How blue lining the recurrent laryngeal nerve can aid in re-operative surgery?

The recurrent laryngeal nerve (RLN), is one of the main structures at risk of injury causing vocal cord paralysis during head and neck surgery, especially during thyroid or parathyroid surgery, central neck dissection and upper oesophageal sphincter surgery. We describe the systematic use of marking of the RLN using non-resorbable blue polypropylene suture after its localisation, just inside its penetration below the cricopharyngeal muscle, to help identify the nerve for cases of re-operative surgery in this area. This specific marking technique could facilitate subsequent preservation of the nerve and reduce nerve injury risk in cases of planned or unexpected future operations, as well as emergency surgery due to postoperative complications. We apply this technique simultaneously with intra-operative laryngeal neuromonitoring. This method is safe and easy to perform.

Hyperparathyroidism in pregnancy and 99mTc-MIBI scintigraphy.

INTRODUCTION: Primary hyperparathyroidism (PHPT) during pregnancy can be responsible for serious maternal and foetal complications and should be treated by elective low-risk, minimally invasive surgery. Preoperative assessment of hyperfunctioning parathyroid glands is classically based on high-resolution neck ultrasound (US) and 99mTc-sestamibi/123I scintigraphy. However, administration of any radiopharmaceutical during pregnancy must be limited and justified and US alone may be sufficient to localize an abnormal parathyroid gland. CASE REPORT: We report the case of a 4-month pregnant woman with severe primary hyperparathyroidism, in whom US failed to localize the abnormal parathyroid gland. 99mTc-sestamibi scintigraphy was performed in preference to 18-fluorocholine (FCH)-PET/CT on the basis of a multidisciplinary decision. As 99mTc-MIBI demonstrated an hyperfunctioning right inferior parathyroid, 123I was not administered. A large right paravertebral parathyroid adenoma was successfully removed, as confirmed by decreased postoperative serum parathyroid hormone and calcium levels. The eutrophic newborn infant was delivered at term, with normal serum calcium and TSH levels. DISCUSSION: In pregnant women with primary hyperparathyroidism, US alone may be sufficient when it localizes the abnormal parathyroid gland, allowing elective low-risk minimally invasive surgery. Otherwise, a multidisciplinary approach is mandatory to select the radiopharmaceutical that can be safely used to identify the hyperfunctioning parathyroid gland with minimal risks for the foetus.

Conservative three-quarter versus subtotal seven-eighths parathyroidectomy in secondary hyperparathyroidism.

OBJECTIVE: There is at present no consensus concerning surgical techniques for secondary hyperparathyroidism (SHPT) in end-stage renal disease (ESRD). Although both subtotal and total parathyroidectomy provide low rates of recurrence, they may induce hypoparathyroidism, damaging the bone and cardiovascular systems. The aim of our study was to compare 3/4 and 7/8 parathyroidectomy in this population and to discuss the potential benefit of more conservative treatment. STUDY DESIGN: Prospective observational study in a university teaching hospital between 2010 and 2014. METHODS: The study included 34 consecutive ESRD patients with SHPT: 19 underwent 3/4 parathyroidectomy (group A*3/4) and 15 underwent 7/8 parathyroidectomy (group B*7/8). Serum intact 1-84 PTH levels (before and 6 months after surgery) and hospital stay were compared between the two groups. RESULTS: Before surgery, PTH levels were similar between the two groups. At month 6 following surgery, median PTH levels were significantly higher in group A*3/4 than in group B*7/8 (109 versus 24pg/mL, respectively; P<0.0006). Hospital stay was shorter in group A*3/4 (4.79 versus 6.80 days, respectively; P=0.008). Postoperative hypoparathyroidism requiring long-term calcium and 1alpha(OH) D3 treatment was reported in 5% of patients in group A*3/4 and 26% of patients in group B*7/8 (P=0.04). CONCLUSIONS: In this preliminary study, 3/4 conservative parathyroidectomy seemed effective and safe, with less reported morbidity than 7/8 parathyroidectomy, as assessed by lower rates of irreversible hypoparathyroidism and shorter hospital stay. LEVEL OF EVIDENCE: 3b, individual case-control study.

Management of incidental discovery of microscopic squamous cell carcinoma in zones of osteoradionecrosis of the mandible.

