Neurosarcoidosis presenting as complicated sinusitis: a case report and review.

Sarcoidosis is a systemic granulomatous disease with widely variable clinical characteristics, including numerous head and neck manifestations. We describe the case of a 49-year-old man who presented to the emergency department with symptoms consistent with complicated sinusitis. He was ultimately found to have an atypical case of neurosarcoidosis. This case illustrates the varied multisystem presentation of sarcoidosis and the diagnostic considerations that are merited.

The use of rapid parathyroid hormone assay in predicting postoperative hypocalcemia after total or completion thyroidectomy.

PURPOSE: To evaluate the rapid parathyroid hormone assay (rPTH) as a perioperative tool in predicting postoperative symptomatic hypocalcemia following thyroidectomy. METHODS: We conducted a prospective study of 69 patients undergoing total or completion thyroidectomy. Rapid PTH levels were obtained preoperatively, intraoperatively, and postoperatively upon arrival in the postanesthesia care unit (PACU). All patients were closely monitored postoperatively for the development of symptomatic or asymptomatic hypocalcemia. RESULTS: Of 60 patients (25%) undergoing thyroidectomy, 15 developed hypocalcemia, 7 (11.7%) were symptomatic, and 8 (13.3%) asymptomatic. An intraoperative rPTH level less than 12 pg/mL was 71% sensitive and 95% specific for predicting postoperative symptomatic hypocalcemia, whereas a PACU rPTH level less than 12 pg/mL was 100% sensitive and 92% specific. A greater than 75% decline in preoperative rPTH level when measured intraoperatively was 71% sensitive and 86% specific, whereas a greater than 75% decline in rPTH level in the PACU was 100% sensitive and 88% specific for predicting symptomatic hypocalcemia. CONCLUSIONS: The rPTH assay is a highly accurate and effective tool for predicting symptomatic hypocalcemia immediately after thyroidectomy. Routine utilization of this assay is recommended, because it will allow safe and timely discharge of normocalcemic patients and the early identification of patients requiring treatment of postthyroidectomy hypocalcemia.

Conservative Management of an Intraoperative Chyle Leak: A Case Report and Literature Review.

Chyle leaks are a rare but potentially fatal complication of head and neck surgery carrying an incidence as high as 8.3%. The development of a chyle leak carries significant morbidity ranging from delayed wound healing to oropharyngeal fistulas. Presented here is a case of a chyle leak that developed following a left posterolateral neck dissection that was successfully managed with a combination of drain suction, pressure dressing, and a fat-restricted diet. However, the patient's course was complicated by repeated chyle leak recurrences that may have been associated with the initiation of medium-chain triglyceride supplementation. Although further research is required to establish a causal relationship, these findings support the concerns of other investigators about the possible counterproductive role of medium-chain triglyceride supplementation in the management of chyle leaks.

Da Vinci robot-assisted excision of a vallecular cyst: a case report.

The da Vinci Surgical System is a new and exciting entrant into the field of robotic technology. This system is undergoing considerable research and is being practically applied in general surgery, cardiothoracic surgery, urology, and gynecology. We have previously described our experience with the da Vinci system in the laboratory setting, and we have reviewed its potential applications in otolaryngology. Here we present a case report of the first da Vinci-assisted excision of a vallecular cyst in a human. Although we initially encountered some difficulties in the setup, we were able to perform the procedure with moderate ease and without complication. The potential of the da Vinci system in otolaryngology is promising. Further research is needed to explore all of its possible uses in our field.

Potential applications of the da Vinci minimally invasive surgical robotic system in otolaryngology.

Anatomic constraints and instrumentation design characteristics have limited the exploitation of endoscopic surgery in otolaryngology. The move toward less invasive and less morbid procedures has paved the way for the development and application of robotic and computer-assisted systems in surgery. Surgical robotics allows for the use of new instrumentation in our field. We review the operative advantages, limitations, and possible surgical applications of the da Vinci Surgical System in otolaryngology. In the laboratory setting, we explored the setup and use of the da Vinci system in porcine and cadaveric head and neck airway models; the setup was configuredfor optimal airway surgery. Endoscopic cautery, manipulation, and suturing of supraglottic tissues were performed in both the porcine and cadaveric models. We found that the da Vinci system provided the advantages of the lower morbidity associated with endoscopic surgery, more freedom of movement, and three-dimensional open surgical viewing. We also observed that the system has several limitations to use in otolaryngology.

Revision choanal atresia repair.

