Impact of intraoperative fluid management on postoperative complications in patients undergoing minimally invasive esophagectomy for esophageal cancer: a retrospective single-center study.

BACKGROUND: Esophagectomy is a high-risk procedure that can involve serious postoperative complications. There has been an increase in the number of minimally invasive esophagectomies (MIEs) being performed. However, the relationship between intraoperative management and postoperative complications in MIE remains unclear. METHODS: After the institutional review board approval, we enrolled 300 patients who underwent MIE at Tohoku University Hospital between April 2016 and March 2021. The relationships among patient characteristics, intraoperative and perioperative factors, and postoperative complications were retrospectively analyzed. The primary outcome was the relationship between intraoperative fluid volume and anastomotic leakage, and the secondary outcomes included the associations between other perioperative factors and postoperative complications. RESULTS: Among 300 patients, 28 were excluded because of missing data; accordingly, 272 patients were included in the final analysis. The median [interquartile range] operative duration was 599 [545-682] minutes; total intraoperative infusion volume was 3,747 [3,038-4,399] mL; total infusion volume per body weight per hour was 5.48 [4.42-6.73] mL/kg/h; and fluid balance was + 2,648 [2,015-3,263] mL. The postoperative complications included anastomotic leakage in 68 (25%) patients, recurrent nerve palsy in 91 (33%) patients, pneumonia in 62 (23%) patients, cardiac arrhythmia in 13 (5%) patients, acute kidney injury in 5 (2%) patients, and heart failure in 5 (2%) patients. The Cochrane-Armitage trend test indicated significantly increased anastomotic leakage among patients with a relatively high total infusion volume (P = 0.0085). Moreover, anastomotic leakage was associated with male sex but not with peak serum lactate levels. Patients with a longer anesthesia duration or recurrent nerve palsy had a significantly higher incidence of postoperative pneumonia than those without. Further, the incidence of postoperative pneumonia was not associated with the operative duration, total infusion volume, or fluid balance. The operative duration and blood loss were related to the total infusion volume. Acute kidney injury was not associated with the total infusion volume or serum lactate levels. CONCLUSIONS: Among patients who underwent MIE, the total infusion volume was positively correlated with the incidence of anastomotic leakage. Further, postoperative pneumonia was associated with recurrent nerve palsy but not total infusion volume or fluid balance.

Assessment of pre-extubating recurrent laryngeal nerve palsy using ultrasound in postoperative patients with esophageal cancer: a prospective observational study.

PURPOSE: Ultrasound performed after extubation has been suggested to be useful for the diagnosis of recurrent laryngeal nerve (RLN) paralysis. However, the use of ultrasound for this purpose before extubation has not been examined. The aim of this study was to examine the versatility (interrater reliability) and usefulness of ultrasound for evaluating the movement of vocal cords before extubation. METHODS: The subjects were 30 patients who underwent radical surgery for esophageal cancer from August 2020 to December 2021. An experienced examiner performed an ultrasound examination before and after elective extubation on the day after surgery to evaluate RLN paralysis and record videos. Bronchoscopy was then performed to make a definite diagnosis. Three anesthetists blinded to the diagnosis also evaluated the cases using the videos, and the versatility of the examination was determined using a kappa test. RESULTS: The diagnostic accuracies of the examiner and three anesthetists were 76.7%, 50.0%, 53.3%, and 46.7%, respectively, and the kappa coefficients for the examiner with the anesthetists were 0.310, 0.502, and 0.169, respectively. The sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of RLN paralysis by the examiner using ultrasound before extubation were 0.57, 0.95, 0.80, and 0.87, respectively. CONCLUSION: These results indicate a lack of versatility of the ultrasound examination based on the low kappa coefficients. However, with an experienced examiner, ultrasound can serve as a non-invasive examination that can be performed before extubation with high accuracy and specificity for diagnosis of postoperative RLN paralysis.

Left recurrent nerve lymph node dissection in robotic esophagectomy for esophageal cancer without esophageal traction.

