Comparison of the diagnostic and prognostic abilities of flexible laryngoscopy and dynamic digital radiography for vocal cord paralysis: A prospective observational study

BACKGROUND

Although flexible laryngoscopy (FL) is the reference modality for diagnosing vocal cord paralysis (VCP), FL involves patient discomfort and insertion intolerance. Dynamic digital radiography (DDR) with high spatial and temporal resolution is easier to use and less invasive when evaluating VCP.

METHODS

Seventy-eight patients underwent FL and DDR before and after neck surgery. Qualitative and quantitative vocal cord movement (VCM) evaluations were conducted. Patients with postoperative VCP were followed-up regularly.

RESULTS

DDR exhibited diagnostic performance with 67% sensitivity and 100% specificity. The cutoff for VCM was 2.4 mm, with DDR exhibiting 100% sensitivity and 78% specificity. All cords with transient VCP had positive VCM at both 3 weeks and 2 months. Additionally, 50% and 75% of cords with permanent VCP had negative VCM at 3 weeks and 2 months, respectively.

CONCLUSIONS

DDR is promising for the diagnosis of postoperative VCP and early prediction of permanent postoperative VCP.

Evaluation of Intraoperative Neural Monitoring During Thoracoscopic Surgery for Esophageal Cancer

BACKGROUND/AIM

Recurrent laryngeal nerve paralysis (RLNP) induces aspiration pneumonia and reduces the patient's quality of life. To decrease the incidence of RLNP, we performed intraoperative neural monitoring (IONM) during thoracoscopic surgery for esophageal cancer and evaluated its usefulness.

PATIENTS AND METHODS

A total of 737 consecutive patients who underwent thoracoscopic surgery for esophageal cancer were enrolled in this study. Between May 1995 and March 2016, thoracoscopic esophagectomies were performed using video-assisted thoracoscopic surgery (VATS) with a small incision, whereas from April to June 2023, we used positive pressure pneumothorax with port placement only [minimum invasive esophagectomy (MIE)]. A total of 110 consecutive patients who underwent thoracoscopic surgery with IONM (IONM group) were retrospectively compared with those who underwent VATS or MIE without IONM (No-IONM group).

RESULTS

The incidence of RLNP [Clavien-Dindo (CD) classification of ≥1] on postoperative day (POD) 5 was 13.9% in the IONM group, which was significantly lower than that of the no-IONM group (31.2%, p<0.001). Even when comparing only patients who underwent MIE, the incidence of RLNP on POD5 was 13.9% in the IONM group, which was significantly lower than that in the no-IONM group (26.2%, p=0.035). The incidence of postoperative pneumonia (CD ≥2) was 10.9% in the IONM group, which was significantly lower than that in the no-IONM group (26.1%, p=0.005). Bilateral RLNP did not occur in any of the IONM groups.

CONCLUSION

IONM is a useful tool for reducing RLNP incidence and postoperative pneumonia after thoracoscopic surgery for esophageal cancer.

Anesthesia Management For A Patient Having Transoral Approach For Anterior Cervical Osteophyte Resection

Anterior cervical osteophytes (ACOs) are a common condition in the elderly, leading to dysphagia, odynophagia, aspiration, neck pain, dysphonia, and dyspnea. Transoral surgical resection is an approach to managing cervical (C1 and C2) ACOs where the endoscopic endonasal approach is contraindicated. Advantages of the transoral approach include it providing direct access to the cervical spine, limits injury to surrounding neurovascular structures, and eliminates scarring. Anesthesia considerations for transoral surgical resection of ACOs will be covered in the following case report. A review of the literature examines the prevalence of and anesthesia considerations for the transoral approach to anterior cervical osteophyte resection.

Distal Arch Aneurysm Discovered With Dysphagia

A 64-year-old man sought medical attention from a family physician, expressing concerns about dysphagia. Recognizing the complexity of the symptoms, the family physician promptly engaged the expertise of an attending physician at a regional hospital to ensure accurate diagnosis and management. Plain computed tomography (CT) revealed a space-occupied lesion located posterior to the trachea. Although mediastinal tumor was suspected at first, contrast-enhanced CT revealed a distal arch aneurysm that compressed the esophagus. The patient underwent total arch replacement, and the postoperative course was uneventful.

