An update on the status of nerve monitoring for thyroid/parathyroid surgery.

PURPOSE OF REVIEW: Recurrent laryngeal nerve (RLN) injury is one of the most common and serious complications associated with thyroid and parathyroid surgery. Although routine visual identification of the RLN is considered the current standard of care, the role of intraoperative neuromonitoring (IONM) of the RLN is more controversial. RECENT FINDINGS: Despite initial enthusiasm that IONM might substantially reduce the rate of RLN injury, most studies failed to show a significant difference in the rate of RLN injury when the use of IONM was compared with visualization of the RLN alone. However, a small number of investigators have reported statistically significant differences in the rates of nerve injury when IONM is used to augment visualization alone, particularly in certain high-risk situations. Despite a lack of conclusive data showing benefit, the use of IONM as an adjunct to visual identification of the RLN has gained increasing acceptance among surgeons. IONM remains an excellent tool to help verify the identity of the RLN, confirm its functional integrity, and pinpoint the site of nerve injury in the event of dysfunction. SUMMARY: The utility of IONM in reducing the rate of RLN injury is largely unproven and remains controversial. However, the use of IONM may be helpful in certain high-risk cases. Promising new technology, such as vagal nerve monitoring, may allow more real-time monitoring of the functional integrity of the RLN and allow the surgeon to react in a timely manner to evolving dysfunction in order to abort maneuvers that may risk definitive injury.

Remote Access Robotic Facelift Thyroidectomy: A Multi-institutional Experience.

BACKGROUND: Robotic facelift thyroidectomy (RFT) was developed as a new surgical approach to the thyroid gland using a remote incision site. Early favorable results led to this confirmatory multi-institutional experience. METHODS: Prospectively collected data on consecutive patients undergoing RFT in five North American academic endocrine surgical practices were compiled. Surgical indications, operative times, final pathology, nodule size, complications, and postoperative management (drain use and length of hospital stay) were evaluated. RESULTS: A total of 102 RFT procedures were undertaken in 90 patients. All but one of the patients (98.9 %) were female, and the mean age was 41.9 ± 13.1 years (range 12-69 years). The indication for surgery was nodular disease in 91.2 % of cases; 8.8 % were completion procedures performed for a diagnosis of cancer. The mean size of the largest nodule was 1.9 cm (range 0-5.6 cm). The mean total operative time for a thyroid lobectomy was 162 min (range 82-265 min). No permanent complications occurred. There were 4 cases (3.9 %) of transient recurrent laryngeal nerve weakness, no cases of hypocalcemia, and 3 (2.9 %) hematomas. There were no conversions to an anterior cervical approach. The majority of patients were managed on an outpatient basis (61.8 %) and without a drain (65.7 %). CONCLUSIONS: RFT is technically feasible and safe in selected patients. RFT can continue to be offered to carefully selected patients as a way to avoid a visible cervical scar. Future prospective studies to compare this novel approach to other remote access approaches are warranted.

Continuous Vagal Nerve Monitoring is Dangerous and Should not Routinely be Done During Thyroid Surgery.

INTRODUCTION: Laryngeal nerve monitoring has been increasingly embraced as a mechanism for mitigating the risk of nerve damage during thyroid and parathyroid surgery. Vagal nerve monitoring has recently been introduced as a potentially increased level of nerve integrity scrutiny. We sought to define the risks and benefits of this technology in a prospective analysis of a series of patients undergoing neck endocrine surgery. SETTING: High-volume academic endocrine surgery practice. METHODS: A prospective, non-controlled trial of continuous vagal nerve monitoring (CVNM) in a projected cohort of 20 non-randomly selected patients undergoing thyroid and parathyroid surgery was planned. A commercially available nerve monitoring system with automatic periodic stimulation was utilized for both laryngeal nerve monitoring and CVNM. Demographic data were obtained, and outcome variables included surgical procedures performed, pathology, complications, incremental time required to achieve CVNM, and benefits of monitoring and stimulation. RESULTS: The patient accrual was aborted after 9 surgeries (12 nerves monitored) because of two serious adverse events (hemodynamic instability and reversible vagal neuropraxia attributable to the monitoring apparatus). No other complications occurred. The time to establish monitoring ranged from 3 to 26 min, with a median of 6 min (representing 2.9-12.2 % of the total surgical procedural time). The stimulation clamp became dislodged 11 times in 5 cases and was replaced in 7 of those instances. Benefits of CVNM included recognition of reduced amplitude and increased nerve latency in two patients. CONCLUSIONS: We report the first evidence that CVNM may cause serious patient harm. This novel approach is invasive and threatens patient safety. Although it may occasionally provide meaningful information, the risk-benefit ratio does not favor widespread adoption.