BACKGROUND: Because the robotic arm is located on the dorsal side of the patient, when the esophagus is pulled dorsally for the left recurrent nerve lymph node (LRLN) dissection, the robotic arm interferes with the surgical field. This made it difficult to prepare for the left recurrent lymph node dissection. We developed LRLN dissection in robotic surgery with natural space creation by physiological organ movement and evaluated the short-term results. METHODS: In this retrospective study, we analyzed 102 cases of robot-assisted thoracoscopic subtotal esophagectomy (RATE) among radical subtotal esophagectomies performed between December 2018 and December 2022 using medical records. LRLN dissection is preceded by a dissection of the esophagus from the trachea. Leaving the esophagus on the vertebral side and away from the trachea resulted in a physiological elevation of the esophagus, providing space between the trachea and esophagus. RESULTS: The thoracic surgery time in RATE was 181 (115-394) min. The number of LRLNs dissected was 4 (1-14). Six patients (6%) had a postoperative recurrence in the mediastinal lymph nodes. Seven patients (7%) had grade ≥ 1 left recurrent nerve palsy. CONCLUSIONS: LRLN dissection with RATE using natural space creation was performed safely with a sufficient number of dissected lymph nodes and little left recurrent nerve palsy.

Histological study of the thin membranous dense connective tissues around the curving portion of the bilateral recurrent laryngeal nerves.

OBJECTIVE/AIM: We aimed to demonstrate the anatomical relationship between the recurrent laryngeal nerves (RLNs), thin membranous dense connective tissue (TMDCT [e.g., the visceral or vascular sheaths around the esophagus]), and the lymph nodes around the esophagus at the curving portion of the RLNs for rational and efficient lymph node dissection. METHODS: Transverse sections of the mediastinum at 5 mm or 1 mm intervals were obtained from four cadavers. Hematoxylin and eosin staining and Elastica van Gieson staining were performed. RESULTS: The visceral sheaths could not be clearly observed the curving portions of the bilateral RLNs, which were observed on the cranial and medial side of the great vessels (aortic arch and right subclavian artery [SCA]). The vascular sheaths could be clearly observed. The bilateral RLNs diverged from the bilateral vagus nerves, which ran along with the vascular sheaths, went up around the caudal side of the great vessels and the vascular sheath, and ran cranially on the medial side of the visceral sheath. Visceral sheaths were not observed around the region containing the left tracheobronchial lymph nodes (No. 106tbL) or the right recurrent nerve lymph nodes (No. 106recR). The regions containing the left recurrent nerve lymph nodes (No. 106recL) and the right cervical paraesophageal lymph nodes (No. 101R) were observed on the medial side of the visceral sheath, with the RLN. CONCLUSION: The recurrent nerve, which branched off from the vagus nerve descending along the vascular sheath, ascended the medial side of the visceral sheath after inversion. However, no clear visceral sheath could be identified in the inverted area. Therefore, during radical esophagectomy, the visceral sheath along No. 101R or 106recL may be recognized and available.

Neuromonitoring of recurrent laryngeal nerves in thyroid surgery comparative study of visualisation and electrophysiology methods.

