Recurrent laryngeal nerve injury in thyroid surgery

Efficacy of Botulinum Toxin Injection for Airway Management in Patients with Transient Bilateral Vocal Fold Paresis Following Thyroidectomy: A Prospective Study

OBJECTIVES

This prospective study evaluated the effectiveness and safety of botulinum toxin injection for airway management in patients with transient bilateral vocal fold paresis (BVFP) after thyroidectomy.

STUDY DESIGN

Prospective clinical study.

METHODS

A prospective study was conducted at Soonchunhyang University, Bucheon, Korea, between March 2005 and February 2023. This study enrolled 12 patients with BVFP after thyroidectomy who received botulinum toxin injections into the thyroarytenoid muscles. Vocal fold mobility and airway distress were assessed using a flexible laryngoscope before and after injection.

RESULTS

Of the 3018 thyroidectomy patients, 12 (0.39%) developed transient BVFP after surgery. Under the guidance of laryngeal electromyography, 3.6 ± 0.6 IU botulinum toxin was administered into the bilateral thyroarytenoid muscles. Notably, nine patients (75%) received a single injection, whereas three (25%) received an additional injection after 7days. The mean time for vocal fold movement recovery was 33.2 ± 17.2days after injection; conventional destructive procedures for BVFP were avoided in 10 of the 12 patients (83.3%).

CONCLUSIONS

Botulinum toxin injection offers a novel approach to airway management in patients with transient BVFP after thyroidectomy.

LEVEL OF EVIDENCE

Level 4.

Immediate Ansa cervicalis-to-recurrent laryngeal nerve low-tension anastomosis: A new technique for phonation recovery and bilateral anastomoses to avoid tracheotomy

OBJECTIVE

This case series study investigated the outcomes of an innovative approach, ansa cervicalis nerve (ACN)-to-recurrent laryngeal nerve (RLN) low-tension anastomosis.

METHODS

Patients who received laryngeal nerve anastomosis between May 2015 and September 2021 at the facility were enrolled. The inclusion criteria were patients with RLN dissection and anastomosis immediately during thyroid surgery. Exclusion criteria were cases with anastomosis other than cervical loop-RLN anastomosis or pronunciation recovery time > 6 months. Patients admitted before January 2020 were assigned to group A which underwent the conventional tension-free anastomosis, and patients admitted after January 2020 were group B and underwent the innovative low-tension anastomosis (Dong's method).

RESULTS

A total of 13 patients were included, 11 patients received unilateral surgery, and 2 underwent bilateral surgery. For patients who underwent unilateral anastomosis, group B had a significantly higher percentage of normal pronunciation via GRBAS scale (83.3 % vs. 0 %, p = 0.015) and voice handicap index (66.7 % vs. 0 %, p = 0.002), and shorter recovery time in pronunciation (median: 1-day vs. 4 months, p = 0.001) than those in group A after surgery.

CONCLUSIONS

ACNs-to-RLN low-tension anastomosis with a laryngeal segment ≤1 cm (Dong's method) significantly improves postoperative pronunciation and recovery time. The results provide clinicians with a new strategy for ACN -to-RLN anastomosis during thyroid surgery.

Fluorescence imaging to visualize the recurrent laryngeal nerve during thyroidectomy procedures: analysis of 65 cases and 81 nerves

BACKGROUND

Recurrent laryngeal nerve (RLN) injury after thyroidectomy is relatively common. Locating the RLN prior to thyroid dissection is paramount to avoid injury. We developed a fluorescence imaging system that permits nerve autofluorescence. We aimed to determine the sensitivity and specificity of fluorescence imaging at detecting the RLN relative to thyroid and other background tissue and compared it to white light.

METHODS

In this prospective study, 65 patients underwent thyroidectomy from January to April 2022 (16 bilateral thyroid resections) using white and fluorescent light. Fluorescence intensity [relative fluorescence units (RFU)] was recorded for RLN, thyroid, and background. RFU mean, minimum, and maximum values were calculated using Image J software. Thirty randomly selected pairs of white and fluorescent light images were independently reviewed by two examiners to compare RLN detection rate, number of branches, and length and minimum width of nerves visualized. Parametric and nonparametric statistical analysis was performed.

RESULTS

All 81 RNLs observed were visualized more clearly under fluorescence (mean intensity, µ = 134.3 RFU) than either thyroid (µ = 33.7, p < 0.001) or background (µ = 14.4, p < 0.001). Forest plots revealed no overlap between RLN intensity and that of either other tissue. Sensitivity and specificity for RLN were 100%. All 30 RLNs and all 45 nerve branches were clearly visualized under fluorescence, versus 17 and 22, respectively, with white light (both p < 0.001). Visible nerve length was 2.5 × as great with fluorescence as with white light (µ = 1.90 vs. 0.76 cm, p < 0.001).

CONCLUSIONS

In 65 patients and 81 nerves, RLN detection was markedly and consistently enhanced with autofluorescence neuro-imaging during thyroidectomy, with 100% sensitivity and specificity.

The use of superior parathyroid gland as an anatomical landmark in identifying recurrent laryngeal nerve during total thyroidectomy: a prospective single-surgeon study

Purpose

This study was performed to determine the anatomical position of recurrent laryngeal nerve (RLN) relative to superior parathyroid gland (SPG) in a consecutive total thyroidectomy series.

Methods

A total of 421 patients (mean age, 45.6 years; female, 76.0%) who had total thyroidectomy accompanied with intraoperative exposure of RLN in relation to SPG were included in this prospective single-surgeon thyroidectomy series study. The relation of RLN to SPG was assessed based on the measurement of the natural distance between the RLN and SPG, which was categorized as 0-5 mm, 6-10 mm, and ≥11 mm.

Results

Most of the thyroidectomy indications (69.1%) were related to malignant disease including papillary carcinoma in 54.9% of cases. Overall, in 90.7% of patients RLN was identified within 5 mm of the SPG, and in 65.1% of cases, it was found within 1 mm of the SPG. The RLN was found between 6 and 10 mm from the SPG in 8.5% of cases, while it was at least 11 mm away from the SPG in 0.7% of cases.

Conclusion

In conclusion, this prospective single-surgeon thyroidectomy series study indicates the likelihood of localizing the RLN in close proximity to SPG during total thyroidectomy operations. Hence, the SPG can be used as a landmark to identify RLN, and as part of routine parathyroid-sparing thyroidectomy, it may represent a convenient complementary approach to minimize the risk of iatrogenic injury to RLN in patients with an intact SPG.