Incision Planning in Thyroid Compartment Surgery: Getting it Perfect.

OBJECTIVE: This study evaluated changes in thyroid compartment incision site locations with patient positioning to define a reliable method for placing the scar in the optimal vertical location. METHODS: The optimal incision location was marked with the patient sitting upright before surgery. The distance from the sternal notch to this mark was measured with the patient in the upright, supine, and final surgical positions. RESULTS: Complete data were available for 104 procedures. The mean distances from the sternal notch to the incision site were 4.8, 21.5, and 31.9 mm in the sitting, supine, and surgical positions, respectively. Each of these distances were significantly different from one another (P<.0001) and were independent of patient age, sex, body mass index (BMI), or height. CONCLUSIONS: Cutaneous cervical landmarks migrate significantly during patient positioning. Marking the thyroid compartment incision site while the patient is in an upright position results in a more predictable final scar location.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY DISEASE STATE CLINICAL REVIEW: THE INCREASING INCIDENCE OF THYROID CANCER.

OBJECTIVE: (1) Describe current epidemiology of thyroid cancer in the United States; (2) evaluate hypothesized causes of the increased incidence of thyroid cancer; and (3) suggest next steps in research and clinical action. METHODS: Analysis of data from Surveillance, Epidemiology and End Results System and the National Center for Vital Statistics. Literature review of published English-language articles through December 31, 2013. RESULTS: The incidence of thyroid cancer has tripled over the past 30 years, whereas mortality is stable. The increase is mainly comprised of smaller tumors. These facts together suggest the major reason for the increased incidence is detection of subclinical, nonlethal disease. This has likely occurred through: health care system access, incidental detection on imaging, more frequent biopsy, greater volumes of and extent of surgery, and changes in pathology practices. Because larger-size tumors have increased in incidence also, it is possible that there is a concomitant true rise in thyroid cancer incidence. The only clearly identifiable contributor is radiation exposure, which has likely resulted in a few additional cases annually. The contribution of the following causes to the increasing incidence is unclear: iodine excess or insufficiency, diabetes and obesity, and molecular disruptions. The following mechanisms do not currently have strong evidence to support a link with the development of thyroid cancer: estrogen, dietary nitrate, and autoimmune thyroid disease. CONCLUSION: Research should focus on illuminating which thyroid cancers need treatment. Patients should be advised of the benefits as well as harms that can occur with treatment of incidentally identified, small, asymptomatic thyroid cancers.

Six-Year Experience With Endoscopic Thyroidectomy: Outcomes and Safety Profile.

BACKGROUND: Though minimally invasive video-assisted thyroidectomy (MIVAT) offers many advantages over traditional thyroid surgery, its adoption in North America has been limited. This study analyzes the largest series of MIVAT in North America to explore its safety. METHODS: A prospectively maintained database of all patients undergoing thyroid surgery by a single surgeon from 2003 to 2011 at an academic tertiary care medical center was evaluated. Demographic information, surgical and pathologic data, and postoperative outcomes were analyzed. RESULTS: Beginning in 2005, a total of 260 MIVATs were performed during the study period. Outpatient surgery was accomplished in 234 MIVATs (90%). MIVAT patients were predominantly young (46.8±14.8 years vs 52.4±14.6 years for conventional thyroidectomy) and female (88.5% vs 75.5% for conventional thyroidectomy). There were no cases of permanent hypoparathyroidism or permanent recurrent laryngeal nerve dysfunction. Observed complications included transient recurrent laryngeal nerve dysfunction (n=10; 3.8%), cellulitis (n=1; 0.4%), and temporary hypocalcemia (n=6; 2.3%). The overall complication rate for MIVAT (6.5%) was lower than the overall complication rate in conventional thyroidectomy (18.5%, P<.0001). CONCLUSION: MIVAT can be performed safely with a low complication profile in a high-volume practice. The safety of MIVAT represented by this experience supports broader adoption across surgical practices.