OBJECTIVES: Osteoradionecrosis (ORN) of the mandible is a common complication of head and neck radiotherapy and often requires surgical treatment. Squamous cell carcinoma (SCC) can be exceptionally discovered within zones of ORN on histological examination of the operative specimen. The authors discuss the management of these lesions based on a short patient series. MATERIALS AND METHODS: This single-centre retrospective study was based on patients managed between 2012 and 2014 for ORN with incidental discovery of microscopic SCC. RESULTS: Five patients with incidental discovery of microscopic SCC in a zone of ORN of the mandible were included in this study. The mean time to onset of ORN after the end of radiotherapy for locally advanced SCC of the oral cavity or oropharynx was 42 months. Surgical treatment consisted of marginal or segmental mandibulectomy with free flap reconstruction. No recurrence was observed with a mean follow-up of 35 months [24-46]. CONCLUSION: The incidental discovery of microscopic SCC in a zone of ORN of the mandible is a rare event and has not been reported in the literature. Optimal management cannot be reliably defined due to the lack of data in the literature, but the present study supports careful histological examination of ORN specimens. Treatment must be as conservative as possible to avoid excessively invasive surgery.

Upper airway obstruction assessment: Peak inspiratory flow and clinical COPD Questionnaire.

OBJECTIVES: Spirometric evaluation of upper airway obstruction (UAO) is not commonly performed by Otolaryngologists. In addition, functional evaluation of UAO by flow-volume loops (FVL) is not available in all clinical settings. More recently, peak inspiratory flow (PIF) has proven to be a useful tool to monitor UAO at the patient's bedside. The aim of this work is to assess the role of PIF measured with a simple flow metre (In-Check method) as a standardised, simple, non-invasive tool in quantifying chronic and subacute UAO in a routine clinical practice. In addition, a Clinical COPD Questionnaire (CCQ), previously validated to assess the psychophysical status in patients with laryngotracheal stenosis, was utilised to evaluate respiratory function in UAO. DESIGN: Prospective cohort study. SETTINGS: University teaching hospital. PARTICIPANTS: Seventy 2 subjects, an UAO group of 26 patients and a control group of 46 healthy subjects. MAIN OUTCOME MEASURES: The ability of PIF values to discriminate between the UAO group and the control group was assessed using a ROC curve. A Spearman rank correlation was used to test the relationship between PIF measurements and the global CCQ score. Additionally, an analysis of CCQ at domain and items levels was performed. RESULTS: Peak inspiratory flow values were accurate, with an area under the ROC curve (AUC) of 0.98 (P < .05) for differentiating the control group from the UAO group. A threshold PIF value of 170 L/min was found for diagnosing UAO. An inconclusive negative trend was found (r = -.19; P = .35) between PIF values and CCQ global score. Concerning CCQ, the symptoms domain was the most affected by UAO, higher than mental domains (P < .001) as well as functional domains (P < .01). Exertional dyspnoea and cough were the items that obtained the highest disturbed scores. CONCLUSIONS: Peak inspiratory flow is a non-invasive, quantitative parameter to evaluate the severity of UAO. Testing can be easily performed in a routine clinical setting, with a non-expensive hand-held device, and could help medical follow-up programmes and prevent emergency situations. However, FVL may be necessary for further assessment of UAO diseases. The CCQ confirms that exertional dyspnoea is the main symptom of UAO, but cough remains a common symptom.

International consensus (ICON) on comprehensive management of the laryngeal nerves risks during thyroid surgery.

The laryngeal monitoring of the inferior and superior laryngeal nerves, and the vagus nerve, has advanced for last years, in practice of thyroid and parathyroid surgery. Different methods are used, using direct or indirect laryngeal stimulation and also intermittent or continuous nerve registration. At present time, various recommendations of it in the world use are reported, and availability of the tool used remains a limit in some countries. The aim of this Icon during Ifos 2017 was to share knowledge about laryngeal intraoperative nerve monitoring (LIONM) procedures and to evaluate current practices used to improve the quality of thyroid and parathyroid surgery. Benefits of LIONM were discussed with three experts (Pr G. Randolph from Boston, Pr Henning Dralle from Halle in Germany, Pr Hoon Yub KIM from Seoul). All of them have been actively involved in the development and use of laryngeal nerve monitoring during thyroid and parathyroid surgery.

Peak inspiratory flow as predictor for tracheotomy.

