Outcomes of Immediate Total Thyroidectomy in First-Side Loss of Neuromonitoring Signal.

Importance: Use of intraoperative neuromonitoring (IONM) during thyroidectomy can nearly eliminate the risk of postoperative bilateral vocal cord palsy (VCP) by indicating staged surgery in cases of loss of signal (LOS) on the first side of planned total thyroidectomy. However, aborting planned total thyroidectomy may lead to persistence of symptoms, delay in adjuvant treatment, and patient inconvenience and distress. There are few data to guide a selective approach to total thyroidectomy in patients with first-side LOS. Objective: To investigate outcomes of immediate bilateral surgery in patients undergoing total thyroidectomy with first-side LOS. Design, Setting, and Participants: This cohort study was a retrospective review of outcomes for patients undergoing thyroidectomy between January 2016 and July 2023 at an academic tertiary referral center for thyroid surgery. Consecutive patients scheduled for total thyroidectomy using IONM were included. Exclusion criteria were preoperative VCP, deliberate sacrifice of recurrent laryngeal nerve (RLN), inadvertent RLN resection, and surgery performed without IONM. Exposures: Total thyroidectomy performed using IONM. Main Outcome Measures: Vocal mobility on first postoperative day as assessed by flexible laryngoscopy; secondary outcome measures included subjective voice assessment, other postoperative complications, and long-term vocal mobility. Results: Among 400 patients undergoing planned total thyroidectomy (mean age, 50.5 years [range, 4-88 years]; 318 female [79.5%]), 51 (12.8%) had first-side LOS, of whom 37 (9.3%) had persistent LOS. Twenty-nine patients (56% of procedures with first-side LOS, including 18 with persistent LOS) proceeded to immediate total thyroidectomy. Postoperatively, 16 patients (55% of patients undergoing total thyroidectomy following first-side LOS, including 14 of 18 with persistent LOS) had impaired vocal mobility. One patient had bilateral VCP that did not require tracheostomy, and 2 had postoperative hypoparathyroidism. Of those whose surgery was aborted after first-side LOS, 8 of 22 (36%) underwent completion thyroidectomy at a later stage. In those undergoing completion thyroidectomy, 2 of 8 (25%) had temporary VCP after the second surgery, 2 (25%) had permanent hypoparathyroidism, and 1 (12.5%) developed inoperable cancer. Postoperative VCP was fully reversible in all but 1 patient. Conclusion and Relevance: Among patients planned for total thyroidectomy who develop first-side LOS, immediate total thyroidectomy may be considered among those who have pressing reasons for same, and where surgical difficulties might be anticipated in a secondary surgery.

Pattern of regional recurrence after selective neck dissection for clinically positive neck in mucosal squamous carcinoma.

BACKGROUND: Selective neck dissection (SND) has traditionally been applied to clinically negative (cN0) necks in mucosal squamous cell carcinoma (SCC). We aimed to examine the oncological safety and patterns of regional recurrence (RR) of SND in clinically positive (cN+) necks. METHODS: Retrospective review of prospective cohort of 206 patients with mucosal SCC undergoing neck dissection. RR was classified as occurring within previously dissected levels, within ipsilateral undissected levels, within unusual locations of ipsilateral neck, or contralateral neck. RESULTS: Seven of seventy-seven (9.1%) cN+ patients undergoing SND developed isolated RR, versus 16.2% after MRND, and 8.7% after SND for cN0 disease. RR was rarely seen within undissected levels of the ipsilateral neck. RR and survival rates were not associated with ND extent (SND vs. MRND) among either cN+ or pN+ patients. CONCLUSION: SND can be safely performed in most patients with cN+ SCC, who do not have gross sternocleidomastoid infiltration or level V metastases.

High-flow nasal oxygen as an adjunct for the safe removal of impacted metallic upper airway foreign bodies.

Foreign body airway obstruction is considered an airway emergency and is a challenging clinical scenario for both the otolaryngologist and the anaesthetist. We present three cases of impacted upper airway metallic foreign bodies. Supra-glottic airways were obstructed and precarious. Apnoeic oxygenation utilizing high-flow nasal oxygen (HFNO), a form of tubeless anaesthetic, was used in all three cases, leading to the safe removal of the foreign bodies. Increased training, awareness and equipment availability to provide HFNO apnoeic oxygenation in the emergency setting for otolaryngology airway procedures will lead to better outcomes for patients and decreases the risk of a potential surgical airway.

Foreign accent syndrome post tonsillectomy: A case report.

Foreign Accent Syndrome (FAS) is a rare clinical entity in which affected patients experience a new pattern of speech resembling an unusual accent. Reported cases are scarce in published literature and are usually the result of a neurological insult. FAS as a complication from a general anesthetic or surgery has not been reported to date. We present the case of a healthy 27-year-old Australian woman who developed FAS following a tonsillectomy. Post operatively, speech patterns resembled an Irish accent. We discuss the potential mechanisms of the unusual complication as well as review the available literature surrounding FAS.

Instrumentation failure during microlaryngoscopy.

Equipment failure can be a cause of morbidity during surgical procedures. We present two cases where a broken surgical instrument, a heart-shaped curved micro-grasper, colloquially termed 'sweetheart' micro-forceps, compromised patient safety during microlaryngoscopy. We discuss the importance of thorough safety protocols and communication between team members to mitigate this risk. Microinstruments used during microlaryngoscopy are at risk of failure or breakage due to their small size. Surgeons must be alert to the risk of equipment failure during surgery as a potential cause of patient morbidity. In our patient, loss of the broken instrument in the respiratory tract could have resulted in iatrogenic aspiration, respiratory infection and would have necessitated rigid bronchoscopy for removal. Instruments and equipment must checked and communicated by the surgical team before and after use to prevent potential patient morbidity.

The road to consultancy: an epidemiological study.

BACKGROUND: Modern medical and surgical training pathways have developed globally in response to changing expectations and requirements for trainees. AIMS: To determine the demographic, educational, and training characteristics of consultants in a model 4 teaching hospital, and to evaluate the requirements met by consultant physicians and surgeons prior to their appointment to consultancy. METHOD: A single-centre study conducted by prospectively distributing written questionnaires. Data was collected and analysed using Microsoft Excel and SPSS. RESULTS: This questionnaire was offered to 166 consultants, 110 of whom responded (66.0%). The vast majority were Irish (91.8%) and 70.9% male. The mean age to appointment was 35.7 ± 2.6 years. Radiology was the specialty with the youngest mean age at appointment: 34.4 ± 2.6 years, while surgery had the oldest: 36.7 ± 2.7 (P = 0.035). Overall, 80.9% trained via Higher Specialist Training (HST) schemes (89/110) and 68.2% completed a higher degree (75/110). Geriatric medicine and dermatology had the highest rate of completed higher degrees (100.0%, 3/3 and 3/3 respectively), followed by surgeons (92.3%; 24/26) and cardiologists (71.4%; 5/7). The overall duration of HST varied greatly; the mean surgical, medical and anaesthesiology durations were 6.7 ± 1.8 years, 6.6 ± 1.7 years, and 5.3 ± 2.0 years. A total of 75.4% of consultants completed fellowship (83/110). CONCLUSION: This study highlights variations in postgraduate Irish medical training pathways and discrepancies in training requirements expected in each specialty. The establishment of a modern guideline for young trainees working towards consultancy may be imperative in ensuring trainees have insight into training requirements expected in their specialty.