Defining anatomical landmarks for robotic facelift thyroidectomy.

BACKGROUND: Robotic facelift thyroidectomy (RFT) is a straightforward remote access thyroidectomy technique. While the anatomy encountered during RFT is well known to surgeons, the vector of approach during this technique may be less familiar. In order to facilitate safe and efficient performance of RFT, the relationships of key anatomical landmarks associated with this technique were determined. METHODS: Eight anatomical dissections were performed in cadavers and included performance of RFT and definition of discrete anatomical relationships. Morphologic assessments of the great auricular nerve (GAN), omohyoid (OH) muscle, inferior constrictor (IC) muscle, and recurrent laryngeal nerve (RLN) were conducted. RESULTS: The mean distance from the incision apex to the anterior and posterior aspects of the GAN were 3.8 ± 1.2 and 7.7 ± 0.8 cm. From the apex of the incision to the OH muscle was 11.1 ± 1.7 cm on average. The OH muscle was located 1.3 ± 0.5 cm inferior to an axial line drawn through the inferior aspect of the thyroid notch. The anterior branch of the RLN was identified coursing deep to the inferior margin of the IC muscle a mean of 1.2 ± 0.2 cm lateral to the origin of this muscle on the cricoid cartilage. CONCLUSIONS: Characterization of the key anatomical landmarks of the lateral neck and thyroid compartment associated with RFT, including the GAN, OH muscle, and RLN, allows for rapid recognition of these critical structures during this operation. Surgeons learning this approach should be familiar with these relationships.

Minimally invasive thyroid surgery in children.

OBJECTIVES: As the prevalence of thyroid nodules and thyroid cancer increases, thyroid surgery is being performed in a growing number of pediatric patients. Minimally invasive thyroid surgery may be particularly beneficial in this patient population. Smaller incisions result in improved cosmesis in this young, predominantly female group, and minimal-access techniques better preserve tissue planes--an advantage, because of younger patients' higher lifetime likelihood of reoperation. METHODS: For this case series with planned data collection, Institutional Review Board approval was obtained to analyze a prospective database and assess outcome data. The outcome measures included pathologic classification, cosmetic results, rates of complications (especially hypocalcemia), true vocal fold paralysis, and the need for admission or readmission. RESULTS: We performed 495 thyroidectomy procedures during the study period (February 2003 to May 2008). Of these, 23 were in patients less than 21 years of age. The mean incision length was 3.3 +/- 1.0 cm (range, 1.5 to 5.0 cm), and 12 of the incisions (52.2%) were 3 cm or shorter. Nine patients (41%) had thyroid cancer, most commonly papillary carcinoma (compared with 21.9% of the adult population). There were no hematomas and no cases of permanent true vocal fold paralysis or permanent hypocalcemia. Two patients (8.7%) had temporary hypocalcemia, and both required readmission. CONCLUSIONS: Minimally invasive thyroid surgery has benefits over conventional thyroid surgery, particularly in a pediatric population. Among its many potential advantages, the social stigma of a large incision is reduced and preservation of tissue planes is improved.

Modifications of Miccoli minimally invasive thyroidectomy for the low-volume surgeon.

