The Zuckerkandl tubercle: problematic or helpful in thyroid surgery?

The Zuckerkandl tubercle is a residue from the embryological development of the thyroid gland. Although it is undeniably well known in surgery, this is not so among otolaryngologists. Our objective is to highlight the importance of the Zuckerkandl tubercle, as it has proven to be a reliable point of reference to locate the upper parathyroid, the lower thyroid artery and the recurrent nerve. In order to study the Zuckerkandl tubercle, we made a prospective analysis of the posterolateral border of the thyroid lobes in 107 thyroidectomies (88 total thyroidectomies and 19 hemithyroidectomies) carried out by the same surgeon; in total, 195 thyroid lobes were analysed. The Zuckerkandl tubercle was certainly detected in 155 thyroid lobes (79.48%). The Zuckerkandl tubercle was most frequent in the right thyroid lobe (P = 0.06). When the Zuckerkandl tubercle was present, we localised the upper parathyroid due to its relationship with the tubercle in 80 right thyroid lobes (95.23%) and in 65 left (91.54%). On 147 occasions (94.83%), the recurrent nerve was directed towards the cricothyroid membrane beneath the Zuckerkandl tubercle, laterally to the tracheal surface in relation with the Berry ligament. The lower thyroid artery and some of the distal branches, such as the recurrent nerve, also ran under the Zuckerkandl tubercle. The areolar tissue underlying the Zuckerkandl tubercle is difficult to dissect, and so this protuberance constitutes a surgical difficulty but it is fundamentally helpful to find those important structures that must be preserved in thyroid surgery.

[No-malignant lessions involving the paranasal sinuses and anterior skull base]. / Lesiones no malignas que implican a senos paranasales y fosa craneal anterior.

BACKGROUND AND OBJECTIVES: The lesions that involve the paranasal sinuses and the anterior cranial base at the same time are not unusual. These diseases have different features. The aim of this study is to set out the particularities of the non-malignant lesions involving both zones. MATERIAL AND METHODS: Retrospective study of 32 patients between 1986 and 2007 diagnosed with: non-malignant tumours (31.2 %), tumorlike lesions (3.1 %), fibrous-osseous lesions (12.5 %), congenital or acquired malformations (18.7 %) and infection disease (34.3 %). We analyse the diagnostic imaging, the treatment and pathogen mechanism. RESULTS: Only 6 of 43 osteomas involved the paranasal sinuses and anterior cranial fossa (13.04 %): 3 cases have developed meningitis and 1 developed a pneumocephalus. 2 cases are meningiomas: 1 was asymptomatic and the other one caused destruction at subtotal frontal bone. 1 giant hemangioma associated with Klippel-Trenaunay syndrome is treated by combined craniofacial approach. The fibrous-osseous lesions were specifically fibrous dysplasia and affected the ethmoides. The encephalocele were predominating in the malformations group, 2 were diagnosed after repeated meningitis. 11 cases are included by infection: 10 cases caused osteomielitis and the eleventh is a patient with a mucormycosis. Surgery has been used in 84.3 % of the cases: frontal craniotomy 37 %, combined craniofacial approach 18.5 %, subfrontal approach 18.5 %, osteoplastic technique 18.5 %, lateronasal approach 3.7 %, endonasal microscopic resection 3.7 %. CONCLUSIONS: In this study the diagnosis, extension and surgical management were supported in the imaging. A closed separation between the anterior cranial fossa ant the sinus is necessary after the resection. The reconstruction was performed using a pedicled pericranial flap and titanium mesh in most of the cases.

[Inverted acoustic reflex: an analysis of its morphological characteristics in different physiological and pathological situations]. / Reflejo acústico invertido: análisis de sus características morfológicas en distintas situaciones fisiológicas y patológicas.

