The surgical management of parotid gland tumours.

BACKGROUND: The parotid tissue can give rise to a large variety of benign and malignant neoplasms. The objective of this study was to describe the management and outcome of parotid gland tumours over a 15-year period. METHOD: The records of consecutive patients treated by parotid gland excision from January 1995 to December 2008 were reviewed retrospectively. Data recorded were age, gender, history, physical findings, surgical procedure, fine-needle aspiration biopsy (FNAB), final pathological diagnosis and complications. RESULTS: The vast majority of patients (306) had benign neoplasms, and 14 patients had malignant neoplasms. Overall, pleomorphic adenoma contributed to 76% of the lesions, and Warthin's tumour to 17%. The sensitivity and specificity of FNAB was 79% and 100%, respectively. There were 15 cases of marginal mandibular transitory paresis and 12 cases of seroma. Marginal mandibular definitive paralysis was observed in three cases with malignant tumour. CONCLUSION: Standardised parotidectomy is a safe operation, with a low complication rate.

Neutrophil-to-lymphocyte ratio as a prognostic factor for pharyngocutaneous fistula after total laryngectomy.

SUMMARY: The role of systemic inflammatory response as a prognostic factor has been proposed in a variety of cancers. The purpose of this study was to investigate the prognostic value of the pretreatment neutrophil-to-lymphocyte ratio (NLR) in the incidence of pharyngocutaneous fistula (PCF) in patients who underwent total laryngectomy. We conducted a retrospective cohort analysis of 141 patients with squamous cell carcinoma of larynx who underwent total laryngectomy from 2009 to 2015. The incidence of PCF was 49.6%. A higher risk of 23% was observed among patients with NLR > 2.5 for the occurrence of PCF (p = 0.007). Patients with laryngeal squamous cell carcinoma who present elevated values in the ration > LR> (> 2.5) presented a higher risk of developing pharyngocutaneous fistula in the postoperative setting of total laryngectomy.

Does the Intensity of IGG4 Immunostaining Have a Correlation with the Clinical Presentation of Riedel's Thyroiditis?

Riedel's thyroiditis (RT) represents one type of IgG4-related thyroid disease (IgG4RTD) and the diagnosis involves quantitative immunohistochemistry showing dense lymphoplasmacellular inflammatory infiltrate consisting of IgG4-positive plasma cells with storiform fibrosis and obliterative phlebitis. We report a case of RT with progressive enlargement of the anterior neck, severe dysphagia, odynophagia, and dyspnea. The patient underwent surgical decompression of the airway, protection tracheotomy, and gastrostomy for nutritional intake 6 months after first symptoms. Complete resolution occurred after surgical treatment combined with prednisolone. Immunostaining revealed IgG4-positive plasma cells 12/HPF (high-power field) and the IgG4/IgG ratio 25%, values that were disproportionate to the intensity of the patient's symptoms. As to this case and the few cases described and analyzed in the literature, our impression is that there is no relation between the intensity of symptoms in RT with the total number of IgG4-positive plasma cells and the IgG4/IgG ratio, but more studies are needed.

Pharyngocutaneous fistula following total laryngectomy.

Pharyngocutaneous fistula is the most common complication after total laryngectomy. The aim of the study was to establish the incidence of this complication in our series and analyse the predisposing factors. This is a retrospective study comprising 55 patients who underwent total laryngectomy. The following aspects were considered: sex, age, tumour site, pathologic staging according to TNM, performance and type of neck dissection, previous radiation therapy, previous tracheotomy, Cumulative Illness Rating Scale for comorbidity analysis, the use of stapler for pharyngeal closure, and peri-operative blood transfusion. In the cases of pharyngocutaneous fistula, we considered the post-operative period in which it was diagnosed, duration, period of hospitalization, as well as therapeutic approach and the eventual result of this treatment. Pharyngocutaneous fistula was diagnosed in 7 patients (12.7%). There were no statistically significant associations between fistula development and sex (p = 1.000), previous radiation therapy (p = 0.354), stapler closure (p = 0.577), comorbidity (p = 1.000) or tumour site (p = 0.926). Patients previously submitted to tracheotomy presented higher fistula incidence (60%), compared to those that had not undergone this procedure (8%) (p = 0.012). Elderly patients (>60 years) were also more predisposed to fistula development (p = 0.051). Although without statistical significance, fistula development was also associated with peri-operative blood transfusion, T stage, and type of neck dissection.

A Case of "Late" Postsurgical Hypoparathyroidism.