OBJECTIVE: The objective of the study was to describe our experience with modifications of the Miccoli minimally invasive thyroidectomy. DESIGN: Planned analysis of a prospectively maintained database was undertaken after Institutional Review Board approval. METHODS: Demographic and surgical data were obtained and analyzed with attention to age, sex, pathology, incision lengths, and complications. RESULTS: From a single-surgeon series of 785 consecutive thyroidectomies, 178 patients were identified who underwent an endoscopic minimally invasive thyroidectomy. A series of modifications of the classic Miccoli technique evolved over a period of 4 years and include presurgical factors (patient marking in holding area, intubation with laryngeal EMG tube using videolaryngoscope, rotation of operating table away from anesthesia), intraoperative principles (use of operative loupes, slave monitor, laryngeal nerve monitoring, and novel instrumentation; identification of the medial cleft and ligation of superior pedicle bundle using ultrasonic technology; avoidance of clips), and postoperative techniques (deep extubation, laryngeal endoscopy, outpatient management, and oral calcium supplementation). CONCLUSIONS: A minimally invasive endoscopic thyroidectomy is possible even in a practice with moderate surgical volumes by using several techniques that facilitate the performance of this procedure. A high success rate and low complication rate can be achieved, resulting in improved patient satisfaction.

Point-of-care rapid intraoperative parathyroid hormone assay of needle aspirates from parathyroid tissue: a substitute for frozen sections.

BACKGROUND: The intraoperative parathyroid hormone (IOPTH) assay is an important tool that facilitates targeted parathyroidectomy and may increase surgical cure rates. We sought to evaluate the utility of a point-of-care assay to distinguish parathyroid adenomas from nonparathyroid tissues, which can sometimes pose a challenge during parathyroidectomy and is commonly achieved with the use of frozen sections. We hypothesized that point-of-care rapid IOPTH assays of needle aspirates from suspected adenomas would be faster and equal in accuracy to frozen sections. METHODS: Parathyroid and nonparathyroid lesions were excised, and the tissues were needle aspirated, diluted in saline, and submitted to a rapid IOPTH assay located in the operating room. Frozen sections were simultaneously sent for analysis. The time intervals to result availability were tracked and compared using a paired t test. RESULTS: Point-of-care IOPTH assays of needle aspirates were available in a mean (±SD) of 11.6 ± 1.5 minutes compared to 18.7 ± 4.0 minutes for frozen sections (P = .005). The findings were concordant 100% of the time for both parathyroid (mean parathyroid hormone [PTH] > 3338.9 pg/mL) and parathyroid tissues (mean PTH = 8.7 pg/mL). CONCLUSION: Point-of-care IOPTH assay of needle aspirates is an accurate method of distinguishing parathyroid from nonparathyroid tissues. It is suggested that this would be particularly useful in instances where use of IOPTH is planned for assessment of a drop in serum PTH.

Minimally invasive techniques for head and neck malignancies: current indications, outcomes and future directions.

The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.

Lessons Learned From a Single-Surgeon Experience of More Than 1700 Parathyroidectomies.

OBJECTIVE: To define critical elements that contribute to successful parathyroidectomy based on a high-volume single-surgeon experience and explore learning curve characteristics. STUDY DESIGN: Systematic analysis of prospectively maintained quality assurance database. SETTING: Academic tertiary care endocrine surgery practice. SUBJECTS AND METHODS: In total, 4737 consecutive patients who underwent thyroid or parathyroid surgery from 2004 to 2020 were identified. Demographic data acquisition was undertaken on a subset of these patients who had initial surgery for primary hyperparathyroidism during the academic years 2005 to 2018. Patients with renal or syndromic hyperparathyroidism and those undergoing reoperative surgery were excluded. RESULTS: From 1710 patients who underwent parathyroid surgery, 1082 met inclusion criteria in order to focus on a homogeneous data set. These patients had a mean age of 60.1 ± 12.5 years and 76.4% were female. The overall cure rate was 98.3%, reflecting a success rate that increased from 95.5% during the first 200 cases to 99.7% over the final 300 cases. The complication rate was 1.7%. Over 2 decades, the patient phenotype evolved toward milder disease and smaller adenomas. A learning curve of 200 cases was required to become a proficient parathyroid surgeon; to achieve exceptional results required several hundred additional cases. Parathyroid surgery represents a higher proportion of an endocrine surgery practice than previously (54.0% in 2019 compared with 25.5% in 2004). CONCLUSION: A focused practice dedicated to endocrine surgery yields surgical volumes exceeding 500 cases annually. There has been a steady shift toward parathyroid surgery. A lengthy learning curve can be shortened by pursuit of several specific strategies that are outlined in detail.