OBJECTIVES: Quantitative evaluation of upper airway obstruction cannot be commonly performed under acute dyspnea, especially in head and neck cancer (HNC); the decision whether or not to perform airway control surgery may be difficult to reach. Peak inspiratory flow (PIF) has been previously demonstrated to be a useful tool to decide on decannulation after HNC surgery. The aim of the present study was to assess the role of PIF as a standardized non-invasive tool in quantifying severe inspiratory dyspnea requiring emergency tracheostomy. MATERIALS AND METHODS: A single-center prospective observational pilot study analyzed PIF measurements in 22 patients exhibiting acute dyspnea due to upper airway obstruction. MAIN OUTCOME MEASURES: The decision whether or not to perform tracheotomy was taken prior to PIF measurement. PIF was measured with a hand-held PIF meter (In-Check method), and laryngeal fiberoscopy was then performed. Obstruction severity was defined by PIF values. RESULTS: PIF could be measured prior to tracheotomy (imminent in 21 cases, postponed in 1) in all cases. PIF values below 53.1 L/min (i.e., 18.3% of theoretic value) correlated with necessity for emergency tracheotomy. This threshold is concordant with that previously found for the feasibility of decannulation (60L/min). CONCLUSIONS: PIF is a non-invasive quantitative parameter assessing severity of upper airway obstruction, that may be helpful in decision-making for tracheostomy. Testing is simple, quick and reproducible.

A tunable copper-catalyzed multicomponent reaction towards alkaloid-inspired indole/lactam polycycles.

A versatile copper(i)-catalyzed cascade multicomponent reaction strategy between readily available (Z)-3-iodoacrylic acids, terminal alkynes, and primary amines is reported, leading to a great diversity of complex heterocyclic backbones based on biorelevant indole/lactam scaffolds.

How to release neck dissections: Role of the triangle between the spinal accessory nerve and the internal jugular vein.

The neck dissection technique has been precisely defined. It allows resection of lymph node groups, comprising at least groups IIA, IIB, III and IV according to Robbins' classification for head and neck cancer. Neck dissection is classically performed in an upwards and forwards direction, but the technique can vary according to the site of lymph nodes. The authors describe the central role of dissection of the triangle between the spinal accessory nerve and the internal jugular vein at the beginning of neck dissection in order to facilitate group IIB dissection while avoiding traction on the spinal accessory nerve and to ensure early control of the internal jugular vein superiorly; release of the vein also facilitates subsequent dissection of the thyrolinguofacial trunk and identification of the hypoglossal nerve. This specific dissection and its role has not been previously described in the literature. This triangle constitutes the posterior part of group IIA, but is intimately related anatomically to group IIB dissection.

Reduction of Parkinson's-related dysphonia by thyroplasty.

Parkinson's-related dysphonia has a negative impact on the quality of speech by increasing the effects of the associated dysarthria. When this dysphonia is related to vocal fold adduction defect, constituting a real glottic insufficiency, vocal fold medialization can be proposed after failure of intensive voice and speech therapy. Acoustic and aerodynamic voice and speech analysis techniques, perceptual evaluation and estimation of vocal handicap, associated with fiberoptic laryngoscopy were performed to determine the indication for vocal fold medialization in these patients with glottic insufficiency. Vocal fold medialization by Montgomery thyroplasty implant was performed under local anesthesia and neuroanalgesia in two patients with Parkinson's disease presenting a dysphonia refractory to speech therapy. Postoperative evaluation showed improvement of voice quality with an increased number of harmonics and improvement of aerodynamic parameters. Vocal fold medialization by Montgomery thyroplasty implant effectively improved voice quality in these two patients allowing a more effective vocal fold adduction. The reducing of the hypophonia has a positive effect on the quality of oral communication. The medialization thyroplasty technique, under local anesthesia, allows intraoperative control of the voice as well as removal of the implant when necessary.

Incidental cervical metastases from thyroid carcinoma during neck dissection.

OBJECTIVES: To quantify and discuss the prevalence of unsuspected thyroid lymph node metastases discovered in specimens from neck dissection for head and neck squamous cell carcinoma (HNSCC) and discuss the impact on patient management. STUDY DESIGN: Retrospective study between May 2004 and January 2007. SETTING: University hospital. METHODS: Pathological analysis of cervical lymph node dissection performed during surgery for HNSCC in a total of 349 neck dissections in 266 consecutive patients. RESULTS: Twenty-one patients showed metastatic lymph nodes from thyroid cancer (prevalence 7.9%): 13 cases were metastatic from a papillary thyroid carcinoma and 8 cases from a follicular carcinoma. In 5 of the 21 patients, classical dissection was associated to recurrent nerve dissection and unilateral lobectomy; no thyroid carcinoma was found. Thirteen patients received radiotherapy for HNSCC. Follow-up comprised annual ultrasonographic examination of the neck and thyroid in these 21 patients. Total thyroidectomy was decided on in 5, with discovery of 3 micro-papillary thyroid carcinomas, in a single patient (complementary 131I treatment). No thyroid carcinomas were found for the other 4 patients. No patients died from thyroid carcinoma during follow-up (mean: 41 months). CONCLUSION: The prevalence of lymph node metastasis from thyroid carcinoma in cervical lymph node dissection during treatment of HNSCC seems higher (7.9%) than rates reported in the literature (0.3 to 1.6%). This may be due to the histopathological methods employed. Management of patients should be discussed in the light of thyroid ultrasonography and prognosis of HNSCC.

