24-hour urinary calcium in primary hyperparathyroidism.

OBJECTIVE: To establish whether urinary and serum calcium levels are correlated in patients with primary hyperparathyroidism (PHPT) and to evaluate related factors including serum levels of parathyroid hormone (PTH) and vitamin D, age, gender and renal function. DESIGN: Retrospective review on patients undergoing a parathyroidectomy for PHPT from 2000- 2008. Data collected included: age, sex, preoperative serum calcium (ionized and total), creatinine, PTH, postoperative ionized calcium, vitamin D, and 24-hour urine calcium and creatinine. Data were evaluated by standard descriptive statistics. RESULTS: Of the 214 patients evaluated, preoperative 24-hour urinary calcium was available for 150 patients (70%). 24-hour urine calcium levels did not correlate significantly with preoperative total serum or ionized calcium, PTH, vitamin D, or postoperative serum ionized calcium. There were significant correlations (P<0.0001) of 24-hour urinary calcium with age, serum creatinine, and urine creatinine. Secondary analysis grouped subjects by urinary calcium level greater or less than 400 mg/24 hours. Age and urinary creatinine were significantly different between the two groups. CONCLUSIONS In patients with PHPT who underwent parathyroidectomy, there was little correlation between preoperative 24-hour urine calcium and preoperative serum calcium, PTH, or vitamin D levels. 24-hour urine calcium levels were correlated with renal function and age, but these correlations are likely to occur in the general population and are not specific to this disease group.

Spontaneous hemorrhage of a parathyroid adenoma into the mediastinum.

OBJECTIVE: To describe the case of a previously healthy 56-year-old woman, who presented with acute, nontraumatic pain in the left side of the neck and mild dysphagia. METHODS: We report the results of the physical examination, imaging studies, and clinical laboratory studies. In addition, we describe the patient's hospital course after surgical intervention. RESULTS: A patient who sought medical attention because of acute, nontraumatic neck pain and dysphagia was subsequently found to have acute extracapsular hemorrhage of a parathyroid adenoma. Computed tomography and magnetic resonance imaging studies revealed a mass effect beginning in the neck and extending into the mediastinum. Surgical exploration of the neck and histopathologic evaluation confirmed the diagnosis of spontaneous rupture of a parathyroid adenoma with associated hemorrhage. CONCLUSION: Extracapsular hemorrhage of a parathyroid adenoma is rare and necessitates a high index of clinical suspicion for diagnosis. This diagnosis should be considered in a patient who presents with acute anemia, hypercalcemia, and a neck mass.

Eccrine porocarcinoma of the external ear.

Eccrine porocarcinoma (EP) is believed to arise from the intraepithelial portion of the eccrine sweat glands. The incidence rate of EP is reported to be 18 per 450,000 biopsies. Most of the diagnosed cases involve the lower extremities; a case of EP involving the ear is rare. We describe the clinical, radiologic, and histopathologic features of EP in an 11-year-old boy.

Telemedicine--an efficient and cost-effective approach in parathyroid surgery.

OBJECTIVES/HYPOTHESIS: To demonstrate the effectiveness and cost benefit of using telemedicine for the postoperative visit in patients undergoing parathyroidectomy for primary hyperparathyroidism. STUDY DESIGN: Prospective noncontrolled study at a tertiary medical center of a cohort of 39 patients undergoing postoperative care after parathyroidectomy through TeleHealth at a number of sites at various distances from the primary surgical facility. METHODS: From October 2006 through January 2010, 149 patients underwent parathyroidectomy for primary hyperparathyroidism at one tertiary medical center by a single surgeon. Age, sex, distance from the patient's home to the surgical center and to the TeleHealth site, effective completion of the TeleHealth visit, and postoperative complications were recorded. RESULTS: Of the 149 patients who underwent parathyroidectomy, 39 had their postoperative visit using TeleHealth (26%). There were 26 females (67%) and 13 (33%) males. Mean age was 64 years. All visits were effectively carried out and completed with a nurse and the patient at a remote TeleHealth site and the surgeon at the surgical center site. There were no postoperative surgical complications noted with the visits. Average round-distance travel saved was 119 miles. The travel distance saved translated into an average savings of $357.00 per patient (which included estimations of transportation costs and lost work time), with further immeasurable benefits to the patient and healthcare system. CONCLUSIONS: TeleHealth is a cost-effective and efficient way to follow-up with patients who have undergone parathyroidectomy, with significant convenience and financial benefits for the patient and healthcare system.

