The utility of parathyroid autofluorescence as an adjunct in thyroid and parathyroid surgery 2023.

Thyroid and parathyroid surgery requires careful dissection around the vascular pedicle of the parathyroid glands to avoid excessive manipulation of the tissues. If the blood supply to the parathyroid glands is disrupted, or the glands are inadvertently removed, temporary and/or permanent hypocalcemia can occur, requiring post-operative exogenous calcium and vitamin D analogues to maintain stable levels. This can have a significant impact on the quality of life of patients, particularly if it results in permanent hypocalcemia. For over a decade, parathyroid tissue has been noted to have unique intrinsic properties known as "fluorophores," which fluoresce when excited by an external light source. As a result, parathyroid autofluorescence has emerged as an intra-operative technique to help with identification of parathyroid glands and to supplement direct visualization during thyroidectomy and parathyroidectomy. Due to the growing body of literature surrounding Near Infrared Autofluorescence (NIRAF), we sought to review the value of using autofluorescence technology for parathyroid detection during thyroid and parathyroid surgery. A literature review of parathyroid autofluorescence was performed using PubMED. Based on the reviewed literature and expert surgeons' opinions who have used this technology, recommendations were made. We discuss the current available technologies (image vs. probe approach) as well as their limitations. We also capture the opinions and recommendations of international high-volume endocrine surgeons and whether this technology is of value as an intraoperative adjunct. The utility and value of this technology seems promising and needs to be further defined in different scenarios involving surgeon experience and different patient populations and conditions.

Insertion of a vacuum based drain for post-parotidectomy non-resolving seroma in an outpatient setting.

We describe a novel technique for the insertion of a vacuum drain, in an outpatient setting, for persistent seroma post-parotidectomy. This is a retrospective case series of a single academic centre. The complete medical records of all patients who underwent parotidectomy between 2014 and 2019 were reviewed. Data regarding demographics, comorbidities, and intraoperative and postoperative courses were extracted for patients for whom a vacuum drain was inserted due to persistent seroma. A size 8 Fr drain was inserted using a novel approach through the parotidectomy incision using 'Biovac' (Biometrix) 50ml, Trocar kit, that had been adjusted and modified for this purpose. Two hundred and eighteen patients had had parotidectomy during the study period. Eight patients (3.6%) underwent insertion of the drain due to persistent seroma. In three patients (37.5%) no drain was inserted during the initial surgery. The mean (SD) time between surgery and insertion of the outpatient vacuum drain was 10 (5) days. All drain insertions were uneventful and no complications were noted. The mean (SD) time for outpatient vacuum drain removal was 12.75 (4.3) days. A single patient (12.5%) underwent additional needle aspiration of 5cc few days following removal of the drain. Persistent seromas may be managed in an outpatient clinic with good results and a high safety profile.

Is dissection of level IV necessary in patients with T1-T3 N0 tongue cancer?

OBJECTIVE: Dissection of the lower jugular level of lymph nodes (level IV), as part of an elective neck dissection, has been advocated recently for all patients with oral tongue cancer because of the possibility of "skip metastases" to levels III and IV. The current study was undertaken to evaluate the need to perform a dissection of level IV in patients with oral tongue cancer with no clinical evidence of nodal metastases. METHODS: Fifty-one patients with T1-3, N0 squamous cell carcinoma of the oral tongue were treated with a partial glossectomy and a selective neck dissection of levels I, II, and III. When enlarged nodes were encountered during surgery in level II or III, the dissection was extended to include the nodes in level IV. Involvement of level IV was determined either by the presence of carcinoma on pathological examination or by the development of recurrence in the untreated level IV during a follow-up period of at least 2 years. RESULTS: Level IV was resected as part of the specimen in 17 of the 51 patients and metastatic tumor was found in this level in only one patient. At an average follow-up of 4.1 years, only one patient recurred at level IV, which had been addressed at the initial neck dissection. Consequently, the rate of metastases to undissected level IV was 2%. CONCLUSIONS: Metastases to level IV lymph nodes is rare in patients with T1-T3, N0 oral tongue cancer. Dissection of these nodes only when there is intraoperative suspicion of metastases in levels II or III does not increase the risk or recurrence of tumor in the neck.

Early oral feeding following total laryngectomy.