Oncocytic parathyroid adenoma.

INTRODUCTION: Fine-needle aspiration cytology (FNAC) of thyroid nodules commonly reveals the presence of oncocytic cells (or Hürthle cells) in a follicular neoplasm. Histological examination is necessary to determine the benign or malignant nature of the tumour. However, oncocytic cells are also normally present in the parathyroid glands. CASE REPORT: A thyroid nodule was discovered on thyroid ultrasound in a woman with a history of left partial thyroid lobectomy. Fine-needle aspiration cytology revealed a follicular neoplasm comprising oncocytic cells (Hürthle cells). This woman also presented features of hyperparathyroidism with hypercalcaemia. (123)I/(99m)Tc-sestamibi and (18)F-fluorocholine PET-CT scan revealed increased uptake over the remaining left thyroid lobe. Left lobectomy was completed together with thyroid exploration. Histological examination revealed a parathyroid adenoma in the residual thyroid tissue. Parathyroid hormone levels subsequently returned to normal. DISCUSSION: Cytomorphological similarities are often observed between parathyroid and Hürthle cell thyroid tumours. The parathyroid rather than thyroid nature of the tumour must be strongly suspected preoperatively in the presence of hyperparathyroidism.

Role of the "rising tide sign" in the diagnosis and assessment of the results of surgery for Zenker's diverticulum.

OBJECTIVE: To evaluate the role of the videoendoscopic "rising tide sign" (RTS) in the diagnosis and assessment of surgical repair of Zenker's diverticulum. STUDY DESIGN: Retrospective. SUBJECTS AND METHODS: A total of 148 patients with Zenker's diverticulum underwent surgery in our department. A videoendoscopic swallowing study (VESS) was performed pre- and postoperatively, and the two examinations compared for the presence of the RTS. VESS characteristics based on the time to RTS onset and the size of diverticulum, as seen on a barium swallow, were also compared in a subset of 38 patients. RESULTS: All patients presented with the RTS on preoperative VESS. No correlation was observed between the time to onset of the sign and size of the diverticulum. Follow-up data were available for 121 patients (mean follow-up: 8 months): 111 patients were significantly improved during follow-up, with complete disappearance of the RTS. Recurrence of symptoms was observed at this time in 10 patients. Seven of these 10 patients had concomitant recurrence of the RTS and required repeat surgery after a mean follow-up of 37 months. CONCLUSION: The RTS observed by videoendoscopy is a supplementary tool for the diagnosis of Zenker's diverticulum and for evaluation of the efficacy of surgery during the postoperative follow-up.

Value of recurrent laryngeal nerve monitoring in the operative strategy during total thyroidectomy and parathyroidectomy.

OBJECTIVE: The purpose of this study was to assess the role of recurrent laryngeal nerve (RLN) monitoring in the operative strategy during total thyroidectomy and parathyroidectomy. Due to the risk of serious respiratory complications of bilateral recurrent nerve paralysis, two-stage surgery may be considered in the case on negative stimulation of the first side. PATIENTS AND METHODS: This prospective study was conducted in 100 consecutive patients between May 2007 and March 2011. Translaryngeal monitoring was performed. When stimulation of the RLN on the first side dissected was negative, dissection of the other side was deferred to avoid the risk of bilateral RLN paralysis. RESULTS: The main surgical indications were thyroid carcinoma (34%), Graves' disease (27%), multinodular goitre (27%) and parathyroid hyperplasia (9%) with seven cases of redo surgery. Four RLN identified on the first side gave a negative response to stimulation and surgery to the other side was therefore deferred. Transient unilateral RLN paralysis was observed in these four patients and two cases of RLN paralysis were observed among patients with positive RLN stimulation. Among the 96 contralateral RLNs tested, two were not visualized (one case of transient RLN paralysis, one case of permanent RLN paralysis), two gave a negative response to stimulation (two cases of permanent RLN paralysis) and 92 gave a positive response to stimulation (nine cases of transient RLN paralysis, including two cases associated with transient paralysis of the first side, and one case of permanent RLN paralysis). The incidence of RLN paralysis by nerve was 9.6% for transient RLN paralysis and 2% for permanent (unilateral) RLN paralysis. CONCLUSION: When bilateral RLN dissection is planned, RLN monitoring is particularly useful to limit the risk of bilateral RLN paralysis. Two-stage thyroidectomy, following functional recovery of the damaged RLN, can therefore be proposed. The risk of bilateral RLN paralysis was avoided in four patients, while transient bilateral RLN paralysis was observed in two patients despite positive stimulation.

