The relation of recurrent laryngeal nerve to inferior thyroid artery and extralaryngeal nerve branching may increase the risk of vocal cord paralysis in thyroidectomy.

PURPOSE: The anatomical variations of the recurrent laryngeal nerve (RLN) are common during thyroidectomy. We aimed to evaluate the risk of RLN paralysis in case of its anatomical variations, retrospectively. METHODS: The patients with primary thyroidectomy between January 2016 and December 2019 were enrolled. The effect of age, gender, surgical intervention, neuromonitorisation type, central neck dissection, postoperative diagnosis, neck side, extralaryngeal branching, non-RLN, relation of RLN to inferior thyroid artery (ITA), grade of Zuckerkandl tubercle on vocal cord paralysis (VCP) were investigated. RESULTS: This study enrolled 1070 neck sides. The extralaryngeal branching rate was 35.5%. 45.9% of RLNs were anterior and 44.5% were posterior to the ITA, and 9.6% were crossing between the branches of the ITA. The rate of total VCP was 4.8% (transient:4.5%, permanent: 0.3%). The rates of total and transient VCP were significantly higher in extralaryngeal branching nerves compared to nonbranching nerves (6.8% vs. 3.6%, p = 0.018; 6.8% vs. 3.2%, p = 0.006, respectively). Total VCP rates were 7.2%, 2.5%, and 2.9% in case of the RLN crossing anterior, posterior and between the branches of ITA, respectively (p = 0.003). The difference was also significant regarding the transient VCP rates (p = 0.004). Anterior crossing pattern increased the total and transient VCP rates 2.8 and 2.9 times, respectively. CONCLUSION: RLN crossing ITA anteriorly and RLN branching are frequent anatomical variations increasing the risk of VCP in thyroidectomy that cannot be predicted preoperatively. This study is the first one reporting that the relationship between RLN and ITA increased the risk of VCP.

Refining postoperative monitoring of recurrent laryngeal nerve injury in esophagectomy patients through transcutaneous laryngeal ultrasonography.

BACKGROUND: Recurrent laryngeal nerve injury (RLNI) leading to vocal cord paralysis (VCP) is a significant complication following minimally invasive esophagectomy (MIE) with upper mediastinal lymphadenectomy. Transcutaneous laryngeal ultrasonography (TLUSG) has emerged as a non-invasive alternative to endoscopic examination for evaluating vocal cord function. Our study aimed to assess the diagnostic value of TLUSG in detecting RLNI by evaluating vocal cord movement after MIE. METHODS: This retrospective study examined 96 patients with esophageal cancer who underwent MIE between January 2021 and December 2022, using both TLUSG and endoscopy. RESULTS: VCP was observed in 36 out of 96 patients (37.5%). The incidence of RLNI was significantly higher on the left side than the right (29.2% vs. 5.2%, P < 0.001). Postoperative TLUSG showed a sensitivity and specificity of 88.5% (31/35) and 86.5% (45/52), respectively, with an AUC of 0.869 (P < 0.001, 95% CI 0.787-0.952). The percentage agreement between TLUSG and endoscopy in assessing VCP was 87.4% (κ = 0.743). CONCLUSIONS: TLUSG is a highly effective screening tool for VCP, given its high sensitivity and specificity. This can potentially eliminate the need for unnecessary endoscopies in about 80% of patients who have undergone MIE.

Critical swallowing functions contributing to dysphagia in patients with recurrent laryngeal nerve paralysis after esophagectomy.

BACKGROUND: Recurrent laryngeal nerve paralysis (RLNP) after esophagectomy can cause aspiration because of incomplete glottis closure, leading to pneumonia. However, patients with RLNP often have preserved swallowing function. This study investigated factors that determine swallowing function in patients with RLNP. METHODS: Patients with esophageal cancer who underwent esophagectomy and cervical esophagogastric anastomosis were enrolled between 2017 and 2020. Videofluoroscopic examination of swallowing study (VFSS) and acoustic voice analysis were performed on patients with suspected dysphagia including RLNP. Dysphagia in VFSS was defined as score ≥ 3 of the 8-point penetration-aspiration scale VFSS and acoustic analysis results related to dysphagia were compared between patients with and without RLNP. RESULTS: Among 312 patients who underwent esophagectomy, 74 developed RLNP. The incidence of late-onset pneumonia was significantly higher in the RLNP group than in the non-RLNP (18.9 vs. 8.0%, P = .008). Detailed swallowing function was assessed by VFSS in 84 patients, and patients with RLNP and dysphagia showed significantly shorter maximum diagonal hyoid bone elevation (10.62 vs. 16.75 mm; P = .003), which was a specific finding not seen in patients without RLNP. For acoustic voice analysis, the degree of hoarseness was not closely related to dysphagia. The length of oral intake rehabilitation for patients with and without RLNP was comparable if they did not present with dysphagia (8.5 vs. 9.0 days). CONCLUSIONS: Impaired hyoid bone elevation is a specific dysphagia factor in patients with RLNP, suggesting compensatory epiglottis inversion by hyoid bone elevation is important for incomplete glottis closure caused by RLNP.