Voice Changes Without Laryngeal Nerve Alterations After Thyroidectomy: The Need For Prospective Trials - A Review Study

BACKGROUND

Thyroidectomy is a commonly performed surgical procedure that is offered for different thyroid pathologies. The most frequent complication after total thyroidectomy is transient or permanent hypoparathyroidism followed by transient or permanent recurrent laryngeal nerve palsy. Patients may experience voice impairment despite intact laryngeal nerve function. These patients are of special interest because they experience subjective symptoms which are difficult to measure and therefore to treat.

SUMMARY

The Voice Handicap Index (VHI) and VHI-10 are the most commonly used subjective questionnaires. Their results correlate with objective findings. Female sex, in particular after menopause, is a dominant factor for developing voice impairment after thyroidectomy. The extent of neck surgery and the weight and volume of the removed thyroid correlates directly with both objective and subjective voice impairment after surgery. Videolaryngostroboscopy should be considered to examine vocal cord pathologies in this patient group. Surprisingly, there are no studies showing that speech and voice therapy are beneficial for patients with voice alterations but with intact laryngeal nerves.

CONCLUSIONS

While recurrent laryngeal nerve (RLN) paralysis can be evaluated by objective exams postoperatively, we are still left with the issue of possible partial or complete external branch of superior laryngeal nerve (EBSLN) injury. It is therefore quite difficult to segregate neural (RLN and EBSLN) and non-neural voice change populations, regardless of the method of literature evaluation. Perhaps patients' perspectives on how they experience voice functionality should play a superior role in deciding which patients should be investigated further with laryngoscopy, acoustic or perceptual analysis, and which patients should be offered treatment.

Extent of Surgery for Follicular Thyroid Carcinoma

OBJECTIVES

To examine the association between the extent of surgery and overall survival in follicular thyroid cancer (FTC) patients.

STUDY DESIGN

Retrospective analysis of the National Cancer Database (NCDB).

METHODS

Patients who underwent surgical intervention for FTC from 2004 to 2015 were selected. Patients were >18 years old, with tumor size 1-4 cm, no other malignancies, and >0 follow up time. Patients were divided into two cohorts based on extent of surgery: lobectomy (≥1 lobe resected) and thyroidectomy (total or near total resection). Pearson's chi-squared analysis was used to compare cohorts. Kaplan-Meier survival and Cox hazards models were utilized to determine overall survival between two cohorts with p < 0.05 used for significance.

RESULTS

A total of 6871 patients were identified with FTC, of which 1507 patients underwent lobectomy and 5364 patients underwent total thyroidectomy. There were no significant differences in patient demographics, comorbidity index, local spread, or tumor grade. Patients undergoing lobectomy had mean survival of 12.94 versus 12.71 years for those undergoing thyroidectomy. Extent of surgery was not associated with a significant difference in survival (5 years OS = 96% in lobectomy and 95.5% in total thyroidectomy, p = 0.08). Stratification by tumor grade resulted in no significant difference in survival between lobectomy and thyroidectomy.

CONCLUSION

Survival time was not significantly different in patients with more extensive resection of FTC.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:993-999, 2023.

Prevalence and Predictors of Post-Thyroidectomy Voice Dysfunction in a Nigerian Cohort

BACKGROUND

Advances in surgical techniques have significantly improved the safety of thyroidectomy. Quality of life issues, such as voice changes, however continue to be important considerations. This study evaluated the prevalence and determinants of voice changes following thyroidectomies for non-malignant goiters in a Nigerian Hospital.

METHODOLOGY

Consecutive adults who had thyroidectomy for non-malignant goiters were evaluated. Preoperatively, each participant had laryngoscopy and voice assessment using the Voice Handicap Index-10. At surgery, the intubation difficulty score, size of endotracheal tubes, and duration of operation were recorded. Laryngoscopy and VHI-10 assessments were repeated 1 week, 1 month, and 3 months after surgery. Pre and postoperative assessments were compared.

RESULT

Fifty-four patients completed the study. Subtotal thyroidectomy was the commonest operation performed in 17 patients (31.48%), with 14 (25.93%) having total thyroidectomy. Baseline median VHI-10 score was 6.5(IQR-10). Five patients had abnormal preoperative laryngoscopy findings (benign vocal cord lesions). Postoperatively, seven patients had endoscopic evidence of vocal cord paralysis, six were unilateral while one was bilateral. Ten patients (18.5%) had early voice changes. Median VHI-10 score at one week was significantly higher than baseline (10 vs. 6.5, p = 0.01). At 3 months, VHI-10 reverted back to baseline in five of the ten patients while five patients (9.3%) had persistent voice changes. Abnormal endoscopic findings predicted the occurrence of early postoperative voice changes.

CONCLUSION

Thyroidectomy for non-malignant goiters is associated with transient voice changes, many of which revert to normal over time. Abnormal endoscopic findings predict its occurrence.

Primary Nonselective Laryngeal Reinnervation in Iatrogenic Acute Recurrent Laryngeal Nerve Injury: Case Series and Literature Review

Treating an acutely injured recurrent laryngeal nerve by primary nonselective laryngeal reinnervation (LR) during thyroidectomy is encouraged to minimize postoperative morbidity. Performing a concurrent transoral temporary injection laryngoplasty (IL) may improve the patient's voice while waiting for the effect of successful reinnervation. Chronological multidimensional voice outcomes (qualitative and quantitative) and combination of the primary nonselective LR with concurrent transoral IL were not explicitly demonstrated in previous cases that published the literature. In this study, the authors presented the multidimensional voice parameters of 3 patients undergoing primary nonselective LR with concurrent IL during thyroidectomy. The parameters were measured at different time points (2 weeks and 1, 3, 6, and 12 months) following the surgery. Laryngeal electromyography was done at 1 to 2 months and 12 months postsurgery. The results showed that the voices, qualitatively and quantitatively, were within normal range at within 3 months postintervention. The parameters were slightly beyond the normal limit at 3 months and returned to normal at 6 months postintervention and beyond. The LEMG depicted evidence of successful reinnervation in which the motor unit was normal comparable to the opposite normal vocal fold.

Recurrent laryngeal nerve injury after thyroidectomy: A national study from Saudi Arabia

OBJECTIVES

To determine the incidence and possible risk factors of recurrent laryngeal nerve injury, to provide a relevant literature review of studies from other centers in Saudi Arabia, and to present basic statistical data for future studies in our local community.

METHODS

A retrospective study enrolled patients who were surgically treated for thyroid disease between January 2015 and December 2021. For concerns during the procedure, direct laryngoscopy was carried out before extubation to assess the vocal cords. Similarly, indirect laryngoscopy was carried out for patients who developed postoperative voice changes. All patients were evaluated clinically 2-3 weeks after surgery. Nerve monitors were not used in either case.