[Prognosis and predictive factors in head-and-neck cancers]. / Facteurs pronostiques et prédictifs des cancers des voies aérodigestives supérieures.

The head-and-neck squamous-cell carcinomas (HNSCC) represent in order of frequency the fourth leading cause of cancer deaths among men in France. The term HNSCC includes various anatomopathological and clinical entities with different evolution patterns. For this reason, it is necessary to identify prognostic and predictive factors able to help in the choice of the treatment. The clinical factors with a prognostic value are the tumor location, the tumor size and the lymph node status. The degree of differentiation is the most important histologic factor. More recently, the identification of molecular factors has opened the way to new therapies. Thus, the overexpression of EGFR is associated with a poor prognosis. Its inhibition improves the survival of patients. p53 mutations and cyclin D1 amplification are actually subject to intensive research. The tumors associated with HPV infection are distinguishable by a better prognosis. 18-alpha-FDG positron emission tomography emerges as a useful tool for the therapeutic evaluation. The evolution of surgical techniques, the development of induction chemotherapy regimen or concurrent ones with radiotherapy and new techniques of conformal irradiation also results in a better locoregional control.

Prospective comparison of FDG and FET PET/CT in patients with head and neck squamous cell carcinoma.

AIM: The clinical usefulness of 2-deoxy-2-[F-18]fluoro-D-glucose-positron emission tomography (FDG-PET) in head and neck squamous cell carcinoma (HNSCC) is now well-documented. However, its sensitivity is greater than its specificity due to false-positive results in inflammatory or infectious lesions, which are frequent in this area, in particular after treatment by surgery and/or radiotherapy. O-2-fluoro-(18F)-ethyl-L-thyrosine (FET) has been reported not to be taken up by such lesions, and a preliminary study indicated that this may be clinically useful in HNSCC. We performed a prospective study to compare the diagnostic performances of FDG and FET PET/CT in the different settings of HNSCC. MATERIALS AND METHODS: Twenty-seven patients (20 men and seven women, aged 48-76, among 30 patients included) and 69 suspected cancer sites are now evaluable on basis of postsurgical histology and/or follow-up greater than 6 months; 15 patients were referred for initial staging and 12 during posttherapy follow-up, a recurrence being suspected in eight of them. FDG and FET PET/CT were performed on two different days, the patient fasting for 6 h, 1 h after injection of 5 MBq/kg of body mass of each radiopharmaceutical. Both PET/CT examinations were blind read more than 6 months after the end of inclusions in a random order for each tracer and with a time interval greater than 1 month between FDG and FET PET/CT blind readings. RESULTS: Overall diagnostic performances, derived from blind reading: FDG PET/CT on a per patient basis: sensitivity 100%, specificity 71%, accuracy 93%; FDG PET/CT on a per site basis: sensitivity 95%, specificity 63%, accuracy 83%; FET PET/CT on a per patient basis: sensitivity 70%, specificity 100%, accuracy 78%; FET PET/CT on a per site basis: sensitivity 64%, specificity 100%, accuracy 78%. At site level, sensitivity was significantly greater with FDG (p<0.02) and specificity with FET (p<0.01). The statistical level of significance was not reached at patient level. CONCLUSION: Although its good specificity was confirmed, FET did not appear to be suited as a first-line PET tracer in HNSCC imaging and cannot replace FDG for staging due to insufficient sensitivity. However, it was useful in a few selected cases to favor a wait and see attitude when a FDG+ FET- focus was discovered in patients referred for systematic FDG PET during follow-up. In contrast, second primary cancers should not be ruled out if FDG was clearly positive in the lungs or the digestive tract.