INTRODUCTION AND OBJECTIVES: Inverted acoustic reflex (IAR) or inverted acoustic effect is the name given to the positive deflexion observed during the carrying out of an admittancemetry when the ear is subjected to a high intensity sound, rather than the typical negative deflexion due to the contraction of the middle ear musculature. The objective of the paper is to analyze the morphology of the IAR by relating it to the situations (physiological or pathological) in which this effect appears with the aim of establishing a pathogenic hypothesis. METHODS: We study the admittance traces obtained in 50 patients on stimulating the ear with high sound intensities (between 100 and 110 dBs HL) in different situations (ageing, death, otosclerosis, facial palsy, perception hypoacusia and normoacusia). We analyse the morphologies of the resulting traces as well as the on-set and off-set latencies of the reflexes. RESULTS: The morphology and latency parameters are similar in all cases in which IAR appears, regardless of the physical conditions of the ear but always with the prior condition of the absence of any contraction of the stapes bone muscle. The inverted acoustic effect does not disappear after deep muscular relaxation induced by anaesthesia and is present in corpses at a time when neural activity can no longer take place. CONCLUSIONS: Although some of the characteristics of IAR cannot be explained by purely mechanical hypotheses, the appearance of this effect in a corpse and its non-disappearance with muscular relaxation means that we consider its origin to be a purely mechanical effect not mediated by any muscular reflex contraction in the human middle ear.

Executive summary of the SEORL CCC-SEEN consensus statement on post-thyroidectomy hypoparathyroidism. / Resumen ejecutivo del documento de consenso SEORL CCC-SEEN sobre hipoparatiroidismo postiroidectomía.

Hypoparathyroidism is the most common complication after total or completion thyroidectomy. It is defined as the presence of hypocalcemia accompanied by low or inappropriately normal parathyroid hormone (PTH) levels. Acute hypocalcemia is a potential lethal complication. Hypocalcemia treatment is based on endovenous or oral calcium supplements as well as oral calcitriol, depending on the severity of the symptoms. The risk of clinical hypocalcemia after bilateral thyroidectomy is considered very low if postoperative intact PTH decrease less than 80% with respect to preoperative levels. These patients could be discharged home without treatment, although this threshold may vary between institutions, and we recommend close surveillance in cases with increased risk (Graves disease, large goiters, reinterventions or evidence of parathyroid gland removal). Long-term treatment objectives are to control the symptoms and to keep serum calcium levels at the lower limit of the normal range, while preserving the calcium phosphate product and avoiding hypercalciuria.

Executive summary of the SEORL CCC-SEEN consensus statement on post-thyroidectomy hypoparathyroidism. / Resumen ejecutivo del documento de consenso SEORL CCC-SEEN sobre hipoparatiroidismo postiroidectomía.

Hypoparathyroidism is the most common complication after total or completion thyroidectomy. It is defined as the presence of hypocalcemia accompanied by low or inappropriately normal parathyroid hormone (PTH) levels. Acute hypocalcemia is a potential lethal complication. Hypocalcemia treatment is based on endovenous or oral calcium supplements as well as oral calcitriol, depending on the severity of the symptoms. The risk of clinical hypocalcemia after bilateral thyroidectomy is considered very low if postoperative intact PTH decrease less than 80% with respect to preoperative levels. These patients could be discharged home without treatment, although this threshold may vary between institutions, and we recommend close surveillance in cases with increased risk (Graves disease, large goiters, reinterventions or evidence of parathyroid gland removal). Long-term treatment objectives are to control the symptoms and to keep serum calcium levels at the lower limit of the normal range, while preserving the calcium phosphate product and avoiding hypercalciuria.

Active middle ear implants. / Implantes activos de oído medio.

Active middle ear implants are surgically implanted prosthesis, which intend to stimulate the ossicular chain or the inner ear fluids through the oval or round windows. These implants may be useful for the treatment of certain patients with sensorineural hearing loss as well as for conductive or mixed hearing loss. This clinical guide attempts to summarize the current knowledge concerning the basic characteristics and indications of the most commonly used middle ear implants, including Vibrant Soundbrige (Med-el, Innsbruck), Carina (Cochlear, Australia), and CodacsTM. (Cochlear, Australia).

Guideline on cochlear implants. / Guía clínica sobre implantes cocleares.

