Neurosarcoidosis-Induced Winging Scapula: Efficacy of Infliximab Treatment in Addressing Multifaceted Challenges

Sarcoidosis, a systemic granulomatous disease primarily affecting the respiratory and lymphatic systems, can rarely manifest as neurosarcoidosis either in isolation or alongside other systemic symptoms. Here, we describe the case of a 45-year-old male with a history of recurrent sinusitis refractory to antibiotics, who presented to the emergency department with sinus congestion and dysphagia. Clinical examination revealed left lower motor neuron facial palsy and enlarged submandibular salivary glands. Despite obtaining negative results from various antibody panels, the patient exhibited elevated Angiotensin Converting Enzyme levels of 83 nmol/kg/min. Additionally, computed tomography chest scans revealed bilateral hilar and mediastinal lymph node enlargement, findings consistent with sarcoidosis. Otorhinolaryngology evaluation for dysphagia confirmed left vocal cord palsy. Following a negative infectious disease workup, submandibular salivary gland biopsy confirmed sarcoidosis. Treatment with mycophenolate mofetil and oral steroids led to gradual improvement in salivary gland swelling, dysphagia, and facial palsy. However, worsening left shoulder pain prompted further investigation, revealing winging of the left scapula on repeat examination. Magnetic resonance imaging (MRI) of the cervical spine revealed a six mm hyperintensity in the left dorsal cord at the C5 level, suggesting possible neurosarcoidosis vs. demyelinating disease. Subsequently, the patient was prescribed anti-tumor necrosis factor alpha inhibitor infliximab. Subsequent MRI of the cervical spine, conducted six months after initiating Infliximab therapy, indicated resolution of the lesions. This positive outcome was supported by the patient's report of symptom improvement, notably reduced shoulder pain and improvement in left scapular winging. This case underscores the unusual co-occurrence of Bell's palsy and vocal cord palsy in the same patient, along with the potential contribution of neurosarcoidosis to the winged scapula. Additionally, it sheds light on the positive response of neurosarcoidosis to Infliximab therapy.

Continuous Intraoperative Nerve Monitoring of a Non-Recurrent Laryngeal Nerve: Real-Life Data of a High-Volume Thyroid Surgery Center

Thyroid surgery is associated with a risk of injury to the recurrent laryngeal nerve, especially in the presence of anatomical variants such as a non-recurrent laryngeal nerve (NRLN). Injury to the nerve leads to transient or permanent vocal cord palsy (VCP). A novel method to prevent VCP is continuous intraoperative nerve monitoring (cIONM), but less is known about the applicability of this method in patients with NRLN. The aim of this study was to evaluate our own data regarding feasibility and detailed characteristics of cIONM in NRLN patients. We performed a monocentric retrospective cohort analysis including clinical data and intraoperative nerve monitoring data (measured by Inomed Medizintechnik GmbH, Emmendingen, 'C2' and 'C2 Xplore' device) of all thyroid surgery patients, showing NRLN between 2014 and 2022. Of 1406 patients who underwent thyroid surgery with cIONM between 2014 and 2022, 12 patients (0.9%) showed NRLN intraoperatively. Notably, cIONM was feasible in eight patients (67%). In all cases the onset latency of the right vagus nerve was shorter (<3.0 ms) than usually expected, suggesting that a short latency might be suitable to distinguish NRLN. None of the patients had a post-operative VCP. Overall, cIONM appears to be feasible and safe in NRLN patients and provides helpful information to prevent VCP.

A Case of Anti-IgLON5 Disease Showing an Improvement in Dysautonomia, Including Vocal Cord Palsy, via Combined Immunotherapy

Anti-IgLON5 disease shows various neurological manifestations, of which dysautonomia is one of the major symptoms and is rarely improved by immunotherapy. We herein report a patient with anti-IgLON5 disease who showed several autonomic failures, including vocal cord palsy for four months. The patient presented with cognitive impairments, bulbar symptoms accompanied by myorhythmia in the pharynx and tongue, cerebellar ataxia with tremor, motor neuron symptoms in the limbs, gastrointestinal dysfunction, orthostatic hypotension, non-rapid eye movement sleep disorder on polysomnography, and severe vocal cord palsy. Combined immunotherapy improved his symptoms, including vocal cord palsy, suggesting that combined immunotherapy might improve dysautonomia in anti-IgLON5 disease.

Tubercular Mediastinal Lymphadenopathy Presenting as an Isolated Unilateral Vocal Cord Palsy and the "Sail" Sign

Tuberculosis continues to remain a major public health challenge, especially in low- and middle-income countries. Unilateral vocal cord palsy in adults as the sole manifestation of tubercular mediastinal lymphadenopathy has been rarely reported. A 22-year-old lady presented with a history of hoarseness of voice for the past month. The general physical examination revealed palpable lymph nodes in the left axilla. Axial CT sections at the level of the vocal cords demonstrated dilation of the right laryngeal ventricle and mild anteromedial deviation of the ipsilateral arytenoid cartilage ("sail" sign) suggestive of a right vocal cord palsy. Contrast-enhanced CT chest revealed right paratracheal, right hilar, and subcarinal lymph nodes with areas of central necrosis. She was started on anti-tubercular therapy and her voice completely improved after three months of treatment. The "Sail" sign on axial CT scans is a useful radiological sign for diagnosing unilateral vocal cord palsy. Rarely, compression of the recurrent laryngeal nerve by enlarged mediastinal lymph nodes due to tuberculosis can present with unilateral vocal cord palsy as the sole manifestation in adults.

Bilateral Vocal Cord Palsy Secondary to Rheumatoid Arthritis

Rheumatoid arthritis (RA) can cause a number of laryngeal manifestations; however, most of these do not cause an airway emergency. Airway obstruction due to vocal cord fixation of one or both vocal cords occurs late in the disease process of RA and can present as an inspiratory stridor. We report the case of an elderly lady who presented with acute stridor secondary to RA-induced bilateral vocal cord palsy and describe the various management options that were considered. An 85-year-old woman presented to A&E Resus with tachypnoea, stridor, and drowsiness. An arterial blood gas (ABG) was performed which showed hypercapnic respiratory failure on 60% oxygen with blood tests revealing moderately raised infective markers and a chest X-ray displaying right lower zone consolidation. A flexible nasendoscopy was performed which demonstrated bilaterally fixed and adducted vocal cords due to bilateral cricoarytenoid joint fixation, with a rima glottidis measurement of approximately 3 mm and evidence of paradoxical breathing. The patient had been admitted with a similar presentation 18 months before, however not as severe, and once again, the bilateral vocal cord palsy had been attributed to her longstanding RA. She was stabilised with non-invasive ventilation and transferred to the acute respiratory care unit. Long-term surgical options were thoroughly discussed including tracheostomy, vocal cord lateralisation, cordotomy, and arytenoidectomy, but ultimately, these options were all deemed unsuitable for the patient and so a palliative care approach was adopted following the withdrawal of bilevel positive airway pressure. Stridor is a late but life-threatening complication of RA that has viable surgical options of tracheostomy and static glottis enlarging procedures; however, the appropriateness of such procedures should always be correlated with the patient's current clinical status and the extent to which they may impact on the patient's quality of life.

