The influence of intraoperative parathyroid hormone monitoring on the surgical management of hyperparathyroidism

OBJECTIVE

To examine the role of intraoperative rapid parathyroid hormone (PTH) monitoring in the surgical management of hyperparathyroidism.

DESIGN

Thirty-eight-month retrospective review.

SETTING

Tertiary care academic medical center.

PATIENTS

One hundred consecutive patients undergoing surgery for primary hyperparathyroidism.

INTERVENTION

All patients underwent preoperative technetium Tc 99m sestamibi scan localization and intraoperative blood PTH monitoring by means of a rapid (12-minute) immunochemiluminometric assay.

MAIN OUTCOME MEASURES

The influence of intraoperative PTH levels on extent of surgical dissection and achievement of postoperative normocalcemia.

RESULTS

Intraoperative PTH levels dropped an average of 64%, 75%, and 83% at 5, 10, and 20 minutes, respectively, after excision of all hyperfunctioning parathyroid tissue. A PTH decrease of 46% or more at 10 minutes and 59% or more at 20 minutes after excision of hyperfunctioning tissue was predictive of postoperative normocalcemia. In 79 patients (79%), the sestamibi scan provided accurate preoperative localization; all but 1 of these patients were treated successfully, most often with a limited, gland-specific dissection. In 24 patients with inaccurate, negative, or misleading preoperative sestamibi scans, 23 (96%) were treated successfully with the use of the intraoperative PTH assay.

CONCLUSIONS

The rapid intraoperative PTH assay accurately predicts postoperative success in patients with primary hyperparathyroidism. The rapid PTH assay allows for greater confidence in performing limited dissections in well-localized uniglandular disease. In cases of inaccurate preoperative localization, the rapid PTH assay directly affects surgical decision making and provides greater confidence in determining when surgical success has been achieved.

Influence of minor ear surgery on infrared tympanic thermometry

BACKGROUND

Infrared tympanic thermometry (ITT) is often used for postoperative recovery room monitoring regardless of recent minor otologic surgery.

OBJECTIVE

To evaluate the use of ITT in pediatric patients who have undergone bilateral myringotomy with insertion of pressure-equalizing tubes.

DESIGN

A prospective cohort study.

SETTING

Tertiary care academic medical center.

PATIENTS

Consecutive patients of a staff pediatric otolaryngologist (M.A.R.): (1) ear surgery group, children aged 10 years or younger undergoing bilateral myringotomy with insertion of pressure-equalizing tubes and (2) non-ear surgery group, children aged 10 years or younger undergoing bilateral tonsillectomy with or without adenoidectomy.

INTERVENTIONS

Immediate preprocedure temperature measurements included right and left ear ITT. Immediate postprocedure temperature measurements included right and left ear ITT and thermistor probe rectal temperature.

MAIN OUTCOME MEASURES

The average difference between the preprocedure and postprocedure tympanic temperature in the ear surgery group was compared with that in the non-ear surgery group. The average difference between postprocedure rectal and ear temperature in the ear surgery group was compared with that in the non-ear surgery group.

RESULTS

There were 20 patients (40 ears) in the ear surgery group and 20 patients (40 ears) in the non-ear surgery group. In the ear surgery group, the average difference between the preprocedure and postprocedure tympanic temperature (0.55 degrees C) was not significantly different from that (0.62 degrees C) in the non-ear surgery group (P =.66, 1-way analysis of variance). In the ear surgery group, the average difference between postprocedural rectal and ear temperature (1.94 degrees C) was not significantly different from that (1.89 degrees C) in the non-ear surgery group (P =.76, 1-way analysis of variance).

CONCLUSION

Recent minor ear surgery (bilateral myringotomy with insertion of pressure-equalizing tubes) does not have a significant effect on ITT measurements in pediatric patients.

Diagnostic accuracy of fine-needle aspiration and frozen section in nodular thyroid disease

OBJECTIVE

To assess the diagnostic accuracy of fine-needle aspiration (FNA) and frozen section (FS) in nodular thyroid disease.

SETTING

Tertiary care academic medical center.

STUDY DESIGN

Retrospective review of 139 consecutive patients undergoing surgery for nodular thyroid disease. FNA and FS sensitivity, specificity, and accuracy were calculated with respect to permanent section histology.