OBJECTIVE: Since the first description of choanal atresia (CA) in 1755, multiple surgical techniques have been proposed to repair the malformation. Today, the transnasal endoscopic method is the most widely accepted repair technique. The bony choanal plates are perforated, the lateral choanae are drilled, and a portion of the vomer removed. Unfortunately, the problem of re-stenosis is a significant issue, and as a result, revision surgery may be a recurring theme in some children. We describe a successful revision endoscopic technique utilizing a microdebrider with straight and 120 degrees telescopes, image guided surgery, and topical mitomycin-C to permanently open the choanae without stenting. METHODS: Described are six children (1-15 years old) with CA or stenosis who have collectively undergone 25 choanal procedures at various institutions. A microdebrider carefully removes the bony septum under direct nasal and intraoral telescopic visualization. No lateral drilling is performed. Image guidance is helpful when excessive scar tissue is present. Topical mitomycin-C minimizes post-operative scarring. The cartilaginous septum is left intact. RESULTS: 2-4-year clinical and endoscopic follow-up on all children revealed a widely patent nasal airway with no complications (epistaxis, crusting, or re-stenosis). Synechiae or re-stenosis did not occur as circumferential mucosal stripping was avoided. No stenting was needed since the bony septum is removed. CONCLUSION: Near total endoscopic removal of the bony septum provides long-term nasal patency for revision CA/stenosis repairs. The endoscopic 'common choanae' technique is aided by transnasal and transoral telescopic visualization with precise microdebrider removal of the bony septum. The technique is safe with no complications in our case series.

Use of Parathyroid Hormone Assay after Thyroidectomy: A Survey of US and European Surgeons.

INTRODUCTION: Hypocalcemia after thyroidectomy results in prolongation of hospitalization and patient discomfort but can be predicted by PTH assays. However, there is considerable variation in their use. METHODS: This study was undertaken to document current US and European practice patterns regarding the use of this assay. Anonymous surveys were collected in 2009-2011 from members of the American Academies of Otolaryngology-Head and Neck Surgery and Endocrine Surgery and the European, Italian, French, Spanish and British Societies of Endocrine Surgery. RESULTS: There were 356 American (3% response) and 61 European (10% response) respondents. 105 (29.8%) American and 25 (41%) European respondents reported routine PTH assay use. Fellowship trained surgeons reported increased use of the PTH assay (P = 0.004). Shorter reported average post-operative hospital stay was associated with American physicians (P = 0.0001), community practice location (P = 0.0002) and routine calcium supplementation (P = 0.0015). CONCLUSIONS: Surgical training was associated with routine use of the PTH assay. Average reported hospital stay was lower for American and community practice physicians and correlated with post-operative oral calcium use.

Prediction of hypocalcemia after using 1- to 6-hour postoperative parathyroid hormone and calcium levels: an analysis of pooled individual patient data from 3 observational studies.

BACKGROUND: Parathyroid hormone (PTH) levels up to 6 hours postthyroidectomy have been shown to have excellent predictive power in determining hypocalcemia. In this study, we investigate the usefulness of combining calcium and PTH to increase the predictive power. METHODS: Individual patient data were obtained from 3 studies (152 patients) that fulfilled our criteria (using PTH assay within hours postthyroidectomy to predict symptomatic hypocalcemia). RESULTS: Changes in combined PTH and calcium threshold levels checked 1 to 6 hours after thyroidectomy were excellent in predicting postoperative hypocalcemia. A decrease in PTH of 60%, coupled with a simultaneous decrease in calcium of 10%, 5 to 6 hours postoperatively resulted in a sensitivity and specificity of 100%. However, combined PTH and calcium threshold changes were not significantly better than using PTH threshold changes alone. CONCLUSIONS: Threshold changes in serum calcium and PTH, checked hours after surgery, can be used together to accurately predict whether a patient will become hypocalcemic after thyroidectomy.

Early prediction of hypocalcemia after thyroidectomy using parathyroid hormone: an analysis of pooled individual patient data from nine observational studies.

BACKGROUND: Monitoring for hypocalcemia after thyroidectomy, using only symptoms and serum calcium levels, can delay the discharge of patients who will remain normocalcemic and can delay the treatment of hypocalcemic patients. STUDY DESIGN: We conducted a systematic search for articles describing use of parathyroid hormone (PTH) assay, checked within hours of completing thyroidectomy, to predict postoperative symptomatic hypocalcemia. Studies were excluded if all patients were treated with postoperative calcium, or if early PTH values were used to alter management of the patient. Individual patient data (perioperative PTH and calcium levels, development of hypocalcemia) were obtained for 457 patients from the corresponding authors of 9 studies and pooled to yield the following results. RESULTS: PTH, checked at three time periods after removal of the thyroid gland (0 to 20 minutes, 1 to 2 hours, and 6 hours), was substantially lower in patients who became hypocalcemic compared with those who remained normocalcemic. The accuracy of PTH in determining hypocalcemia increased with time and was excellent when checked 1 to 6 hours postoperatively. A single PTH threshold (65% decrease compared with preoperative level), checked 6 hours after completing thyroidectomy, had a sensitivity of 96.4% and specificity of 91.4% in detecting postoperative hypocalcemia. CONCLUSIONS: PTH assay, when checked 1 to 6 hours after thyroidectomy, has excellent accuracy in determining which patients will become symptomatically hypocalcemic. Routine use of this assay should be considered because it may allow earlier discharge of the normocalcemic patient and earlier identification of patients requiring treatment of postthyroidectomy hypocalcemia.