Atrophy of the Posterior Cricoarytenoid Muscle as an Indicator of a Recurrent Laryngeal Nerve Injury History Before Revision Anterior Cervical Spine Surgery

STUDY DESIGN

Retrospective study.

OBJECTIVES

In our recent study, we observed some cases of symptomatic normal vocal cord motility instead of asymptomatic vocal cord palsy (VCP) in preoperative laryngoscopy of a revision anterior cervical spine surgery (ACSS) cohort. We assumed the intrinsic muscle atrophy caused by recurrent laryngeal nerve injury could cause vocal cord-related symptoms. Thus, radiological examinations were reviewed in relation to the posterior cricoarytenoid (PCA) muscle, one of the intrinsic muscles.

METHODS

We retrospectively analyzed 64 patients who underwent a revision ACSS. Patients with vocal cord-related symptoms were classified as symptomatic group (group S, n = 11), and those without symptoms as asymptomatic group (group AS, n = 53). The bilateral size and signal intensity of the PCA muscles in these patients were measured in the axial view with preoperative computed tomography (CT) and magnetic resonance imaging (MRI) evaluations. Since the size and signal intensity values were different on each image, the ratios of the contralateral and ipsilateral muscle values were analyzed for each modality.

RESULTS

There was no VCP on laryngoscopy study. However, the mean ratio of the PCA muscle size on CT was 1.40 ± .37 in group S and 1.02 ± .12 in group AS (P = .007). These values on the MRI were 1.49 ± .45 in group S and 1.02 ± .14 in group AS, which was also a significant difference (P = .008).

CONCLUSIONS

Evaluating the size of the PCA muscle before revision ACSS may predict a previous recurrent laryngeal nerve injury. Careful planning for the appropriate approach should be undertaken if vocal cord-related symptoms and atrophy of PCA muscle are evident.

A Unique Case of Unilateral Vocal Cord Palsy Following an Electrocution Injury

Electric injuries (in the form of lightning or electric shock) may lead to various implications in the human body, the most important of which include neurological insults. The damage caused is influenced by the route of its entry into the body, its strength, and the duration of exposure. The muscles of the larynx receive motor supply from the recurrent laryngeal nerve (RLN) (except cricothyroid, which gets innervation from the external laryngeal nerve). Recurrent laryngeal nerve (RLN) palsy leading to vocal cord palsy is seen in several pathologies, but after thorough research of existing literature, we could only find a single case of vocal cord palsy following electric injuries, which was also lost in follow-up. In this report, we present a case of unilateral vocal cord palsy following an electric injury on the ipsilateral arm of a young male. He presented to the emergency department of our center soon after the accident. A multidisciplinary team was engaged in the overall management of the patient (in view of pleural effusion, acute kidney injury, and burn injury). He was started on steroids, speech therapy, and other supportive management. On follow-up, his condition improved, and laryngeal endoscopy showed positive signs. This case highlights a unique but rare possibility of vocal cord palsy following electric injuries and may help in the prompt diagnosis and management of the same.

A single-arm, prospective study comparing translaryngeal ultrasonography with direct visualisation by flexible laryngoscopy for vocal cord assessment in patients undergoing oesophagectomy or mediastinoscopy

Background and Aims

Translaryngeal ultrasonography (TLUSG) for diagnosis of vocal cord palsy, a relatively new, safe and noninvasive bedside technique with minimal risk of respiratory infection transmission, has been effective in patients with thyroid disease. We studied its use as an alternative method to visual inspection by flexible laryngoscopy (FL) for vocal cord assessment in patients undergoing thoracic surgeries.

Methods

After Institutional Ethics Committee approval and trial registration, in this single-arm, prospective study, the vocal cord function of 110 patients who underwent either total oesophagectomy or mediastinoscopy was assessed immediately after extubation by both FL and TLUSG. A follow-up assessment was done by laryngoscopy using Hopkin's endoscope (HL) and a repeat TLUSG. The primary outcome was the concordance between direct visualisation (FL or HL) and TLUSG.

Results

Vocal cords were successfully visualised by TLUSG in 90% of male and all female patients. Findings of FL and TLUSG done at the first assessment matched in 89 (86.4%) out of 103 patients, and the degree of concordance was 0.69 (95% confidence interval [CI] =0.52-0.83). At the second assessment, HL and TLUSG findings matched in 83 (94.3%) out of 88 patients, and the degree of concordance was 0.89 (95% CI = 0.77-0.98).

Conclusion

TLUSG is an effective noninvasive alternative to direct visualisation for vocal cord assessment in both male and female patients undergoing thoracic surgery.

Clinico-pathological initial outcome of a newly adopted novel surgical technique for nodal metastatic thyroid cancer at a large-volume centre in a high-income developing country

Introduction

Thyroid cancer is the most common tumour in the endocrine system. In the past decade, the incidence of lymph node metastasis has increased, and so has the patient demand for a smaller scar. This research reports the surgical and patho-oncological short-term outcomes of a novel, minimally invasive neck dissection approach for thyroid carcinoma with lymph node metastases at the UAE's leading endocrine surgery centre.

Methods

This study employed a prospectively maintained surgical database to retrospectively analyse relevant parameters such as surgical complications, including bleeding, hypocalcaemia nerve injury and lymphatic fistula, as well as oncological metrics such as the type of tumour and the ratio of lymph node metastasis to the number of harvested lymph nodes in 100 patients that underwent open minimally invasive selective neck dissection.

Results

The study comprised 50 patients with thyroidectomy, with bilateral central compartment neck dissection (BCCND; 50%); 34 with thyroidectomy, BCCND and selective bilateral lateral compartment neck dissection (BLCND; 34%); and 16 patients with selective unilateral central and lateral compartment neck dissection by recurrent nodal disease (ULCND; 16%). The female-to-male gender ratio was 78:22, with median ages of 36 and 42 years, respectively. Histopathology findings revealed that 92% of patients had papillary thyroid cancer (PTC) and 8% had medullary thyroid cancer. The mean total number of lymph nodes removed was 22 in the BLCND group, 17 in the ULCND group and 8 in the BCCND group (p = 0.001). Furthermore, the average lymph node metastasis was significantly higher in the BLCND group (p = 0.002). The percentage of temporary hypoparathyroidism was 29.8% and it persisted for 1.3%. The lateral compartment dissection morbidity was as follows: Four male patients with tall cell infiltrative PTC presented with pre-existing vocal cord paresis, necessitating nerve resection and anastomosis, and two more developed it after surgery (1.1% of the nerve at risk). Lymphatic fistulas occurred in four patients (4%) who were treated conservatively. Two patients were readmitted due to symptomatic neck collection. Horner syndrome was discovered in just one female patient. Male gender, aggressive histology and lateral compartment dissection independently increased surgical morbidity. In a high-volume endocrine centre, the adoption of minimally invasive selective neck dissections to treat nodal metastatic thyroid cancer did not increase specific cervical surgery complications.