INTRODUCTION: In the last decade numerous hospitals have started to work with patients who are candidates for a cochlear implant (CI) and there have been numerous and relevant advances in the treatment of sensorineural hearing loss that extended the indications for cochlear implants. OBJECTIVES: To provide a guideline on cochlear implants to specialists in otorhinolaryngology, other medical specialities, health authorities and society in general. METHODS: The Scientific Committees of Otology, Otoneurology and Audiology from the Spanish Society of Otolaryngology and Head and Neck Surgery (SEORL-CCC), in a coordinated and agreed way, performed a review of the current state of CI based on the existing regulations and in the scientific publications referenced in the bibliography of the document drafted. RESULTS: The clinical guideline on cochlear implants provides information on: a) Definition and description of Cochlear Implant; b) Indications for cochlear implants; c) Organizational requirements for a cochlear implant programme. CONCLUSIONS: A clinical guideline on cochlear implants has been developed by a Committee of Experts of the SEORL-CCC, to help and guide all the health professionals involved in this field of CI in decision-making to treathearing impairment.

[Total idiopathic laryngotracheal stenosis. Treatment with mitomycin C]. / Obstrucción laringotraqueal completa idiopática. Tratamiento con mitomicina C.

This case report involves a 69-year-old woman who presented idiopathic laryngotracheal stenosis with total obstruction of the airway. Seven surgical procedures involving open field and endoscopy techniques had to be performed due to repeated re-obstructions. The novelty in this case is that success was finally obtained with the use of mitomycin C. The drug action is well known, but is interesting to report a case in which success was only obtained when we used mitomycin C.

[Analysis of the mechanical-acoustic features of the middle ear after stapedial surgery both with and without stapes muscle preservation]. / Estudio de las características mecanoacústicas del oído medio sometido a cirugía estapedial con y sin conservación del tendón del estribo.

INTRODUCTION AND OBJECTIVE: Stapes replacement surgery performed in cases of otosclerosis alters various anatomical (ossicular, ligament, and tendon) elements of the middle ear affecting their physical properties. The goal of our work is to determine which of the surgical techniques applied during otosclerosis most respects the mechanical-acoustic features of the middle ear. PATIENTS AND METHOD: We analyzed the audiological and admittance results of 100 patients who underwent various stapedial replacement techniques and compared them to 20 otologically healthy subjects. RESULTS: The audiological results obtained are similar in the different surgical techniques compared. However, those techniques in which the stapedial muscle tendon is preserved offer similar hearing resonance frequencies post intervention as healthy ears, which was not found to be the case in the remaining techniques evaluated. CONCLUSIONS: We feel that the stapedial tendon should be preserved during otosclerosis surgery as the mechanical-acoustic features of the ear are thus better conserved, leading to enhanced language recognition in noisy environments.

A new malleostapedotomy prosthesis. Experimental analysis by laser doppler vibrometer in fresh cadaver temporal bones. / Análisis experimental mediante vibrometría láser doppler en huesos temporales de cadáver fresco de una nueva prótesis de maleovestibulopexia.

INTRODUCTION AND OBJECTIVES: One of the problems with total ossicular replacement prostheses is their stability. Prosthesis dislocations and extrusions are common in middle ear surgery. This is due to variations in endo-tympanic pressure as well as design defects. The design of this new prosthesis reduces this problem by being joined directly to the malleus handle. The aim of this study is to confirm adequate acoustic-mechanical behaviour in fresh cadaver middle ear of a new total ossicular replacement prosthesis, designed using the finite elements method. METHODS: Using the doppler vibrometer laser, we analysed the acoustic-mechanical behaviour of a new total ossicular replacement prosthesis in the human middle ear using 10 temporal bones from fresh cadavers. RESULTS: The transfer function of the ears in which we implanted the new prosthesis was superimposed over the non-manipulated ear. This suggests optimum acoustic-mechanical behaviour. CONCLUSIONS: The titanium prosthesis analysed in this study demonstrated optimum acoustic-mechanical behaviour. Together with its ease of implantation and post-surgical stability, these factors make it a prosthesis to be kept in mind in ossicular reconstruction.

Characterization of nasal paraffinoma following septorhinoplasty by attenuated total reflection--fourier transform infrared spectroscopy (ATR-FTIR).