Thyroid drains and postoperative drainage.

OBJECTIVE: To evaluate postoperative drainage in patients undergoing thyroid lobectomy versus total thyroidectomy and to establish a correlation between intraoperative blood loss and postoperative drainage. STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary medical center. SUBJECTS AND METHODS: Consecutive patients (n = 100) undergoing thyroid surgery from October 2006 through November 2008 were examined. Data collected included age, gender, postoperative drainage, estimated intraoperative blood loss, type of surgery, length of hospital stay, pathology, and postoperative complications. Standard descriptive statistics were used to summarize characteristics of subjects, surgical procedures, and outcomes. Spearman rank correlation was used to evaluate association of drainage with blood loss and Kruskal-Wallis test to compare results by surgery type. RESULTS: There were 100 surgeries performed: 52 lobectomies and 48 total thyroidectomies. Total postoperative drainage ranged from 0 to 230 mL, median was 32 mL. Estimated intraoperative blood loss ranged from 10 to 300 mL, median was 20 mL. We noted a statistically significant association of postoperative drainage with intraoperative blood loss (r = 0.39, P < 0.001), but substantial variability in drainage was observed even among patients with similar blood loss. Although there was significantly less drainage among thyroid lobectomies (P = 0.012), the distributions were quite similar apart from 10 patients (9 lobectomy) with exceptionally low drainage. CONCLUSION: There was a statistically significant association of postoperative drainage with intraoperative blood loss and significantly less postoperative drainage among patients undergoing thyroid lobectomies. However, the observed associations do not appear to be strong enough to accurately predict patients who will experience substantial drainage.

Serum PTH and ionized calcium levels as predictors of symptomatic hypocalcemia after parathyroidectomy.

OBJECTIVE: To evaluate whether perioperative PTH levels or ionized calcium levels are associated with symptomatic hypocalcaemia, in patients undergoing parathyroidectomy for primary hyperparathyroidism. STUDY DESIGN: Prospective noncontrolled study of a cohort of 100 patients, undergoing parathyroidectomy at a single tertiary care medical centre. METHODS: Prospectively collected data from January 2002 to April 2008 on 100 unique patients undergoing parathyroidectomy for primary hyperparathyroidism were evaluated for age, sex, preoperative and intraoperative PTH levels, and preoperative and postoperative ionized calcium levels, extent of operation, final pathology, and postoperative symptomatic hypocalcaemia. Comparisons of those with and without symptomatic hypocalcaemia were made with Fisher's exact test for binary characteristics and with the Wilcoxon test for continuous characteristics. Results were deemed statistically significant at the 5% level (p < 0.05) with no correction for multiple comparisons. RESULTS: Twelve patients (12%) developed symptomatic hypocalcaemia in the post operative period. Neither, initial levels nor subsequent changes in PTH or ionized calcium were found to be associated with symptomatic postoperative hypocalcaemia. Patients developing hypocalcaemia tended to be younger (p = 0.057) and showed a significantly higher percentage when multiple glands were removed (p = 0.026). CONCLUSION: Initial levels or subsequent changes in PTH or ionized calcium were not found to be associated with symptomatic hypocalcaemia. The removal of more than one gland did correlate with symptomatic post operative hypocalcaemia.

Superficial parotidectomy and postoperative drainage.

OBJECTIVES: A shift toward shorter hospitalizations and outpatient procedures has become the standard in perioperative care. Two factors affecting the length of hospitalization following parotidectomy are duration of postoperative drainage and the use of surgical drains. Identifying factors that are predictive of postoperative drainage may allow earlier discharge or selection of patients suitable for outpatient procedures. The aim of this study was to identify any factors that may be predictors of postoperative drainage. DESIGN: Retrospective review. SETTING: A 500+ bed tertiary care medical center in central Wisconsin. PARTICIPANTS: Patients who underwent superficial parotidectomies over a 5-year period. METHODS: Clinical charts were retrospectively reviewed. Age, gender, anticoagulation use, history of hypertension, estimated intraoperative blood loss, postoperative complications, total postoperative drainage, length of hospital stay, and final pathology were recorded for each patient. Spearman rank correlation was used to evaluate associations, and the Kruskal-Wallis test was used for subgroup comparisons. RESULTS: Ninety-six superficial parotidectomies were performed during the 5-year time period and 69 met our criteria for inclusion in the study. Final pathology was directly associated with postoperative drainage with benign tumors having significantly less drainage than malignant tumors (P=0.011). Length of hospital stay was also significantly associated with postoperative drainage (r=0.36, P=0.002). No significant associations with age (P=0.209), gender (P=0.904), history of hypertension (P=0.780), or estimated intraoperative blood loss (P=0.109) were noted. CONCLUSIONS: Malignant pathology is associated with increased postoperative drainage and increased length of hospitalization. Accurately predicting malignancies preoperatively may expedite and facilitate postoperative planning and offer insight into the expected duration of postoperative drainage.