Anterior palatoplasty for the treatment of OSA: three-year results.

OBJECTIVE: Review long-term results of the modified cautery-assisted palatoplasty (mod CAPSO)/anterior palatoplasty for the treatment of mild-moderate obstructive sleep apnea (OSA). STUDY DESIGN: Prospective series of 77 patients. All patients were >18 years old, type I Fujita, body mass index (BMI)<33, Friedman clinical stage II, with apnea-hypopnea index (AHI) from 1.0 to 30.0. The mean follow-up time was 33.5 months. The procedure involved an anterior soft palatal advancement technique with or without removal of the tonsils. The procedure was done under general or local anesthesia. RESULTS: There were 69 men and eight women; the mean age was 39.3 years old; and mean BMI was 24.9 (range 20.7-26.8). There were 38 snorers and 39 OSA patients. The AHI improved in patients with OSA, 25.3+/-12.6 to 11.0+/-9.9 (P<0.05). The overall success rate for this OSA group was 71.8 percent (at mean 33.5 months). The mean snore scores (visual analog score) improved from 8.4 to 2.5 (for all 77 patients). Lowest oxygen saturation also improved in all OSA patients. Subjectively, all patients felt less tired. CONCLUSION: This technique has been shown to be effective in the management of patients with snoring and mild-moderate OSA.

Neck Dissection in the Surgical Treatment of Thyroid Cancer.

The incidence of thyroid cancer is increasing, largely attributable to overdetection related to prevalent diagnostic and radiologic imaging modalities. Papillary thyroid cancer remains the most common thyroid malignancy. It has a high tendency for regional metastasis to the cervical lymph nodes. The optimal management of the neck in patients with thyroid carcinoma has long been an important topic of debate. This article addresses central and lateral neck dissection, providing a simplified guide to the most up-to-date and evidence-based practices.

Evolving phenotype of the head and neck surgeon.

OBJECTIVE: Characterize the evolution of head and neck (H&N) surgical practices in the United States over two decades by using resident case log data as a surrogate. METHODS: National residency case log data from all Accreditation Council for Graduate Medical Education-accredited otolaryngology residency programs was reviewed for the past 20 academic years (1996-2015). Key indicator procedures in each subcategory of H&N were analyzed to characterize standard ablative H&N surgical practices. Mean number of cases completed per resident each year was calculated. RESULTS: The proportion of H&N surgeries contributing to the total number of otolaryngology cases performed yearly remained relatively stable during the study period, ranging from 6.4% to 8.7%, indicating concurrent growth of H&N cases with all otolaryngology surgeries. Although each subcategory within H&N demonstrated modest increases in the number of cases performed per resident each year over the study period, the most significant growth occurred in the endocrine surgery subcategory: a 288% increase from 18.4 in 1996 to 71.5 in 2015. The proportion of H&N cases represented by each subcategory decreased, except for endocrine, which more than doubled in proportion from 21% in 1996 to 43% in 2015. CONCLUSION: Our findings suggest that the modern H&N surgeon is increasingly becoming an endocrine and H&N surgeon. The proportion of endocrine surgeries performed in residency, which serves as a surrogate for H&N practices, has more than doubled over the past 20 years and now represents the largest subcategory of H&N surgery. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1150-1154, 2019.

Routine bilateral neck exploration and four-gland dissection remains unnecessary in modern parathyroid surgery.