The risk factors for postoperative temporary vocal cord paralysis after thyroid cancer surgery: an observational retrospective cohort study.

OBJECTIVE: To analyze the potential factors influencing new-onset postoperative transient vocal cord paralysis (VCP) in thyroid cancer patients. METHODS: Case information of 8340 thyroid cancer patients hospitalized at China-Japan Union Hospital of Jilin University, Jilin Province, China, in the Thyroid Surgery Department from January 2018 to December 2020 was collected retrospectively and analyzed. The possible influencing factors were analyzed using a χ2 test, rank-sum test, and multiple logistic regression analysis. A nomogram was used to construct the clinical prediction model that was validated in the validation set by receiver operating characteristic, calibration curves, and Decision curve analysis. RESULTS: The strengthening the reporting of cohort, cross-sectional, and case-control studies in surgery (STROCSS) guideline was followed to conduct a retrospective cohort study. A total of 8340 patients, including 1817 (21.8%) men and 6523 (78.2%) women, were enrolled in this study. The rate of temporary VCP was 3.6% (308/8340). Based on the results of postoperative laryngoscopy, the patients were divided into VCP group and non-VCP group. Comparative analysis between the groups revealed that potential factors associated with postoperative transient VCP were tumor location on the dorsal side of the gland ( P =0.042), ultrasound showing a maximum nodal diameter >1 cm ( P =0.002), multifocal carcinoma ( P <0.001), invasion of surrounding tissue ( P =0.005), lymph node metastases in the central compartment ( P =0.034), lateral cervical lymph node metastasis ( P <0.001), and prolonged operation ( P <0.001). A multiple logistic regression analysis showed that the independent risk factors in postoperative transient VCP were T stage (OR=1.411, P =0.013, 95% CI: 1.075-1.853), multifocal carcinoma (OR=1.532, P =0.013, 95% CI: 1.095-2.144), and duration of surgery (OR=1.009, P <0.001, 95% CI: 1.006-1.012). Finally, a clinical prediction model was established via a nomogram and was validated in the validation set, although its diagnostic efficacy needs to be improved further. CONCLUSION: High T stage, multifocal carcinoma, and prolonged operation time may be independent risk factors for the occurrence of postoperative transient VCP in patients undergoing initial surgery for thyroid cancer.

Occurrence and recovery of vocal cord paralysis after minimally invasive McKeown esophagectomy, risk factors, and clinical outcome.

BACKGROUND: This study aimed to observe the occurrence of recurrent laryngeal nerve injury after McKeown esophagectomy for esophageal squamous cell carcinoma, as well as its recovery and influencing factors within 7 months after surgery. METHODS: From July 2020 to July 2021, among all patients who underwent minimally invasive McKeown esophagectomy, 90 patients who developed vocal cord paralysis after surgery were included in the study. These patients underwent endoscopic vocal cord function assessment every 1 to 2 months and continued until 7 months postoperatively. RESULTS: Among all 388 patients undergoing esophagectomy, 23.2% (90/388) of patients suffered postoperative vocal cord paralysis. Left, right, and bilateral injuries were confirmed in 73 (81.1%), 12 (13.3%), and 5 patients (5.6%), respectively. With a median recovery time being 183 days, the cumulative overall recovery rate was 65.4% at 7 months, 68.6% for the left side, 55.6% for the right, and 20.0% for bilateral injuries. In multivariable analysis, cervical paraoesophageal lymph node dissection and conventional thoracoscopic-assisted esophagectomy were demonstrated to be independent risk factors associated with non-recovery of vocal cord paralysis. CONCLUSIONS: After intensive endoscopic follow-up, a cumulative vocal cord paralysis recovery rate of 65.4% within 7 months was observed in patients after minimally invasive McKeown esophagectomy. Cervical paraoesophageal lymph node dissection and conventional thoracoscopic-assisted esophagectomy were demonstrated to be risk factors hindering vocal cord paralysis recovery.

