The circumstances in which recurrent laryngeal nerve palsy occurs after surgery for benign thyroid disease: a retrospective study of 1026 patients.

OBJECTIVE: To evaluate the circumstances in which recurrent laryngeal nerve palsy occurs after thyroid surgery. METHODS: This study assessed 1026 patients who underwent surgery for benign thyroid disease over a seven-year period in a retrospective, single-centre study. RESULTS: With a total of 1835 recurrent laryngeal nerves at risk, there were 38 cases (2.07 per cent) of transient recurrent laryngeal nerve palsy and 8 (0.44 per cent) of permanent recurrent laryngeal nerve palsy. No explanation was found for 10 of the 46 cases of recurrent laryngeal nerve palsy. Among the 38 other cases, the probable causes included poor identification of the recurrent laryngeal nerve during surgery, involuntary resection of the nerve and several other factors. CONCLUSION: Apart from accidental resection of the recurrent laryngeal nerve during thyroid surgery, the causes of post-operative recurrent laryngeal nerve palsy are often unclear and likely multifactorial. Poor identification of the recurrent laryngeal nerve during surgery is still the main cause of post-operative recurrent laryngeal nerve palsy, even when intra-operative neuromonitoring is used.

Impact of incidental parathyroidectomy and mediastinal-recurrent cellular and lymph-node dissection on parathyroid function after total thyroidectomy.

OBJECTIVES: To determine the impact of incidental parathyroidectomy and mediastinal-recurrent cellular and lymph-node dissection on parathyroid function after total thyroidectomy. MATERIAL AND METHODS: A single-center retrospective study was conducted for a 5-year period in a university hospital center, including 605 patients undergoing total thyroidectomy, 52 of whom had mediastinal-recurrent cellular and lymph-node dissection. ENDPOINTS: The main endpoint was intraoperative number of parathyroid glands as predictor of parathyroid hormone (PTH) level and postoperative hypocalcemia. The secondary endpoint was the correlation between associated mediastinal-recurrent cellular and lymph-node dissection and incidental parathyroidectomy and its impact on PTH level and calcemia in the immediate postoperative period and at 1 month. RESULTS: 161 patients (26.61%) showed hypocalcemia in the immediate postoperative period and 12 (1.98%) at 1 month. Mediastinal-recurrent cellular and lymph-node dissection increased incidental parathyroidectomy risk 4.6-fold. Mediastinal-recurrent cellular and lymph-node dissection was associated with a statistically "suggestive" decrease in day-1 calcemia (P=0.03), and no significant decrease at 1 month (P=0.52). Incidental parathyroidectomy (6.7% of cases with parathyroidectomy versus 1.3% without) did not significantly increase the rate of early hypocalcemia (P=0.28), but was associated with a "suggestive" worsening at 1 month (P=0.02). CONCLUSION: Hypocalcemia after total thyroidectomy is a complex, probably multifactorial issue. Systematic parathyroid gland identification is not recommended due to the increased risk of gland lesion, mainly by devascularization. Incidental parathyroidectomy may induce hypocalcemia at 1 month postoperatively (statistically "suggestive" association).

Head and neck squamous cell carcinoma and metachronous second primaries.

OBJECTIVES: To assess the rate of second (or more) primaries after treatment for head and neck squamous cell carcinoma (HNSCC), and survival compared to patients with a single head and neck cancer. MATERIAL AND METHOD: A single-center retrospective study was performed in a University Hospital Center in 541 patients between 2002 and 2010. RESULTS: One hundred and forty-one patients (26.06%) presented 172 metachronous cancers. Overall 5-year survival was 20.3% with and 38.1% without metachronous cancer. Median and mean survival were respectively 21.9 and 51 months in patients with a single cancer, versus 13.9 and 26.5 months in case of metachronous cancer. Specific survival was comparable to overall survival. All-cause and specific survival were significantly poorer in metachronous cancer (P=0.001; log-rank α=0.05). CONCLUSION: At least a quarter of HNSCC patients go on to develop a metachronous second primary. These are of poor prognosis, whatever their location.