RESULTS

Among 63 patients with an FNA interpreted as either benign (n = 38) or malignant (n = 25), FNA was accurate (sensitivity 89%, specificity 97%, accuracy 94%). FS identified only one case of carcinoma missed by FNA. Among 76 patients with a "suspicious" FNA, FS was reasonably accurate (sensitivity 67%, specificity 100%, accuracy 89%), but was deferred in 50% of cases.

CONCLUSION

Given high FNA accuracy, more selective use of FS is suggested.

SIGNIFICANCE

The study results will assist with intra-institutional patient counseling and intraoperative decision-making with respect to FNA and FS results in patients with nodular thyroid disease.

Head and neck anomalies related to the branchial apparatus

An understanding of the branchial apparatus and its anomalies may lead to greater precision in the clinical diagnosis and management of these congenital head and neck lesions. Although branchial anomalies have been well described, controversial issues, such as the branchial origin of lateral cervical cysts and the differentiation between third and fourth branchial pouch sinuses, remain unresolved.

Posterior scalping flap revisited

OBJECTIVE

To report our experience in a case series of 5 posterior scalping flaps.

DESIGN

Retrospective review of a case series.

SETTING

A tertiary academic care otolaryngology-head and neck surgery referral center.

PATIENTS

Five patients having undergone posterior scalping flap reconstruction of cutaneous midface defects.

METHODS

Reconstruction was performed for 4 cheek defects, 1 of which included the lateral third of the upper and lower lips, and 1 combined midfacial and lateral nasal wall defect.

RESULTS

All 5 patients had excellent cosmetic and functional results. The only complication was a single case of partial-thickness distal flap necrosis.

CONCLUSION

The posterior scalping flap offers a reliable source of skin with appropriate color and texture and minimal donor-site morbidity.

Videolaryngostroboscopy following vertical partial laryngectomy

Phonation after partial laryngeal ablative surgery has not often been examined. Videolaryngostroboscopic recordings made after vertical partial laryngectomy (VPL) were retrospectively reviewed and correlated with patient historical and operative factors. Among VPL patients (n = 42), the most common site of vibration during phonation was the contralateral false vocal fold (17/42 patients or 40.5%), followed by the contralateral arytenoid mucosa (10/42 or 23.8%) and the contralateral true vocal fold (8/42 patients or 19.0%). There was no overall difference in vocal quality judgment with respect to site of vibration (ANOVA, p = .373). Vocal quality scores were similar with use of the pyriform mucosal flap versus other reconstructive methods (Student's t-test, p = .568). This study highlights the fact that reconstruction of a new vibratory source after VPL is important for voice production. Because VPL patients infrequently demonstrated true vocal fold vibration, alternative sites (ie, false vocal fold, arytenoid mucosa) must be considered as new phonatory sources after VPL.

Upper aerodigestive tract liposarcoma: report on four cases and literature review

OBJECTIVE

To report on the clinical behavior, histopathology, treatment, and prognosis of laryngeal, hypopharyngeal, and cervical esophageal liposarcomas.

STUDY DESIGN

Retrospective reviews of pathology files and hospital records at a tertiary care hospital and a retrospective search of the English-language literature.

METHODS

Cases of upper aerodigestive tract (UADT) liposarcoma with adequate histopathologic documentation and clinical information were included for review.

RESULTS

Four cases of UADT liposarcomas were identified. The literature review revealed 26 cases of laryngeal liposarcomas, 7 cases of hypopharyngeal liposarcomas, and 6 cases of esophageal liposarcomas: the mean age at presentation was 55.8 years, the male:female ratio was 5:1, and 60% of the patients presented with dysphagia. Eighty-six percent of tumors had low-grade histologic findings. The recurrence rate after primary resection was 50%. Recurrence correlated with surgical procedure rather than with histologic subtype; 94.7% of recurrences happened after simple excision. Distant metastases occurred in three patients; two of them died of the disease.

CONCLUSIONS

The literature supports that UADT liposarcomas are rare and usually of low-grade histologic type. The rate of metastatic disease and tumor-related mortality is low. However, high recurrence rates have been noted, particularly when less radical surgery is employed.