INTRODUCTION: Postsurgical hypoparathyroidism normally occurs a short time after thyroid surgery in form of two clinical syndromes of different etiology and prognosis. The first is transitory and might spontaneously recover within a few weeks or months. The second is permanent and needs a definitive treatment. Only few cases of hypoparathyroidism clinically evident after many years from surgery have been reported. CASE REPORT: A case of hypoparathyroidism clinically evident only three and a half years after surgery is reported. Our findings and review of a few cases reported by medical literature suggest the existence of a third form of postsurgical hypoparathyroidism, characterized by a late beginning.

Transcutaneous fine needle aspiration biopsy of the preepiglottic space.

OBJECTIVE: To evaluate transcutaneous fine needle aspiration biopsy of the preepiglottic space for staging supraglottic squamous cell carcinoma. STUDY DESIGN: We studied 28 patients who underwent total or horizontal supraglottic laryngectomy as their main therapy modality due to supraglottic squamous cell carcinoma, followed in some cases by adjuvant radiation therapy. All the patients underwent transcutaneous fine needle aspiration. RESULTS: The cytopathologic examination of the material obtained by aspiration was compared to the histopathologic analysis of the laryngectomy specimens; the efficiency was 96.4%. The method did not cause any morbidity. CONCLUSION: Transcutaneous fine needle aspiration biopsy of the preepiglottic space is useful for preepiglottic space evaluation, with a high correlation with histopathologic results and no morbidity.

Papillary thyroid carcinoma in thyroglossal duct cyst.

Thyroglossal duct remnants are the most common midline neck swellings, but carcinoma is found in approximately 1% of these lesions. The cysts are usually asymptomatic and the presentation of the patient with carcinoma is indistinguishable from the common cyst. Papillary adenocarcinoma comprises 75-85% of the tumors reported. A 36-year-old woman underwent Sistrunk procedure for excision of a thyroglossal cyst. No thyroid abnormality was noted pre-operatively nor during the surgical examination. The histopathological examination revealed papillary carcinoma. She has been maintained on thyroxine suppression and was doing well at 14 months' follow-up. Carcinoma of the thyroglossal duct cyst is rare. The ultrasonographic examination should be performed pre-operatively for thyroid gland study. The main question is what to do with the thyroid gland. There still is controversy about thyroid removal for a papillary carcinoma, but all the patients should receive suppressive doses of thyroid hormone. As the cure rate is 95% for the patients whose thyroid is preserved and further postoperative complications are avoided, we can consider that the optimal surgical procedure for thyroglossal duct carcinoma is the same as that for the benign cyst.

Surgical treatment of the substernal goitre.

This report describes the surgical experience gained from 32 patients with substernal goitre, operated on during January 1995 to December 1997. The material corresponds to 15.7% of the total thyroidectomies performed. The diagnosis was clinical. In spite of 65.6% of the patients being asymptomatic, breathing problems, dysphagia and hyperthyroidism were observed. The patients underwent tests of thyroid function, simple chest radiograph and computerized tomography of mediastinum. All patients underwent surgical treatment through a transverse cervical incision. Two patients (6.25%) needed median sternotomy. Vocal cord palsy (3.12%), transient hypocalcemia (6.25%) and one death due to cardiac causes (3.12%) were the complications that occurred.

Frontal sinus adenocarcinoma.

CONTEXT: Paranasal sinus cancer is considered rare, with an incidence of less than 1 per 100,000 per year, with the frontal sinus being the primary site in only 0.3%. We report a case of adenocarcinoma arising in the frontal sinus. DESIGN: Case report. CASE REPORT: A 59-year-old woman, secretary, came in February 1998 with a 4-month history of low intensity frontal headache. She denied contact with wood dust. On examination a non-tender swelling was noted over her right forehead next to the medial aspect of the right orbit. CT scan showed a soft-tissue mass involving frontal sinus with intracranial invasion through the posterior wall. The anterior ethmoid sinus and the medial aspect of the right orbit were also involved. MRI demonstrated dural thickening in communication with the frontal mass. She underwent an en-bloc tumor resection by craniotomy including orbital clearance. Histology revealed an adenocarcinoma. After surgery she had tumor recurrence, and chemotherapy and radiotherapy were started resulting in partial improvement.

Stapler suture of the pharynx after total laryngectomy.

The use of a stapler for pharyngeal closure during total laryngectomy was first described in 1971. It provides rapid watertight closure without surgical field contamination. The objective of our study was to compare the incidence of pharyngocutaneous fistula after total laryngectomy with manual and mechanical closures of the pharynx. This was a non-randomised, prospective clinical study conducted at two tertiary medical centres from 1996 to 2011 including consecutive patients with laryngeal tumours who underwent total laryngectomy. We compared the incidence of pharyngocutaneous fistula between two groups of patients: in 20 patients, 75 mm linear stapler closure was applied, whereas in 67 patients a manual suture was used. Clinical data were compared between groups. The groups were statistically similar in terms of gender, age, diabetes mellitus, smoking and alcohol consumption and tumour site. The group of patients who underwent stapler-assisted pharyngeal closure had a higher number of patients with previous tracheotomy (p < 0.001) and previous chemoradiation (p < 0.001). The incidence of pharyngocutaneous fistula was 30% in the mechanical closure group and 20.9% in the manual suture group (p = 0.42). In conclusion the use of the stapler does not increase the rate of fistulae.

