Practice analysis: techniques of head and neck surgeons and general surgeons performing thyroidectomy for cancer.

OBJECTIVE: Medical practice governance is made more challenging by the fact that many procedures may be performed by various medical or surgical specialties. Thyroid cancer surgery is performed by both physicians with general surgery (GS) and those with otolaryngology/head and neck surgery (HNS) credentials. Analyses describing differences in practice patterns between the 2 services have not been published previously. PATIENTS AND METHODS: The records of the Tumor Registry at the Naval Medical Center San Diego were reviewed for patients presenting with thyroid cancer between January 1, 1990, and December 31, 1999. The review included all patients undergoing partial or total thyroidectomy, and the operative techniques and complications were noted. RESULTS: Of the 178 patients who underwent thyroid cancer surgery in this period, charts were available for 136 (n = 87 HNS, n = 49 GS, 1 combined HNS/GS). There was no difference between the 2 services in terms of the percentage of patients undergoing lymph node sampling (P = 1.000), but each had different approaches to sampling techniques. Head and neck surgeons performed more total thyroidectomies (P < .001) and referred patients more frequently for postoperative radioiodine (P = .025); they resected 426 nodes in 32 patients (mean 13.3, median 6.5), of which 120 (28.2%) were positive. General surgeons resected 28 nodes in 11 patients (median 2.0, mean 2.6), of which 12 (42.8%) were positive (P = .009). Other variables were similar for services, including inpatient hospital days, estimated blood loss, number of patients with temporary hypoparathyroidism, and duration of hypocalcemia. CONCLUSION: In this cohort, otolaryngologists/head and neck surgeons and general surgeons have a significantly different approach with respect to lymph node sampling in the surgical therapy of thyroid cancer. Outcomes appear independent of technique.

Wegener granulomatosis presenting as an infiltrative retropharyngeal mass with syncope and hypoglossal paresis.

We describe a woman who presented with syncopal episodes and unilateral hypoglossal paresis in association with a highly infiltrative retropharyngeal mass. After an extensive malignancy workup, the patient was found to have Wegener granulomatosis (WG), an autoimmune necrotizing vasculitis that presents with inflammatory lesions anywhere in the respiratory tract and variable renal involvement. The archetypal presentation in the head and neck is erosive sinonasal crusting, though otologic, pharyngeal, and laryngeal findings are common. Highly uncharacteristic lesions are occasionally encountered and may contribute to significant diagnostic dilemmas. Neurologic involvement is not uncommon, but few reports of hypoglossal paresis and no reports of syncope as a result of WG are found in a review of the literature. Given the variability of presentation of WG in the head and neck, the otolaryngologist must maintain a high degree of suspicion for this disease in the evaluation of airway lesions.