Cardiovascular risk and severity factors in patients admitted to hospital for spontaneous epistaxis.

OBJECTIVES: To assess the role of cardiovascular risk factors, intake of drugs altering hemostasis and severity signs in patients admitted with spontaneous epistaxis. MATERIAL AND METHODS: A single-center retrospective study covering a 7-year period in a university hospital center included 205 patients admitted with spontaneous epistaxis. Study variables comprised: cardiovascular risk factors (cardiovascular disease or history of cardiovascular disease with hemorrhagic or thromboembolic risk, high blood pressure, type-2 diabetes, dyslipidemia), intake of drugs altering hemostasis, blood pressure and minimum hemoglobin level during hospital stay. Groups of serious and non-serious epistaxis were distinguished. RESULTS: There were no significant inter-group differences for mean age, sex ratio, history of high blood pressure or number of cardiovascular risk factors. Serious epistaxis was associated with significantly lower blood pressure and hemoglobinemia. Number of cardiovascular risk factors correlated with probability of blood transfusion. CONCLUSION: The real influence of the various study factors, including severity factors, on onset of spontaneous epistaxis remains to be elucidated.

Impact of pre-operative serum 25-hydroxyvitamin D on post-operative serum calcium in patients undergoing total thyroidectomy for benign goitre: retrospective study of 246 patients.

OBJECTIVE: To determine whether pre-operative serum 25-hydroxyvitamin D has an impact on post-operative parathyroid hormone and serum calcium levels in patients undergoing total thyroidectomy for benign goitre. METHODS: This single-centre, retrospective study comprised 246 unselected surgical patients who had undergone total thyroidectomy for bilateral, benign, multinodular goitre. The correlation between pre-operative serum 25-hydroxyvitamin D and post-operative serum parathyroid hormone and serum calcium was studied to determine whether low pre-operative serum 25-hydroxyvitamin D was predictive of post-operative hypocalcaemia. RESULTS: Seventy-nine patients (32 per cent) had post-operative hypocalcaemia. Eighteen patients (7.32 per cent) experienced unintentional parathyroidectomy (1 parathyroid gland in 15 patients, 2 parathyroid glands in 3 patients). In univariate analysis, pre-operative serum 25-hydroxyvitamin D was not correlated with post-operative serum calcium (p = 0.69) or post-operative serum parathyroid hormone (p = 0.5804). Furthermore, in multivariate analysis, which took into account unintentional parathyroidectomy, no correlation was found (p = 0.33). Bilateral unintentional parathyroidectomy was statistically associated with post-operative hypocalcaemia (p = 0.032). CONCLUSION: Pre-operative serum 25-hydroxyvitamin D did not appear to have any impact on post-operative serum calcium in patients undergoing total thyroidectomy for benign goitre.

Intra-operative neuromonitoring of the vagus nerve during thyroidectomy. A prospective study.

OBJECTIVES: To determine whether intra-operative neuromonitoring (IONM) of the vagus nerve during thyroidectomy can predict postoperative vocal fold palsy. DESIGN: A single-centre, prospective study. SETTING: University Hospital. PARTICIPANTS: A total of 95 patients underwent thyroid surgery. A total of 160 vagus nerves were studied. The amplitude of the action potential of vocal muscles was recorded intra-operatively by indirect supramaximal stimulation of the vagus nerve. All patients underwent flexible fibre-optic laryngoscopy on postoperative day 1 to detect the presence of vocal fold palsy. MAIN OUTCOME MEASURES: The primary outcome measure was the difference of the action potential amplitude of the vagus nerve before and after resection of the thyroid lobe. Statistical analysis determined the amplitude variation cut-off able to accurately predict postoperative vocal fold palsy. RESULTS: Transient vocal fold palsy was observed in 4.375% of cases, and permanent fold palsy was observed in 1.25% of cases. A decrease of the action potential amplitude by more than 61% was statistically significantly associated with postoperative vocal fold palsy. A greater than 87% decrease of the amplitude of the action potential was correlated with permanent postoperative vocal fold palsy. CONCLUSION: IONM of the vagus nerve during thyroidectomy may accurately predict postoperative vocal fold palsy.