Úvod: Poranění zvratného nervu je jedna z nejzávažnějších komplikací chirurgie štítné žlázy, chirurgie příštítných tělísek a chirurgie krčních obratlů. V literatuře se popisuje poranění zevní větve hrtanových nervů jako méně časté. Tato komplikace je natolik vážná, že může vést k invalidizaci hlasových profesionálů (učitelů, herců, zpěváků, profesionálních řečníků a manažerů). Současná klinická praxe je spojena se zvýšeným úsilím o peroperační ochranu funkce zvratných nervů využíváním elektrofyziologické monitorace funkce inervace hrtanu a současné vizualizace zvratných nervů. Metody: Design studie je prospektivní observační. Ze souboru 100 po sobě jdoucích operací byly chirurgy náhodně vytvořeny dvě skupiny: Skupina A - s použitím neuromonitoringu (IONM) a skupina B - identifikace a vizualizace zvratného nervu (NLR) bez IONM. Jeden tým chirurgů byl složen z experta (více než 1000 provedených operací) a začínajícího chirurga (méně než 100 operací) a druhý ze dvou zkušených chirurgů (jeden více než 150 operací a druhý více než 500 operací). Každý tým byl zapojen do operací několikrát v týdnu. Porovnání bylo provedeno statistickými metodami a pomocí indexu poranění zvratného nervu (recurrent nerve injury - IRI). Cílem studie je porovnat incidenci parézy zvratných nervů při využití neuromonitorace (IONM) a využití peroperační vizualizace anatomicky neporaněného nervu dvěma týmy chirurgů. Výsledky: Bylo analyzováno 100 operací, respektive 50 operací ve skupině A a 50 ve skupině B. Skupina A zahrnovala 43 totálních thyreoidektomií a 7 hemithyreoidektomií a byly zjištěny dvě dočasné jednostranné parézy. Skupina A měla IRI=1,075. Skupina B zahrnovala 48 totálních thyreoidektomií a 2 hemithyreoidektomie. V této skupině byly zjištěna také dvě jednostranné dočasné parézy zvratného nervu. Skupina B měla IRI=1,02. Uvedené hodnoty IRI tak charakterizují asymetrické soubory, i tato drobná asymetrie je ve výsledku hodnoty patrna. Celková incidence poranění zvratných nervů v celém souboru operovaných sledovaného roku, ve kterém byl výběr pacientů dle metodiky této práce, byla 1,3 %. V souboru bylo 16 dočasných a 4 permanentní parézy zvratného nervu ve všech případech na jedné straně. Ve sledovaném období nebyla zjištěna ani jediná oboustranná paréza trvalá ani dočasná. Index IRI pro operace štítné žlázy v uvedeném období byl 2,26. Tento soubor byl srovnáván se soubory skupiny A a skupiny B a výsledky nevykazují statisticky významné rozdíly na hladině významnosti 1 % (p=0,01). Závěr: Studie neprokázala statisticky významné rozdíly incidence poranění zvratného nervu (trvalá jednostranná paréza) v závislosti na chirurgické technice bez využití IONM a s využitím IONM prováděných chirurgem s rozdílnou zkušeností v chirurgii štítné žlázy. Studie prokázala, že IONM může pomoci vyrovnat handicap u začínajících a méně zkušených chirurgů a omezit incidenci morbidity zvratného nervu v chirurgii štítné žlázy.

Morbidity and mortality associated with thyroid surgery - retrospective analysis 19912010.

INTRODUCTION: The incidence of thyroid disorders has been rising worldwide. Unlike the incidence, mortality associated with malignant thyroid cancer shows only a modest increase. Between 1979 and 2009, mortality in Czech women increased from 1.21 to 1.31 and in Czech men from 0.54 to 0.74 cases per 100,000 individuals.  Methods: A retrospective statistical analysis was performed in patients undergoing thyroid surgery at the Department of Otorhinolaryngology and Head and Neck Surgery of the 1st Faculty of Medicine, Charles University and University Hospital Motol, and at the Department of Otorhinolaryngology of the Institute for Postgraduate Medical Education in Prague from 1991 to 2010 (twenty years). In this period, 11,005 procedures were done for thyroid disease. The study analysed the incidence, morbidity, mortality, surgical complications and lethality. RESULTS: The study group included surgeries in 1588 male and 9417 female patients. The male/female ratio was 1:5.93. Benign thyroid tumours - mean patient age is 54.7 years; recurrent nerve morbidity is 1.37% (calculated from exposed nerves). Hypocalcaemia incidence is low, 5.4% of permanent hypocalcaemia or hypoparathyroidism, respectively, based on decreased serum parathyroid hormone (PTH) levels. Temporary hypocalcaemia is much more frequent, occurring in almost 15% cases depending on age, season of the year, and nutritional status. Hypoparathyroidism was demonstrated based on laboratory serum PTH levels only in 0.3% patients. In total, 442 patients were operated for the mechanic syndrome (a large goitre). The mean thyroid volume was 493 ml±136 ml; however, the maximum volume was 980 ml and weight 1115 g. The incidence of recurrent nerve injury occurs in 4.5%, i.e. the morbidity is 2 times higher compared to surgeries for other diagnoses. The incidence of hypoparathyroidism is not higher compared to other surgeries. Revision surgeries were indicated more commonly in malignant thyroid diseases, particularly in papillary and follicular carcinomas. Cervical lymph nodes procedures comprise another large segment in tumour treatment. Our analysis supports selective neck dissections while preserving non-lymphatic structures. As a rule, mortality associated with thyroid surgery is divided as mortality in the perioperative period (within 24 hours after the procedure) and early postoperative mortality (within 120 hours after the procedure). Surgery-related mortality was never classified as perioperative or within 24 hours after the procedure. Despite that, we believe that perioperative mortality within 120 hours after the procedure, which occurred in 7 cases, is very important. Mortality of the group was 0.007%. CONCLUSIONS: Each surgery procedure is associated with complications, morbidity and mortality. Experience of endocrine surgeons of all disciplines leads to a very low incidence of recurrent nerve and parathyroid gland injuries while at the same time achieving sufficient radicality. This, in cooperation with other medical fields such as endocrinologists, nuclear medicine specialists and oncologists, supports a safe and effective management of all thyroid disorders, including a good prognosis of patients with most types of cancer. Key word: thyroid surgery - complications recurrent nerve - hypoparathyroidism lethality.