Parálisis laríngea posoperatoria en cirugía de tiroides y paratiroides / Postoperative laryngeal paralysis in thyroid and parathyroid surgery

INTRODUCCIÓN Y OBJETIVO: La parálisis de los nervios laríngeos (superior e inferior) es una complicación típicamente asociada a la cirugía tiroidea pero no exclusiva de ella. En el presente artículo se realiza un repaso en su epidemiología, clínica, diagnóstico y una actualización de los diferentes tratamientos aplicados hasta la fecha. Síntesis: La parálisis de las cuerdas vocales, a pesar de ser una complicación posible en la cirugía tiroidea, es a menudo deficientemente tratada. Su diagnostico, su tratamiento adecuado a las expectativas y la realidad del paciente y el tiempo en el que se aplica son fundamentales para obtener un éxito que permita hacer una vida normal a quienes la sufren. CONCLUSIONES: Al contrario de lo que se ha venido haciendo hasta ahora, la precocidad del tratamiento esta demostrado como determinante en el futuro de una parálisis de las cuerdas vocales. La rápida actuación, mas allá de dejar pasar el tiempo como antaño, empleando las diferentes técnicas en el momento preciso, mejora los resultados obtenidos

INTRODUCTION AND GOALS: Laryngeal nerve palsy (both superior and inferior) is a typical-but not exclusive-complication of thyroid surgery. The aim of this report is to review its epidemiology, clinical presentation, diagnosis and up-to-date treatments. Abstract: In spite of being a possible thyroid surgery complication, vocal fold palsy is often poorly treated. Diagnosis, an adapted treatment to meet both expectations and reality of the patients or even the time of application are key to obtain a successful outcome that allows them to live a normal life. CONCLUSIONS: Contrary to what has been done to date, the precocity of the treatment is demonstrated to be a determinant in the future of vocal cord paralysis. Fast acting-beyond letting time pass by like in the past- and the just-in-time use of different techniques improves the results

Laryngeal and vocal alterations after thyroidectomy / Alterações laríngeas e vocais após tireoidectomia

Abstract Introduction: Dysphonia is a common symptom after thyroidectomy. Objective: To analyze the vocal symptoms, auditory-perceptual and acoustic vocal, videolaryngoscopy, the surgical procedures and histopathological findings in patients undergoing thyroidectomy. Methods: Prospective study. Patients submitted to thyroidectomy were evaluated as follows: anamnesis, laryngoscopy, and acoustic vocal assessments. Moments: pre-operative, 1st post (15 days), 2nd post (1 month), 3rd post (3 months), and 4th post (6 months). Results: Among the 151 patients (130 women; 21 men). Type of surgery: lobectomy + isthmectomy n = 40, total thyroidectomy n = 88, thyroidectomy + lymph node dissection n = 23. Vocal symptoms were reported by 42 patients in the 1st post (27.8%) decreasing to 7.2% after 6 months. In the acoustic analysis, f0 and APQ were decreased in women. Videolaryngoscopies showed that 144 patients (95.3%) had normal exams in the preoperative moment. Vocal fold palsies were diagnosed in 34 paralyzes at the 1st post, 32 recurrent laryngeal nerve (lobectomy + isthmectomy n = 6; total thyroidectomy n = 17; thyroidectomy + lymph node dissection n = 9) and 2 superior laryngeal nerve (lobectomy + isthmectomy n = 1; Total thyroidectomy + lymph node dissection n = 1). After 6 months, 10 patients persisted with paralysis of the recurrent laryngeal nerve (6.6%). Histopathology and correlation with vocal fold palsy: colloid nodular goiter (n = 76; palsy n = 13), thyroiditis (n = 8; palsy n = 0), and carcinoma (n = 67; palsy n = 21). Conclusion: Vocal symptoms, reported by 27.8% of the patients on the 1st post decreased to 7% in 6 months. In the acoustic analysis, f0 and APQ were decreased. Transient paralysis of the vocal folds secondary to recurrent and superior laryngeal nerve injury occurred in, respectively, 21% and 1.3% of the patients, decreasing to 6.6% and 0% after 6 months.

