Unilateral versus bilateral neck exploration in parathyroid surgery: an assessment of 55 cases.

We retrospectively evaluated the cases of 55 patients who had undergone surgery for primary hyperparathyroidism at our institution to determine whether their parathyroid glands were abnormal on both sides. Thirty-six of these patients had undergone a bilateral neck exploration, and 19 had had a unilateral investigation. Of the 36 bilaterally explored patients, 30 had a solitary adenoma and no parathyroid pathology on the opposite side, five patients had hyperplastic glands with more than one gland involved, and one patient had two adenomas. In the unilaterally explored group, all 19 patients had a solitary adenoma. There were no failures in the way of persistent hypercalcemia in either group. Based on our findings, we conclude that a unilateral neck exploration should be performed during surgery for primary hyperparathyroidism whenever a large parathyroid adenoma and a normal parathyroid gland are found on the same side. Bilateral exploration should be reserved for patients in whom pathology cannot be found on the initially explored side during surgery and for patients who have obvious parathyroid hyperplasia.

Intraoperative gamma probe localization of parathyroid adenomas.

OBJECTIVES/HYPOTHESIS: In an effort to reduce operative time, improve diagnostic accuracy, and decrease perioperative morbidity, we combined preoperative technetium Tc 99m-sestamibi localization with the use of the gamma probe intraoperatively. This report examines our experience with the gamma probe for rapid intraoperative localization of parathyroid adenomas. STUDY DESIGN: A retrospective chart review was performed to identify all patients who underwent parathyroid exploration with the aid of the gamma probe at Lenox Hill Hospital (New York, NY). METHODS: Charts were reviewed for operative details, radiological findings, and pathological diagnoses. RESULTS: Between November 1, 1998, and June 30, 2000, 35 parathyroid explorations were performed with the aid of the gamma probe. The preoperative localization study was accurate in 34 of 35 cases. The gamma probe successfully identified the parathyroid adenoma in 33 of 35 cases. There were two false-positive cases in which the gamma probe mistakenly identified a thyroid adenoma rather than a parathyroid adenoma. In 11 of 35 cases, the gamma probe was judged essential for rapid localization of the parathyroid adenoma. These cases included patients with multiple or ectopic adenomas and patients who had previous parathyroid surgery. Average operative time to remove parathyroid disease was 80 minutes (range, 45-140 min), which included 20 to 40 minutes waiting for frozen-section results. All patients became normocalcemic, and there were no major complications in this series. CONCLUSION: The gamma probe is a useful tool that complements a well-performed localization study. It is most useful in patients who have multiple or ectopic adenomas or have had prior parathyroid surgery.

Transsphenoidal surgery utilizing computer-assisted stereotactic guidance.

Computer-assisted guidance technology represents the next step in the application of stereotactic techniques to skull base surgery. Use of this 3-D technique reduces operative time and complications as the technique allows a more direct approach with precise real-time anatomical guidance. We present seven cases of transsphenoidal parasellar surgery where this technique has been employed. The pathology included lesions of the sella turcica, parasellar region and the petrous apex.

Reduced-time-window sestamibi scanning for nonlocalized primary hyperparathyroidism.

BACKGROUND: Technetium Tc 99m sestamibi scan is the standard of care for localizing parathyroid adenomas. METHODS AND MATERIAL: We performed a retrospective, single-institution study of 111 consecutive patients with primary hyperparathyroidism who underwent standard sestamibi scan for localization of a parathyroid lesion. A revised protocol of reduced-time-window sestamibi scan was used in nonlocalized patients. The protocol was composed of single-view scans at 15, 30, 45, and 120 minutes and tomograms at 60 minutes. RESULTS: Thirty-five patients underwent surgery at our institution. Thirty-one had adenomas, and 4 had hyperplasia. Three of 31 patients did not show localization on the standard scan and underwent reduced-time-window scans, which localized 2 more adenomas. These were confirmed at the time of surgery. CONCLUSION: We suggest that all patients with a high degree of suspicion for a parathyroid adenoma, which is not visualized by a standard scan, undergo a reduced-time-window scan.

Follicular variant of papillary carcinoma: the diagnostic limitations of preoperative fine-needle aspiration and intraoperative frozen section evaluation.