Ortner syndrome caused by aberrant right subclavian artery: A case report

INTRODUCTION

Ortner syndrome (cardiovocal hoarseness) is characterized by recurrent laryngeal nerve paralysis secondary to a cardiovascular abnormality. Ortner syndrome caused by an aberrant right subclavian artery following a retroesophageal course without aneurysm formation is rare, with only 1 case reported in the literature. Cardiovascular abnormalities could be life-threatening and require early diagnosis and treatment. However, such abnormalities are not often considered by clinical practitioners when patients initially present with hoarseness.

PATIENT CONCERNS

A 34-year-old woman without any medical history presented to our outpatient department with hoarseness and mild dysphagia for 1 month.

DIAGNOSIS

Upon stroboscopic examination, left vocal cord incomplete paralysis was noted. Contrast-enhanced computed tomography revealed an aberrant right subclavian artery arising from the left aortic arch, causing focal compression of the esophagus and, potentially, compression of the left recurrent laryngeal nerve compression. The patient was diagnosed as left recurrent laryngeal nerve paralysis caused by an aberrant right subclavian artery following a retroesophageal course without aneurysm formation.

INTERVENTIONS

The patient was referred to a cardiovascular surgeon for resection and bypass surgery. Both the dysphagia and the hoarseness improved after the surgery.

OUTCOMES

Significant improvement of the left vocal cord paralysis and no vocal cord adduction were seen upon stroboscopic examination after 3 months. During the 5-year follow-up period, the patient remained well, and no signs of recurrence were noted.

CONCLUSION

This case can increase otolaryngologists' awareness of this etiology of hoarseness and consider it in their differential diagnosis.

Intraoperative Neuromonitoring and Optical Magnification in the Prevention of Recurrent Laryngeal Nerve Injuries during Total Thyroidectomy

Background and Objectives: Recurrent laryngeal nerve (RLN) paralysis is a fearful complication during thyroidectomy. Intraoperative neuromonitoring (IONM) and optical magnification (OM) facilitate RLN identification and dissection. The purpose of our study was to evaluate the influence of the two techniques on the incidence of RLN paralysis and determine correlations regarding common outcomes in thyroid surgery. Materials and Methods: Two equally sized groups of 50 patients who underwent total thyroidectomies were examined. In the first group (OM), only surgical binocular loupes (2.5×−4.5×) were used during surgery, while in the second group (IONM), the intermittent NIM was applied. Results: Both the operative time and the length of hospitalization were shorter in the OM group than in the IONM group (median 80 versus 100 min and median 2 versus 4 days, respectively) (p < 0.05). The male patients were found to have a five-fold higher risk of developing transient dysphonia than the females (adjusted OR 5.19, 95% IC 0.99−27.18, p = 0.05). The OM group reported a four-fold higher risk of developing transient hypocalcemia than the IONM group (OR 3.78, adjusted OR 4.11, p = 0.01). Despite two cases of temporary bilateral RLN paralysis in the IONM group versus none in the OM group, no statistically significant difference was found (p > 0.05). No permanent RLN paralysis or hypoparathyroidism have been reported. Conclusions: Despite some limitations, our study is the first to compare the use of IONM with OM alone in the prevention of RLN injuries. The risk of recurrent complications remains comparable and both techniques can be considered valid instruments, especially if applied simultaneously by surgeons.

Perioperative outcomes of thyroid cancer surgery in children and adults: a nationwide inpatient database study in Japan

BACKGROUND

Little is known about perioperative outcomes after pediatric thyroidectomy. This study was performed to compare perioperative outcomes between children and adults undergoing thyroid cancer surgery using a nationwide inpatient database in Japan.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we identified patients aged 0 to 40 years with thyroid cancer who underwent thyroidectomy from July 2010 to March 2020. To compare the occurrence of in-hospital morbidities including local complications (e.g., recurrent laryngeal nerve paralysis, postoperative bleeding), duration of anesthesia, postoperative length of stay, and total hospitalization costs between children (0-18 years) and adults (19-40 years), we used multivariable logistic regression analysis for the occurrence of in-hospital morbidities and linear regression for other outcomes.