Resumo Introdução: A disfonia é um sintoma comum após a tireoidectomia. Objetivo: Analisar os sintomas vocais, auditivo-perceptivos e acústica vocal, videolaringoscopia, procedimento cirúrgico e achados histopatológicos em pacientes submetidos à tireoidectomia. Método: Estudo prospectivo. Pacientes submetidos à tireoidectomia foram avaliados da seguinte forma: anamnese, laringoscopia e avaliações vocais acústicas. Momentos: pré-operatório, 1ª avaliação pós (15 dias), 2ª avaliação pós (1 mês), 3ª avaliação pós (3 meses) e 4ª avaliação pós-operatória (6 meses). Resultados: Dos 151 pacientes, 130 eram mulheres e 21, homens. Tipos de cirurgia: lobectomia + istmectomia n = 40, tireoidectomia total n = 88, tireoidectomia + dissecção de linfonodo n = 23. Sintomas vocais foram relatados por 42 pacientes na 1ª avaliação pós-operatória (27,8%), reduzidos para 7,2% após 6 meses. Na análise acústica, f0 e APQ estavam diminuídos nas mulheres. As videolaringoscopias mostraram que 144 pacientes (95,3%) tiveram exames normais no momento pré-operatório. Paralisia das cordas vocais foi diagnosticada em 34 pacientes na 1ª avaliação pós-operatória, 32 do nervo laríngeo recorrente (lobectomia + istmectomia - n = 6; tireoidectomia total - n = 17; tireoidectomia total + dissecção de linfonodos - n = 9) e 2 do nervo laríngeo superior (lobectomia + istmectomia - n = 1; tireoidectomia total + dissecção de linfonodos - n = 1). Após 6 meses, 10 pacientes persistiram com paralisia do nervo laríngeo recorrente (6,6%). Histopatologia e correlação com paralisia das cordas vocais: bócio coloide nodular (n = 76; paralisia n = 13), tireoidite (n = 8; paralisia n = 0) e carcinoma (n = 67; paralisia n = 21). Conclusão: Os sintomas vocais, relatados por 27,8% dos pacientes na 1ª avaliação pós-operatória, diminuíram para 7% em 6 meses. Na análise acústica, f0 e APQ diminuíram. A paralisia transitória de cordas vocais secundária à lesão do nervo laríngeo recorrente e nervo laríngeo superior ocorreu, respectivamente, em 21% e 1,3% dos pacientes, reduziu-se para 6,6% e 0% após 6 meses.

Lesión bilateral del nervio laríngeo recurrente en tiroidectomía total con o sin neuromonitorización intraoperatoria. Revisión sistemática y metaanálisis / Bilateral recurrent laryngeal nerve injury in total thyroidectomy with or without intraoperative neuromonitoring. Systematic review and meta-ana

Introducción y objetivo: El riesgo de parálisis laríngea bilateral (PLB) tras tiroidectomía total (TT) es bajo pero una de las mayores preocupaciones del cirujano y un incidente de seguridad grave que puede comprometer la vía aérea, precisar reintubación o traqueotomía y provocar secuelas graves o la muerte. No se ha demostrado que la neuromonitorización (NM) como herramienta diagnóstica precoz de lesión del nervio laríngeo recurrente (NLR) reduzca el riesgo. Objetivo: estimar el riesgo de PLB con y sin NM en TT mediante revisión sistemática y metaanálisis. Método: Revisión sistemática de ensayos clínicos, estudios de cohortes y series de casos de TT con y sin NM publicados en el periodo 2000-2014 en PubMed, Scopus (EMBASE) y Cochrane Library. Se exploró la heterogeneidad entre estudios y se estimaron riesgos ponderados agrupados siguiendo modelos de efectos aleatorios. Resultados: Se seleccionaron 40 artículos con estimaciones del riesgo en 54 series (25 sin NM, 29 con NM) con 30.922 pacientes. La incidencia de PLB con NM resultó inferior que sin NM (2,43‰, [1,55-3,5‰] versus 5,18‰, [2,53-8,7‰]). Esta diferencia equivale a una reducción absoluta del riesgo de 2,75‰ y un número necesario de pacientes a tratar de 364,13. El grupo con NM resultó más homogéneo (I2 = 7,52%) que sin NM (I2 = 79,32%). Las diferencias del análisis por subgrupos fueron imprecisas por el escaso número de parálisis. Conclusiones: El riesgo de PLB es menor en los estudios con neuromonitorización (AU)