OBJECTIVE: Fine-needle aspiration (FNA) and frozen section (FS) have been widely reported in the literature as having high sensitivity in the diagnosis of papillary carcinoma. With the increased recognition of the follicular variant of papillary thyroid carcinoma (FVPTC), several reports have pointed out the difficulty in diagnosing this variant of papillary carcinoma owing to its overlapping cytomorphological features with benign and malignant follicular lesions. We undertook this study to determine the sensitivity of FNA and FS in the diagnosis of FVPTC. METHODS: Retrospective review of patients who underwent thyroidectomy from June 1994 to June 1999. Of the 63 patients found with a final pathological diagnosis of papillary thyroid carcinoma, only 47 had an adequate FNA and FS and were included in the study. These patients were divided into two groups, the usual type (n = 23) and the follicular variant (n = 24) of papillary carcinoma. Sensitivities of FNA and FS for these two groups of papillary carcinoma were then determined. RESULTS: The sensitivity of the FNA was 25% and of the FS was 29% for the follicular variant of papillary thyroid carcinoma. This is in contrast to the sensitivity of FNA and FS for the usual papillary carcinoma, which were 74% and 87%, respectively. CONCLUSION: FNA and FS have low sensitivity in the diagnosis of the FVPTC. High degree of suspicion may increase the accuracy in the diagnosis of this variant of papillary carcinoma before or during surgery. However, the thyroid surgeon needs to realize that, like follicular carcinoma, FVPTC is often diagnosed only on final pathological examination.

Need for tracheotomy is rare in patients with acute supraglottitis: findings of a retrospective study.

We retrospectively reviewed the cases of 23 adults and six children who had been given a presumed diagnosis of acute supraglottitis between 1987 and 1997. The most common symptoms in these patients were odynophagia, dysphagia, hoarseness, and fever. Stridor and drooling were also observed, primarily in the children. Fiberoptic laryngoscopy confirmed the presence of edema and erythema of the supraglottic structures in all patients. Blood cultures were positive for Hemophilus influenzae type b in three children and for Serratia marcescens in one adult. All other blood cultures were negative. All patients were treated with intravenous broad-spectrum antibiotics and humidified oxygen, and two-thirds received intravenous corticosteroids. Patients were monitored with pulse oximetry and serial fiberoptic laryngoscopy. Two patients required intubation; one had an epiglottic abscess, and the other had laryngeal edema so severe that vocal fold mobility could not be assessed. The length of stay in the intensive care unit ranged from 1 to 7 days (mean: 1.9). All patients recovered and were discharged free of symptoms after 2 to 11 days of overall hospitalization (mean: 4.4).

Surgical management of thyroid masses: assessing the need for frozen section evaluation.

OBJECTIVE/HYPOTHESIS: To determine the need for intraoperative frozen section to guide the extent of thyroid surgery in the presence of an adequate preoperative fine-needle aspiration (FNA) finding. METHODS: Charts of patients who presented from 1995 to 1998 to the two senior authors were reviewed. A total of 82 patients were found who satisfied the inclusion criteria of having both an adequate FNA and frozen section. The extent of surgery was based on the frozen section finding for all the patients in this study. The authors looked at the number of cases in which the surgical management would be changed if the frozen section was not obtained and the surgical decision was based only on preoperative FNA and intraoperative findings. RESULTS: FNA revealed papillary carcinoma in 18 patients that was confirmed by intraoperative frozen section and final pathology. In the remaining 64 patients, the FNA diagnosis was either benign or suspicious. When routine frozen section was done, 61 of these 64 patients were found to have either benign pathology or pathological diagnosis that was deferred to permanent section. Only three patients were found to have malignancy on frozen section that was missed by FNA. Of these three patients, two had obvious findings of malignancy at the time of surgery. This leaves only one patient with carcinoma that was missed by FNA and intraoperative findings but detected by the intraoperative frozen section. CONCLUSION: Of the 82 patients in this study, only one extra case of malignancy would be missed by elimination of the routine use of intraoperative frozen section. The authors conclude that the routine use of intraoperative frozen section may be unnecessary. The use of an adequate preoperative FNA together with sound clinical judgment at time of surgery can adequately guide the extent of surgical resection.

Long-term follow-up after subtotal parathyroidectomy in patients with renal failure.

OBJECTIVES/HYPOTHESIS: The most appropriate type of surgery for hyperparathyroidism secondary to renal failure remains controversial. We report a 5-year experience of patients with hyperparathyroidism secondary to end-stage renal disease who underwent subtotal parathyroidectomy. We believe that this is the procedure of choice, offering several advantages over total parathyroidectomy with and without reimplantation. STUDY DESIGN: Retrospective review. METHODS: Review of 14 consecutive renal failure patients who underwent subtotal parathyroidectomy by one surgeon (A.K.) was performed. Follow-up ranged from 4 to 54 months. All patients were receiving chronic maintenance dialysis. All patients came to surgery with clinical symptoms of parathyroid bone disease, elevated serum calcium levels (10.1-12.4 mg/dL), and intact parathyroid hormone levels (619-4160 pg/mL), despite maximal medical therapy. At exploration four glands were identified in all patients and three and a half were removed. RESULTS: All patients experienced symptomatic relief postoperatively with normalization or near-normalization of serum calcium concentration and intact parathyroid hormone concentrations. One patient developed recurrent disease 4 months after surgery, and on re-exploration a supernumerary substernal gland was identified. A second patient developed recurrent symptoms 4 years after surgery and at the time of this writing was awaiting re-exploration. CONCLUSIONS: All patients had either resolution of or marked improvement in their subjective complaints. There have been no cases of permanent hypoparathyroidism. We believe that subtotal parathyroidectomy is the best procedure for patients with refractory symptoms of secondary hyperparathyroidism.