Evaluation of a method for assessing pulmonary function in laryngectomees.

In total laryngectomies the impairment of pulmonary function reflects the sum of pre- and post-operative ventilatory changes. Objective information on the respiratory condition in laryngectomees, as assessed in the pulmonary function laboratory is somewhat limited, perhaps because of difficulties related to methodology. The aim of our study was to evaluate the reproducibility of a method employed to assess the pulmonary function in laryngectomized patients. The experimental extra-tracheal device was set up with a silicone adapter through a cardboard tube to the skin around the tracheostoma. Pulmonary function tests included measurements of forced vital capacity, force expiratory volume at 1 second and Tiffeneau index in 3 consecutive evaluations, in 11 patients who underwent total laryngectomy. The control group comprised 11 patients, not laryngectomized, evaluated by conventional spirometry. Those responsible for evaluating were asked to report possible technical failures and to demonstrate the reproducibility of the curves resulting from the tests. The use of the silicone adapter and skin adhesive provided a complete, airtight seal of the system, in all cases. The presence of the tracheo-oesophageal prosthesis did not negatively affect the test results. All patients attributed a maximum value, both for comfort and acceptance, of the device. The values are comparable in both groups, thus indicating the accuracy of the proposed methodology. All examinations were reproducible. After total laryngectomy, pulmonary function testing, with an extra-tracheal device, is not only reliable but also easy to perform in a routine out-patient setting. The methodology did not present air leaks and was, therefore, well accepted by all patients tested.

Contact endoscopy for identifying the parathyroid glands during thyroidectomy.

Aim of this study was to analyse contact endoscopy as an auxiliary method for identifying parathyroid glands during thyroid surgery and to identify other variables that may interfere with this correlation. Overall, 125 patients underwent thyroid surgery between January 2004 and February 2006. The variables analysed were: the total duration of surgery; time taken to locate and identify parathyroid glands; improvement in identifying these; numbers of parathyroid glands located by the surgeon and confirmed by contact endoscopy; histopathological diagnosis; presence of thyroiditis; thyroid weight; number of parathyroid glands left in thyroid specimens; and number of parathyroid gland autotransplantations. A total of 331 parathyroid glands were observed by the surgeon. However, 282 glands were identified by contact endoscopy. Nine parathyroid glands (7.2%) were observed together with thyroid specimens (Kappa = 0.534). The longer the total duration of surgery (p = 0.03) and time taken to locate and identify (p = 0.00) the parathyroid glands by contact endoscopy, the lower the observed agreement. The second year of performing contact endoscopy led to better agreement between the results (p = 0.02). In conclusion, contact endoscopy is an efficient auxiliary method for identifying parathyroid glands during thyroid surgery. During the period studied, association between total duration of surgery and time taken to locate and identify parathyroid glands was statistically significant.

Videokymographic analysis of patients after frontolateral laryngectomy with sternohyoid muscle flap reconstruction.

A retrospective study was conducted to analyse videokymographic findings from patients who underwent vertical frontolateral laryngectomy with reconstruction using a sternohyoid muscle flap. Overall, 22 patients with T1b and T2 glottic tumours and more than one year of follow-up were studied. Two experienced observers analysed the recorded videokymographic data. A cross-sectional descriptive design was used. The images showed the vocal vibratory behaviour during sustained /i/ phonation. The vibratory source was supraglottic in 7/22 patients, glottic in 11 and mixed in 4. The mean duration of the glottic cycles extracted from the supraglottic, mixed and glottic vibratory sources was 6.4 ms, 5 ms and 4.6 ms, corresponding to the fundamental frequency (f0) of 188.7 Hz, 200 Hz and 215.7 Hz, respectively. Of the 11 patients with a glottic vibratory source, 4 did not present a closed phase in the glottic cycle. The mean open quotient was 79%, 40% and 63%, for the supraglottic, mixed and glottic vibratory sources, respectively. All 11 reconstructed vocal cords presented a rounded lateral peak. Of the 15 preserved vocal cords, 11 presented a rounded lateral peak and 4 had sharp peaks. All patients with a glottic vibratory source presented a rounded medial peak. All the vocal cords evaluated presented a mucosal wave, which was normal in 3 patients with a glottic source and clearly reduced in the others. Only one case presented phase asymmetry. The mean values for the amplitude asymmetry index were 0.92 and 0.68, for the mixed and supraglottic vibratory sources, respectively.