Introduction and Objective: The risk of producing bilateral laryngeal paralysis (BLP) in total thyroidectomy (TT) is low, but it is a concern for the surgeon and a serious safety incident that may compromise the airway, require reintubation or tracheostomy and cause serious sequelae or death. Neuromonitoring (NM), as an early diagnostic tool for the existence of injury to the recurrent laryngeal nerve (RLN), has not been shown to have reduced the risk, even though published series show lower incidences. Our objective was to estimate the risk of bilateral RLN paralysis with and without NM TT by systematic review and meta-analysis. Method: We performed a systematic review of clinical trials, cohort studies and case series with total thyroidectomy without NM published in the period 2000-2014. A database search was performed using PubMed, Scopus (EMBASE) and the Cochrane Library. Heterogeneity between studies was explored and weighted risks grouped according to random effects models were estimated. Results: We selected 40 articles and estimates of risk were identified in 54 case series (without NM, 25; with NM, 29) with 30,922 patients. The prevalence of BLP in the series with NM was lower compared to that without NM (2.43‰, [1.55 to 3.5‰] versus 5.18‰ [2.53 to 8.7‰]). This difference is equivalent to an absolute risk reduction of 2.75‰ with a number needed to treat of 364.13. The NM group was more homogeneous (I2 = 7.52%) than those without NM (I2 = 79.32%). The observed differences in the subgroup analysis were very imprecise because the number of observed paralysis was very low. Conclusions: The risk of bilateral paralysis is lower in studies with neuromonitoring (AU)

Descripción de los casos de disfonías atendidos en una mutua durante el año 2013 / Description of dysphonia cases evaluated in a mutua in 2013

Objetivo: Describir los casos de disfonía atendidos en una Mutua española de ámbito nacional. Métodos: Se revisan las historias clínicas informatizadas durante 2013, identificándose 129 pacientes con diagnósticos compatibles con disfonías. Resultados: De los casos analizados 86 han sido declarados enfermedad profesional (67%), tres casos accidente de trabajo(dos de ellos diagnosticados con edema de Reinke) y 40 contingencia común. La mayoría de casos son mujeres (90%)entre 30 y 49 años. Han seguido tratamiento logopédico el 93% de las Enfermedades Profesionales, siendo las altas por curación en este grupo del 72%. La mayoría de los casos (61%) son profesionales de la enseñanza. En los casos que cursaron con baja laboral (n=36), la duración media de la baja fue de 113,5 días. Conclusiones: Todos los casos declarados como enfermedad profesional cumplen los requisitos marcados por la normativa(RD 1299/2006). Los casos considerados contingencia común se derivaron al Sistema Público de Salud. El tratamiento logopédico personalizado ha permitido la mayoría de las altas por curación. En nuestra serie, la media de días de baja por esta patología resulta elevada

Objective: To describe a case series of patients with dysphonia evaluated in a national Spanish mutua. Methods: Computerized medical records of 2013 were reviewed and 129 patients with diagnoses compatible with dysphonia were identified. Results: Eighty-six (67%) of the 129 cases were recognized as occupational diseases, three cases were considered as occupational injuries (two with a diagnosis of Reinke's edema) and the remaining 40 cases were considered to not be work-related. Most of the cases (90%) occurred in women between the ages of 30 and 49 years. Ninety-three percent of the cases diagnosed as occupational diseases underwent speech therapy and, of these, 72% were cured. The majority of the cases(61%) occurred in teachers. Average duration of sickness absence, among those patients who took it, was 113.5 days. Conclusions: All cases reported as occupational disease met the criteria set by the Spanish legislation (RD 1299/2006).Non-occupational diseases were referred to the national health service. Customized speech therapy was effective for most of the patients. The average duration of sick leave in our series was high

Parálisis laríngea detectada en la laringoscopia preoperatoria en enfermedad de tiroides maligna y benigna. Revisión sistemática y metaanálisis / Laryngeal paralysis detected in preoperative laryngoscopy in malignant and benign thyroid disease. Systematic review and meta-analysis

Hay controversia sobre la realización de laringoscopia preoperatoria (LP) en cirugía de tiroides. Las recomendaciones, basadas en estudios observacionales, varían entre unas publicaciones y otras. El objetivo del estudio es conocer la prevalencia de parálisis laríngea hallada en LP de pacientes a los que se realizó tiroidectomía en enfermedad benigna y maligna. Se realizó la revisión sistemática con 29 artículos incluidos para el estudio cualitativo y metaanálisis de 13 artículos en los que pudieron obtenerse los datos para evaluar el mismo efecto (LP realizada en todos los pacientes incluidos; se recoge a los pacientes con parálisis laríngea preoperatoria, figura el número total de pacientes y pueden asignarse las parálisis preoperatorias a los grupos de histología posoperatoria maligna o benigna). La prevalencia agrupada de parálisis preoperatoria en enfermedad benigna fue del 1,1% (IC del 95%, 0,7 a 1,7%; I2 71%) y en enfermedad maligna 6,3% (IC del 95%, 3,8 a 9,4%; I2 85%). La prevalencia es significativamente superior entre pacientes con enfermedad maligna con un efecto estimado RR 5,66, IC del 95%, 2,48, 12,88. Los estudios analizados presentan sesgos que será necesario corregir en investigaciones futuras, eliminando los sesgos de cegamiento en la selección y asignación de pacientes o en la técnica de laringoscopia empleada. La LP en cirugía de tiroides evalúa posibles trastornos de motilidad laríngea. La prevalencia de la parálisis laríngea en enfermedad de tiroides hallada en la LP en pacientes con diagnóstico posoperatorio de enfermedad maligna es más elevada que en el grupo de enfermedad benigna. Esta información es necesaria para interpretar la señal de neuromonitorización intraoperatoria y tomar decisiones

