Non-cancerous thyroid lesions: immunologic and surgical evaluation

The present study was designed to determine T helper-l/T helper-2 [Th[1]/Th[2]] pattern in patients with Graves' disease [GD], benign multinodular goiter [MNG] and Hashimoto thyroiditis [HT] and evaluate the applicability of near-total thyroidectomy as a therapeutic strategy for surgical interference. The study included 75 patients [56 females and 19 males; with mean age of 43.8 +/- 8.2 years] with thyroid swelling and 15 healthy volunteers [control group]. Patients underwent clinical examination including direct laryngoscopy using fiberoptic endoscopy, laboratory investigations and ultrasonographic and [99m] Tc pertechnetate scintigraphy for establishment of diagnosis. Patients with HT received medical treatment and were followed-up, while patients with GD and MNG underwent near-total thyroidectomy. Preoperative blood samples were collected from patients and control subjects for ELISA estimation of serum levels of interleukin-2 [IL-2], IL-18, IL-4 and IL-5. Patients were observed for appearance of postoperative manifestations of recurrent laryngeal nerve [RLN] palsy and/or hypoparathyroidism. Mean operative time, duration of wound drainage and hospital stay were recorded. The study included 43 patients with GD [8 of them had thyroid orbitopathy], 17 patients had MNG and the remaining 15 patients had HT. All patients had smooth intraoperative course and no patient had permanent RLN palsy, but 4 [6.7%] patients had transient unilateral RLN palsies that recovered spontaneously after a mean duration of 24.5 +/- 11.6 days. Temporary hypocalcaemia occurred in 9 patients [15%] and permanent hypoparathyroidism resulted in one [1.7%]. All patients developed wound edema, 7 patients had wound seroma and 2 patients had wound infection. Mean serum levels of lL-2, IL-4 and IL-5 were significantly higher in patients compared to control levels irrespective of the type of thyroid lesion. Mean serum levels of IL-18 were significantly higher in patients with HT and MNG disease and non-significantly higher in patients with GD compared to control levels. Moreover, mean serum levels of IL-2 and IL-18 were significantly higher and mean serum levels of IL-4 and IL-5 were significantly lower in patients with HT and MNG disease compared to those with GD and in MNG patients compared to those with HT. The percentage of postoperative increase of serum IL-2 and IL-18 levels relative to the median control level were significantly higher in patients with HT than in patients with GD or MNG with a significantly higher percentage of increase in patients with MNG compared to those with GD. On the other hand, the percentages of increase of IL-4 and IL-5 were significantly higher in patients with GD compared to patients with HT or MNG with a significantly but non-significantly higher percentage of increase of IL-5 and IL-4, respectively, in patients with MNG compared to those with HT. It could be concluded that there was a disturbed pattern of Th[1]/Th[2] cytokines in patients with non-cancerous thyroid lesion in favor of humoral pattern of immune response in GD with predominance of Th[2] cytokines and a Th[1]-pattern of immune response characteristic of cellular immunity is dominant in HT. Also, near total thyroidectomy was found appropriate therapeutic modality with transient minimal complications for patients with MNG or GD

Furlow's double Z-plasty is a convenient procedure for cleft palate repair

The present study aimed to evaluate and compare the surgical outcome of Von Langenbeck and Furlow's procedures for repair of primary cleft palate. The study included 22 children with mean age of 16.5 +/- 3.1 months allocated into 2 equal groups: Group A underwent Von Langenbeck procedure and Group B underwent Furlow's procedure. Von Langenbeck palatoplasty involved elevation of large mucoperiosteal flaps from the hard palate and side-to-side approximation of the cleft margins of both soft and hard palates with detachment of the levator muscles from their bony insertions and the use of long relaxing lateral incisions without lengthening maneuver. Furlow's procedure involved Z-plasty incision with the cleft is the central limb, lateral limbs end over the hamuli, transposition of the posteriorly based nasal Z-plasty flap brings the palatal muscle posteriorly and across the cleft, insetting the anteriorly based Z-plasty flap closes the front of the soft and hard palates. Then, oral Z-plasty flaps were transposed to overlap the palatal muscles creating a palatal muscle sling. The cleft width, length increase in the soft palate, length of Z-plasty, the frequency of the need for hamulus fracture, duration of surgery and intraoperative blood loss were recorded. The postoperative distance between last molar tooth and the uvula was determined and compared versus preoperative one. Both procedures provided a significant increase of the length of distance between last molar and uvula, with a significant increase of length in group B compared to group A. All patients in group A required relaxing incision irrespective of the preoperative cleft width; while only 2 of patients in group B [18.2%] required relaxing incision with a significant difference in favor of group B. Mean length of Z-plasty incision required in group B was 1.5 +/- 0.17; range: 1.1-1.7 cm. Mean operative time was significantly shorter in group A [76.8 +/- 10.6 min] compared to group B [91.8 +/- 13.1 min] and Furlow's procedure was associated with significantly more blood loss compared to Von Langenbeck procedure. One patient [9.1%] in group B had small fistula, but no patient had wound dehiscence; while in group A, one patient had wound dehiscence and another had oronasal fistula with a postoperative complication rate of 18.2%. It could be concluded that Furlow's palatoplasty improves the outcome of cleft palate repair irrespective of the width of the cleft with acceptable complication rate and significant lengthening of the uvula