Volume, outcomes, and quality standards in thyroid surgery: an evidence-based analysis-European Society of Endocrine Surgeons (ESES) positional statement.

INTRODUCTION: Continuous efforts in surgical speciality aim to improve outcome. Therefore, correlation of volume and outcome, developing subspecialization, and identification of reliable parameters to identify and measure quality in surgery gain increasing attention in the surgical community as well as in public health care systems, and by health care providers. The need to investigate these correlations in the area of endocrine surgery was identified by ESES, and thyroid surgery was chosen for this analysis of the prevalent literature with regard to outcome and volume. MATERIALS AND METHODS: A literature search that is detailed below about correlation between volume and outcome in thyroid surgery was performed and assessed from an evidence-based perspective. Following presentation and live data discussion, a revised final positional statement was presented and consented by the ESES assembly. RESULTS: There is a lack of prospective randomized controlled studies for all items representing quality parameters of thyroid surgery using uniform definitions. Therefore, evidence levels are low and recommendation grades are based mainly on expert and peer evaluation of the prevalent data. CONCLUSION: In thyroid surgery a volume and outcome relationship exists with respect to the prevalence of complications. Besides volume, cumulative experience is expected to improve outcomes. In accordance with global data, a case load of < 25 thyroidectomies per surgeon per year appears to identify a low-volume surgeon, while > 50 thyroidectomies per surgeon per year identify a high-volume surgeon. A center with a case load of > 100 thyroidectomies per year is considered high-volume. Thyroid cancer and autoimmune thyroid disease predict an increased risk of surgical morbidity and should be operated by high-volume surgeons. Oncological results of thyroid cancer surgery are significantly better when performed by high-volume surgeons.

[Modern thyroid surgery - the surgeon's endocrine-surgical understanding and his responsibility for the extent of surgery and complication rate]. / Moderne Schilddrüsenchirurgie ­ das endokrin-chirurgische Verständnis des Operateurs und seine Verantwortung für Resektionsausmaß und Komplikationsrate.

High quality thyroid surgery implies a surgeon with an endocrine-surgical understanding aiming at best possible outcome. This includes an appropriate extent of the resection and a low rate of complications. It is important that the surgeon is involved at an early stage being part of the decision process for or against partial or total thyroidectomy. Furthermore, the surgeon should not only be able to perform thyroid and cervical lymph node sonography, but also to be capable to interpret cross-sectional imaging modalities and nuclear medicine imaging procedures. A thorough knowledge of modern principles of radicality is essential.Benign goiters require individualized surgical strategy: solitary nodules can be treated with a tissue-preserving selective nodular resection. However, a multinodular goiter does not necessarily require total thyroidectomy-prevention of a permanent hypoparathyroidism is of paramount importance. For recurrent goiters, removal of the dominant side and therefore, unilateral procedure is favored. Nowadays, there is an increasing tendency to set the indication for thyroid surgery separately for each lobe. Graves' disease requires thyroidectomy, and occasionally, hypertrophic Hashimoto's thyroiditis may also result in surgery.The principles of radical surgical treatment of malignant goiters have changed significantly over the past few years and, so far, strict indication for postoperative radioiodine treatment is being reconsidered. This is especially relevant for papillary thyroid microcarcinomas and minimally invasive follicular tumors. Even the radical surgical treatment of medullary thyroid carcinoma, especially considering synchronous or metachronous lateral neck dissection, is currently under review.Hypoparathyroidism is the most relevant complication in radical thyroid surgery and has devastating influence on the patients' life quality. Nowadays, permanent recurrent laryngeal nerve injury and postoperative hemorrhage rarely occur due to subtle surgical techniques. Extracervical surgical access to the thyroid is still a matter of clinical trials and should be restricted to centers. Radiofrequency ablation is an alternative method for benign lesions or hyperfunctioning nodules in patients with high surgical risk.