There is controversy regarding the performance of preoperative laryngoscopy (LP) in thyroid surgery, with different recommendations being made, based on observational studies, in various publications. The aim of the study was to know the prevalence of laryngeal paralysis found in the LPs of patients who underwent thyroidectomy in benign and malignant pathology. A systematic review was carried out with 29 articles included for the qualitative study and a meta-analysis of 13 articles in which the data could be obtained to evaluate the same effect (in all patients in which an LP was carried out, those with preoperative laryngeal paralysis were included, and assigned to malignant or benign postoperative histology groups). The pooled prevalence of preoperative paralysis in benign pathology was 1.1% (95% CI 0.7 to 1.7%, 71% I2) and in 6.3% malignant pathology (95% CI 3.8 to 9.4%; I2 85%). The prevalence was significantly higher among patients with malignant pathology with an estimated effect RR 5.66, 95% CI, 2.48, 12.88. The studies analyzed present biases that will need to be corrected in future research, eliminating blinding biases in the selection and allocation of patients or in the laryngoscopy technique used. The LP in thyroid surgery evaluates possible disorders of laryngeal motility. The prevalence of laryngeal paralysis in thyroid pathology found in LPs in patients with a postoperative diagnosis of malignant pathology was higher than in the benign pathology group. This information is necessary for interpreting the intraoperative neuromonitoring signal and for making informed decisions

Etiología y tratamiento de la parálisis laríngea: estudio retrospectivo de 108 pacientes / Aetiology and treatment of vocal fold paralysis: retrospective study of 108 patients

Objetivos: Revisar la etiología y el tratamiento de la parálisis laríngea de los pacientes atendidos en nuestro centro y describir las opciones terapéuticas disponibles. Métodos: Revisión retrospectiva de las historias clínicas de 108 pacientes diagnosticados de parálisis glótica unilateral y bilateral entre el año 2000 y el 2012, identificando la causa de la parálisis y el tratamiento realizado. Resultados: De los 108 casos analizados, el 70% presentaron inmovilidad glótica unilateral y el 30% bilateral. La etiología más frecuente en ambos casos fue la traumática representada principalmente por lesión quirúrgica, seguida de la tumoral en parálisis unilaterales y de causas médicas en parálisis bilaterales. La mitad de los pacientes con inmovilidad unilateral (38) fueron tratados con cirugía consistente en una tiroplastia de medialización. El tratamiento de la inmovilidad glótica bilateral consistió en traqueotomía en pacientes con compromiso ventilatorio (40%). Se propuso ampliar el paso aéreo en 9 pacientes (27%), efectuando cordotomía en la mayoría de los casos. Conclusiones: La etiología de nuestros pacientes es similar a la descrita en la literatura. En las parálisis unilaterales consideramos que la tiroplastia de medialización es el procedimiento de elección. En las bilaterales, una vez que se ha asegurado la permeabilidad de la vía aérea se puede plantear cordotomía en determinados pacientes (AU)

Objectives: To review the aetiology and treatment of laryngeal paralysis diagnosed at our hospital and to describe the available therapeutic options. Methods: Retrospective review of medical records of 108 patients diagnosed with unilateral and bilateral vocal fold paralysis between 2000 and 2012, identifying the cause of paralysis and its treatment. Results: Of the 108 cases analysed, 70% had unilateral vocal fold immobility and 30% bilateral immobility. The most frequent aetiology in both cases was trauma (represented mainly by surgical injury), followed by tumours in unilateral paralysis and medical causes in bilateral paralysis. Half of the patients with unilateral paralysis (38) were treated surgically, with medialization thyroplasty. In bilateral vocal fold immobility, the treatment consisted of tracheostomy in patients with threatened airway (40%). We planned to widen the air passage in 9 patients (27%), performing cordectomy in most of them. Conclusions: The aetiology observed in our patients is similar to that described in the literature. In cases of unilateral vocal fold paralysis, we believe thyroplasty is the procedure of choice. In bilateral paralysis, it is possible to perform cordectomy in selected patients once the airway has been secured (AU)