Lightning Strike Presenting as Fatal Lung Contusion: A Case Report

Electrical injuries to humans from a lightning strike are associated with significant rates of morbidity and fatality. High-voltage injuries including those caused by lightning strikes are pulmonary edema, pulmonary contusion, acute respiratory distress syndrome, and pulmonary hemorrhages. Patients who get injured experience secondary trauma in addition to direct and indirect injury. In this report, we present the case of a 62-year-old male patient with complaints of shortness of breath, vomiting, and hoarseness of voice. The patient's treatment included airway protection, antibiotics, corticosteroids, and supportive care; however, the patient did not survive due to a severe lung contusion.

Continuous intraoperative neuromonitoring of the recurrent laryngeal nerve by eliciting the laryngeal adductor reflex (LAR-CIONM)

The laryngeal adductor reflex (LAR) is a life-sustaining airway protective mechanism that serves to shield the lower airways from inhaled foreign bodies. Over the past half century, the LAR has been extensively investigated and its dysfunction has been linked to far-ranging pathologies, from dysphagia to sudden infant death syndrome. Over the past 6 years, specific electromyographic waves in the LAR response have been used to devise a methodology for monitoring the vagus and recurrently laryngeal nerves during surgical procedures. This methodology involves continuous intraoperative neuromonitoring of the laryngeal adductor reflex and isthus termed 'LAR-CIONM'. In this review paper, the physiology of the LAR will be summarized as it relates to LAR-CIONM and the technique of LAR-CIONM will be described. Applications of this technique and published outcomes of LAR-CIONM will be highlighted.

Heavier Weight of Resected Thyroid Specimen Is Associated With Higher Postoperative Morbidity in Benign Goiter

OBJECTIVE

The impact of heavier weight of resected thyroid specimen on postoperative morbidity after total thyroidectomy for multinodular benign goiter remains unclear.

METHODS

Data from the prospective StuDoQ|Thyroid registry of the German Society of General and Visceral Surgery were analyzed regarding the weight of the resected thyroid specimen and perioperative morbidity (vocal cord palsy, hemorrhage, surgical site infection, and hypocalcemia). To achieve a homogeneous patient population, only patients with total thyroidectomy for multinodular benign goiter were included.

RESULTS

A total of 7911 patients from 105 departments underwent total thyroidectomy for benign conditions (January 2017-July 2020). The median resected weight of the thyroid specimen in all patients was 53 g (interquartile range 32-92). In 1732 patients, the specimen weight exceeded 100 g. Intraoperative neuromonitoring was used in 99.5% of patients. Postoperative laryngoscopy revealed vocal cord dysfunction in 480 of 15 822 (3.03%) nerves at risk, with unilateral dysfunction in 454 (2.87%) of patients and bilateral dysfunction in 13 patients (0.08%). In multivariable analysis, a thyroid weight >100 g was an independent predictor of early postoperative vocal cord dysfunction [odds ratio (OR) 1.462, 95% CI 1.108-1.930, P = 0.007). Heavier (>100 g) thyroid weight was an independent predictor of surgical site infection (OR 1.861, 95% CI 1.203-2.880, P = 0.005) and also predicted postoperative hemorrhage in the univariate analysis (OR 1.723, 95% CI 1.027-2.889, P = 0.039). On the contrary, postoperative parathyroid function was not affected.

CONCLUSIONS

Heavier (>100 g) resected thyroid weight independently predicts higher postoperative morbidity, including early vocal cord palsy and surgical site infection after total thyroidectomy for benign multinodular goiter.

Implementation of a novel vocal cord dysfunction management pathway using the consolidated framework for implementation research

Every year in Australia over a thousand children who are born with congenital heart disease require surgical intervention. Vocal cord dysfunction (VCD) can be an unavoidable and potentially devastating complication of surgery for congenital heart disease. Structured, multidisciplinary care pathways help to guide clinical care and reduce mortality and morbidity. An implementation study was conducted to embed a novel, multidisciplinary management pathway into practice using the consolidated framework for implementation research (CFIR). The goal of the pathway was to prepare children with postoperative vocal cord dysfunction to safely commence and transition to oral feeding. Education sessions to support pathway rollout were completed with clinical stakeholders. Other implementation strategies used included adaptation of the pre-procedural pathway to obtain consent, improving the process of identifying patients on the VCD pathway, and nominating a small team who were responsible for the ongoing monitoring of patients following recruitment. Implementation success was evaluated according to compliance with pathway defined management. Our study found that while there were several barriers to pathway adoption, implementation of the pathway was feasible despite pathway adaptations that were required in response to COVID-19.

Translaryngeal ultrasound in thyroid surgery: state of the art review

BACKGROUND

Clinical voice assessment prior to thyroid and parathyroid surgery is essential, but the paradigm of indirect laryngoscopy (IDL), when indicated, has been challenged by the risk of aerosolised SARS-Cov-2 during endoscopy of the aerodigestive tract. Translaryngeal ultrasound (TLUS) to assess the vocal cords has been proposed as a safe, non-invasive and sensitive alternative. The aim of this review was to verify TLUS as a viable tool for perioperative laryngeal assessment.

METHOD

A literature review was performed using Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials and Scopus with the following search strategy: (vocal cord OR vocal fold OR glottic OR glottis OR vocal ligaments OR rima glottidis) AND (ultras* OR sonograph* OR echography OR echotomography).

RESULTS

Fifteen studies were included in this review. All studies compared TLUS to IDL in visualizing the vocal cords in adults. Ten studies compared pre-operative TLUS to IDL where 50.6-100% of vocal cords were successfully visualized. Nine studies compared post-operative TLUS to IDL and reported visualization between 39.6% and 100%. Pre- and post-operative negative predictive values ranged from 60% to 100%.

CONCLUSION

Whilst promising, successful visualization of the cords is limited by inter-user variability, older age and male gender. Thus, we see the role of TLUS as an alternative to IDL in the post-operative setting in the young patient following uncomplicated surgery with a normal voice on clinical examination, to confirm recurrent laryngeal nerve integrity while minimizing the risk of aerosolization.

Intraoperative Neuromonitoring, Nerves at Risk and Staged Thyroidectomy, our Experience on 377 Consecutive Cases

PURPOSE

The aim of this study was firstly to report the experience of intermittent intraoperative neuromonitoring (I-IONM) and evaluate the impact of loss of signal (LOS) in staged thyroidectomy management.