TOTAL THYROIDECTOMY FOR MALIGNANCY - IS CENTRAL NECK DISSECTION A RISK FACTOR FOR RECURRENT NERVE INJURY AND POSTOPERATIVE HYPOCALCEMIA? A TERTIARY CENTER EXPERIENCE IN ROMANIA.

INTRODUCTION: Surgery for thyroid cancer carries a higher risk of morbidity given the region's complicated anatomy, the setting of malignancy and extent of the surgery. AIM: To investigate the rate of complications related to the recurrent nerve and parathyroid glands lesions in patients with thyroid carcinoma that undergo thyroid surgery and lymph node dissection. PATIENTS AND METHODS: The data of 71 patients who underwent total thyroidectomy and 19 patients who underwent total thyroidectomy and central neck dissection with various associated neck dissection techniques were investigated using appropriate statistical tests. RESULTS: As expected, the rate of recurrent nerve injury observed in the neck dissection group was higher than in the total thyroidectomy group (15.7% vs. 2.8%, p=0.05). As for postoperative hypocalcemia, the rate observed in the neck dissection group, both for postoperative day 1 (p<0.0001) and day 30 (p=0.0003) was higher than in the total thyroidectomy group (68.4% vs. 19.7% postoperative day 1, 31.5% vs. 4.2% postoperative day 30). CONCLUSIONS: The risk of morbidity concerning the recurrent nerve injury and postoperative hypoparathyroidism increases with the extent of surgery. Extensive surgery may achieve proper oncologic outcomes but increases the risk of postoperative morbidity and decreases quality of life. In deciding for extensive surgery, both patient and medical team need to understand these risks.

Residual Recurrent Nerve Paralysis After Esophagectomy is Associated with Preoperative Lower Serum Albumin.

Esophagectomy for esophageal cancer is invasive thoracic surgery with a high incidence rate of postoperative complications and prolongation of hospitalization, even if the standardized clinical pathway improves the outcome (mortality and morbidity). Postoperative recurrent nerve paralysis (RNP) is related to respiratory complications concomitant with prolonged hospitalization. However, it has not been elucidated which factors affect the incidence and recovery of RNP. To detect the predictive factor for postoperative RNP, we focused on preoperative serum albumin. Patients who had esophageal cancer with standard esophagectomy were evaluated. In total, 94 patients were divided into three groups depending on the presence of RNP (46 in patients without RNP, 29 in those with transient RNP who recovered within 6 months follow-up and 19 in those with residual RNP). We retrospectively investigated factors associated with residual RNP. Preoperative lower serum albumin was associated with residual RNP. In addition, days to the resumption of oral intake and duration of stay in the hospita postoperatively were delayed in the group of residual RNP. Multiple regression analysis indicated that preoperative serum albumin was a predictive factor for residual RNP. Preoperative lower serum albumin level might be linked to residual RNP which could prolong the resumption of postoperative oral intake and shorten the period of stay at the hospital after esophagectomy, leading to unfavorable outcomes for patients.

Diagnosis and management of unilateral thyroarytenoid muscle palsy.