RESULTS

For 16,016 eligible patients (666 children vs. 15,350 adults), no significant differences between the two groups were found in any in-hospital morbidity (5.4% vs. 5.9%; adjusted odds ratio [OR], 0.80; 95% confidence interval [CI], 0.57-1.14; P = 0.23), local complications (5.0% vs. 5.5%; OR, 0.80; 95% CI, 0.55-1.15; P = 0.22), recurrent laryngeal nerve paralysis (2.1% vs. 2.4%; OR, 0.78; 95% CI, 0.45-1.35; P = 0.37), or postoperative bleeding (1.7% vs. 1.4%; OR, 0.99; 95% CI, 0.53-1.87; P = 0.98). Children showed a longer duration of anesthesia (difference, 20 minutes; 95% CI, 13-27; P < 0.001) and higher total costs (difference, 445 US dollars; 95% CI, 239-651; P < 0.001) than adults.

CONCLUSION

This large nationwide cohort study showed no significant difference in perioperative complications between children and adults undergoing thyroid cancer surgery.

Surgical outcomes in survivors of childhood cancer undergoing thyroidectomy: A single-institution experience

BACKGROUND

Childhood cancer survivors (CCS) are at increased risk for thyroid disease, and many require definitive management with thyroid surgery. Despite this, there is limited evidence on surgical outcomes among CCS. We sought to evaluate postoperative outcomes at our institution among CCS undergoing thyroid surgery compared to patients without a history of primary childhood malignancy.

PROCEDURE

Medical records were reviewed for 638 patients treated at the Children's Hospital of Philadelphia Pediatric Thyroid Center between 2009 and 2020. Rates of surgical complications, including recurrent laryngeal nerve (RLN) paralysis and hypoparathyroidism, among CCS were compared to patients with sporadic/familial thyroid cancer, Graves' disease, and other benign thyroid conditions. Operative time and intraoperative parathyroid hormone levels were also evaluated.

RESULTS

There were no significant differences in long-term surgical complication rates, such as permanent RLN paralysis and hypoparathyroidism, between CCS and patients without a history of primary childhood malignancy (all p > .05). For all surgical outcomes, there were no significant differences in complication rates when CCS were compared to those undergoing surgery for sporadic/familial thyroid cancer or Graves' disease (all p > .05). CCS with benign final pathology had significantly higher rates of transient hypoparathyroidism compared to patients with benign thyroid conditions (p < .001).

CONCLUSIONS

Our study suggests that CCS are not at higher risk of long-term complications from thyroid surgery when treated by high-volume surgeons within a multidisciplinary team.

Recurrent Laryngeal Nerve Paralysis Following Thyroidectomy: Analysis of Factors Affecting Nerve Recovery

OBJECTIVES

Paralysis of the recurrent laryngeal nerves (RLNs), albeit decreased over the years, leaves the surgeon helpless as there is not much that can be done once it occurs. Nimodipine has been suggested as a remedy that could accelerate the recovery of the nerve. Our study aimed to examine the factors that affect the recovery rate (RR) and time to recovery (TTR) of post-thyroidectomy RLN paralysis, with an emphasis on the use of nimodipine.

METHODS

A total of 197 patients who had undergone thyroid and parathyroid surgeries were retrospectively reviewed from October 2016 to August 2019. Patients who had RLN paralysis following surgery were assessed. The medical records were retrospectively analyzed to look for possible factors that may influence RLN recovery.