RESULTS

The study examined 437 participants: 361 (82.6%) female and 76 (17.4%) male individuals. The incidence of recurrent laryngeal nerve injury was 1.1%. The demographic characteristics, pathology (benign vs. malignant), and extent of thyroidectomy were not significantly associated with the risk of recurrent laryngeal nerve injury.

CONCLUSION

A recurrent laryngeal nerve injury is a serious complication, and further studies are required to determine the safest techniques for thyroidectomy. However, centralization of thyroid surgery in high-volume centers might reduce this risk.

Use of fluorescence imaging and indocyanine green during thyroid and parathyroid surgery: Results of an intercontinental, multidisciplinary Delphi survey

BACKGROUND

In recent years, fluorescence imaging-relying both on parathyroid gland autofluorescence under near-infrared light and angiography using the fluorescent dye indocyanine green-has been used to reduce risk of iatrogenic parathyroid injury during thyroid and parathyroid resections, but no published guidelines exist regarding its use. In this study, orchestrated by the International Society for Fluorescence Guided Surgery, areas of consensus and nonconsensus were examined among international experts to facilitate future drafting of such guidelines.

METHODS

A 2-round, online Delphi survey was conducted of 10 international experts in fluorescence imaging use during endocrine surgery, asking them to vote on 75 statements divided into 5 modules: 1 = patient preparation and contraindications to fluorescence imaging (n = 11 statements); 2 = technical logistics (n = 16); 3 = indications (n = 21); 4 = potential advantages and disadvantages of fluorescence imaging (n = 20); and 5 = training and research (n = 7). Several methodological steps were taken to minimize voter bias.

RESULTS

Overall, parathyroid autofluorescence was considered better than indocyanine green angiography for localizing parathyroid glands, whereas indocyanine green angiography was deemed superior assessing parathyroid perfusion. Additional surgical scenarios where indocyanine green angiography was thought to facilitate surgery are (1) when >1 parathyroid gland requires resection; (2) during redo surgeries, (3) facilitating parathyroid autoimplantation; and (4) for the predissection visualization of abnormal glands. Both parathyroid autofluorescence and indocyanine green angiography can be used during the same procedure and employing the same imaging equipment. However, further research is needed to optimize the dose and timing of indocyanine green administration.

CONCLUSION

Though further research remains necessary, using fluorescence imaging appears to have uses during thyroid and parathyroid surgery.

Factors Associated With Injury to Recurrent Laryngeal Nerve in Patients Undergoing Surgery for Thyroid Cancer: A Single-centre Study Using Translaryngeal Ultrasound

AIMS

Intraoperative injury to the recurrent laryngeal nerve (RLN) is a serious complication occurring more frequently in patients with thyroid cancer than in those with benign thyroid diseases. However, data on the risk factors for RLN injury among patients with thyroid cancer are scarce. Currently, RLN injury is diagnosed by laryngoscopy, but translaryngealultrasonography (TLUS), which is less invasive, appears to have a similar accuracy. Herein, we analysed risk factors ofintraoperative RLN injury in patients with thyroid cancer and assessed the diagnostic performance of TLUS.

PATIENTS AND METHODS

In this prospective study, we enrolled patients undergoing surgery for thyroid cancer from October 2020 to October 2021. Medical and surgical variables were analysed as risk factors of RLN injury. TLUS was compared with laryngoscopy in diagnosing RLN injury.

RESULTS

There were 185 patients who underwent 196 surgeries. Of all surgeries, 23 (11.7%) caused RLN injury ascertained on laryngoscopy. Compared with laryngoscopy, TLUS displayed high sensitivity (97.7%; 95%CI: 94.3%-99.4%) and specificity (100%; 95% CI: 82.4%-100%). Before surgery, medical and surgical characteristics did not differ significantly between patients with or without RLN injury, but RLN entrapment by tumour was more frequent in those with the injury (P < 0.001). The risk of RLN injury was increased in patients undergoing thyroidectomy with lateral neck dissection (OR = 4.53; 95% CI: 1.29-14.32) and in those with lymph node metastases (OR = 2.76; 95% CI: 1.03-7.01).

CONCLUSION

Intraoperative RLN injury in patients with thyroid cancer is more common after operations requiringgreater resections and with lymph node involvement. TLUS could be used to diagnose RLN injury.

Nerve autofluorescence under near-ultraviolet light: cutting-edge technology for intra-operative neural tissue visualization in 17 patients

BACKGROUND

Nerve visualization and the identification of other neural tissues during surgery is crucial for numerous reasons, including the prevention of iatrogenic nerve and neural structure injury and facilitation of nerve repair. However, current methods of intra-operative nerve detection are generally expensive, unproven, and/or technically challenging. Recently, we have documented, in both in vivo animal models and ex vivo human tissue, that nerves autofluorescence when viewed in near-ultraviolet light (NUV). In this paper, we describe our use of nerve autofluorescence to facilitate the visualization of nerves and other neural tissues intra-operatively in 17 patients undergoing a range of surgical procedures.

METHODS

Employing the same prototype axon imaging system previously documented to markedly enhance nerve visualization in both in vivo animal and ex vivo human models, surgical fields were observed in 17 patients under both white and NUV light during parotid tumor resection (n = 3), thyroid tumor resection (n = 7), and surgery for peripheral nerve and spinal tumors and injury (n = 7).

RESULTS

In all 17 patients, the intra-operative use of the imaging system both was feasible and markedly enhanced the localization of all neural tissues throughout their course within the surgical field. All 17 procedures were successful and devoid of any peri-operative complications or post-operative neurological deficits.

CONCLUSIONS

Intra-operatively visualizing auto-fluorescent peripheral nerves and other neural tissues under NUV light is feasible in human patients across a range of clinical scenarios and appears to appreciably enhance nerve and other neural tissue visualization. Controlled studies to explore this technology further are needed.

Assessment of Radiofrequency Ablation for Papillary Microcarcinoma of the Thyroid: A Systematic Review and Meta-analysis

IMPORTANCE

Papillary microcarcinomas of the thyroid (mPTCs) account for an increasing proportion of thyroid cancers in past decades. The use of radiofrequency ablation (RFA) has been investigated as an alternative to surgery. The effectiveness and safety of RFA has yet to be determined.

OBJECTIVE

To evaluate the effectiveness and safety of RFA for low-risk mPTC.

DATA SOURCES

Embase, MEDLINE via Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and the top 100 references of Google Scholar were searched from inception to May 28, 2021.

STUDY SELECTION

Articles reporting on adult patients with mPTC treated with RFA were included. Studies that involved patients with pre-ablation lymph node or distant metastases, recurrence of disease, or extrathyroidal extension were excluded. Final article selection was conducted by multiple reviewers based on consensus. The proportion of eligible articles was 1%.