The objective of this study is to assess and propose a method of diagnosis and management of patients with unilateral thyroarytenoid muscle palsy (TAMP). This is a retrospective review of clinical records. The records of seven patients diagnosed as having idiopathic TAMP were reviewed. Despite the adductive and abductive functions of the vocal folds being within normal range, apparent palsy was seen in the unilateral thyroarytenoid muscle of these patients. TAMP was confirmed by laryngeal electromyography, and the adductive and abductive movements of the vocal folds were evaluated as the mobility of the arytenoid cartilages by three-dimensional computed tomography and endoscopy. Most of patients with TAMP had been diagnosed as having other diseases or normal, and in one patient, it took over 6 years to establish a correct diagnosis. Two patients recovered by conservative treatment; however, in five patients, TAMP remained even after 6 months. In 4 of those 5 patients, treatment with hyaluronic acid injections was performed. In the remaining patient, surgical treatment, namely, nerve-muscle pedicle flap implantation was performed, which resulted in a favorable recovery of phonation. The average maximum phonation time (MPT) of all patients was extended from 11.4 (±4.4) s before treatment to 19.9 (±4.3) s after treatment, and the pitch range was also increased from 25.1 (±7.2) to 34.6 (±5.8) semitones following our management course. Our results indicate that there is a possibility that TAMP can be diagnosed and treated sufficiently. Therefore, further research toward establishing the concept of and treatment for TAMP is anticipated.

Report of a rare case: Double recurrent laryngeal nerve.

One of the most important and feared complications of thyroid and parathyroid surgery is injury to the recurrent laryngeal nerve. The main reason for this type of injury is anatomical variations. Currently, nerve monitoring is being widely used to reduce complications due to the high variation rate. However, it is not being used extensively in our country, due to cost related issues. In this case, we present a left sided double recurrent laryngeal nerve.

Non-recurrent nerve from the vagus anterio-medially located in the carotid sheath.

Non-recurrent inferior laryngeal nerve (ILN) arising from the vagus nerve is a rare anatomic variation. The vagus descends vertically in the cervical neurovascular bundle, between and posterior to common carotid artery (CCA) and internal jugular vein (IJV). The vagus has also some anatomic variations. We present a case of two coincident anatomic variations both ILN and the vagus nerve. A patient with multinodular goiter was surgically treated with total thyroidectomy. Both two ILNs were identified, fully exposed and preserved along their cervical courses. We found that the right non-recurrent ILN directly arises from cervical vagal trunk, and enters the larynx at usual point after a short transverse course parallel to the inferior thyroid artery. The vagus nerve, easily exposed after dissection of the right lobe of the thyroid gland, is located medially to the CCA. We discovered the association of non-recurrent ILN and medially located vagus nerve in the same patient. Non-recurrent nerve and medially located vagus nerve in the cervical neurovascular bundle are two different variations. The coincidence of right non-recurrent ILN arising from cervical part of the vagus medial to the CCA in the same patient is a very interesting feature. The safety of thyroid operations is dependent on proper identification, dissection and full exposition of ILN. The safe procedure requires complete knowledge on the anatomy of neural structures including all their anatomic variations.

Case report: Successive ipsilateral and contralateral laryngeal nerve palsy as probable manifestation of neuroborreliosis.

Neuroborreliosis is part of advanced stage of Lyme disease and often characterized by damage to the cranial and/or peripheral nerves. Involvement of one or both recurrent nerves is rare. Diagnosis is often difficult and based on a set of clinical manifestations, biological arguments, and cerebrospinal fluid (CSF) analysis. A 70-year-old man was referred to our Voice Clinic with a 3-month history of dysphonia caused by right vocal fold paralysis (VFP) without any cutaneous symptoms of tick bite or erythema migrans in the previous weeks and normal initial radiological examination (neck and thorax CT). Methylprednisolone had already been prescribed but without any clinical improvement. Late biological investigation 3 months after initial symptoms of VFP showed high IgG (93 U/mL; reference <10 U/mL) against Borrelia burgdorferi (BB), which was confirmed by two immunoblot markers (VIsE, p39 antigens). Therefore, a possible manifestation of Lyme disease with involvement of the right inferior laryngeal nerve was suspected, namely Lyme neuroborreliosis. However, given the spontaneous recovery of the patient after 7 months without any adapted antimicrobial regimen treatment, the diagnosis of neuroborreliosis was not confirmed by a lumbar puncture. Nineteen months later, the patient presented again for the same symptomatology but as left VFP. High IgG (68 U/mL) and IgM (>6, reference <0.90) levels against BB were confirmed by immunoblot. Subsequently, lumbar puncture was performed and revealed IgG against BB at 46.1 UA/mL (reference<5.5 UA/mL) in the CSF, with an extremely high IgG intrathecal synthesis antibody index (281.33, positive if > 1.5). Intrathecal antibody synthesis is the gold standard for Lyme neuroborreliosis demonstrating a specific immune response to BB in the central nervous system, but with the limitation of persistence for years after eradication. Our patient did not exhibit pleocytosis in the CSF. Therefore, two criteria of the European Federation of Neurological Societies (EFNS) guidelines are fulfilled for possible neuroborreliosis. Doxycycline treatment led to rapid recovery in less than 8 weeks and normal mobility of the left vocal fold. Because of this very uncommon clinical presentation with two successive episodes of VFP for no other obvious reason and serological evidence from the serum and CSF during the second episode, we consider it possible that the first episode of VFP could also have been a manifestation of neuroborreliosis. This case is the first report of possible relapse of laryngeal palsy successively on the right, and then the left side as a manifestation of Lyme neuroborreliosis.