Contact endoscopy of the larynx as an auxiliary method to the surgical margins in frontolateral laryngectomy.

Contact laryngomicroscopy is in vivo laryngeal mucosa microscopic examination and rigid telescopy is a non-invasive technique that enables the systematic observation of many details in the large area of vocal fold mucosa. These are performed during laryngomicroscopy. This study was performed in order to evaluate the use of rigid and contact endoscopy effectiveness in establishing the margins in patients undergoing frontolateral laryngectomy. Ten patients with glottic squamous cell carcinoma underwent frontolateral laryngectomy from 2000 to 2003. Eight were staged as T1bN0M0, whereas two were staged as T2N0M0. During the frontolateral approach, the lesion and its limits were carefully defined, the surgical margins were established under the rigid telescope and the patients' margins were studied under contact endoscopy after methylene blue staining. Frozen section examination of the margins was performed and the histopathological analysis was compared to the surgical and endocopic findings. The infraglottic region and the surgical margins were free of disease in all cases and there was a 100% correlation with the histopathological examination. All patients are alive with no evidence of disease after a minimum of 5 years' follow-up. In conclusion, rigid and contact laryngoscopy is effective in establishing the disease-free surgical margins in patients submitted to frontolateral laryngectomy.

Analysis of safety of short-stay thyroid surgery.

The duration of hospital stay, following surgical procedures, has undergone a significant reduction in recent years. However, there are some risks associated with short-stay thyroid surgery. An analysis has been made of data from patients who underwent short-stay thyroid surgery, analyzing the complications associated with this procedure. Overall 270 consecutive patients undergoing thyroidectomy in 2007 and 2008 were prospectively analyzed. Post-operative care included routine ward overnight observation. The discharge criteria were: stable vital signs; apyretic; no wound or airway problems; tolerating diet; and established autonomy at discharge. Data were collected regarding patients' discharge criteria status, length of hospital stay and readmission, as well as morbidity (post-operative haemorrhage, recurrent laryngeal nerve injury and hypocalcaemia) and mortality. This series comprised 175 total thyroidectomies, 93 hemi-thyroidectomies and 2 isthmusectomies. No cases of death or post-operative haemorrhage occurred in any of these patients. Permanent unilateral recurrent laryngeal nerve injury was observed in 4 patients (1.48%). Transient post-operative hypocalcaemia occurred in 23 patients, whereas permanent post-operative hypocalcaemia was observed in 8 patients (2.96%); 4 patients were re-admitted and required early calcium supplementation. Five patients failed to tolerate the diet during the immediate post-operative period. The average duration of hospital stay was 1.02 days. Considering the 4 patients who required re-admission due to hypocalcaemia, the total length of hospital stay was 1.05 days. In conclusion, the one-day surgery model is safe and effective in patients undergoing surgery for thyroid disorders.

Interobserver perceptual analysis of smokers voice.

The purpose of this study was to investigate variations in the voice by three experienced speech-language therapists. Forty-eight men and nine women from the Associação dos Alcoólicos Anônimos, Santos were studied. Their ages were from 28 to 81 years, with median of 49 years and everyone was a smoker for 60 to 720 months. Most of them used more than 20 cigarettes a day and all of them had stopped alcohol use for 1 to 25 months. The perceptual analysis of the voices was performed by means of the GRBAS scale. The voice sample consisted of a sustained vowel /a/ at a comfortable pitch and loudness level. The three judges were blinded to the opinion of their colleagues and a kappa test was applied. For roughness, the concordance rates were 59.6% for observers 1 and 2 (kappa = 0.234); 47.4% for 1 and 3 (kappa = 0.047) and 52.6% (kappa = 0.016) for 2 and 3. For breathiness, the concordance rates were 80.7% for observers 1 and 2 (kappa = 0.191); 57.9% for 1 and 3 (kappa = 0.147) and 57.9% (kappa = 0.156) for 2 and 3. With regard to asthenic quality, there was concordance of 100% for observers 1 and 2, so kappa could not be applied; the concordance rate was 96.5% for 1 and 3 and for 2 and 3. The evaluation for strained voice revealed concordance rates of 71.9% for observers 1 and 2 (kappa = -0.017); 59.6% for 1 and 3 (kappa = 0.095) and 70.2% (kappa = 0.039) for 2 and 3. The disagreement among the observers was worst for pathological rather than normal voices; when disagreement was present among experienced judges, it was of only one point in the scale used.