Parálisis laríngea en la población infantil / Paediatric vocal fold paralysis

Introducción y objetivos: La parálisis laríngea es una causa relativamente frecuente de estridor y disfonía en la edad pediátrica. Este artículo describe nuestra experiencia sobre la parálisis laríngea en la población pediátrica. Métodos: Se incluyeron en el estudio todos los pacientes que acudieron a consulta con el diagnóstico de parálisis laríngea durante un año completo. Se examinaron las historias clínicas de forma retrospectiva. El diagnóstico de parálisis laríngea se llevó a cabo mediante exploración clínica con nasofibroscopio flexible. Se registraron los siguientes datos: etiología de la parálisis, síntomas de presentación, retraso en el diagnóstico, lado afecto, posición de la cuerda vocal y tratamiento recibido. Resultados: Los síntomas de presentación más frecuentes fueron el estridor y la disfonía. La mayor parte de los casos eran de origen iatrogénico, seguido por los casos idiopáticos, neurológicos y obstétricos. La mayoría de los pacientes tenían una parálisis unilateral. El retraso medio en el diagnóstico fue de un mes, y fue significativamente mayor en los casos iatrogénicos. En la mayor parte de los casos no fue necesario ningún procedimiento quirúrgico como tratamiento. Conclusiones: El diagnóstico de parálisis laríngea se sospecha por la clínica, y se confirma por la exploración endoscópica. Los niños que presentan estridor tras un procedimiento quirúrgico deben ser examinados sin demora. Se debe tener en cuenta la posibilidad de recuperación espontánea o de compensación en las parálisis laríngeas (AU)

Introduction and objectives: Vocal fold paralysis (VFP) is a relatively common cause of stridor and dysphonia in the paediatric population. This report summarises our experience with VFP in the paediatric age group. Methods: All patients presenting with vocal fold paralysis over a 12-month period were included. Medical charts were revised retrospectively. The diagnosis was performed by flexible endoscopic examination. The cases were evaluated with respect to aetiology of the paralysis, presenting symptoms, delay in diagnosis, affected side, vocal fold position, need for surgical treatment and outcome. Results: The presenting symptoms were stridor and dysphonia. Iatrogenic causes formed the largest group, followed by idiopathic, neurological and obstetric VFP. Unilateral paralysis was found in most cases. The median value for delay in diagnosis was 1 month and it was significantly higher in the iatrogenic group. Surgical treatment was not necessary in most part of cases. Conclusions: The diagnosis of VFP may be suspected based on the patient's symptoms and confirmed by flexible endoscopy. Infants who develop stridor or dysphonia following a surgical procedure have to be examined without delay. The surgeon has to keep in mind that there is a possibility of late spontaneous recovery or compensation (AU)

Experiencia clínica en el manejo de parálisis cordales en posición abierta: tratamiento actual / Clinical experience in the management of vocal cords paralysis in abduction position: actual treatment

Introduction: The larynx is nerved by the recurrent and superior laryngeal nerves, translating its damage in pareses or paralysis of vocal cords, causing hoarseness in most of patients, and occasionally dispnea and deglutory alterations. The management of vocal cords paralysis in abduction position has been controversial. It seems that phoniatric treatment would seem to be a reasonable and effective alternative because the compensation capacity. Surgical manage, in other hand, has offered demonstrated effectiveness in the paralyses that don’t respond to phoniatric treatment, emphasizing techniques of medialization thiroplasty. Objectives: To reflect our epidemiology, phoniatric manage and experience as surgical team in medialization hiroplasty and to evaluate the results. Materials and Methods: retrospective study of patients with vocal cord paralysis in abduction position evaluated in Voice Unit of Clinic Hospital of University of Chile. Complete otolaryngological evaluation plus laryngeal electromyography were performed. Two groups were analyzed according manage received, describing clinicallythe degree of hoarseness at the beginning and the end of treatment. Results: 61 percent of the nonsurgical manage paralysis causes were secondary to surgery, mainly on the thyroid gland (81 percent). In these a significant improvement of the hoarseness with the phoniatric manage exists. In the group subject medialization thiroplasty 55 percent were secondary to surgery with a 77 percent of postoperating satisfactory evaluation.