OBJECTIVES: The time to begin oral feeding after total laryngectomy remains a subject of debate among head and neck surgeons. The prevailing assumption is that early initiation of oral feeding may cause pharyngocutaneous fistula; thus, the common practice of initiating oral feeding after a period of 7 to 10 days. The objective of the study was to demonstrate the feasibility and safety of oral feeding 48 hours after total laryngectomy. STUDY DESIGN: Two-part study includes, first, a sequential study and, second, a prospective analysis of our practice. METHODS: Patients undergoing total laryngectomy without partial pharyngectomy or radiation treatment (except irradiation through small ports for a T1 or T2 glottic carcinoma) were included. In the first, sequential part of the study (part I), a group of 18 patients who were fed 7 to 10 days after total laryngectomy (control group) was compared with a group of 20 patients who received oral feeding within 48 hours. To confirm the results of part I, a prospective analysis of this practice was conducted (part II) in which 35 additional patients who met the above criteria were fed within 48 hours after surgery. RESULTS: In part I, pharyngocutaneous fistula occurred in one patient (5%) in the early feeding group and in two patients (11%) in the control group. In part II, pharyngocutaneous fistula occurred in one patient (2.8%). Overall, fistula occurred in two patients in the combined early feeding group (3.6%). This rate of pharyngocutaneous fistula compares favorably with the fistula rate in the control group of 18 patients. Pharyngeal stricture that required dilation occurred in three of our patients in the study group and two in the control group (5.5% vs. 11%, respectively). The length of hospital stay was significantly shortened from 12 to 7 days. CONCLUSION: Our results indicate that in this patient population initiation of oral feeding 48 hours after total laryngectomy is a safe clinical practice.

Treatment of giant cell granuloma of the maxilla with intralesional injection of steroids.

BACKGROUND: Giant cell granuloma is rare in the head and neck region and most commonly affects the maxilla and mandible. Although it is a benign disease process, it may be locally destructive. Surgery is the treatment currently recommended. Because of the location of the disease, surgery may be disfiguring. Because it is a benign process, less radical nonsurgical treatment alternatives are desirable. METHODS: A case report of a giant cell granuloma treated with steroid injections. RESULTS: After six weekly intralesional steroid injections, a giant cell granuloma of the maxilla became calcified and smaller. After a follow-up period of 2 years, there was no evidence of regrowth, and the bony osteolytic lesion had filled with bone. A review of the literature revealed two case reports of successful steroid injections with similar response. CONCLUSIONS: Steroid injections are a viable alternative in the treatment of giant cell granuloma, which may avoid surgery.

Hürthle cell carcinoma: A malignancy of low-grade potential.

BACKGROUND: Hürthle cell carcinoma of the thyroid is a variant of follicular carcinoma, which has been considered by many as a more aggressive disease than the usual well-differentiated carcinoma of the thyroid. Others, however, have found Hürthle cell carcinoma to be a low-grade malignancy with little morbidity or mortality. METHODS: This is a retrospective report on all patients with Hürthle cell carcinoma diagnosed during the years 1951-1997 by the authors. The behavior of the disease and results of treatment were analyzed biostatistically and the outcome was compared with that of patients with pure follicular carcinoma treated during the same period. RESULTS: Forty-two patients were diagnosed with Hürthle cell carcinoma and 153 with follicular carcinoma during this period (2.8% and 10.3% of all differentiated carcinomas of the thyroid, respectively). The rate of local recurrence and disease-related mortality were both 9.5%, compared with 3.2% & 15.7%, respectively, for the follicular cancers. There was a trend for better outcome in patients younger than 55 years of age, in patients with tumors under 4 cm in size, and in patients treated by total thyroidectomy. Distant metastases occurred in four patients (9.5%) and were the cause of disease-related mortality in three. CONCLUSIONS: When treated assertively, Hürthle cell carcinoma of the thyroid, an oncocytic variant of follicular carcinoma, has a favorable outcome, similar to that of pure follicular carcinoma. Uniting those two entities in a future classification and reporting should be considered.

Green tea regulates cell cycle progression in oral leukoplakia.

