Retrieval of the parathyroid glands during thyroidectomy.

A recommended technique of intraoperative search of the removed thyroid lobe or entire gland for attached parathyroid glands is presented. Diligent examination of the thyroid capsule and folds of the thyroid gland is made in the sterile operative field. Any recovered parathyroid gland or glands are then finely sectioned and reimplanted in a location which is not likely to be violated in any future surgical procedure. This technique has significantly reduced the incidence of permanent hypoparathyroidism after total thyroidectomy.

Management of the airway in patients with angioedema.

Angiodema can be frequently encountered in clinical practice, and usually represents transient areas of tissue edema and erythema. In general, lesions involve the deep dermis as well as subcutaneous or submucosal sites and can affect multiple organ systems, including the respiratory and gastrointestinal tracts. Although the underlying cause for the angioedema is frequently not known, it can result from atopy, specific antigen sensitivities, physical stimuli, as well as disorders that affect the complement cascade. These latter entities may be congenital or acquired. Pathogenesis for angioedema is generally thought to be activation of mast cells or basophils, with subsequent release of histamine and other mediator products which can induce inflammatory changes. In most patients with physical and allergic causes of angioedema, swelling can usually be treated with epinephrine, antihistamines and/or steroids. Management of the airway in such patients is usually symptomatic, although certain patients require hospitalization for supervised care. On the other hand, patients with hereditary angioedema do not often respond well to these agents. In such patients, we currently add infusions of epsilonaminocaproic acid as well as nembulized racemic epinephrine to our therapeutic regimen, but even this may not be satisfactory. At the National Institute of Allergy and Infectious Disease, endotracheal intubation is usually preferred to tracheostomy for securing a temporary airway, though certain patients may require placement of tracheostomies for better control of the airway. Patients with frequent recurrences of airway obstruction are rarely seen--even among those patients with known hereditary angioedema. However, such patients may require tracheal fenestrations to secure long-term protection of the airway. The Institute's experiences in the management of patients with angioedema are reviewed, and therapies employed are described.

Standardizing neck dissection terminology. Official report of the Academy's Committee for Head and Neck Surgery and Oncology.

The emergence of the multitude of modified techniques for neck dissection procedure has resulted in a nomenclature system that is nonuniform. To eliminate potential misinterpretation, overlap, and lack of standardization, the Academy's Committee for Head and Neck Surgery and Oncology, with input from the Education Committee of the American Society of Head and Neck Surgery, has developed a classification system for these procedures. This has now been adopted by the American Academy of Otolaryngology-Head and Neck Surgery. The classification is based on the following concepts: (1) radical neck dissection is the fundamental procedure with which all other neck dissections are compared, (2) modified radical neck dissection denotes preservation of one or more nonlymphatic structure(s), (3) selective neck dissection denotes preservation of one or more group(s) of lymph nodes, and (4) extended radical neck dissection denotes removal of one or more additional lymphatic and/or nonlymphatic structure(s). Adherence to the principles of this classification system to describe neck dissection techniques should provide an improved method of communication. Furthermore, the system provides a rational framework on which subsequent terminology can be added.

Tonsil concretions and tonsilloliths.

Although infrequently seen in many clinical practices, tonsillar concretions can be the source of both fetor oris and physical and social concern for the patient. Though stones rarely form in the tonsil or peritonsillar area, the findings of calcified objects or stones anywhere within the body has long been a subject of interest. The salient features of these entities and their relevance to clinical practice are discussed in this article.

Nasogastric tube perforation of the nasopharynx.

We have presented two unusual cases of nasogastric tube perforation of the posterior nasopharynx. Complications included subcutaneous emphysema, pneumomediastinum, and pleural effusion. Both patients recovered. Recommendations to improve nasogastric tube safety include gentle placement using lubricant and an appropriately sized tube, confirmation of tube placement before any infusion, and awareness of patients at increased risk of mucosal injury.