METHODS

We retrospectively reviewed patients who underwent total thyroidectomy, performed by a single surgeon in two years. All patients have been subjected to I-IONM. In case of intraoperative loss of signal (LOS), planned total thyroidectomy was always aborted. Six-month follow-up was performed. Postoperative dysphonia was evaluated with VHI-10 score in 3 time settings T1, during hospital stay, T2 after 30 days, T3 after 6 months. Dysphonia has been compared to IONM results to evaluate sensitivity and specificity.

RESULTS

377 patients were included. Incidence of dysphonia was calculated based on the number of nerves at risk (NAR). We evaluated a total of 724 NAR. LOS encountered were 43 cases (5.9% of total NAR), of these 14 were LOS 1 while 29 were LOS 2. 27 patients (3.7% of NAR) presented early post-operative dysphonia with VHI-10 score > 13 (T1), among these 16 had presented LOS at IONM (true positives) while11 had no LOS (false negatives). In T2 and T3 we reported a decrease in true positive cases increasing false positives. Sensitivity at T3 reached 85.7% while specificity and odds ratio were respectively 94.8% and 110.

CONCLUSIONS

Given the high sensitivity and specificity, IONM should be considered a useful tool for thyroid surgery and its use should be suggested for patients undergoing planned total thyroidectomy. Its right application may cancel the risk of bilateral paralysis.

Innovative surgical solutions for laryngeal stenoses in newborns and infants

Összefoglaló. A veleszületett légúti szűkületek gyakran kombináltan jelentkeznek, és más szervrendszert is érintő kísérőbetegségekkel, illetve malformációkkal is társulhatnak. Figyelembe véve ezeket a tényezőket, illetve a csecsemőkori légút speciális anatómiáját és sérülékeny szöveteit, a felső légúti szűkületek sebészi kezelése újszülött- és csecsemőkorban igen nagy kihívást jelentő feladat, melynek célja a mihamarabbi definitív, stabil légút biztosítása a hangképzés és a nyelési funkció megőrzésével. A laryngomalacia, a hangszalagbénulás és a subglotticus stenosis együttesen a gége veleszületett rendellenességeinek megközelítőleg 90%-áért felelős. A szerzők erre a három kórképre fókuszálva egy-egy eset kapcsán bemutatják a Szegedi Tudományegyetem Fül-Orr-Gégészeti és Fej-Nyaksebészeti Klinikáján működő légútsebészeti munkacsoport által rutinszerűen alkalmazott innovatív sebészi módszereket. A bemutatott sebészeti megoldások egy lépésben, tracheostoma, sztentelés és graft beültetése nélkül azonnali stabil légutat biztosítanak jó hangminőséggel és nyelési funkcióval a supraglottis, a glottis és a subglottis dinamikus és statikus szűkületei esetén egyaránt. Orv Hetil. 2021; 162(52): 2100-2106. Summary. Congenital airway stenoses occur frequently in combinations or may be associated with comorbidities and malformations affecting other organ systems. Considering these factors as well as the special anatomy and vulnerable tissues of the pediatric airway, surgical treatment in neonates and infants is an extremely challenging task. The ultimate goal of the management is to ensure a definitive and adequate airway as soon as possible with the preservation of voice and swallowing. Laryngomalacia, vocal cord palsy and subglottic stenosis together account for approximately 90% of congenital laryngeal disorders. Focusing on these three diseases, the authors - the airway surgery working group at the Department of Otolaryngology and Head and Neck Surgery, University of Szeged, Hungary - present their routinely applied innovative surgical strategies in connection with three cases. The presented 'one-step' surgical solutions provide immediate stable airway with good voice quality and swallowing function without tracheostomy, stenting, or graft implantation for both dynamic and static stenoses of the supraglottis, glottis, and subglottis. Orv Hetil. 2021; 162(52): 2100-2106.

Clarifying optimal outcome measures in intermittent and continuous laryngeal neuromonitoring

BACKGROUND

Intraoperative neuromonitoring (IONM) techniques have evolved over the past decade into intermittent IONM (I-IONM) and continuous IONM (C-IONM) modes of application. Despite many prior publications on both types of IONM, there remains uncertainty about what outcomes should be measured for each form of IONM. The primary objective of this paper is to define categories of benefit for I-IONM/C-IONM and to clarify and standardize their reporting outcomes.

METHODS

Expert review consensus statement utilizing modified Delphi methodology.

RESULTS

I-IONM provides diagnosis, classification, and prevention of nerve injury through accurate and early nerve identification. C-IONM provides real-time information on nerve functional integrity and thus may prevent some types of nerve injury but cannot assist in nerve localization. Sudden mechanisms of nerve injury cannot be predicted or prevented by either technique.

CONCLUSIONS

I-IONM and C-IONM are complementary techniques. Future studies evaluating the utility of IONM should focus on outcomes that are appropriate to the type of IONM being utilized.

Vincristine-Induced Bilateral Vocal Cord Palsy in an Adult Male With Diffuse Large B-Cell Lymphoma

Acute bilateral vocal cord palsy (BLVCP) is an airway emergency. Elucidating the underlying cause is imperative to enable appropriate management. Vincristine-related neurotoxicity is a potentially reversible cause of BLVCP and is rarely described in the literature. We report a case of a 65-year-old man who presented with acutely worsening dyspnoea and stridor following his fifth cycle of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) chemotherapy for hematological malignancy. His airway limitation was managed with supportive measures until he was able to compensate, at which point he was discharged home. His chemotherapy regimen was altered and he underwent serial examinations until he regained full vocal cord mobility at three months following his initial presentation. Through reporting this case, we hope to raise awareness of the potential for vincristine to cause sudden BLVCP and resultant airway deterioration, as well as emphasize the reversible nature of the condition with prompt cessation of therapy. 

Recurrent Laryngeal Nerve Preservation Strategies in Pediatric Thyroid Oncology: Continuous vs. Intermittent Nerve Monitoring

Simple Summary

Thyroid operations in children are difficult because children have thinner nerves than adults, and there is less space for the surgeon to operate. Since it runs closely behind the thyroid capsule, the nerve innervating the vocal cords can be injured during the operation. In thyroid cancer, the thyroid gland typically needs to be removed completely, putting the nerve at greater risk of injury. This surgical risk can be reduced by monitoring the function of the nerve before it is lastingly damaged. There are two methods to achieve this: intermittent (longer intervals between pulses) and continuous (very small intervals between pulses) nerve stimulation. In this study of 258 children with suspected or confirmed thyroid cancer, nerve damage and vocal cord palsy were observed only after intermittent and not after continuous nerve stimulation. This demonstrated that continuous nerve stimulation was safer than intermittent nerve stimulation.

