Assessment of voice quality after carotid endarterectomy

OBJECTIVES

vocal cord paralysis is considered a rare complication of carotid endarterectomy (CEA), but alteration in voice quality may be more common. The aim of this prospective study was to evaluate the effect of CEA on voice quality and to correlate any changes with the extent of the dissection. DESIGN-MATERIAL-METHODS: thirty-five patients who underwent CEA were divided in two groups, according to the level of surgical dissection performed. The high-level dissection group was comprised of those patients that required mobilisation of hypoglossal nerve and division of the posterior belly of digastric muscle. The low-level dissection group included the rest. All the patients' voices were recorded and analysed digitally before CEA, one and three months after the operation. Voice data were measured for standard deviation of fundamental frequency, jitter, shimmer and normalised noise energy (NNE). All patients underwent a laryngeal examination pre- and post-operation.

RESULTS

none of the patients had any vocal cord dysfunction on laryngoscopy. Significant changes of voice quality (jitter, shimmer, NNE) were noticed in the high-level dissection group (p<0.05) one month after the operation. Two months later, the voice changes had subsided, but still significant disturbances remained (jitter, shimmer).

CONCLUSIONS

voice-related disturbances are far more common following CEA than is generally believed and, although they seem to for the most part temporary, they deserve attention. Specifically, high-level surgical dissection seems to be a risk factor of postoperative vocal impairment.

Evolving techniques in the treatment of carotid artery kinking: the use of resected redundant arterial segment

Internal carotid artery kinking is frequently accompanied by atheromatous disease at the carotid bifurcation, and in this case both lesions may be treated simultaneously. Various surgical techniques have been used to correct carotid kinking but no particular one has been widely established. We conducted a retrospective review of 18 patients operated upon for internal carotid kinking during the last 5 years, which represents 4.1 per cent of the total carotid procedures performed during the same period. In 13 of the 18 patients carotid endarterectomy was performed before the repair of the kink. In four patients resection of the kinked segment with end-to-end anastomosis was performed combined with longitudinal arteriotomy at the carotid bifurcation. Two patients developed restenosis at the site of anastomosis requiring reoperation with patch angioplasty. Three patients were treated with eversion endarterectomy and end-to-side anastomosis, whereas in six patients we performed resection of the redundant internal carotid artery combined with longitudinal arteriotomy at the bifurcation. The posterior wall was reconstructed with interrupted sutures and the procedure was completed with patch angioplasty of the anterior wall. In four of these cases we used the autogenous resected arterial segment as patch material. None of these patients developed restenosis or symptoms in a follow-up period of 3 to 32 months. In cases in which significant carotid artery stenosis and internal carotid kinking coexist resection of the involved segment with end-to-end anastomosis of the posterior wall and patch angioplasty using the resected autogenous arterial segment constitute a convenient and satisfactory method of reconstruction.

Role of malignancy and preoperative embolization in the management of carotid body tumors

The purpose of this retrospective study is to present our approach to the management of patients with carotid body tumors (CBTs), emphasizing the role of malignancy and preoperative embolization. Between 1975 and 1998 a series of 18 patients with CBTs were treated, and 16 of them underwent successful excision of the tumor. According to the Shamblin classification, six of the tumors were type I, six type II, and six type III. In three of these patients (two with type II tumors and one with type III) in whom preoperative embolization had been performed, mean intraoperative blood loss was 400 ml, whereas in the remaining 13 cases this loss was 700 ml. Two patients with intracranial tumor spread underwent only radiotherapy. Neither postoperative deaths nor strokes occurred. Temporary cranial nerve injury occurred in four cases (25%). Local lymph node invasion was found in two patients, establishing the diagnosis of malignancy. One of these patients developed distal metastases 3 years after the operation and was treated with radiotherapy and octreotide. Follow-up ranging from 30 months to 23 years (mean 5 years) revealed no local recurrence except for the two patients who were treated with radiotherapy only. In conclusion, surgical excision remains the treatment of choice for CBTs and can be performed without major risks and with low morbidity and mortality. Preoperative embolization is helpful by diminishing intraoperative bleeding, and malignancy, though rare justifies early management.