BACKGROUND: A complete in vitro multi-stage carcinogenesis model for oral cancer was developed to examine chemopreventive strategies. In the present study, the effects of EGCG [(-)-epigallocatechin-3-gallate], the major constituent of green tea, is being examined to understand mechanisms of action. METHODS: Effects of EGCG on the cell populations were examined with growth assays, cell cycle analysis, and western blots for retinoblastoma protein (pRB). RESULTS: In each cell type, EGCG inhibited growth, with a decrease in efficacy as cells progressed from normal to cancer. A G1 block was induced with an increase in the underphosphorylated form of pRB; EGCG-induced inhibition was not permanent, cells recovered, and no resistance developed. CONCLUSIONS: Our multistage carcinogenesis model for chemoprevention was effective in defining the chemopreventive value of EGCG. The observation that cancerous oral epithelium was less responsive than normal or dysplastic tissues has implication in the use of this agent, and the mechanisms responsible for this result remain to be defined.

Ethanol injection to parathyroid tissue: indications and limitations.

Hyperparathyroidism is a potentially life-threatening disease, caused primarily by parathyroid adenoma. Surgical excision of the tumor, with consequent return of calcium levels to the normal range, is considered the treatment of choice. Within the last few years, several reports have described the destruction of parathyroid tissue using ultrasonically guided injection of 96% ethanol into pathologic parathyroid glands, resulting in successful regulation of both primary and secondary hyperparathyroidism. The procedure was reported as an alternative to operative treatment for patients as high surgical risk, such as the elderly and the critically ill. We report the occurrence of transient Horner's syndrome and vocal fold paralysis after successful injections of ethanol into a parathyroid adenoma, and discuss the implications and restrictions of the procedure in view of the medical literature.

Acute mastoiditis: a 10-year review.

PURPOSE: To study how antibiotic treatment and an early decision to aspirate subperiosteal abscesses can reduce hospitalization periods and costs in patients with acute mastoiditis. PATIENTS AND METHODS: During a 10-year period, 134 patients were diagnosed with acute mastoiditis at the Department of Ear, Nose, and Throat and Head and Neck Surgery (Kaplan Medical Center, Rehovot, Israel). The diagnoses was based on physical findings of retroauricular swelling and erythema and tenderness, with protrusion of the auricle forward and downward. The majority of patients (77) reached medical treatment during the first 3 days of their disease. Wide myringotomy and intravenous antibiotic treatment, aspiration, and complete cortical mastoidectomy were the treatment options. RESULTS: With the administration of wide myringotomy and intravenous antibiotic treatment, 115 patients recovered; nine received aspiration and did not need surgery; and only 15 patients who received the antibiotic treatment needed a complete cortical mastoidectomy. CONCLUSION: With the wise use of antibiotics and early decision to aspirate subperiosteal abscesses, the hospitalization period, the cost, and the need for surgery can be reduced.

Quantitation of chemopreventive synergism between (-)-epigallocatechin-3-gallate and curcumin in normal, premalignant and malignant human oral epithelial cells.

An in vitro model for oral cancer was used to examine the growth inhibitory effects of chemopreventive agents when used singly and in combination. The model consists of primary cultures of normal oral epithelial cells, newly established cell lines derived from dysplastic leukoplakia and squamous cell carcinoma. Two naturally occurring substances, (-)-epigallocatechin-3-gallate (EGCG) from green tea and curcumin from the spice turmeric were tested. Cells were treated singly and in combination and effects on growth determined in 5-day growth assays and by cell cycle analysis. Effective dose 50s and the combination index were calculated with the computerized Chou-Talalay method which is based on the median-effect principle. Agents were shown to differ in their inhibitory potency. EGCG was less effective with cell progression; the cancer cells were more resistant than normal or dysplastic cells. In contrast, curcumin was equally effective regardless of the cell type tested. Cell cycle analysis indicated that EGCG blocked cells in G1, whereas curcumin blocked cells in S/G2M. The combination of both agents showed synergistic interactions in growth inhibition and increased sigmoidicity (steepness) of the dose-effect curves, a response that was dose and cell type dependent. Combinations allowed for a dose reduction of 4.4-8.5-fold for EGCG and 2.2-2.8-fold for curcumin at ED50s as indicated by the dose reduction index (DRI). Even greater DRI values were observed above ED50 levels. Our results demonstrate that this model which includes normal, premalignant and malignant oral cells can be used to analyse the relative potential of various chemopreventive agents. Two such naturally-occurring agents, EGCG and curcumin, were noted to inhibit growth by different mechanisms, a factor which may account for their demonstrable interactive synergistic effect.