RESULTS

A total of 289 nerves were at risk. Temporary RLN paralysis rate was 7.9% while 1.7% was permanent. Age (odds ratio [OR] = 4.8) and intra-operative extra-thyroid extension (OR = 9.0) were independent risk factors for RLN paralysis. The rate of recovery was 82.1%. Loss of signal (LOS; P = .066) was a factor trending for an impact on RR but not nimodipine (P > .05). The mean TTR was 32 days. LOS, nimodipine, and steroid use, among others, were factors trending for an impact on the TTR.

CONCLUSION

Although not reaching statistical significance, nimodipine and steroids might influence TTR but not the RR. Larger studies are warranted to address the effect of nimodipine on the outcome of RLN paralysis.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Total thyroidectomy versus lobectomy: surgical approach to T1-T2 papillary thyroid cancer

The incidence of papillary thyroid carcinoma, which accounts for 80-90% of all thyroid cancers, has recently been increasing. The current study aimed to compare the oncological and functional outcomes of total thyroidectomy (TT) and thyroid lobectomy (TL). To this end, a retrospective single-centre cohort study involving a tertiary care institution was conducted. Data regarding demographics, clinicopathology and postoperative complications from 586 patients with papillary thyroid cancer treated in a single institution were collected. Cox proportional-hazards models were utilised to determine differences in outcomes stratified according to propensity score. Our data suggested no significant difference in the risk for locoregional recurrence or distant metastasis between TL and TT among patients with pT1-2 pN0 papillary carcinoma. TT plays an important role in improving prognosis among patients with metastatic lymph nodes in the central neck compartment (pN1a) (p = 0.001). Moreover, TT had significantly higher rates of postoperative hypocalcaemia and recurrent laryngeal nerve paralysis compared to TL (p < 0.001 and p = 0.02, respectively).

Management of patients with bilateral recurrent laryngeal nerve paralysis following esophagectomy

Background

Recurrent laryngeal nerve paralysis (RLNP) is a common complication after esophagectomy which can cause severe pulmonary complications. However, bilateral RLNP has been rarely reported in esophagectomy patients. The objective of our study is to investigate the clinical significance of patients who had bilateral RLNP following esophagectomy.

Methods

We retrospectively reviewed patients who underwent esophagectomy at a single center from 1994 to 2018. Among these, patients with bilateral vocal cord paralysis were included in this study.

Results

A total of 3217 patients were reviewed and 400 (12.4%) patients had RLNP, including 56 patients with bilateral RLNP identified by laryngoscopic examination. During the postoperative managements, 10 of the 56 patients (17.9%) required tracheostomy. Among them, two died of acute respiratory distress syndrome and the other eight patients were discharged after removing the tracheostomy tube. The median lengths of hospital and intensive care unit stay were 19.5 (range 8–157) and 2 (range 1–46) days, respectively. Forty‐six patients (83.6%) were discharged with oral feeding after swallowing therapy including tongue holding maneuver and head tilt exercise. The other five patients (8.9%) were discharged with alternative enteral feeding via jejunostomy, but they were able to achieve oral diet 2–3 months after surgery.

Conclusion

Bilateral RLNP following esophagectomy was rare, but it required great attention to prevent severe respiratory complications. However, only a few patients required tracheostomy and the majority achieved oral ingestion after intensive rehabilitation. Feeding education and respiratory rehabilitation are critical during the management of patients with bilateral RLNP.

Morbidity and long-term survival in patients with cervical re-exploration for papillary thyroid carcinoma

Background

Papillary thyroid carcinoma (PTC) has a favorable prognosis following one-stage surgical therapy, whereas two-stage resections bear the risk of increased morbidity and possibly impaired prognosis. To further elucidate the value of surgical re-exploration in PTC, a retrospective study was performed.

Methods

The study involved 187 patients with PTC who underwent total thyroidectomy with central lymph node dissection between 2001 and 2011. The number of two-stage surgeries, the rates of recurrent laryngeal nerve paralysis (RLNP) as well as hypocalcemia, and the long-term survival were assessed.