DATA EXTRACTION AND SYNTHESIS

This meta-analysis was conducted in accordance with the MOOSE guidelines. Random and fixed-effect models were applied to obtain pooled proportions and 95% CIs.

MAIN OUTCOMES AND MEASURES

The primary outcome was the complete disappearance rate of mPTC. Secondary outcomes were tumor progression and complications.

RESULTS

Fifteen studies were included in this meta-analysis. A total of 1770 patients (1379 women [77.9%]; mean [SD] age, 45.4 [11.4] years; age range, 42.5-66.0 years) with 1822 tumors were treated with RFA; 49 tumors underwent 1 additional RFA session and 1 tumor underwent 2 additional RFA sessions. Mean (SD) follow-up time was 33.0 (11.4) months (range, 6-131 months). The pooled complete disappearance rate at the end of follow-up was 79% (95% CI, 65%-94%). The overall tumor progression rate was 1.5% (n = 26 patients), local residual mPTC in the ablation area was found in 7 tumors (0.4%), new mPTC in the thyroid was found in 15 patients (0.9%), and 4 patients (0.2%) developed lymph node metastases during follow-up. No distant metastases were detected. Three major complications occurred (2 voice changes lasting >2 months and 1 cardiac arrhythmia). Minor complications were described in 45 patients.

CONCLUSIONS AND RELEVANCE

The findings of this systematic review and meta-analysis suggest that RFA is a safe and efficient method to treat selected low-risk mPTCs. Radiofrequency ablation could be envisioned as step-up treatment after local tumor growth under active surveillance for an mPTC or initial treatment in patients with mPTCs with anxiety about active surveillance.

A clinically relevant formulation for direct administration of nerve specific fluorophores to mitigate iatrogenic nerve injury

Iatrogenic nerve injury significantly affects surgical outcomes. Although intraoperative neuromonitoring is utilized, nerve identification remains challenging and the success of nerve sparing is strongly correlated with surgeon experience levels. Fluorescence guided surgery (FGS) offers a potential solution for improved nerve sparing by providing direct visualization of nerve tissue intraoperatively. However, novel probes for FGS face a long regulatory pathway to achieve clinical translation. Herein, we report on the development of a clinically-viable, gel-based formulation that enables direct administration of nerve-specific probes for nerve sparing FGS applications, facilitating clinical translation via the exploratory investigational new drug (eIND) guidance. The developed formulation possesses unique gelling characteristics, allowing it to be easily spread as a liquid followed by rapid gelling for subsequent tissue hold. Optimization of the direct administration protocol with our gel-based formulation enabled a total staining time of 1-2 min for compatibility with surgical procedures and successful clinical translation.

Application of Translaryngeal Ultrasound (TLUS) in Patients with Neck Surgery—A Single-Centre, Prospective Cohort Study on Technique Evaluation

Purpose: The primary objective of this study was to assess the value of translaryngeal ultrasound (TLUS) in assessing vocal fold (VF) function in patients after thyroid, parathyroid and neck lymph node surgery. Methods: A total of 219 patients that underwent 230 surgical procedures were enrolled in this prospective study. The study was conducted from October 2020 to October 2021. Patients’ VFs were analysed independently with TLUS and laryngoscopy before and after the surgery. Various TLUS variables, such as vocal folds displacement velocity (VFDV), arytenoids symmetry and angle between VFs, were measured. The questionnaire evaluating discomfort caused to patients by both methods was conducted. Results: Of the 230 surgeries in this study, 85% were from oncological indications. The incidence of RLN injury was 10.4%. The accuracy of TLUS compared to laryngoscopy was 98.3%, with sensitivity 98.1%, specificity 100%, PPV 100% and NPV 83.3%. Laryngoscopy was found to cause significantly more discomfort than TLUS. VF visibility was lower in men; smokers; and patients with higher BMI (32 vs. 28 kg/m²), multifocal cancer, higher left lobe volume and higher fT3 levels. Arytenoid symmetry VFDV was lower for “e” and “i” right side and “i” left side in injured/disabled VFs/RLN. Conclusions: TLUS can be an excellent and non-invasive method of VF evaluation in most patients. There are some technical aspects that can improve its accuracy. Sometimes, RLN injury after the surgery, especially among oncological patients, is unavoidable. Therefore, it is vital to diagnose dysphonia early with convenient methods, such as TLUS.

Laryngeal Nerves and Voice Change in Thyroid Surgery

The low incidence of injury to the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN) quoted in the literature is derived from expert series. The exact incidence of nerve injury of a thyroid surgeon will be revealed only if pre-operative and post-operative laryngoscopy is becoming routine practice. It is found that the injury rates are increased with routine post-operative laryngoscopy. Subjective voice change occurred in one third of patients all whom had normal vocal cord motion. Therefore, it is important to take written informed consent for voice change in addition to identification of both nerves and documenting it.

Post-thyroidectomy complications in southwestern Saudi Arabia: a retrospective study of a 6-year period

BACKGROUND

Thyroidectomy is the surgical removal of all or part of the thyroid gland for non-neoplastic and neoplastic thyroid diseases. Major postoperative complications of thyroidectomy, including recurrent laryngeal nerve injury, hypocalcemia, and hypothyroidism, are not infrequent.

OBJECTIVE

Summarize the frequency of surgical complications of thyroidectomy.

DESIGN

Retrospective.

SETTING

Secondary health facility in southwestern Saudi Arabia.

PATIENTS AND METHODS

We collected data from the records of patients who were managed for thyroid diseases between December 2013 and December 2019.

MAIN OUTCOME MEASURE

Complications following thyroidectomy.

SAMPLE SIZE

339 patients, 280 (82.6%) females and 59 (17.4%) males.

RESULTS

We found 311 (91.7%) benign and 28 (8.3%) malignant thyroid disorders. Definitive management included 129 (38.1%) total thyroidectomies, 70 (20.6%) hemithyroidectomies, 10 (2.9%) subtotal thyroidectomies and 5 (1.5%) near-total thyroidectomies with 125 (36.9%) patients treated non-surgically. The overall complication rate was 11.3%. There were 4 (1.9%) patients with recurrent laryngeal nerve palsy, 16 (7.5%) patients with temporary hypoparathyroidism, 1 (0.5%) patient with paralysis of the external branch of the superior laryngeal nerve and 3 (1.4%) patients with wound hematoma.

CONCLUSION

The rate of complications following thyroidectomy is still high. There is a need for emphasis on comprehensive measures to control the high rate of complications.

LIMITATIONS

Retrospective design and no long-term follow up to monitor late complications.

CONFLICT OF INTEREST

None.