OBJECTIVE: Recent advances in preoperative imaging techniques and intraoperative parathyroid hormone (ioPTH) assays have made single-gland, minimally invasive parathyroidectomy (MIP) the preferred treatment option for most patients with primary hyperparathyroidism (pHPT). Despite this evolution, a recommendation for bilateral neck exploration (BNE) with four-gland dissection in all patients has recently been advocated by a parathyroid surgical group. The current study compares the long-term outcomes of MIP with those of conventional BNE with four-gland dissection in patients with pHPT. METHODS: In order to objectively assess a recommendation in the literature that universal BNE with four-gland dissection is advisable, all patients undergoing an initial MIP with ioPTH assessment for pHPT in a tertiary endocrine practice during a 10-year period were reviewed. The cure rates from this procedure were compared with published results of conventional BNE with four-gland dissection. RESULTS: Of the 561 patients undergoing parathyroidectomy during the study period, 337 had initial surgery for pHPT; 282 of these patients met inclusion criteria and 212 had sufficient follow-up data available. A single adenoma was identified in 87.3% of cases. Preoperative imaging studies were co-localizing in 148 (69.8%), and 127 (85.8%) of these patients with co-localizing imaging required only single-gland surgery. Imaging studies did not co-localize in 49 patients, yet 32 (65.3%) of these patients were still cured with unilateral surgery. The cure rate for patients undergoing MIP was 98.6%, with a long-term recurrence rate of <2%. CONCLUSION: When coupled with the ioPTH assay, patients with at least one preoperative localizing study can undergo MIP and anticipate a cure rate of 99%, which is as good as or better than the published rates for conventional BNE with four-gland dissection. With unilateral surgery, the risks of permanent hypoparathyroidism and airway obstruction from bilateral vocal fold paralysis are completely eliminated. Therefore, despite recommendations to the contrary, most patients with pHPT should not have a planned four-gland exploration. LEVEL OF EVIDENCE: III or IV.

Baseline intraoperative intact parathyroid hormone levels in parathyroid surgery.

BACKGROUND: We sought to evaluate the relationship between the preoperative core-laboratory parathyroid hormone (CL-PTH) level and the baseline intraoperative PTH (IOPTH) level and assess the impact of any differences on clinical decision making in consecutive surgical patients with primary hyperparathyroidism undergoing parathyroidectomy. METHODS: The CL-PTH and baseline IOPTH levels were compared. The influence of relying on either the CL-PTH or baseline PTH levels for intraoperative decision making was determined. RESULTS: Data were available for 316 patients. Baseline IOPTH measurements were usually higher than the CL-PTH (247 patients; 78.2%) measurements, with a mean difference of 68.2 pg/mL (P < .001). Using the CL-PTH as a surrogate for the baseline parathyroid hormone (PTH) would have prolonged the operation in 23 patients (7.3%). CONCLUSION: Baseline point-of-care IOPTH levels were higher than the preoperative CL-PTH levels in >75% of patients undergoing parathyroidectomy. Using the CL-PTH in lieu of an IOPTH baseline value would prolong the operation in some patients.

Protocol driven outcomes in renal parathyroid surgery.

BACKGROUND: Patients who require surgery for renal hyperparathyroidism represent a special population that is at high risk for postoperative complications. To optimize their treatment, we developed a multidisciplinary approach to the perioperative management of these patients undergoing parathyroidectomy. METHODS: The Augusta University endocrine surgery parathyroid database was interrogated to identify dialysis-dependent patients undergoing parathyroidectomy from 2005 to 2015. Numerous clinical parameters were quantified. Patients were stratified into protocol patients and nonprotocol patients. RESULTS: A total of 42 patients undergoing renal parathyroidectomy who met the inclusion criteria were identified. Serious adverse events were nearly twice as common in the patients not treated on protocol. The length of stay was nearly 2 days shorter in the protocol group. Lowest calcium level and ionized calcium was higher in the protocol cohort despite a lower postoperative parathyroid hormone. The protocol group had fewer laboratory draws. CONCLUSION: Implementation of a multidisciplinary renal hyperparathyroidism protocol has resulted in improved perioperative outcomes.