Results

Two-stage surgeries were performed in 43%. No statistically significant difference was seen between the one- and two-stage resection groups regarding the rate of RLNP (transient 5.6% vs. 6.3%, permanent 2.6% vs. 0%) nor for hypocalcemia (transient 25.2% vs. 18.8%, permanent 14.0% vs. 22.5%). The 10-year recurrence-free survival was 95.5% and the 10-year disease-specific survival was 98.9% with no difference between groups.

Conclusion

Even though two-stage surgeries do not lead to a higher incidence of RLNP and hypocalcemia, optimal preoperative and intraoperative diagnostics have to be carried out to reduce the amount of completion surgeries.

Endo-extralaryngeal Laterofixation of the Vocal Folds in Patients with Bilateral Vocal Fold Immobility

BACKGROUND

Bilateral vocal fold paralysis can result in shortness of breath and severe dyspnea which can be life-threatening.

PATIENTS AND METHODS

Thirty-five patients with bilateral vocal fold paralysis who underwent endo-extralaryngeal laterofixation according to Lichtenberger were retrospectively analyzed regarding etiology, symptoms, treatment and complications.

RESULTS

In 27 patients, laterofixation of the vocal cord alone was performed. Eight patients underwent laterofixation and additional posterior chordectomy of the opposite vocal cord according to Dennis and Kashima. The time of intervention ranged from 1 day to 38 years after the onset of bilateral vocal cord immobility. The intraoperative course was uneventful in all patients. None of the patients had postoperative aspiration. Postoperative voice function was acceptable in all patients. Complications of suture laterofixation were laryngeal edema, formation of fibrin, and malposition of the suture.

CONCLUSION

Laterofixation of the vocal cords according to Lichtenberger is a safe and easy method that can be used as a first-stage treatment of vocal cord paralysis.

Speech therapy after thyroidectomy

Common complaints of patients who have received thyroidectomy include dysphonia (voice dysfunction) and dysphagia (difficulty swallowing). One cause of these surgical outcomes is recurrent laryngeal nerve paralysis. Many studies have discussed the effectiveness of speech therapy (e.g., voice therapy and dysphagia therapy) for improving dysphonia and dysphagia, but not specifically in patients who have received thyroidectomy. Therefore, the aim of this paper was to discuss issues regarding speech therapy such as voice therapy and dysphagia for patients after thyroidectomy. Another aim was to review the literature on speech therapy for patients with recurrent laryngeal nerve paralysis after thyroidectomy. Databases used for the literature review in this study included, PubMed, MEDLINE, Academic Search Primer, ERIC, CINAHL Plus, and EBSCO. The articles retrieved by database searches were classified and screened for relevance by using EndNote. Of the 936 articles retrieved, 18 discussed "voice assessment and thyroidectomy", 3 discussed "voice therapy and thyroidectomy", and 11 discussed "surgical interventions for voice restoration after thyroidectomy". Only 3 studies discussed topics related to "swallowing function assessment/treatment and thyroidectomy". Although many studies have investigated voice changes and assessment methods in thyroidectomy patients, few recent studies have investigated speech therapy after thyroidectomy. Additionally, some studies have addressed dysphagia after thyroidectomy, but few have discussed assessment and treatment of dysphagia after thyroidectomy.

Vocal cord paralysis following orthognathic surgery intubation

The incidence of recurrent laryngeal nerve paralysis following short-term oro-endotracheal intubation for any surgical procedure is very rare. The diagnosis becomes very difficult if the surgical procedure may alter the vocal characteristics following surgery. We report a case of a 24 year-old healthy male patient who developed prolonged hoarseness which developed after having undergone a bimaxillary orthognathic surgical procedure. Following surgery, the patient's complaints of hoarseness and mild coughing on taking thin liquids were investigated with the assistance of the otolarynology voice department. A flexible fiberoptic laryngoscopy and videostroboscopy showed a partial paralysis of the left vocal cord suggesting damage to the left recurrent laryngeal nerve. The recovery was gradual and resolved without any intervention in approximately 6 weeks. Prolonged change or loss of voice quality following an orthognathic surgical procedure, as discussed in this case, when associated with difficulty in swallowing thin or thick liquids warrants a thorough investigation and can be managed at times with observation alone.