Computer-assisted ultrasonographic analysis of carotid plaques in relation to cerebrovascular symptoms, cerebral infarction, and histology

The objective of this study was to determine the relationship between plaque echogenicity as measured by computer and the incidence of cerebrovascular symptoms and cerebral infarction. The correlation between carotid plaque echogenicity and plaque histology was also evaluated. In this prospective nonrandomized study, 38 consecutive patients with 54 atherosclerotic carotid plaques producing 50-99% stenosis were reviewed. The ultrasonic images of the plaques were digitized and transferred to a computer. A histogram for each plaque representing its composition was obtained. The median of the gray scale (GSM) of each histogram was used as measure of plaque echogenicity. All patients had a computed tomography (CT) brain scan performed to determine the presence of cerebral infarction. Twenty-eight plaques were examined histologically to determine the deposition of calcium, hemorrhage, cholesterol, and amorphous granular material. It is possible to identify carotid plaques at high risk for development of cerebrovascular symptoms and cerebral infarction by the computerized measurement of plaque echogenicity. This method may be used to improve the criteria of patients selection for carotid endarterectomy.

Recurrent liposarcomas of the abdomen and retroperitoneum: three case reports

We report three cases of patients with liposarcomas of the abdomen who had been treated during the last 13 years (1980-1993). Two patients were men, aged 29 and 51 years, with tumors of the retroperitoneal space and the third patient was a woman aged 64 years with a tumor in the peritoneal cavity. Therapeutic treatment was as aggressive as possible excision of the tumor. In the case of the first male patient, the histological examination revealed a retroperitoneal myxoid liposarcoma which recurred 5 times within 13 years. In the second male patient, it revealed a well differentiated retroperitoneal liposarcoma of the sclerosing type which recurred 5 times within 5 years since the first treatment. Finally, the one female patient had 2 recurrences of myxoid liposarcoma of the abdomen 9 years after the first operation, presented with an infected mass and has been well since then.

Experimental echinococcus infection in the mouse model: pericystic cellular immunity reaction and effects on the lymphoid organs of immunocompetent and thymectomized mice

Echinococcus can infect man as an accidental intermediate host causing hydatid disease. The infection persists and the growth of the cysts advances, while the patient usually remains asymptomatic for years. Experimental Echinococcus infection in mice provides a well described model for the study of the parasite-host relationship that permits the evolution of the disease despite the activation of the host's immune system. The aim of the present study was to assess the immune response to Echinococcus infection in normal and thymectomized mice. For this purpose, a total of 150 mice, divided into three equal groups (A, B and C), were infected by intraperitoneal inoculation of live protoscoleses. The mice of groups B and C underwent thymectomy, two weeks prior and after the infection, respectively. The mice of each group were further divided into three subgroups and were sacrificed at three consecutive time points: 45 days, 3 and 6 months post the infection. The hydatid cysts that subsequently developed by the metacestode-lavral stage, along with the spleen and lymph nodes were excised from each mouse and histologically studied. The results revealed a marked activation of the cell-mediated immunity against the parasite at the early stages of the disease. The initial response of the host abated with time and was minimal six months after the infection suggesting a local immunosuppression state that could account for the advancement of the disease. In addition, the thymectomized mice exhibited a higher susceptibility to the infection, which corresponded to the weak and delayed cellular immunity response observed in these groups. These results suggest that the cell-mediated immunity is crucial for the defense against Echinococcus, especially early in the course of the disease where suppression of larval growth is critical for the final outcome of the infection.

