TORS as Part of Multilevel Surgery in OSA: The Importance of Careful Patient Selection and Outcomes

Transoral robotic surgery (TORS) for Obstructive Sleep Apnea (OSA) is a relatively young technique principally devised for managing apneas in the tongue base area. This study summarizes and presents our personal experience with TORS for OSA treatment, with the aim to provide information regarding its safety, efficacy, and postoperative complications. A retrospective study was conducted on patients undergoing TORS with lingual tonsillectomy through the Da Vinci robot. The effectiveness of the surgical procedure was assessed employing the Epworth Sleepiness Scale (ESS) and overnight polysomnography with the Apnea-Hypopnea Index (AHI). A total of 57 patients were included. Eighteen patients (31.6%) had undergone previous surgery. The mean time of TORS procedure was 30 min. Base of tongue (BOT) management was associated with other procedures in all patients: pharyngoplasty (94%), tonsillectomy (66%), and septoplasty (58%). At 6 months follow-up visit, there was a significant improvement in AHI values (from 38.62 ± 20.36 to 24.33 ± 19.68) and ESS values (from 14.25 ± 3.97 to 8.25 ± 3.3). The surgical success rate was achieved in 35.5% of patients. The most frequent major complication was bleeding, with the need for operative intervention in three cases (5.3%). The most common minor complications were mild dehydration and pain. TORS for OSA treatment appears to be an effective and safe procedure for adequately selected patients looking for an alternative therapy to CPAP.

[Incidental differentiated thyroid carcinoma is less prevalent in Graves' disease than in multinodular goiter]

OBJECTIVE

Risk factors for differentiated thyroid carcinoma (DTC) are poorly understood, but serum TSH levels, thyroid nodularity, and presence of autoimmunity are well-recognized factors that modulate DTC prevalence. TSH stimulates proliferation of both normal and neoplastic follicular cells. Consequently, thyroid-stimulating immunoglobulins (TSI), because of its TSH-like action, should induce DTC progression in patients with Graves' disease (GD). The study objective was to compare the prevalence of incidental DTC in patients undergoing thyroidectomy for benign thyroid disease.

METHODS

The pathology reports of 372 patients with preoperative diagnosis of euthyroid multinodular goiter (EMG) or hyperthyroidism were reviewed. Scintigraphy results and serum TSI levels were used to diagnosed either GD or hyperactive MG (HMG) to hyperthyroid subjects. Prevalence of DTC in each category was calculated using a Chi-square test.

RESULTS

EMG, GD, and HMG were diagnosed in 221, 125, and 26 patients. There were 58 DTCs, distributed as follows [n (%)]: EMG, 49 (22.2%); GD, 8 (6.4%), and HMG, 1 (3.8%). Difference in prevalence of incidental DTC between the groups was statistically significant (p<0.001). After adjustment for age, patients with EMG had a greater DTC prevalence than GD patients, with an OR of 4.17 (p<0.001). Tumor size (mm, mean ± SD) was 6.92 ± 11.26, 1.97 ± 1.85, and 9.0 for EMG, GD and HMG respectively (p=0.017).

CONCLUSIONS

Incidental DTC was less prevalent in GD as compared to EMG irrespective of age. This finding may suggest a predisposition to develop DTC in patients with thyroid nodular disease and/or a potential effect of autoimmunity to protect against development of neoplastic disease.