Tratamiento quirúrgico del bocio intratorácico / Surgical treatment of intrathoracic goitre

La definición de Katlic es la que mejor describe el bocio intratorácico, entidad que incluye un pequeño subgrupo (1-4%) de los pacientes con bocio multinodular que generalmente se presentan con síntomas compresivos graves y requieren atención especializada en centros de referencia. El estudio preoperatorio debe incluir técnicas de imagen torácicas para planificar la intervención más adecuada. La cirugía debe ser la tiroidectomía total y en más del 95% de los casos el bocio se puede extraer por vía cervical. Es necesario un abordaje cervical amplio y la identificación del nervio recurrente cerca de la unión cricotiroidea lo cual facilita la liberación del tiroides de todas sus fijaciones cervicales antes de traccionar suavemente hacia arriba del componente torácico para su extracción. Los bocios intratorácicos que requieren esternotomía para su extracción son los bocios recidivados, los que presentan cáncer avanzado, algunos de los que alcanzan la carina y los bocios posteriores izquierdos que se extienden hacia la cavidad pleural derecha (AU)

The definition by Katlic gives the best description of intrathoracic goitre, a condition that includes a small sub-group (1-4%) of patients with multinodular goitre who generally have severe compression symptoms and require specialised care in reference centres. The preoperative study must include thoracic imaging techniques to plan the most suitable action. Total thyroidectomy is recommended, and in more than 95% of cases the goitre can be removed using a cervical approach. A wide cervical approach and the identification of the recurrent nerve near the cricothyroid joint help to free the thyroid from all its cervical attachments before gently retracting it upwards from the thoracic component for its removal. Intrathoracic goitres that require a sternotomy for its removal are recurrent goitres, those that have advanced cancer, those that reach the carina, and left posterior goitres that extend to the right pleural cavity (AU)

Vocal fold immobility after thyroidectomy with intraoperative recurrent laryngeal nerve monitoring

CONTEXT AND OBJECTIVE: Intraoperative nerve monitoring has emerged as a valuable tool to facilitate recurrent laryngeal nerve identification during thyroid surgery, thereby avoiding its injury. The aim was to evaluate vocal fold mobility in patients who underwent thyroidectomy with intraoperative nerve monitoring. DESIGN AND SETTING: Cohort formed by a consecutive series of patients, at a tertiary cancer hospital. METHODS: The subjects were patients who underwent thyroidectomy using intraoperative laryngeal nerve monitoring, between November 2003 and January 2006. Descriptive analysis of the results and comparison with a similar group of patients who did not undergo nerve monitoring were performed. RESULTS: A total of 104 patients were studied. Total thyroidectomy was performed on 65 patients. Vocal fold immobility (total or partial) was detected in 12 patients (6.8 percent of the nerves at risk) at the first postoperative evaluation. Only six (3.4 percent of the nerves at risk) continued to present vocal fold immobility three months after surgery. Our previous series with 100 similar patients without intraoperative nerve monitoring revealed that 12 patients (7.5 percent) presented vocal fold immobility at the early examination, and just 5 (3.1 percent) maintained this immobility three months after surgery, without significant difference between the two series. CONCLUSION: In this series, the use of intraoperative nerve monitoring did not decrease the rate of vocal fold immobility.

CONTEXTO E OBJETIVO: A monitorização intra-operatória de nervos surgiu como uma ferramenta valiosa para facilitar a identificação do nervo laríngeo recorrente durante a cirurgia de tireóide, evitando a sua lesão. O objetivo foi avaliar a mobilidade das pregas vocais em pacientes submetidos a tireoidectomia com monitorização intra-operatória do nervo laríngeo recorrente. TIPO E LOCAL DO ESTUDO: Coorte de uma série consecutiva de pacientes em um hospital terciário de tratamento de câncer. MÉTODOS: Pacientes foram submetidos à cirurgia de tireóide usando a monitorização intra-operatória do nervo laríngeo recorrente, entre novembro de 2003 e janeiro de 2006. Uma análise descritiva dos resultados e uma comparação com um grupo similar de pacientes que não foram submetidos a monitorização dos nervos foram realizadas. RESULTADOS: Um total de 104 pacientes foi estudado. Tireoidectomia total realizada em 65 pacientes. Imobilidade de pregas vocais (parcial ou total) foi detectada em 12 pacientes (6.8 por cento dos nervos sob risco) na primeira avaliação pós-operatória. Apenas 6 (3.4 por cento dos nervos sob risco) permaneceram com imobilidade de prega vocal três meses após a cirurgia. Nossa série prévia com 100 pacientes similares sem a monitorização intra-operatória revelou que 12 pacientes (7.5 por cento) apresentaram imobilidade de prega vocal na avaliação precoce, e apenas 5 (3.1 por cento) mantiveram a imobilidade três meses após a cirurgia, sem diferença significativa entre as séries. CONCLUSÃO: Nesta série, o uso da monitorização intra-operatória do nervo laríngeo recorrente não diminuiu a taxa de imobilidade de prega vocal.