Abstract

(1) Background: Pediatric thyroidectomy is characterized by considerable space constraints, thinner nerves, a large thymus, and enlarged neck nodes, compromising surgical exposure. Given these challenges, risk-reduction surgery is of paramount importance in children, and even more so in pediatric thyroid oncology. (2) Methods: Children aged ≤18 years who underwent thyroidectomy with or without central node dissection for suspected or proven thyroid cancer were evaluated regarding suitability of intermittent vs. continuous intraoperative neuromonitoring (IONM) for prevention of postoperative vocal cord palsy. (3) Results: There were 258 children for analysis, 170 girls and 88 boys, with 486 recurrent laryngeal nerves at risk (NAR). Altogether, loss of signal occurred in 2.9% (14 NAR), resulting in six early postoperative vocal cord palsies, one of which became permanent. Loss of signal (3.5 vs. 0%), early (1.5 vs. 0%), and permanent (0.3 vs. 0%) postoperative vocal cord palsies occurred exclusively with intermittent IONM. With continuous nerve stimulation, sensitivity, specificity, positive and negative predictive values, and accuracy reached 100% for prediction of early and permanent postoperative vocal cord palsy. With intermittent nerve stimulation, sensitivity, specificity, positive and negative predictive values, and accuracy were consistently lower for prediction of early and permanent postoperative vocal cord palsy, ranging from 78.6% to 99.8%, and much lower (54.2–57.9%) for sensitivity. (4) Conclusions: Within the limitations of the study, continuous IONM, which is feasible in children ≥3 years, was superior to intermittent IONM in preventing early and permanent postoperative vocal cord palsy.

Neuromonitoring of the Recurrent Laryngeal Nerve Reduces the Rate of Bilateral Vocal Cord Dysfunction in Planned Bilateral Thyroid Procedures

Purpose: Bilateral vocal cord dysfunction (bVCD) is a rare but feared complication of thyroid surgery. This long term retrospective study determined the effect of intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) during thyroid surgeries with regard to the rate of bVCD and evaluated the frequency as well as the outcome of staged operations. Methods: Retrospective analysis of prospectively documented data (2000–2019) of a tertiary referral centers’ database. IONM started in 2000 and, since 2010, discontinuation of surgery was encouraged in planned bilateral surgeries to prevent bVCD, if non-transient loss of signal (ntLOS) occurred on the first side. Datasets of the most recent 40-month-period were assessed in detail to determine the clinical outcome of unilateral ntLOS in planned bilateral thyroid procedures. Results: Of 22,573 patients, 65 had bVCD (0.288%). The rate of bVCD decreased from 0.44 prior to 2010 to 0.09% after 2010 (p < 0.001, Chi2). Case reviews of the most recent 40 months period identified ntLOS in 113/3115 patients (3.6%, 2.2% NAR), of which 40 ntLOS were recorded during a planned bilateral procedure (n = 952, 2.1% NAR). Of 21 ntLOS occurring on the first side of the bilateral procedure, 15 procedures were stopped, subtotal contralateral resections were performed, and thyroidectomy was continued in 3 patients respectively, with the use of continuous vagal IONM. Eighteen cases of VCD were documented postop, and all but one patient had a full recovery. Seven patients had staged resections after 1 to 18 months (median 4) after the first procedure. Conclusion: IONM facilitates reduced postoperative bVCD rates. IONM is, therefore, recommendable in planned bilateral procedures. The rate of non-complete bilateral surgery after intraoperative non-transient LOS was 2%.

Pediatric Oncology Patients With Vincristine-Induced Recurrent Laryngeal Nerve Palsy: Two Case Reports and a Brief Review of Literature

INTRODUCTION

Vincristine (VCR) is a chemotherapeutic agent used widely in the treatment of hematologic and solid tumors, known to result in neurotoxicity, especially with cumulative administrations. Bilateral vocal fold palsy (VFP) is a rare but life-threatening complication of VCR. We report 2 patients with hepatoblastoma presenting with stridor following VCR treatment and propose a management plan.

METHODS

Electronic medical records of oncology patients treated at a tertiary hospital with VCR-induced VFP were reviewed. Literature review was performed in PubMed using the terms: hoarseness, VFP, stridor, vincristine.

RESULTS

A total of 23 children with VCR-induced VFP were identified from the literature review and adding on our 2 cases. Seventeen (77.3%) were male and 5 (22.7%) were female. The median presenting age was 36.0 months (5-204 months). Acute lymphoblastic leukemia, 15 of 23 (65.2%), was the most common malignancy. Eighteen patients (78.3%) had bilateral VFP and 5 (21.7%) had unilateral VFP. The mean time to VF function recovery was 167.3 days (median: 200.5 days, range: 7-270 days) in the intervention group versus 72.1 days (median: 31.5 days, range: 3-240 days) in the conservative group. One patient in the intervention group had persistent VFP. Sixteen patients (69.6%) were observed, 4 (17.4%) underwent tracheostomy, 1 (4.35%) was intubated, 1 (4.35%) underwent cordectomy, and 1 (4.35%) required positive pressure support. Vincristine was restarted in 12 patients (54.5%), of which 4 developed recurrence of airway symptoms and had to stop VCR.

CONCLUSION

A new-onset hoarseness or stridor in a child on VCR should raise the suspicions of VFP. The assumption of an upper respiratory-induced hoarseness or stridor should be avoided. Decisions regarding readministration of VCR and possible airway interventions should be made via a multidisciplinary team approach.

Pharyngolaryngeal spasm-induced dysphagia in an epileptic patient undergoing vagus nerve stimulation therapy

Vagus nerve stimulation for refractory epilepsy may induce laryngeal side effects such as dysphonia and dysphagia. Careful tuning of the stimulation parameters and collaboration between epileptologists and otolaryngologists can help significantly reduce side effects.

Intraoperative Neuromonitoring in Thyroid Surgery: An Efficient Tool to Avoid Bilateral Vocal Cord Palsy

OBJECTIVES

This study aimed to analyze the effects of intraoperative neuromonitoring (IONM) on the prevalence of vocal cord palsy (VCP) in thyroid surgery.

METHODS

Data from 493 patients (839 nerves at risk [NAR]) who underwent thyroid surgery between July 2014 and May 2016 were retrospectively evaluated. The patients were divided into 2 groups: Group 1 (G1) consisted of patients who underwent surgery without IONM, whereas group 2 (G2) consisted of patients who underwent surgery with IONM. The surgical techniques were identical, and experienced surgeons performed the procedures in both groups. Intraoperative neuromonitoring was performed in compliance with the International Neural Monitoring Guidelines.

RESULTS

In total, 211 patients (170 female, 41 male) with 360 NAR were included in G1, and 282 patients (220 female, 62 male) with 479 NAR were included in G2. The number of VCP per NAR in G1 and G2 was 33 (9.2%) and 27 (5.6%), respectively (P = .005). The number of transient VCP per NAR in G1 and G2 was 27 (7.5%) and 23 (4.8%; P = .230), respectively. The number of permanent VCP per NAR in G1 and G2 was 6 (1.7%) and 4 (0.8%; P = .341), respectively. Bilateral VCP was detected in 4 (2.7%) patients in G1, whereas there was no patient with bilateral VCP in G2 (P = .033).