Vaseline and paraffin have been injected into various parts of the body. Vaselinoma and paraffinoma are well-described complications, despite which nasal packing with Vaseline gauze is still common in the management of epistaxis, after rhinoplasty, endonasal surgery, to control bleeding and prevent synechiae or restenosis. Our aim is to highlight this complication, propose a safe method for its diagnosis and establish guidelines for its prevention. We report two cases of paraffinoma occurring after rhinoplasty and discuss prevention of this rare but serious complication, and suggest an alternative dressing. Attenuated total reflection (ATR) FI7R spectra have proven to be a definitive characterising tool for surgical extracts, guaranteeing detection of mineral products that histology does not offer. For these lesions we propose the name "petroleum oilomas" which we feel to be more appropriate than the more commonly used paraffinomas. Relevance of the work: a description of an innovative and safe method of diagnosis, and proposal of a procedure for postrhinoplasty packing (without mineral oils) to avoid this complication.

Primary cutaneous neuroendocrine carcinoma, Merkel cell carcinoma. Case series 1991-2012.

INTRODUCTION AND OBJECTIVES: Merkel cell carcinoma was first described by Toker in 1972. It is an uncommon, primary neuroendocrine skin carcinoma which appears in the dermoepidermic area, grows fast, is very aggressive and has a poor prognosis. The aim of this work is to highlight the importance of this tumour, which develops mainly in the skin of the head and neck area, and whose prevalence has increased in recent years. MATERIAL AND METHOD: We gathered data on 16 patients suffering cutaneous neuroendocrine carcinoma treated at our hospital between September 12, 1991 and July 13, 2012. We indicated the age and gender of patients. We described the area where the tumour was located, indicating the size in millimetres, according to the major axis of the lesion. RESULTS: Most of the patients studied were over 70 years old, except for one who was 55. The highest frequency of cases appeared among patients aged over 80 years. In the cases studied, when the tumour appeared in the head and neck region (10/16), its location could be nasal-lateronasal, cheek-malar, upper eyelid, frontal or mandibular. The major axis of the lesion ranged between 7 and 35 mm. Unlike with epidermoid or basocellular carcinomas, recurrence and ganglionar metastases were common. Immunohistochemical (CK20) tests are essential for a correct diagnosis. Treatment is usually surgical and occasionally followed by radiotherapy and chemotherapy. CONCLUSION: This carcinoma is not a very common skin tumour. It appears in old age, in the head and neck region in 50% of cases and often leads to exitus.

High-riding innominate artery in neck surgery.

We present two cases of innominate artery (IA) in a cervical position. In the first case, surgery was not performed because there was no indication. In the second, it was possible to obtain surgical images of the AI and its branches located in front of the laryngotracheal axis. A warning about the serious risk involved in cervical surgery in these cases is indicated.

[Is the middle ear the first filter of frequency selectivity?]. / Es el oído medio el primer filtro de selección frecuencial?

INTRODUCTION AND OBJECTIVES: The cochlea has traditionally been considered as the first frequency selection filter in the auditory pathway due to the contraction of its external ciliated cells. Yet, much evidence has emerged from work carried out during experiments with animals, some of which is anatomical (connections between the auditory pathway and motor nuclei of the middle ear muscles) and other physiological, which indicates that the middle ear might be the first filter through which specific sounds from noisy environments may initially be isolated. METHODS: In cooperation with the Department of Mechanical Engineering of the Technical School of Industrial Engineering at the University of Valladolid (UVa) we have developed and refined a new admittance meter capable of evaluating changes in impedance that occur in the human middle ear depending on frequency. Using this device we have measured variation in impedance in 7 otologically healthy volunteers submitted to a varied range of sound environments. RESULTS: We have found that hearing impedance is not constant but rather that the attention offered by the examined subjects when following a conversation in a noisy environment leads to variations in hearing impedance at high frequencies. CONCLUSIONS: In the light of these findings we feel that the middle ear does not play a merely passive role in hearing but rather that the contraction of the endotympanic muscles makes possible variations in impedance such that the resonance frequency of the ear shifts towards higher frequencies, thus enhancing sound discrimination in noisy environments.