Neuromonitoring of recurrent laryngeal nerves in thyroid surgery comparative study of visualisation and electrophysiology methods.

Úvod: Poranění zvratného nervu je jedna z nejzávažnějších komplikací chirurgie štítné žlázy, chirurgie příštítných tělísek a chirurgie krčních obratlů. V literatuře se popisuje poranění zevní větve hrtanových nervů jako méně časté. Tato komplikace je natolik vážná, že může vést k invalidizaci hlasových profesionálů (učitelů, herců, zpěváků, profesionálních řečníků a manažerů). Současná klinická praxe je spojena se zvýšeným úsilím o peroperační ochranu funkce zvratných nervů využíváním elektrofyziologické monitorace funkce inervace hrtanu a současné vizualizace zvratných nervů. Metody: Design studie je prospektivní observační. Ze souboru 100 po sobě jdoucích operací byly chirurgy náhodně vytvořeny dvě skupiny: Skupina A - s použitím neuromonitoringu (IONM) a skupina B - identifikace a vizualizace zvratného nervu (NLR) bez IONM. Jeden tým chirurgů byl složen z experta (více než 1000 provedených operací) a začínajícího chirurga (méně než 100 operací) a druhý ze dvou zkušených chirurgů (jeden více než 150 operací a druhý více než 500 operací). Každý tým byl zapojen do operací několikrát v týdnu. Porovnání bylo provedeno statistickými metodami a pomocí indexu poranění zvratného nervu (recurrent nerve injury - IRI). Cílem studie je porovnat incidenci parézy zvratných nervů při využití neuromonitorace (IONM) a využití peroperační vizualizace anatomicky neporaněného nervu dvěma týmy chirurgů. Výsledky: Bylo analyzováno 100 operací, respektive 50 operací ve skupině A a 50 ve skupině B. Skupina A zahrnovala 43 totálních thyreoidektomií a 7 hemithyreoidektomií a byly zjištěny dvě dočasné jednostranné parézy. Skupina A měla IRI=1,075. Skupina B zahrnovala 48 totálních thyreoidektomií a 2 hemithyreoidektomie. V této skupině byly zjištěna také dvě jednostranné dočasné parézy zvratného nervu. Skupina B měla IRI=1,02. Uvedené hodnoty IRI tak charakterizují asymetrické soubory, i tato drobná asymetrie je ve výsledku hodnoty patrna. Celková incidence poranění zvratných nervů v celém souboru operovaných sledovaného roku, ve kterém byl výběr pacientů dle metodiky této práce, byla 1,3 %. V souboru bylo 16 dočasných a 4 permanentní parézy zvratného nervu ve všech případech na jedné straně. Ve sledovaném období nebyla zjištěna ani jediná oboustranná paréza trvalá ani dočasná. Index IRI pro operace štítné žlázy v uvedeném období byl 2,26. Tento soubor byl srovnáván se soubory skupiny A a skupiny B a výsledky nevykazují statisticky významné rozdíly na hladině významnosti 1 % (p=0,01). Závěr: Studie neprokázala statisticky významné rozdíly incidence poranění zvratného nervu (trvalá jednostranná paréza) v závislosti na chirurgické technice bez využití IONM a s využitím IONM prováděných chirurgem s rozdílnou zkušeností v chirurgii štítné žlázy. Studie prokázala, že IONM může pomoci vyrovnat handicap u začínajících a méně zkušených chirurgů a omezit incidenci morbidity zvratného nervu v chirurgii štítné žlázy.

Morbidity and mortality of parathyroid surgery - a retrospective analysis.

INTRODUCTION: The incidence of parathyroid - glandula parathyreoideae (PTG) diseases has been increasing worldwide. Unlike benign tumours, the incidence of malignant PTG tumours is rather a rare diagnosis. The morbidity of parathyroid surgery is associated with surgical removal of one or more pathologically altered parathyroid glands, particularly parathyroid adenoma associated with primary hyperparathyroidism (HPPT), but also hyperplasia associated with secondary or tertiary HPPT, and last but not least, HPPT due to parathyroid cancer. METHODS: A retrospective statistical analysis was performed in the set of patients undergoing surgery for a parathyroid disorder at the Department of Otorhinolaryngology and Maxillofacial Surgery, 3rd Faculty of Medicine, Charles University and Military University Hospital in Prague in 2013-2019 (7-year period). In this period, 127 procedures were performed. The incidences of morbidity, mortality, complications and lethality were analysed. RESULTS: Parathyroid surgery was performed in 20 male and 107 female patients. The mean age was 54.7 years, and the morbidity expressing recurrent laryngeal nerve (RLN) palsy was 0.7% of the nerves exposed during the procedure. The incidence of permanent normal postoperative calcaemia was 98.43%, demonstrated by a decrease in serum parathyroid hormone (PTH) levels. In 12 cases, this state was achieved only after a surgical revision (primary procedure for primary HPPT in 2 cases; 10 patients came for surgical revision with secondary or tertiary HPPT from other centres). Decreased PTH levels were demonstrated intraoperatively in 12.6% patients using the so-called PTH assay (a rapid serum PTH assay). Surgery for secondary or tertiary hyperparathyroidism was done in 33 patients (26% procedures). PTG surgery lethality (mortality) was divided into perioperative mortality within 24 hours from the procedure and early mortality within 120 hours. Lethality related to PTG surgery was 0.0% including patients undergoing the surgery while being in a dialysis programme and those with kidney transplant. CONCLUSIONS: Surgery is always associated with complications, with morbidity and mortality. Experience of endocrinology surgeons of all specialties is reflected in a very low incidence of RLN injuries and in sufficient oncological, or respectively, surgical radicality. This, in connection with other medical fields of endocrinology, nephrology, transplantology, nuclear medicine and oncology, allows a safe and effective treatment of all PTG disorders with a good prognosis for the patients. In those with secondary or tertiary HPPT, it not only improves their quality of life, which was not explored in our study, but in many cases it is an essential step for listing the patient for the transplant surgery. The current level of experience in the field of parathyroid carcinoma does not enable us to formulate any conclusions in terms of prognosis which should be considered as very serious in all cases.