Clinical Outcomes of Diffuse Sclerosing Variant Papillary Thyroid Carcinoma in Pediatric Patients

OBJECTIVES/HYPOTHESIS

The diffuse sclerosing variant of papillary thyroid carcinoma (DSV) may be more aggressive than conventional well-differentiated non-DSV related papillary thyroid carcinomas (N-PTC).

STUDY DESIGN

Retrospective chart review.

METHODS

Retrospective review of clinical outcomes for patients 21 years of age or younger who underwent initial surgery for PTC at a single institution from January 1, 2005 to April 1, 2020. Genomic analysis was performed using targeted next-generation sequencing. Data were analyzed using Fischer's exact test and Kaplan-Meier curve log-rank test.

RESULTS

Our cohort consisted of 72 patients, nine with DSV and 63 with N-PTC. Age at diagnosis was comparable (15.4 vs. 16.2 years, respectively, P = .46). DSV were more likely to be in the high-risk American Thyroid Academy pediatric risk group (100% vs. 41.3%, P = .004), to present with regional cervical lymph node metastases (100% vs. 60.3%, P = .036), and to present with distant metastases (67% vs. 22%, P = .005). No mortality seen in either group over 27.5 (interquartile range 14.8, 46.00) months average follow-up. Throughout the follow-up period, DSV were more likely to experience progression than N-PTC (hazard ratio = 5.7 [95% confidence interval 1.7-20.0; P = .0056]). In a subset of 19 patients with aggressive disease who had molecular testing as part of clinical care we detected RET fusions in nearly all DSV compared to a minority of N-PTC (83% vs. 15.4%, P = .0095).

CONCLUSIONS

Pediatric patients with DSV have more advanced disease at diagnosis and are more likely to experience progression of disease compared to patients with N-PTC. The prevalence of RET fusions in our cohort recapitulates the frequency of this alteration described in prior studies.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Nerve monitoring decreases recurrent laryngeal nerve injury risk for neoplasm-related thyroidectomy

OBJECTIVE

Conflicting reports exist regarding the benefit of intraoperative neuromonitoring (INM) for patients undergoing thyroidectomy. We hypothesized that in a national sample, the risk of mild and severe RLNi is decreased for patients undergoing neoplasm-related disease (NRD) thyroidectomy with INM compared to patients without INM.

METHODS

The database was queried for patients that underwent total thyroidectomy for NRD with and without INM. A multivariable logistic regression model was used to determine the associated odds of RLNi.

RESULTS

From 6942 patients, 4269 (61.5%) had INM during thyroidectomy. Patients with INM had a similar rate of overall RLNi compared to patients without INM (5.7% vs. 6.6%, p = 0.118). After adjusting for covariates, INM was associated with decreased odds of severe-RLNi (OR 0.23, p = 0.036) but not mild-RLNi (p = 0.16).

CONCLUSION

INM is associated with a nearly 80% decreased associated odds of severe RLNi during thyroidectomy for NRD. Future prospective confirmation is needed, and if confirmed, patients undergoing thyroidectomy for NRD should have INM to reduce the risk of RLNi and its associated morbidity.

Ultrasound-guided thermal ablation for papillary thyroid microcarcinoma: a multicenter retrospective study

PURPOSE

Ultrasound-guided thermal ablation (including microwave ablation [MWA] and radiofrequency ablation [RFA]) has emerged as a remarkable technology for the treatment of benign and malignant diseases. The objective of this multicenter study was to assess the efficacy and safety of thermal ablation in a large cohort of patients with papillary thyroid microcarcinoma (PTMC).

MATERIALS AND METHODS

Retrospective study of 725 patients who underwent MWA/RFA at 11 centers between March 2015 and March 2020. The mean age of patients was 46 ± 11 years (range, 22-81); the mean follow-up time was 21 ± 13 months (range, 6-60). Changes in size of tumor, the rates of tumor disappearance, disease progression, and complications were assessed.

RESULTS

From 6 months post-ablation, the size of tumors was significantly reduced compared with those recorded pre-ablation (p < 0.001 for all). Five hundred and fifteen (71.0%) PTMCs had completely disappeared as assessed by ultrasound examination. Six (0.8%) patients developed disease progression post-ablation; of these, 5 (0.7%) patients developed new PTMCs, while one (0.1%) patient developed cervical lymph node metastasis. Nineteen (2.6%) patients developed complications post-ablation; of these 14 (1.9%) patients developed voice hoarseness, 4 (0.6%) developed hematoma, and one (0.1%) patient developed cough.

CONCLUSIONS

Ultrasound-guided thermal ablation represents an effective and safe treatment for patients with PTMC besides active surveillance and surgery.

Thyroid neoplasm in Makkah region, Saudi Arabia. A retrospective epidemiological study

Objectives:

To improve our local data and demographics of thyroid neoplasm in Makkah region, Kingdom of Saudi Arabia and provide some basic statistics for future studies in our local community.

Methods:

A record based retrospective epidemiological study was conducted and included 314 thyroid disease patients who were presented to our centers at Makkah region, Kingdom of Saudi Arabia between December 2009 and December 2019.

Results:

A descriptive statistical analysis was carried out. The average age was 42.77 years, with a female-to-male ratio of 3:1, and most of the patients were Saudi (77%). Fifty-seven percent of cases were benign, while in malignant cases, 33.4% were papillary thyroid carcinoma. The mean follow-up time was 15.44 months, with excellent compliance in 39.4% of the patients.

Conclusion:

Thyroid tumors have a leading incidence in head and neck tumors in Makkah, Kingdom of Saudi Arabia, mandating further studies to determine the causes and distribution in other regions of the country.

Clinical observation of end-to-end neuroanastomosis in the treatment of complete injury of the unilateral recurrent laryngeal nerve

Background

Complete injury of the recurrent laryngeal nerve (RLN) is a serious complication of thyroid surgery. Increasingly researches focus on the voice recovery of patients with RLN injury. This paper studied the effect of immediate end-to-end neuroanastomosis after complete injury of the unilateral RLN during thyroid surgery on postoperative vocal function.

Methods

Thirteen patients who underwent end-to-end neuroanastomosis for the treatment of complete injury of the unilateral RLN caused by thyroid surgery in Hunan Provincial People's Hospital between October 2009 and January 2020 were selected. The basic information, cause of RLN injury, postoperative voice recovery, recovery time, and subjective assessment of voice by auditory perception results (Grade, Roughness, Breathiness, Asthenia, and Strain, the GRBAS score) of the patients were recorded.