Diffuse idiopathic skeletal hyperostosis: a rare cause of Dysphagia, airway obstruction, and dysphonia.

BACKGROUND: We retrospectively query the clinical records of patients with cervical osteophytes to distinguish the clinical features of those presenting with symptomatic dysphagia and airway obstruction. STUDY DESIGN: Retrospective review of all patients presenting over a 20-year period (1985 to 2005) with the diagnosis of cervical osteophytes and dysphagia with or without airway compromise. Two hundred thirty-four patients were identified at Marshfield Clinic between 1985 and 2005; 9 (3.8%) met criteria for inclusion. RESULTS: Eight of nine patients presented with dysphagia. Three of nine patients presented with acute airway obstruction requiring intubation and tracheotomy. Osteophytes occurred at multiple levels, with C4, C5, and C6 being most commonly involved. Surgical decompression resulted in complete resolution of symptoms in four of five patients. CONCLUSIONS: Although commonly found and usually asymptomatic in the older population, anterior cervical osteophytes can be a source of considerable morbidity and potential life-threatening airway obstruction. Recognizing this clinical entity is imperative in establishing a diagnosis and initiating appropriate treatment. Surgical decompression appears to be beneficial in relieving symptoms.

Primary laryngeal lymphoma: case report.

Extranodal laryngeal lymphoma is extremely rare. We report a case of primary laryngeal lymphoma in a 76-year-old man who had presented with a 7-week history of progressive hoarseness. Laryngoscopy revealed asymmetry of the right false vocal fold. Pathology of a deep biopsy specimen identified a malignant, diffuse, CD20-positive, B-cell lymphoma. The stage IE lymphoma completely resolved after treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) and rituximab. Despite its relative rarity, the consequences of a missed diagnosis warrant vigilance for this type of laryngeal tumor.

Idiopathic vocal cord palsies and associated neurological conditions.

OBJECTIVE: To retrospectively review the clinical case records of patients with idiopathic vocal cord palsies (VCPs) for the presence of preexisting or subsequent development of neurological disease, including multiple sclerosis, motor neuron disease, myasthenia gravis, cerebrovascular disease, and Guillain-Barré syndrome. DESIGN: Retrospective case review of all patients with VCP presenting sequentially within a 45-month time span. SETTING: Tertiary referral center. PATIENTS: One hundred ninety-three patients with VCP. RESULTS: Thirty-five cases of VCP (18.1%) were idiopathic. Eight (22.8%) resolved after a mean time of 5 months. A preexisting central nervous system condition was noted in 9 (25.7%) of 35 patients with idiopathic VCP. A subsequent central nervous system condition developed in 7 patients (20.0%). These included 2 cases of cerebrovascular accidents, 1 case of postpolio syndrome with respiratory failure, and 1 case of polyneuropathy secondary to paraneoplastic syndrome. CONCLUSIONS: A high frequency of neurological conditions was observed in adult patients initially presenting with idiopathic VCP. Patients with VCP but without overt neurological disease may also subsequently develop a serious neurological condition. Careful neurological evaluation of all patients with idiopathic VCP is recommended.

Management of mandibular invasion: when is a marginal mandibulectomy appropriate?

There has been a great deal of controversy regarding the appropriate method of management of oral cavity and oropharyngeal tumors that invade the mandible. The inability to acquire intraoperative bone margins can make the decision process complex. Preoperative imaging offers several advantages, however, there is no single modality that has proven accurate. Intraoperative assessment has been suggested as a method of evaluation, however, this approach does not allow for preoperative planning. The following is a review of the current literature regarding mandibular invasion and the indications for a marginal mandibulectomy.

Arterial and venous parathyroid hormone levels in minimally invasive surgery.