A Case of Unilateral Recurrent Nerve Palsy with Chronic Inflammatory Demyelinating Polyradiculoneuropathy.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disease in which peripheral sensory and motor nerves of the four limbs are impaired due to autoimmune mechanism-induced demyelinating changes through a 2-month or longer chronic course. The incidence of complication by cranial neuropathy has been reported to be 15%, but there have been very few reports on disorder of the vagus nerve and its branch, the recurrent nerve. We report a patient who developed left recurrent nerve palsy with CIDP. The patient was a 48-year-old male. The disease developed as progressive muscle weakness and numbness of the four limbs 3 years before and was diagnosed as CIDP. The symptoms had been improved by high-dose intravenous gamma-globulin therapy. However, from 2 months before he became aware of breathy hoarseness, and bilateral decreased grip strength and sensory disturbance of the upper and lower limbs recurred and progressed. On laryngoscopy disorder of left vocal fold movement and glottal closure incompetence during phonation were observed, and neurogenic changes were detected in the left thyroarytenoid muscle by needle electromyography for the intrinsic laryngeal muscles. High-dose intravenous gamma-globulin therapy was performed and left vocal fold movement recovered with recovery of bilateral grip strength and sensory disturbance of the upper and lower limbs, and phonation was also normalized.

Preoperative ultrasound mapping of the vagus nerve in thyroid surgery.

BACKGROUND: Intraoperative neuromonitoring (IONM) in thyroid surgery requires electric stimulation of the vagus nerve to verify correct electrode placement. Classically the nerve is found deep to or in-between the common carotid artery and internal jugular vein, but previous studies have shown that the nerve can sometimes be found superficial to the vessels. Our aim was to determine the incidence of a superficial vagus nerve using ultrasound (US) and study possible clinical factors associated with an anteriorly-located vagus nerve. METHODS: Retrospective study of patients undergoing thyroid surgery (lobectomy or total thyroidectomy) with intermittent IONM. Substernal goiters, locally invasive tumors or bulky lymph nodes were excluded. The vagus nerve was identified at the level of the mid-thyroid lobe on each side on preoperative US performed by two specialized radiologists, and its location according to 6 possible positions in relationship to the common carotid artery was recorded. The anatomic variability of the vagus nerve was analyzed in relationship to patient demographics and thyroid pathology. RESULTS: Five-hundred twenty-seven patients were included. The right vagus nerve (n=522) was in-between, superficial or deep to the vessels in 92.3%, 6.1% and 1.5% and of cases, respectively, and the left vagus (n=517) in 80.2%, 18.6% and 1.2% of cases, respectively, with a statistically significant difference between right and left vagus nerves (P<0.001). The type of pathology, size of the dominant nodule or the volume of the thyroid lobe were not correlated to finding a superficial vagus nerve. CONCLUSIONS: The vagus nerve was identified in all cases on US and found to be anterior to common carotid artery at the level of the thyroid lobe in 18.6% of cases on the left and 6.1% of cases on the right. Identifying this anatomic variant preoperatively may facilitate IONM and avoid inadvertent trauma to the vagus nerve during thyroid surgery.