Results

Among the 13 cases with RLN injury, the cause of RLN injury in 10 cases was transection by sharp instruments, and the voice was recovered one day after the operation. The cause of RLN injury in one case was suture of the RLN branch, and the voice was recovered one day after the operation. The cause of RLN injury in two cases was thermal injury, and the times for voice recovery after end-to-end neuroanastomosis were 3 and 4 months. The patients with a GRBAS score of 0 or 1 recovered their voice one day after the operation. The GRBAS score reached 1 in the two thermal injury cases, with voice recovery at 3 and 4 months after surgery. By 6 months, the voice recovery rate of the patients was 100%.

Conclusions

After complete injury of the unilateral RLN, immediate end-to-end anastomosis of the RLN can maximally preserve the postoperative vocal function of patients.

Energy Based Vessel Sealing Devices in Thyroid Surgery: A Systematic Review to Clarify the Relationship with Recurrent Laryngeal Nerve Injuries

Background and objectives: The principal complications associated with thyroid surgery consist in postoperative recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, intra-operative and post-operative hemorrhage. In this paper, structured as a literature review, we describe the current knowledge and the technical improvements currently employed in the field of thyroid surgery, focusing on the contribution of energy based devices in relation with the reduction of the operating time and the odds of possible complication. Materials and methods: a relevant systematic literature search on Pubmed was carried out including works from 2004 through 2019, selecting studies providing information on the energy based devices employed in surgeries and statistic data concerning RNL (transient and permanent) injury and operative time. Results: Nineteen studies were reviewed, dealing with 4468 patients in total. The operative variables considered in this study are: employed device, number of patients, pathological conditions affecting the patients, surgical treatment, RNL injury percentage and the operating time, offering an insight on different patient conditions and their relative operative outcomes. A total of 1843 patients, accounting to the 41.2% of the total pool, underwent the traditional technique operation, while 2605 patients (58.3%) were treated employing the energy based devices techniques. Thyroidectomy performed by approaches different from traditional (for example robotic, MIVAT (Mini Invasive Video Assisted thyroidectomy)) were excluded from this study. Conclusions: The energy-based vessel sealing devices in study, represent a safe and efficient alternative to the traditional clamp-and-tie hand technique in the thyroidal surgery scenario, granting a reduction in operating time while not increasing RNL injury rates. According to this information, a preference for energy based devices techniques might be expressed, furthermore, a progressively higher usage rate for these devices is expected in the near future.

The Anatomical Relationship of Inferior Thyroid Artery and Recurrent Laryngeal Nerve: A Review of the Literature and Its Clinical Importance

Background

Thyroidectomy is a quite common daily operation in general surgery. However, the anatomical structures of the region, mainly the relationship of recurrent laryngeal nerve (RLN) and inferior thyroid artery (ITA) makes the procedure challenging. The current review of the literature aims to report the anatomical variations of this relationship.

Methods

The preferred reporting items for systemic reviews and meta-analyses (PRISMA) guidelines were used for the systematic review of the articles found after an extensive research through PubMed, Science Direct, EMBASE and Web of Science. A total of 16 studies were included for the statistical analysis.

Results

The results showed that the most common type of RLN was posterior to the ITA. However, according to Higgins I² statistics the heterogeneity of the studies was quite high.

Conclusions

The relationship between the RLN and the ITA is quite variable. Anatomical knowledge of the region is vital for attempting to eliminate the risk of injuring the nerve during thyroidectomy.

Overview of Thyroid Surgery Complications

Introduction

The most obvious indication for thyroid surgery is malignancy, but other indications are also not rare. As with any other surgical procedure, those surgeries also carry risks which can be classified as minor or major.

Discussion

In this overview, we present minor (seroma, scarring) and major complications of thyroid surgery (recurrent nerve injury, hypoparathyroidism, and bleeding). We discuss the possibilities of prevention and treatment of each of those complications.

Conclusion

In recent years, thyroid surgery is becoming safer due to the development of new surgical, hemostatic, and other techniques such as intraoperative monitoring of the recurrent laryngeal nerve and parathyroid gland detection.

Serial transcutaneous laryngeal ultrasonography in intensive care unit for assessment of vocal cord palsy: a case report

A direct laryngoscopy is currently the standard method for diagnosing RLN (Recurrent Laryngeal Nerve) paralysis after thyroid or parathyroid surgery but this procedure can be uncomfortable for patients and may cause undesirable changes in vital signs. A 40 years old female after a total thyroidectomy was assumed to have a bilateral vocal cord palsy on direct laryngoscopy after surgery. Patient was shifted to intensive care unit (ICU) on ventilatory support. We used serial transcutaneous laryngeal ultrasonography in the ICU for assessing the vocal cord functions along with conservative management. After 3 days, we were able to safely extubate the trachea and tracheostomy was avoided.

Laryngeal paralysis detected in preoperative laryngoscopy in malignant and benign thyroid disease. Systematic review and meta-analysis

There is controversy regarding the performance of preoperative laryngoscopy (LP) in thyroid surgery, with different recommendations being made, based on observational studies, in various publications. The aim of the study was to know the prevalence of laryngeal paralysis found in the LPs of patients who underwent thyroidectomy in benign and malignant pathology. A systematic review was carried out with 29 articles included for the qualitative study and a meta-analysis of 13 articles in which the data could be obtained to evaluate the same effect (in all patients in which an LP was carried out, those with preoperative laryngeal paralysis were included, and assigned to malignant or benign postoperative histology groups). The pooled prevalence of preoperative paralysis in benign pathology was 1.1% (95% CI 0.7 to 1.7%, 71% I²) and in 6.3% malignant pathology (95% CI 3.8 to 9.4%; I² 85%). The prevalence was significantly higher among patients with malignant pathology with an estimated effect RR 5.66, 95% CI, 2.48, 12.88. The studies analyzed present biases that will need to be corrected in future research, eliminating blinding biases in the selection and allocation of patients or in the laryngoscopy technique used. The LP in thyroid surgery evaluates possible disorders of laryngeal motility. The prevalence of laryngeal paralysis in thyroid pathology found in LPs in patients with a postoperative diagnosis of malignant pathology was higher than in the benign pathology group. This information is necessary for interpreting the intraoperative neuromonitoring signal and for making informed decisions.

Is Vocal Cord Assessment before Total Thyroidectomy Required for All Patients?

We investigated whether laryngoscopy should be performed before total thyroidectomy on all patients without a history of neck surgery. A total of 2523 patients who underwent total thyroidectomy between January 1, 2013, and March 18, 2018, were retrospectively examined. Pre-operative vocal cord examination was performed on 2070 of these patients by the otorhinolaryngology department using indirect laryngoscopy. Patients with a history of neck or thyroid surgery were not included in the study. The patients were evaluated in terms of age, gender, symptom (hoarseness/dyspnea), comorbidity, surgical history, biopsy, nodule diameter, pathological diagnosis, and tracheal deviation. Preoperative vocal cord paralysis was detected in 0.8 per cent of the patients (17/2070). Four patients (23.5%) were male and 13 patients (76.5%) were female. The mean age was 62 (range, 25–82) years. Seven of the 17 patients (41%) were symptomatic, with complaints of dyspnea in five and hoarseness in two. The univariate analysis revealed that a nodule diameter >30 mm and the presence of dyspnea were associated with vocal cord damage. Furthermore, the multivariate analysis showed that dyspnea alone was an independent variable ( P = 0.011). It is recommended that preoperative vocal cord evaluation should be performed only in patients with severe symptoms, such as dyspnea.