[Reconstruction of Isolated Orbital Floor Fractures by Nasoseptal Cartilage]. / Rekonstrukce izolovaných zlomenin spodiny ocnice nazoseptální chrupavkou.

PURPOSE OF THE STUDY The incidence of isolated orbital floor fractures has an increasing tendency. Their optimal management is not uniform and is still being discussed in the literature. The therapeutic decision as to whether surgical intervention is necessary or conservative approach is adequate vitally depends on clinical and CT findings. Incorrect treatment can lead to serious consequences, especially to persistent diplopia and enophthalmos. The objective of our study was to evaluate the radiological indication criteria for surgery and the clinical outcomes thereafter. MATERIAL AND METHODS The retrospective monocentric study of the group of 53 patients who underwent the isolated orbital floor fracture reconstruction during the period from 1/1/2006 to 31/12/2016 at the Clinic of Otolaryngology and Head and Neck Surgery of the St. Anne's University Hospital, Brno. The ealuated parameters wee the following: trauma cause, clinical symptoms, evaluation of CT parameters (MH index, RF index, MRI index), time interval from injury to surgery, complications. RESULTS Trauma cause: an assault 30/53 (57%), a fall 14/53 (26%), sports 4/53 (7%), a road traffic accident 4/53 (7%), an accident at work 1/53 (2%). Clinical symptoms: eyelid haematoma and/or swelling 53/53 (100%), diplopia 29/53 (55%), emphysema 29/53 (55%), infraorbital nerve hypoesthesia 4/53 (7%). Radiological report of the CT: RF index > 50% (defect length more than a half of the orbital floor length) 49/53 (92%), RF index <50% (defect length less than a half of the orbital floor length) 4/53 (7%). MH index (maximum height of periorbital herniation): mean value 9.0 mm (2.8-14.2 mm), MRI index (rectus inferior muscle index): <1.5 15/53 (28%), ≥ 1.5 38/53 (72%). Time interval from injury to surgery: mean value 11 days (3-21 days). Complications 6 weeks postoperatively: diplopia 4/53 (7%), ectropion 2/53 (4%), enophtalmos 0/53 (0%), visual damage 0/53 (0%). CONCLUSIONS The choice between the surgical and conservative management of the isolated orbital fracture is the key factor to ensure a good therapeutic result. The evaluation of CT findings is crucial for the decision-making process. The key radiological parameters are the standardized assessment of the orbital floor defect size (RF index), orbital tissue herniation (MH index) and the assessment of damage to the intraorbital muscles (MRI index). As demonstrated by the results of our analysis, surgical reconstruction of the orbital floor by nasoseptal cartilage represents a highly effective and safe method. Key words: orbital fractures, blow-out fracture, orbital floor, orbital reconstruction.

Treatment of a maxillary defect following resection of carcinoma.

A group of 37 oncological patients with tumours of the head and neck where extensive resection of the face, maxilla or mandible or calva was necessary, comprised five patients with a typical defect after resection of part of the maxilla including half of the palate and exenteration of the orbit. This extensive defect causes discomfort to the patient and his environment--functional i.e. impaired speech, and cosmetic. A satisfactory solution during reconstruction of the maxilla without the need of skeletal reconstruction is microsurgical transplantation of a narrow flap of the latissimus dorsi, usually with two cutaneous islands--one to close the palate and the other to close the orbit and face.

[Rational treatment of necrotizing external otitis]. / Racionální lécba nekrotizující externí otitidy.

Advances in the diagnosis and treatment of necrotizing external otitis (NEO) during the past 20 years improved substantially the prognosis of this disease. The use of hyperbaric oxygen therapy greatly potentiates the effect of newly developed highly effective antibiotics. Radioisotope examination of the petrous bones facilitates the diagnosis and indicates the time to terminate treatment. Medicamentous treatment is preferable to surgical treatment, which is reserved for exceptional very advanced cases of the disease. As NEO has been known for 30 years and the means to control it have been improved, it is no longer "malignant" for the majority of patients where the disease is diagnosed in time and treated adequately.

[The psychological and social condition of patients after total laryngectomy]. / Psychická a sociální situace nemocných po totální laryngektomii.

The paper reports on a group of 55 patients after total laryngectomy performed on average 6.5 years ago. Their average age was 62 years. The patients were given a questionnaire and answered 103 questions related to their psychic and social situation after the surgery, which necessitated the use of permanent endotracheal cannula. The patients' most common complaints were speech defects, then a feeling of insufficient air, or "being short of breath", loss of physical fitness, and limited job opportunities. Comprehensive rehabilitation starts well before surgery. Assistance of the family and friends is also considered important, especially during oesophageal speech. The authors recommend to take more advantage of comprehensive spa rehabilitation for patients with total laryngectomy.