Pathological Analysis of Encased Resected Recurrent Nerves in Locally Invasive Thyroid Cancer.

OBJECTIVE: Thyroid cancer encasing the recurrent nerve is rare, and the decision to resect or preserve the nerve is multifactorial. The objective of this study was to histopathologically analyze resected encased nerves to assess the rate of nerve invasion and risk factors. MATERIALS AND METHODS: A retrospective study was carried out on consecutive patients with resection of the recurrent nerve for primary or recurrent follicular cell-derived or medullary thyroid carcinoma from 2005 to 2020. Demographics, pathology, locoregional invasion, metastases, recurrences and survival were analyzed. Slides were reviewed blindly by two specialized pathologists (AAG, RC) for diagnosis of invasion deep to the epineurium. RESULTS: Fifty-two patients were included: 25 females; average age, 55 (range 8-87). In total, 87% percent (45/52) were follicular cell-derived with 17/45 (37.8%) aggressive variants; 13% (7/52) were medullary carcinoma. Preoperative vocal fold (VF) paralysis was present in 16/52 (30.7%). Pathologically, the nerve was invaded in 44/52 cases (85%): 82% of follicular cell-derived tumors (37/45), 88% of pediatric cases, and 100% of medullary carcinomas (7/7). Nerve invasion was observed in 11/16 (69%) with preoperative VF paralysis and 33/36 (92%) with normal VF function. Only aggressive histology was correlated with nerve invasion in follicular cell-derived tumors (p = 0.019). CONCLUSIONS: The encased nerves were pathologically invaded in 82% of follicular cell-derived tumors and in 100% of medullary carcinomas. Nerve invasion was statistically correlated with aggressive histopathological subtypes and was observed in the absence of VF paralysis in 92% of cases.

Ortner's Syndrome in an Infant With Congenital Heart Disease.

Cardio-vocal or Ortner's syndrome is dysphonia or hoarseness resulting from left recurrent laryngeal nerve palsy caused by a mechanical effect on the nerve due to enlarged cardiovascular or mediastinal structures. It was first described in adults with left atrial enlargement due to mitral stenosis. To date, there are a paucity of reports regarding its occurrence in infants and children. We report hoarseness and left vocal cord paresis in an infant with a large left-to-right shunt associated with a patent ductus arteriosus. The history of Ortner's syndrome is presented, its pathogenesis described, and previous reports of its occurrence in infants and children reviewed.

Extralaryngeal causes of unilateral vocal cord paralysis: Aetiology and prognosis.

INTRODUCTION AND METHODOLOGY: Unilateral vocal cord paralysis without laryngeal lesions is a relatively frequent entity. It can be the manifestation of numerous diseases of the thorax, neck, skull, or systemic disease. The objective is to study the extralaryngeal aetiology of unilateral vocal cord paralysis, its prognosis, and the relationship of both with different clinical variables. Retrospective study of 116 patients with complete unilateral vocal cord paralysis without laryngeal lesions. The patients underwent cervical-thoracic CT ±â€¯evaluation by Neurology with brain MRI to establish the aetiology and were followed-up for at least 1 year. RESULTS: The most common extralaryngeal cause of vocal cord paralysis was cervical surgery (46.5%), followed by tumour (24.1%). Idiopathic paralysis was the cause in 15.5%. An association was obtained between sex and aetiology (P < .01), men in relation to malignant pathology and women to iatrogenic disease. Cardiovascular, cerebrovascular, tumour and idiopathic aetiology predominated in elderly patients; while surgical aetiology predominated in younger patients (P < .01). A total of 18.1% recovered vocal cord mobility. The female sex was related to recovery (P < .01). Tobacco and malignant aetiology were related to persistence (P < .01). CONCLUSIONS: The first extralaryngeal cause of unilateral CV paralysis is surgical followed by lung and thyroid neoplasms. There is a great diversity of lesions that can cause the condition, in many cases involving a diagnosis of malignant tumours. Recovery is more frequent in female patients, non-smokers and with benign pathology.

SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Surgical treatment.

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French-speaking Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the surgical management of thyroid nodules.