Study protocol to develop a patient-reported outcome measuring disability associated with unilateral vocal fold paralysis: a mixed-methods approach with the CoPE collaborative

INTRODUCTION

Patient-reported outcome (PRO) measures are increasingly developed with multisite, representative patient populations so that they can serve as a primary endpoint in clinical trials and longitudinal studies. Creating multisite infrastructure during PRO measure development can facilitate future comparative effectiveness trials. We describe our protocol to simultaneously develop a PRO measure and create a collaborative of tertiary care centres to address the needs of patients with unilateral vocal fold paralysis (UVFP). We describe the stakeholder engagement, information technology and regulatory foundations for PRO measure development and how the process enables plans for multisite trials comparing treatments for this largely iatrogenic condition.

METHODS AND ANALYSIS

The study has three phases: systematic review, measure development and measure validation. Systematic reviews and qualitative interviews (n=75) will inform the development of a conceptual framework. Qualitative interviews with patients with UVFP will characterise the lived experience of the condition. Candidate PRO measure items will be derived verbatim from patient interviews and refined using cognitive interviews and expert input. The PRO measure will be administered to a large, multisite cohort of adult patients with UVFP via the CoPE (vocal Cord Paralysis Experience) Collaborative. We will establish CoPE to facilitate measure development and to create preliminary infrastructure for future trials, including online data capture, stakeholder engagement, and the identification of barriers and facilitators to participation. Classical test theory psychometrics and grounded theory characterise our approach, and validation includes assessment of latent structure, reliability and validity.

ETHICS AND DISSEMINATION

Our study is approved by the University of Wisconsin Health Sciences Institutional Review Board. Findings from this project will be published in open-access journals and presented at international conferences. Subsequent use of the PRO measure will include comparative effectiveness trials of treatments for UVFP at CoPE Collaborative sites.

Degree of technical difficulty of thyroidectomy for autoimmune thyroid disease

BACKGROUND

Our goal was to elucidate the differences in degree of technical difficulty of thyroidectomy in patients with autoimmune thyroid diseases.

METHODS

Charts of adult patients who had undergone thyroidectomy were reviewed. Patients with Hashimoto's Thyroiditis (HT) or Graves' Disease (GD) were individually compared to a control group of patients with early stage malignancy or goiter.

RESULTS

The HT (n = 65) group was significantly more likely to have friable (P = .001) and fibrotic (P < .001) thyroids, longer operative times (P = .02), and a 22-modifier (P = .005). The GD (n = 169) group was significantly more likely to have friable (P < .001), vascular (P < .001), fibrotic (P = .038), and heavy (P = .002) thyroids, longer operative times (P = .03), increased length of stay (P = .01) and a 22-modifier (P = .01).

CONCLUSION

Our experience at an institution with a high-volume thyroid practice demonstrates that patients with autoimmune thyroid disease have consistent qualitative changes of the thyroid and significantly increased operative times and surgical difficulty.

Importance of incorporating intraoperative neuromonitoring of the external branch of the superior laryngeal nerve in thyroidectomy: A review and meta-analysis study

BACKGROUND

Voice changes are frequently reported after thyroidectomy due to injury to the external branch of the superior laryngeal nerve (EBSLN) and paralysis of the cricothyroid muscle, The objective is to evaluate the advantage of intraoperative neuromonitoring (IONM) in identifying EBSLN during thyroid surgery.

METHODS

Data sources were MEDLINE, PubMed, Web of Science, and Cochrane Library from January 1, 1995, through July 1, 2018. Published studies of adult patients who had thyroid surgery and an attempt to identify EBSLN done by conventional methods and/or IONM were selected.

RESULTS

Seven studies met all inclusion criteria. Patients who had IONM during thyroid surgery had a significantly increased number of identified EBSLN at risk, compared to the control group.

CONCLUSION

The use of IONM during open thyroid surgery increases EBSLN identification/visualization, and hence it may decrease the incidence of post-thyroidectomy voice disorders.

Voice outcomes following medialization laryngoplasty with and without arytenoid adduction

OBJECTIVE

Voice outcomes following medialization laryngoplasty (ML) for unilateral vocal fold paralysis (UVFP) were compared to those who underwent ML plus arytenoid adduction (AA) (ML+AA).

METHODS

Single institution retrospective review of patients with UVFP undergoing ML and ML+AA (2009-2017). Demographic information and history of laryngeal procedures were collected. Preoperative and postoperative Voice Handicap Index-10 (VHI-10) and Consensus Perceptual Auditory Evaluation of Voice (CAPE-V) were assessed.

RESULTS

Of 236 patients, 119 met study criteria. Of those, 70 (59%) underwent ML and 49 (41%) underwent ML+AA. Significant differences between groups at baseline were found for age at time of thyroplasty (P = 0.046), VHI-10 scores (P < 0.001), and CAPE-V scores (P = 0.007). Baseline VHI-10 scores for ML+AA (28 ± 7) were greater than those for ML alone (24 ± 7). At 12 months, overall VHI-10 scores improved compared to baseline for both groups (ML+AA = 9 ± 7, ML = 16 ± 9); however, there was greater improvement for the ML+AA group compared to ML group (P = 0.001). CAPE-V scores at 3 or 12 months improved, but differences between the groups were not statistically significant once controlled for covariates.

CONCLUSION

Based on current findings, patients who undergo ML+AA likely have greater voice handicap at baseline compared to those undergoing ML alone. Patients selected for ML+AA improve as much or more than those who underwent ML alone. This highlights the importance of appropriate selection of candidates for AA.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1876-1881, 2019.

Recovery of respiratory function and autonomic diaphragm movement following unilateral recurrent laryngeal nerve to phrenic nerve anastomosis in rabbits

The authors studied restoration of respiratory function in rabbits, using the recurrent laryngeal nerve to restore function after the phrenic nerve had been severed. The results of this animal study are encouraging and suggest that a similar technique could possibly be used to help patients with severe cervical spinal cord injuries.

