Transcervical thymectomy and thymus remnants

Outcome after thymectomy for myasthenia gravis: a retrospective review

This is a retrospective study of 54 patients, who in the period November 1977 to November 1986 underwent thymectomy as treatment for myasthenia gravis. Patients in whom difficulty attempting complete excision of the gland was anticipated were selected for a transthoracic procedure. All others underwent an initial transcervical approach, proceeding to an upper sternal splitting incision if further access was required to remove adequately a large gland. The sample was split almost equally between the two surgical procedures. Patients in the transthoracic group were significantly older and experienced significantly greater peri-operative morbidity or mortality. There was no significant difference in outcome between the two groups, 52% achieving a good result (defined as remission or clinically significant improvement of symptoms) that was sustained over the five year follow-up period. In our opinion, complete removal of the thymus should be the goal of surgical treatment for myasthenia gravis.

Myasthenia gravis in otolaryngological practice

A retrospective study of 48 unselected patients with myasthenia gravis was undertaken to evaluate the head and neck manifestations of this disease and to examine the role of the otolaryngologist in diagnosis and management. Oropharyngeal features were found in 56% of patients at presentation. In 20 the initial complaint was of one or more symptoms referable to the upper aerodigestive tract, whilst in 9 (18.8%) these were the only symptoms. The importance of maintaining a high index of clinical suspicion is emphasized, as the early muscle weakness is invariably mild and fluctuant. Contemporary aspects of the aetiology, diagnosis and management are considered. Particular attention is focused on the characteristics of the stapedius reflex in this disorder, as this is probably the most sensitive objective test for assessing defective neuromuscular transmission.

Recurrence of thymic hyperplasia after thymectomy in myasthenia gravis. Its importance as a cause of failure of surgical treatment

Persistence of symptoms in patients with myasthenia gravis who have undergone previous thymectomy has been attributed to thymus remnants. Patients with partial or no recovery were studied 40 +/- 31 months (mean +/- SD) after surgery, which had been carried out by the transcervical approach in 20 and trans-sternal approach in four. Lateral x-ray tomography of the mediastinum after injection of air showed images compatible with residual thymus gland in 18 patients (75 percent). Thirteen of these underwent reoperation by the trans-sternal approach, and thymic tissue was found in 11 (85 percent). After repeated thymectomy, 67 percent of the patients improved clinically. Therefore, it is quite reasonable to infer that incomplete removal of the thymus was responsible, at least partly, for failure of the first procedure.