CONCLUSIONS

Intraoperative neuromonitoring may decrease the incidence of total VCP and prevent the development of bilateral VCP, which has unfavorable results for both patients and health-care professionals.

Neural monitoring in thyroid surgery is here to stay

The iatrogenic injury of the recurrent laryngeal nerve (RLN), more clinically significant than those affecting the external branch of the superior laryngeal nerve (EBSLN), constitute one of the most feared perioperative complications of thyroid surgery and parathyroid glands, in terms of impact in clinical and economic-social costs. Moreover, these events rank among the leading reasons for medicolegal litigation of surgeons because of its attendant reduction in quality of life. The average incidence of RLN paralysis, permanent and temporary, after thyroidectomy is high and stands between 2.3% and 9.8% respectively. Given the elements described above, it is essential for the surgeon to adhere to a carefully standardized intraoperative technique that minimizes the possibility of RLN injuries. Intraoperative neuromonitoring (IONM) was introduced to reduce RLN injuries and for this reason, it achieved considerable success among endocrine surgeons. However, even today it is considered an adjunct device to the direct identification of the RLN. In this perspective, IONM of RLN constitutes an important aid, since it represents a reliable tool for the evaluation of functional neural integrity. Despite the ever-increasing diffusion of the IONM, prospective randomized studies are needed for further validation. The purpose of this work is to analyze scientific evidence to show that IONM in thyroid surgery is here to stay.

Thyroid surgery outcomes analysis in an oral and maxillofacial surgery department

The purpose of this study was to identify complication rates of thyroidectomies performed within the Department of Oral and Maxillofacial Surgery, University of Florida Health - Jacksonville, and to compare these with quantified data regarding complications of thyroidectomies performed by other specialties. A retrospective cohort analysis was implemented to determine complication rates amongst patients treated in the department between January 2012 and December 2017. Data variables included demographics, ASA status, social history, and preoperative signs and symptoms. The primary outcome variables were length of hospital length, secondary procedures in the same admission, and postoperative complications including hypocalcemia, hematoma, and voice changes. A total of 402 patients were identified, of whom six were excluded for insufficient data. The mean age of the 396 patients included was 47.9 years and 84.6% were female. Of the patients included, 338 experienced no complications; 86 patients spent more than one postoperative day in the hospital. A statistically significant (P=0.033) correlation was found between higher ASA status (III, IV, V) and increased length of stay. The results indicated safe and efficient thyroid surgery within a department of oral and maxillofacial surgery by current prevailing standards.

Cadaveric Measurements of the Left Recurrent Laryngeal Nerve, Ligamentum Arteriosum, Aortic Arch, and Pulmonary Artery in the Thorax with Clinical Implications and Comparison Between Two Sexes in the American Population

The left recurrent laryngeal nerve (RLN) is prone to get compressed or damaged, leading to vocal cord palsy, due to pathologies or surgeries of the structures closely surrounding this nerve in the thorax, including the esophagus, aortic arch, pulmonary trunk, and ligamentum arteriosum. We wanted to provide a data set including nerve diameter, its distance from the esophagus, measurements of the pulmonary artery, aorta, and ligamentum arteriosum in close proximity of the nerve in a healthy population to avoid its damage during surgery and predict its chances of compression during the diseased condition. We measured the left RLN and the surrounding structures in 39 well-embalmed cadavers. We compared the values among the male and female cadavers. We found that the mean diameter of the left RLN was 1.75 mm, the mean distance of the nerve from esophagus was 9.88 mm, the mean diameters of the aortic arch and pulmonary artery just distal to the attachment of the ligamentum arteriosum were 26.14 and 19.93 mm, respectively, and the length and width of ligamentum arteriosum were 15.89 and 2.79 mm, respectively. No clinically significant differences were found between male and female parameters. This set of values might be useful while investigating the cause of vocal cord palsies or during surgeries in close proximity to left RLN to avoid its damage.

The first reported case of vincristine-induced unilateral vocal cord palsy in an adult patient with HIV-associated Burkitt-like lymphoma being treated with dose-escalated R-EPOCH

Vincristine-induced vocal cord palsy (VCP) is a rare but critical complication. Prompt recognition of VCP is imperative. Vincristine-induced VCP is reversible, and a complete remission of a lymphoma is still feasible upon withdrawal of vincristine from the chemotherapeutic regimen early in the course of treatment.

Recurrent laryngeal nerve injury assessment by intraoperative laryngeal ultrasonography: a prospective diagnostic test accuracy study

Introduction

Recurrent laryngeal nerve injury is one of the major complications related to thyroid surgery. Intraoperative recurrent laryngeal nerve functional status monitoring is becoming a standard part of thyroid surgery. However, the current methods for intraoperative nerve functional status assessment are associated with a demand for specialized devices and increased costs.

Aim

To assess the validity of a new method – intraoperative laryngeal ultrasonography – for prediction of recurrent laryngeal nerve injury.

Material and methods

This prospective diagnostic test accuracy study included 112 patients undergoing thyroid surgery in Vilnius University Hospital Santaros Clinics. Neurostimulation combined with laryngeal ultrasonography and laryngeal palpation was performed intraoperatively to evaluate recurrent laryngeal nerve functional status. Recurrent laryngeal nerve injury was confirmed by laryngoscopy, which was performed on the first postoperative day and considered to be the gold standard method.

Results

Data on 112 consecutive patients and 200 nerves at risk were collected. The temporary vocal cord palsy rate was 5.4% per patient and 3% per nerve at risk. No permanent palsy or bilateral injury cases were registered in the study cohort. Laryngeal ultrasound sensitivity counted per nerve at risk was 83.3%, specificity 97.2%, accuracy 96.4%, positive predictive value 62.5% and negative predictive value 99%.

Conclusions

Laryngeal ultrasonography is a feasible new technique for accurate intraoperative recurrent laryngeal nerve injury evaluation.

Extralaryngeal division of the recurrent laryngeal nerve: A common and asymmetric anatomical variant

OBJECTIVE

Recognition of extralaryngeal branching of the recurrent laryngeal nerve is crucial because prevention of vocal cord paralysis requires preservation of all branches of the recurrent laryngeal nerve. We assessed the prevalence of extralaryngeal branching of the recurrent laryngeal nerve and the median branching distance from the point of bifurcation to the entry point of the nerve into the larynx.

MATERIAL AND METHODS

Prospective operative data on recurrent laryngeal nerve branching were collected from 94 patients who underwent thyroid or parathyroid surgery between September 2011 and May 2012.

RESULTS

A total of 161 recurrent laryngeal nerves were examined (82 right, 79 left). Overall, 77 (47.8%) of 161 recurrent laryngeal nerves were bifurcated before entering the larynx. There were 36 (43.9%) branching nerves on the right and 41 (51.9%) branching nerves on the left, and there was no significant difference between the sides in terms of branching (p=0.471). Among 67 patients who underwent bilateral exploration, 28.4% were found to have bilateral branching, 40.3% had unilateral branching, and the remaining 31.3% had no branching. The median branching distance was 15 mm (5-60mm).