Outcomes of CO2 laser-assisted posterior cordectomy in bilateral vocal cord paralysis in 132 cases

The purpose of the study was to assess the role of laser-assisted posterior cordectomy in the management of patients with bilateral vocal cord paralysis. We aimed an analysis of 132 consecutive patients treated by CO₂ laser posterior cordectomy, aged 38-91, 31% tracheotomized on admission. Cordectomy was performed under microlaryngoscopy using CO₂ laser (Lumenis AcuPulse 40 CO₂ laser, wavelength 10.6 μm, Lumenis Ltd., Yokneam, Israel). We looked at the number of laser glottic procedures necessary to achieve decannulation in tracheotomized patients and to achieve respiratory comfort in non-tracheotomized subjects and we evaluated the two groups for differences in patient characteristics. In tracheotomized patients, we also assessed factors affecting the success of decannulation and we evaluated the impact of tracheotomy on patients' lives. Decannulation was performed in 63% of tracheotomized patients. In terms of the number of procedures, 54% (14), 19% (5), and 27% (7) tracheotomized vs. 74% (61), 24% (20), and 2% (2) non-tracheotomized subjects underwent one, two, or three procedures, respectively. In the group of tracheotomized patients who were successfully decannulated, the number of multiple laser-assisted procedures was significantly higher than in the group of non-tracheotomized subjects with respiratory comfort after treatment (p = 0.04). Advanced age (> 66 years), comorbidities (diabetes, gastroesophageal reflux disease (GERD)), multiple thyroid surgeries, and tracheotomy below the cricoid cartilage were found to decrease the likelihood of successful decannulation. Posterior cordectomy is a simple method allowing for airway improvement and decannulation in patients with bilateral vocal cord paralysis. It is less effective in tracheotomized subjects with diabetes or GERD, older than 66 years old, after two or more thyroidectomies.

Thyroid reoperation using intraoperative neuromonitoring

PURPOSE

Thyroid reoperations are at a high risk of recurrent laryngeal nerve (RLN) injury. The aim of the study was to investigate whether the use of intraoperative neuromonitoring (IONM) can aid in the RLN identification and minimize the risk of its injury, in comparison with visual RLN identification.

METHODS

This was a retrospective cohort study of patients who underwent thyroid reoperations with and without the use of IONM. Primary endpoint was the RLN identification rate; secondary: the prevalence of RLN injury, the frequency of total thyroidectomies, and the course of the RLN.

RESULTS

The study involved 61 patients undergoing thyroid reoperation among whom 24 were operated on with visual RLN identification only, while 37 procedures used IONM. In the non-monitored reoperations, 44.4% of the RLN were visually identified, as opposed to 91.6% in the IONM group (p < 0.001). Transient paresis occurred in three nerves with visualization (6.6%), and in one in IONM group 1.6% (p = 0.185). Permanent paresis occurred in the group with visualization (6.6%), as opposed to none with neuromonitoring. The extent of resection in both groups was significantly different (p = 0.043). Total, near-total thyroidectomies, Dunhill operations and subtotal thyroidectomies were performed in 71, 17, 4, and 8% in the visualization group, and in 94, 0, 3, and 3%, respectively, in the IONM group. A non-anatomical RLN course was observed in 80% of the reoperations with IONM.

CONCLUSIONS

Thyroid reoperation should be performed using IONM, because it allows for a significantly improved RLN identification rate and a significantly more radical resection.

Bilateral vocal cord palsy after total thyroidectomy-A new treatment-Case reports

INTRODUCTION

Dyspnea due to bilateral vocal cord palsy after total thyroidectomy (BVCPATT) is a life-threatening complication; nevertheless, we try to avoid tracheotomy.

METHODS

Using normalized glottal area (NGA), we retrospectively studied 14 patients with BVCPATT. Nine patients without dyspnea were treated conservatively, while five with dyspnea received immediate bilevel positive air-way pressure (BiPAP) treatment. Both right and left recurrent nerves were grossly intact during surgery.

RESULTS

The mean NGA during inspiration of five patients with dyspnea was less than that of nine patients without (6.21±1.57 (mean±standard deviation) vs. 20.5±9.5; p=0.001). The mean age of patients with dyspnea was more than that of patients without (61.6±15.6 vs. 38±10.2; p=0.007). Five patients with dyspnea that occurred at 0-8days post operation recovered within 3-17days after BiPAP.

CONCLUSION

Dyspnea occurred in patients with BVCPATT who were relatively older. The mean NGA during inspiration in patients with dyspnea was less than that in patients without. BiPAP might be a new treatment for dyspnea.

Radioactive Iodine Therapy and Glucose Tolerance

Radioactive iodine therapy is commonly used as an adjuvant therapy in follicular and papillary thyroid carcinoma (PTC) and in the treatment of Graves’ disease (GD). The basis of this therapy is the accumulation of radioactive iodine by the sodium-iodide symporter (NIS) in the thyroid gland. Expression of NIS by extrathyroidal tissues such as islets of pancreas has been reported. Radioactive iodine uptake by pancreatic beta-cells can potentially damage these cells. In this study, we discuss the possible associations between radioactive iodine and glucose intolerance. Overall, radioactive iodine uptake by the pancreas may damage beta-cells and predispose patients to glucose intolerance or type 2 diabetes, particularly in patients exposed to radioactive iodine therapy following total thyroidectomy. Further studies are needed to clarify and confirm this association.

Evaluation of Vocal Cord Function Before Thyroidectomy: Experience from a Developing Country

Vocal cord palsy (VCP) is a major complication of thyroidectomy. Some patients have preexisting VCP prompting the need for routine or selective preoperative evaluation of the vocal cords. The study aims at ascertaining the prevalence of preoperative VCP and making appropriate recommendations. This is a retrospective study of all adult patients who had thyroidectomy at the University of Nigeria Teaching Hospital. Case notes of patients who had thyroidectomy at the hospital from July 2010 to June 2015 were retrieved. Variables studied included biodata, duration of goiter, preoperative hoarseness, outcome of indirect laryngoscopy (IDL), histology of specimen, duration of follow-up, and incidence of postoperative hoarseness. Descriptive statistical analysis was done using SPSS version 20. Of the 91 patients aged 21-70 years (mean 42.08 years, SD 15.40), females outnumbered males with a M:F ratio of 1:10.4. Five patients had preoperative hoarseness, but only three had VCP. IDL was done for 25 (27.4%) patients out of which 22 (88.0%) had normal studies while the remaining three (all from the five with hoarseness) had VCP. Histology of the specimens showed malignancy in 10 (11%), benign in 55 (60.4%), and no report in 26 (28.6%). Five of the malignant histology patients showed normal findings on IDL, three had VCP and two had no preoperative IDL. There was no case of asymptomatic VCP. Vocal cord evaluation is recommended for patients with voice symptoms and those with malignant goiter.