OBJECTIVE: To establish if venous and arterial parathyroid hormone (PTH) levels are similar during minimal access parathyroid surgery. DESIGN: Prospective study. SETTING: Marshfield Clinic, a large multispecialty tertiary care referral center in central Wisconsin. PATIENTS: All patients who underwent minimally invasive parathyroid surgery over a 10-month period. RESULTS: Fifteen consecutive patients were evaluated. There were 11 women and 4 men, with an average age of 65 years. All patients underwent a preoperative technetium Tc 99m sestamibi scan, with 11 localizing to the site of a probable adenoma. Mean ionized calcium levels were 5.95 mg/dL (1.49 mmol/L) preoperatively and 4.84 mg/dL (1.21 mmol/L) postoperatively. Of 13 patients undergoing both arterial and venous sampling, mean baseline venous PTH level was 221 pg/mL and 37 pg/mL at 10 minutes after excision of suspected adenoma (83% decline). Mean baseline arterial PTH level was 247 pg/mL and 38 pg/mL at 10 minutes after excision (84% decline). Using the Wilcoxon signed rank test, there was no significant difference in the arterial vs venous levels at baseline (P = .70) or 10 minutes (P = .48). CONCLUSIONS: Intraoperative PTH levels during minimal access parathyroid surgery are similar for venous and arterial samples. Blood samples for PTH level monitoring can be obtained using a temporary indwelling arterial line.

Neck dissections: predicting postoperative drainage.

OBJECTIVES: Most head and neck dissections performed in conjunction with carcinomas of the upper aerodigestive tract require drain insertion. The time that the drains remain in place largely determines the duration of postoperative hospitalization. This study sought to retrospectively compare different neck dissections in terms of postoperative drainage and duration of hospitalization. We also sought to identify any correlation between total intraoperative blood loss and postoperative drainage. MATERIALS AND METHODS: Radical, modified radical, and selective neck dissections performed in conjunction with resection of a carcinoma of the upper aerodigestive tract over a 3-year period were evaluated. Total intraoperative blood loss at surgery, and amount and duration of postoperative drainage for each neck dissection were recorded. RESULTS: Seventy-nine neck dissections were performed on 52 patients, 27 (52%) of whom had bilateral neck dissections. Median drainage was 116.5 mL, 172 mL, and 319 mL for selective, modified radical, and radical neck dissections, respectively. Drainage differed significantly by type of neck dissection (P <.001). Drains remained in place a median of 4 days with no significant difference between different types of neck dissections. Drainage was clearly correlated with total intraoperative blood loss (Spearman correlation = 0.44, P <.001). CONCLUSION: The postoperative drainage per day was higher in radical neck dissections than modified radical neck dissections and lowest in selective neck dissections. This difference was not reflected in the duration that the drains would remain in place. Total intraoperative blood loss is a strong predictor of the amount and duration of postoperative drainage.

Distinguishing non-Hodgkin lymphoma from squamous cell carcinoma tumors of the head and neck by computed tomography parameters.

OBJECTIVE: Computed tomography (CT) remains the first-line imaging procedure for pre-therapeutic staging of head and neck tumors. Non-Hodgkin lymphoma (NHL) is not easily distinguished from squamous cell carcinoma (SCC), especially because NHL often appears in extranodal locations. We sought to explore whether specific CT characteristics could be used to distinguish these tumor types. METHOD: Cases of NHL and SCC involving the head and neckwere retrospectively identified. Of 165 subjects (110 NHL, 55 SCC) identified, 45 patients (19 NHL, 26 SCC) had complete CT scan records. The scans with no group identifiers were randomly presented to the radiologist for blinded review. Radiologic distribution, size, and tumor characteristics were recorded. Descriptive summaries of the data were analyzed by standard univariate statistical procedures. RESULTS: Significant differences between NHL and SCC tumors were observed: stage IV tumors (17% vs. 85%; P < .001), extranodal occurrence in the oral cavity (0% vs. 38%; P = .002), evidence of primary or extranodal tumor (11% vs. 73%; P < .001), tumor necrosis (5% vs. 54%; P <.001), non-isodensity nodes (16% vs. 50%; P = .03), and nodes in zones 5-7 (32% vs. 4%; P = .03). No significant difference was seen in the total number of nodes, the number of large nodes, or the maximum nodal diameter. CONCLUSION: While none of these features can be considered pathognomonic for either type of tumor, the distinctions may assist in distinguishing NHL from SCC of the head and neck until more sophisticated imaging techniques become widely available.