CONCLUSION

Extralaryngeal division of recurrent laryngeal nerve is a common and asymmetric anatomical variant. These variations can be easily recognized if the recurrent laryngeal nerve is identified at the level of the inferior thyroid artery and then dissected totally to the entry point of the larynx. Inadvertent division of a branch may lead to vocal cord palsy postoperatively, even when the surgeon believes the integrity of the nerve has been preserved.

Vocal cord paresis following single-session high intensity focused ablation (HIFU) treatment of benign thyroid nodules: incidence and risk factors

BACKGROUND

Vocal cord paresis (VCP) may occur following high intensity focused ultrasound (HIFU) of thyroid nodules. We hypothesised its occurrence relates to the distance of the focus point (FP) of the HIFU beams from the recurrent laryngeal nerve (RLN) and the thermal power that this point received. Their relationships were examined.

METHODS

One hundred and three patients who underwent HIFU for symptomatic benign thyroid nodule from October 2015 to March 2017 were analysed. All treatment images were captured and were later watched by 2 reviewers to identify three FPs closest to the tracheoesophageal groove (TEG) on transverse sonographic view. TEG was taken as the RLN position. After identifying these FPs, their distance (mm) from the TEG, thermal power (W) used and depth from skin (mm) were recorded. These parameters were compared between those with and without VCP. VCP was defined as a cord with reduced or no movement.

RESULTS

Four (3.9%) patients suffered from a unilateral VCP afterwards but they all recovered fully within 6 weeks. There were no significant differences in baseline characteristics and treatment efficacy between the two groups. The distance from TEG (OR = 1.706, 95%CI = 1.001 to 2.915, p = 0.050) was the only significant factor for VCP. None of the other variables including thermal power were significant.

CONCLUSIONS

The incidence of VCP was 3.9% (4/103) and they completely recovered within 6 weeks. The distance between the FP and the TEG was the only related factor for VCP. The safe distance between FP and TEG should be ≥1.1 cm.

Lessons Learned After 1000 Cases of Transcutaneous Laryngeal Ultrasound (TLUSG) with Laryngoscopic Validation: Is There a Role of TLUSG in Patients Indicated for Laryngoscopic Examination Before Thyroidectomy?

INTRODUCTION

Patients with hoarseness of voice, previous neck operation, or suspicion of malignancy are at high risk of having pre-thyroidectomy vocal cord (VCP) palsy. Therefore, vocal cord (VC) functions should be evaluated before surgery. This study aimed to evaluate the accuracy of hoarseness, a voice-related questionnaire (Voice Handicap Index [VHI]-30), and transcutaneous laryngeal ultrasound (TLUSG) in diagnosing VCP, as well as the role of TLUSG in the evaluation of high-risk patients.

METHODS

A total of 1000 patients undergoing thyroidectomy or other endocrine-related neck procedures were prospectively included. Symptoms of hoarseness, the VHI-30 score, and TLUSG were evaluated. Validation laryngoscopies were performed by a separate endoscopist after performing TLUSG. All the assessments were performed one to seven days before surgery. The findings of hoarseness, the VHI-30 score, and TLUSG were correlated with laryngoscopic findings to evaluate the diagnostic accuracy.

RESULTS

Of 1000 patients, nine preoperative VCP were diagnosed with laryngoscopy. Sensitivity in detecting VCP by hoarseness, the VHI-30 score, and TLUSG were 33.3%, 62.5%, and 88.9%, respectively. A total of 342 patients were considered as high risk, and eight preoperative VCP were confirmed with laryngoscopy. Despite it not being possible to visualize the VCs in 26 (7.7%) patients, TLUSG had a higher accuracy in detecting VCP than the VHI-30 did (96.8% vs. 74.2%; p < 0.001). If patients had been selected who were unassessable or who had had VCP on assessment for confirmatory laryngoscopy, TLUSG saved more patients from laryngoscopic examinations than the VHI-30 did (87.7% vs. 71.3%; p < 0.001). A history of neck operation and suspicion of malignancy did not affect the assessment by TLUSG (p > 0.05).

CONCLUSION

TLUSG is a feasible, non-invasive, and sensitive tool in detecting VCP in high-risk patients. It has safely precluded 87.7% high-risk patients from laryngoscopy. TLUSG should be incorporated as a part of the ultrasound examination of the thyroid.

Vocal cord paralysis predicted by neural monitoring electrophysiologic changes with recurrent laryngeal nerve compressive neuropraxic injury in a canine model

BACKGROUND

Recurrent laryngeal nerve (RLN) injury is a known complication of thyroid/parathyroid surgery. Intraoperative nerve monitoring (IONM) has been used to gain more information regarding the functional status of the RLN intraoperatively; however, the electromyography (EMG) parameters of RLN after nontransection neuropraxic compressive injury remain unknown.

METHODS

We developed a canine model to identify IONM EMG correlates of postoperative vocal cord paralysis (VCP) using a standardized method to simulate surgical RLN compression sufficient to cause VCP.

RESULTS

Compression nerve injury decreased EMG amplitude and increased EMG latency, with a 60% increase in RLN threshold stimulation compared to preinjury values. If RLN amplitude decreases by 80% with an absolute amplitude of 300 μV or less in combination with a latency increase of 10% or more, then nerve injury and associated VCP is likely.

CONCLUSION

These results may help surgeons to prognosticate postoperative neural function and intraoperative decision-making regarding contralateral thyroid surgery. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1341-E1350, 2016.

Loss of signal in recurrent nerve neuromonitoring: causes and management

During recurrent laryngeal nerve (RLN) neuromonitoring in thyroid surgery, laryngeal electromyography (EMG) amplitude may be correlated with the number of muscle fibers participating in the polarization and these might be correlated with the function of RLN. If RLN is severely injured during the operation, most nerve fibers do not transmit nerve impulse and substantial decrease of EMG amplitude or loss of signal (LOS) will occur. True LOS at the end of an operation often indicates a postoperative fixed vocal cord, and the surgeon should consider the optimal contralateral surgery timing in patients with planned bilateral thyroid operation to avoid the disaster of bilateral vocal cord palsy. However, LOS recovery and false LOS may occur and may lead to an unnecessary 2(nd) operation. Therefore, a reliable modality for intraoperative LOS evaluation and management would afford the surgeon real-time information that could help guide surgical procedure and planning. The updated causes, algorithm, and management of LOS during RLN neuromonitoring are reviewed and summarized.

Stridor in children: Is airway always the cause?

Stridor in children is usually, but not always caused by airway pathology. The anesthesiologists should have a sound knowledge of the neurological associations of stridor and its management. In such cases, prompt treatment of the neurological pathology usually resolves the stridor and may prevent unnecessary airway evaluation and intervention in the child.