Diagnostic value of the preoperative sestamibi scan in intraoperative localization of parathyroid adenomas: a case study.

A retrospective chart review of 43 patients who underwent technetium 99m (Tc-99m) sestamibi scans from June 1995 to January 1997 was performed. Only those who underwent subsequent parathyroid exploration with excision were included in the study. Twenty subjects (13 women and seven men) were included in the study. Ages ranged from 21 to 84 years (mean, 58 years). All patients had laboratory values and clinical findings consistent with primary hyperparathyroidism. Two patients had preoperative magnetic resonance imaging (MRI) scans (one patient with recurrent disease), and one had a preoperative computed tomography (CT) scan. The remaining patients had the sestamibi scan as the only preoperative localization study. There were 18 pathologic diagnoses of parathyroid adenoma and two of parathyroid hyperplasia. Sestamibi failed to correctly identify the location of the parathyroid lesion in two cases. In 18 cases the preoperative sestamibi scan correctly localized the lesion, a predictive value of 90%. We conclude that the Tc-99m sestamibi scan is an accurate preoperative tool that can be used as a single modality to localize parathyroid adenomas.

The management of post-thyroidectomy hypocalcemia.

Postoperative hypocalcemia was studied in 40 patients undergoing total thyroidectomy for a malignancy or massive goiter. Parameters evaluated included serum calcium, phosphate and magnesium levels. All patients exhibited a postoperative decline in serum calcium, however, the lowest serum calcium level was not seen until 48 hours after surgery. Serum calcium levels returned to normal in five to six days after surgery in 37 patients. Five patients required calcium supplementation for either symptomatic hypocalcemia or serum calcium levels lower than 7.0 mg/dl. Only three of these five patients were discharged home on oral calcium supplements. In this series, we discovered that the critical period for monitoring of serum calcium was 24 to 96 hours after surgery. If serum calcium replacement was not needed in the first 72 hours after surgery, it would not be needed during the remainder of the patient's hospital course. In addition, we found that serum magnesium levels should also be monitored in the postoperative period and corrected if low.

Voice failure after tracheoesophageal puncture: management with botulinum toxin.

Primary or secondary tracheoesophageal puncture with a speaking prosthesis has provided rehabilitation of speech in most patients after total laryngectomy. Persistent constrictor spasm is thought to be responsible for a small percentage of these patients' inability to speak with the prosthesis. Management of these patients has included bougienage and pharyngeal myotomy and/or pharyngeal neurectomy. Botulinum toxin injections of the cricopharyngeus muscle complex in six patients have been successfully used diagnostically and therapeutically for tracheoesophageal puncture failures. The assessment, technique, and results are discussed.

Tongue paralysis following head trauma.

Paralysis of the tongue due to isolated bilateral hypoglossal nerve palsy is a rare occurrence. Due to a trauma the cause in our case may have been a traction injury to both hypoglossal nerves at the base of skull. In some cases a contributing factor may be malformation of the skull base. Most cases have a good prognosis for recovery.

Mandible preservation in cancer of the floor of the mouth. Anatomical and oncological considerations.

An extended marginal mandibulectomy can be performed in most T2-T3 carcinomas of the floor of the mouth that abut the anterior mandible if there is no radiologic evidence of bony invasion or clinical evidence of fixation. We propose a modification of the marginal mandibulectomy that maintains viability to the anterior mandibular remnant and thus decreases the morbidity associated with a loss of blood supply. This modification permits preservation of a viable mandibular remnant with significantly less loss of function than with the traditional segmental mandibular resection, while remaining oncologically sound.

Computer-generated presentations: current status and future directions.

The personal computer allows the user to create professional presentations as good as any created by commercially available services. With the new generation of inexpensive software, myriad fonts, layouts, graphics, and imported images can all be used by the novice. The technology is currently available that can project images directly from the computer, obviating the need for slides. This presentation will discuss the relative merits and costs of such systems and the problems that remain concerning implementation at a national level.

Ambulatory pH monitoring in the management of reflux.

Ambulatory pH monitoring is a useful tool in the diagnosis and treatment of different esophageal and pharyngeal complaints. We have studied its use in an office setting in 15 patients with suspected gastroesophageal reflux disease (GERD). The patients were monitored for at least 18 hours while wearing a two-channel probe at home. Data obtained confirmed severe GERD in 6 patients and chest pain without GERD in 2 patients. Two patients continued to have symptoms in spite of appropriate therapy, while 2 untreated patients had symptoms of GERD with normal pH studies. We feel this technique is relatively safe and cost-effective and causes minimal disruption of the patient's life-style, while enabling the physician to monitor therapy and help achieve a good therapeutic outcome.