locally invasive DTC with gross extrathyroidal extension invading surrounding anatomical structures may lead to several functional deficits and poor oncological outcomes. At present, the optimal extent of surgery in locally invasive DTC remains a matter of debate, and there are no adequate guidelines. On October 8, 2021, four experts searched the PubMed, Embase, and Cochrane Library databases; the identified papers were reviewed by 39 experts in thyroid and head and neck surgery. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of evidence, and to develop and report recommendations. The strength of a recommendation reflects the confidence of a guideline panel that the desirable effects of an intervention outweigh any undesirable effects, across all patients for whom the recommendation is applicable. After completing the draft guidelines, Delphi questionnaires were completed by members of the Korean Society of Head and Neck Surgery. Twenty-seven evidence-based recommendations were made for several factors, including the preoperative workup; surgical extent of thyroidectomy; surgery for cancer invading the strap muscles, recurrent laryngeal nerve, laryngeal framework, trachea, or esophagus; and surgery for patients with central and lateral cervical lymph node involvement. Evidence-based guidelines were devised to help clinicians make safer and more efficient clinical decisions for the optimal surgical treatment of patients with locally invasive DTC.

Optimal Management of the Unilateral Recurrent Laryngeal Nerve Involvement in Patients with Thyroid Cancer

Simple Summary

Recurrent laryngeal nerve (RLN) is the second most common structure invaded by primary or metastatic thyroid cancer. However, little is known about the optimal procedure for maintaining vocal function in patients with unilateral RLN involvement in thyroid cancer. This study aimed to evaluate various parameters of vocal function to establish the optimal management of thyroid cancer patients with unilateral RLN involvement. Based on our findings, we propose that for optimal management of unilateral RLN involvement in thyroid cancer, first, sharp dissection should be performed, and if this is impossible, a simultaneous RLN reconstruction procedure should be adopted whenever possible. These findings may help improve management of RLN involvement in patients with thyroid cancer and ensure vocal function preservation.

Abstract

We aimed to determine the optimal management of recurrent laryngeal nerve (RLN) involvement in thyroid cancer. We enrolled 80 patients with unilateral RLN involvement in thyroid cancer between 2000 and 2016. Eleven patients with preoperatively functional vocal folds (VFs) underwent sharp tumor resection to preserve the RLN (shaving group). Thirty-three patients underwent RLN reconstruction with RLN resection (reconstruction group). We divided the reconstruction group into two subgroups based on preoperative VF mobility (normal-reconstruction and paralyzed-reconstruction subgroups). In the cases where RLN reconstruction was difficult, phonosurgeries including arytenoid adduction (AA), with or without thyroplasty type I, or nerve muscle pedicle implantation with AA were performed later (phonosurgery group). We evaluated and compared vocal function among the evaluated periods and different groups. Postoperative vocal function in the shaving and normal-reconstruction subgroups was favorable. There were no significant differences between the two groups. In the paralyzed-reconstruction and phonosurgery groups, postoperative vocal function was significantly improved, and vocal function in the paralyzed-reconstruction subgroup was significantly better than that in the phonosurgery group. For optimal management of unilateral RLN involvement in thyroid cancer, first, sharp dissection should be performed, and if this is impossible, a simultaneous RLN reconstruction procedure should be adopted whenever possible.