The effect of various types of splenectomy on the development of B-16 melanoma in mice

260 CB57BL/J6 mice were used in an experimental protocol designed to investigate the effects of 4 different varieties of splenectomy on the growth rate of subcutaneously implanted GB-16 melanoma. In addition, the mean and absolute survival of the mice, the histopathology of the tumour and the effects of the same procedures on the immunological status of the tumour-bearing animals as assessed by serum IgG levels and immunoelectrophoresis were determined. The effects of the timing of the splenectomy and the removal of the primary tumour after splenectomy on the above parameters were also annotated. The following were found: First, splenectomy performed 1 week after B-16 melanoma tumour implantation in mice i.e. in the early period of oncogenesis, lengthened the survival of the grafted experiments, delayed tumour growth, reduced the "activity" of the tumour and caused pseudoencapsulation of the tumour by fibrous tissue. It increased, but not by a statistically significant degree (p > 0.05), the circulating levels of the IgG immunoglobulin. Second, splenectomy performed 4 weeks prior to grafting of the same tumour did not affect the circulating IgG levels, nor did it prolong survival; however, it reduced the rate of tumour growth and pseudoencapsulation of the tumour was observed. Third, splenectomy at the early stages of oncogenesis in combination with surgical removal of the primary tumour increased absolute and mean survival, delayed the tumour growth rate, increased the time to relapse and reduced the "activity" of the pseudocapsulated tumour.

Rupture of an abdominal aortic aneurysm following acute descending thoracic aortic dissection. Case report

The coexistence of an abdominal aortic aneurysm and an acute aortic dissection seems to be rare and only a few reports are to be found in the literature. We report a case of a patient with acute aortic dissection of the descending thoracic aorta that caused rupture of a pre-existing abdominal aortic aneurysm. The literature is also thoroughly reviewed.

[Aneurysms of splanchnic arteries]

Aneurysms of splanchnic arteries represent an uncommon but important vascular disease, which many times presents itself as clinical emergency and often results in death. 11 patients with splanchnic aneurysms were treated in our Department during the last 15 years. These aneurysms were located in 5 cases in splenic artery, 4 cases in hepatic artery, 1 case in celiac axis and 1 case in right gastroepiploic artery. Surgical treatment of these aneurysms was successful in all but one patient (he died from rupture of a hepatic artery aneurysm). Giving an overall mortality similar to that reported in the literature. The treatment of these aneurysms is discussed, while literature about this uncommon disease is reviewed.

Vascular manifestations of Behçet's disease

The purpose of this article is to present the spectrum of vascular disease accompanying Behçet's disease. Four cases of the disease with various vascular manifestations are presented. In the first case superior vena cava syndrome due to thrombosis was the presenting symptom. In the second case foot ischemia with toe necrosis was prevalent. In the third case the patient developed recurrent aneurysmal disease in large and medium size arteries requiring successive vascular surgery, and in the fourth case the patient had SVC thrombosis and ruptured femoral aneurysm. All four patients were young males. Although vascular complications of Behçet disease are uncommon they may pose serious therapeutic problems.

Scanning of the adrenals in Cushing's syndrome

131I-19-iodocholesterol adrenal scans were obtained in seven patients with Cushing's syndrome. Characteristic imaging patterns were seen in three patients with bilateral adrenal hyperplasia with symmetrical uptake of the isotope. Two patients with adrenocortical adenoma and one patient with a well-differentiated adrenocortical carcinoma showed intense activity in one adrenal gland and absent activity in the contralateral gland. In one patient with adrenal nodular hyperplasia asymmetrical uptake was found with increased activity in the right adrenal gland where a larger adenomatous nodule was found at histologic examination. Adrenal imaging with radioactive cholesterol is a useful noninvasive technique for the diagnosis and treatment of Cushing's syndrome.

Cushing's syndrome. Analysis of 18 cases

Eighteen patients with Cushing's syndrome were analyzed retrospectively. Eleven patients had diffuse or adenomatous hyperplasia, 5 an adenoma and 3 a carcinoma. Iodocholesterol scanning provides considerable help in localization of the disease. Surgical treatment, while curative for benign cases, affects only slightly the course of malignant disease.