Ortner's Syndrome: Secondary Laryngeal Paralysis Caused by a Great Thoracic Aorta Aneurysm

Introduction Recurrent laryngeal nerve injury caused by cardiovascular disease is a rare condition, and often it is the only prominent sign of an imminent break of an aortic artery aneurysm.

Objective To report left laryngeal paralysis caused by a great aortic arch aneurysm and to highlight the importance of an otorhinolaryngologic evaluation along with a thoracic radiologic study.

Resumed Report A 42-year-old man complained of thickness of his voice and dysphagia for 3 months, but no thoracic pain or other relevant complaints. Video laryngoscopy revealed immobility of his left vocal fold in the paramedian position. Imaging was obtained for investigation, including magnetic resonance imaging of his thorax, which showed a fusiform aneurysm in the aortic arch, leading to recurrent compression of the left laryngeal nerve. The patient was successfully treated with endovascular repair of the aneurysm. At 2-month follow-up, there was still no recovery of the laryngeal mobility.

Conclusion An aortic artery aneurysm can suddenly break, requiring emergency heart surgery, and the results can be fatal in many cases. We suggest routine exam of the vocal folds in all patients with a heart condition, and we review the literature and suggest the use of imaging to reduce the number of emergency procedures.

Hoarseness as the sole symptom of an impending thoracic aneurysm rupture?

Unilateral vocal cord palsy secondary to thoracic aortic aneurysm is a rare occurrence. Direct compression of the enlarging thoracic aneurysm on the left recurrent laryngeal nerve causes neuronal injury of the nerve, which is manifested as hoarseness. We present a rare case of unilateral vocal cord palsy in a 60-year-old healthy gentleman caused by a large thoracic aortic aneurysm. This rare presentation, with a serious underlying pathology might be misdiagnosed or delayed. Therefore, it is important for us to have high index of suspicion in cases with a rare presentation such as this.

Autologous platelet-poor plasma gel for injection laryngoplasty

PURPOSE

To overcome the potential disadvantages of the use of foreign materials and autologous fat or collagen, we introduce here an autologous plasma gel for injection laryngoplasty. The purpose of this study was to present a new injection material, a plasma gel, and to discuss its clinical effectiveness.

MATERIALS AND METHODS

From 2 mL of blood, the platelet poor serum layer was collected and heated at 100°C for 12 min to form a plasma gel. The plasma gel was then injected into a targeted site; the safety and efficacy thereof were evaluated in 30 rats. We also conducted a phase I/II clinical study of plasma gel injection laryngoplasty in 11 unilateral vocal fold paralysis patients.

RESULTS

The plasma gel was semi-solid and an easily injectable material. Of note, plasma gel maintains the same consistency for up to 1 year in a sealed bottle. However, exposure to room air causes the plasma gel to disappear within 1 month. In our animal study, the autologous plasma gel remained in situ for 6 months in animals with minimal inflammation. Clinical study showed that vocal cord palsy was well compensated for with the plasma gel in all patients at two months after injection with no significant complications. Jitter, shimmer, maximum, maximum phonation time (MPT) and mean voice handicap index (VHI) also improved significantly after plasma gel injection. However, because the injected plasma gel was gradually absorbed, 6 patients needed another injection, while the gel remained in place in 2 patients.

CONCLUSION

Injection laryngoplasty with autologous plasma gel may be a useful and safe treatment option for temporary vocal cord palsy.

Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury

BACKGROUND

Conventional intraoperative nerve monitoring, predicated on intermittent stimulation, can predict recurrent laryngeal nerve (RLN) palsy only after the damage has been done.

METHODS

Fifty-two patients (52 nerves at risk) who underwent continuous intraoperative nerve monitoring (CIONM) for thyroid surgery via vagus nerve stimulation had their electromyographic (EMG) tracings recorded and correlated with surgical maneuvers and postoperative RLN function.

RESULTS

There was 1 imminent loss of signal (LOS) with intraoperative signal recovery and there were 4 losses of signal with corresponding unilateral transient RLN palsy. When EMG amplitude decreased >50% and EMG latency increased >10%, LOS and postoperative RLN palsy were noted in 4 of 8 patients (50%) who had multiple combined events. In 9 of 13 patients (70%) who developed adverse EMG changes, modification of the causative surgical maneuver resulted in recovery of those EMG changes and aversion of impending RLN palsy.

CONCLUSION

CIONM reliably signaled impending nerve injury, enabling immediate corrective action.

Vocal cord palsy: An uncommon presenting feature of myasthenia gravis

Vocal cord palsy can have myriad causes. Unilateral vocal cord palsy is common and frequently asymptomatic. Trauma, head, neck and mediastinal tumors as well as cerebrovascular accidents have been implicated in causing unilateral vocal cord palsy. Viral neuronitis accounts for most idiopathic cases. Bilateral vocal cord palsy, on the other hand, is much less common and is a potentially life-threatening condition. Myasthenia gravis, an autoimmune disorder caused by antibodies targeting the post-synaptic acetylcholine receptor, has been infrequently implicated in its causation. We report here a case of bilateral vocal cord palsy developing in a 68-year-old man with no prior history of myasthenia gravis 2 months after he was operated on for diverticulitis of the large intestine. Delay in considering the diagnosis led to endotracheal intubation and prolonged mechanical ventilation with attendant complications. Our case adds to the existing literature implicating myasthenia gravis as an infrequent cause of bilateral vocal cord palsy. Our case is unusual as, in our patient, acute-onset respiratory distress and stridor due to bilateral vocal cord palsy was the first manifestation of a myasthenic syndrome.

Endoscopic thyroidectomy via an axillo-breast approach without gas insufflation for benign thyroid nodules and micropapillary carcinomas: preliminary results

PURPOSE

To examine the feasibility of endoscopic thyroidectomy (ET) via an axillo- breast approach without gas insufflation for large thyroid tumors and micropapillary carcinomas.

MATERIALS AND METHODS

The patients in the benign group were separated into groups 1 (n=95, <4 cm in tumor diameter) and 2 (n=37, ≥4 cm in tumor diameter). Also, 57 patients in the micropapillary carcinoma group underwent an endoscopic hemithyroidectomy (HT) (group 3) and were compared with 60 patients who received conventional open HT (group 4). Postoperative functional outcome, local complications, surgical outcomes, and pathological outcomes were compared between the groups.

RESULTS

In the benign group, there was no significant difference in mean operating time, hospital stay, or overall perioperative complications between the two groups. In the micropapillary carcinoma group, mean operating time and hospital stay in group 3 were significantly longer than in group 4 (p=0.015 and p≤0.001). The overall perioperative complications did not differ significantly between the groups. The postoperative cosmetic result was better in groups 1-3 (endo group) than in group 4 (open group).

CONCLUSION

ET via a gasless axillo-breast approach seems to be a safe procedure even for benign thyroid lesions ≥4 cm and micropapillary carcinomas. Although it has the advantage of better cosmetic results over open thyroidectomy, there is room for improvement in terms of lessening its invasiveness and shortening the operative time.