Clinical outcomes of T4a papillary thyroid cancer with recurrent laryngeal nerve involvement: a retrospective analysis.

Preoperative vocal cord palsy (VCP) may indicate locally invasive papillary thyroid cancer (PTC); using this relationship, we evaluated the clinical outcomes and risk factors for recurrence in post-thyroidectomy T4a PTC patients with recurrent laryngeal nerve (RLN) involvement. We retrospectively investigated thyroidectomy patients, recorded their clinical factors, recurrence rate, and pathological findings, and analysed the relationship between recurrence rate and clinical factors. Of 72 patients, 37 (51%) had preoperative VCP and 35 (49%) had normal preoperative vocal cord movement with confirmed intraoperative RLN invasion. Tracheal and esophageal invasion was observed in 13 (18%) and 15 (21%) patients, respectively. Thyroid cancer recurred in 18 (25%) patients over 58 months, resulting in 2 (3%) deaths. Recurrence was not associated with surgical extent, organ invasion, enlarged tumour size, or lymph node infiltration (p > 0.05). The recurrence rate was significantly higher in patients with positive resection margins (p < 0.05). T4a PTC patients with RLN involvement showed a poor prognosis. The recurrence rate was not affected by preoperative VCP, intraoperative detection of RLN invasion, nerve resection, nerve preservation by shaving, lymph node metastasis, or tracheal or esophageal invasion. The most important prognostic factor for recurrence was a positive resection margin.

Comparison of Medial Underlay and Lateral Underlay Endoscopic Type I Tympanoplasty for Anterior Perforations of the Tympanic Membrane.

OBJECTIVES: To compare the outcomes of medial and lateral underlay endoscopic type I tympanoplasty for anterior tympanic membrane (TM) perforations. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care academic referral center. PATIENTS: Patients who were diagnosed with either chronic otitis media with dry and stable anterior TM perforations or traumatic anterior TM perforations and underwent endoscopic type I tympanoplasty between 2017 and 2019. INTERVENTIONS: Medial or lateral underlay type I endoscopic tympanoplasty. MAIN OUTCOME MEASURES: Patient demographics, size, and location of TM perforation, graft success rate, and hearing outcome. RESULTS: Of the 170 patients, 68 and 102 patients underwent the medial and lateral underlay techniques, respectively. Patient demographics were not significantly different between groups, except the middle ear mucosa status. Graft success rates were significantly different between groups regardless of the perforation size (85.3 and 95.1%, p < 0.001). The lateral underlay group had a significantly better outcome (p < 0.001) when anterior superior quadrant TM perforation was included than the medial underlay group (p = 0.552). Hearing outcomes did not significantly differ between groups, but a significant audiological improvement was observed in both groups (p < 0.05). CONCLUSION: Lateral underlay type I endoscopic tympanoplasty can be challenging as it requires dissection of the malleus. However, the lateral underlay group had a high graft success rate without sensorineural hearing loss in the repair of anterior TM perforations. Thus, lateral underlay type I endoscopic tympanoplasty should be considered for repairing anterior TM perforations, especially when the anterior superior quadrant is involved.

Real-time light-guided vocal fold injection as a simulation-based training tool.

OBJECTIVE: Cricothyroid (CT) approach for vocal fold injection (VFI) has advantages of a low complication rate, suitability for in-office practice, and good patient compliance. However, it requires a high level of experience and a steep learning curve due to invisibility of needle. Recently, real-time light-guided VFI (RL-VFI) was developed for safe and precise injection into laryngeal structures under light guidance. Herein, we describe the development of a simulation-based training (SBT) program using RL-VFI for CT approach and report its preliminary application with in-training otolaryngologists. METHODS: The workshop comprised 3 sessions: mini-lectures, and two hands-on training courses of conventional VFI and RL-VFI. Excised canine larynges and the device for RL-VFI were prepared for hands-on courses. Comfort levels for VFI was evaluated using visual analogue scale after each session. Trainees were requested to identify the needle tip on the target point lateral to vocal process. The time (s) to reach the target point was measured in all procedures. After workshop, all participants filled out questionnaires regarding their future preference for conventional VFI and RL-VFI. RESULTS: Eleven otolaryngology residents participated in the study. The mean comfort levels were 1.7 ±â€¯1.6, 5.5 ±â€¯2.6, 4.8 ±â€¯1.7, and 7.5 ±â€¯1.6 for pre-workshop, post-lecture, post-conventional VFI, and post-RL-VFI (P < .001). The mean time (s) to reach the target point were 146.4 ±â€¯90.1 and 42.7 ±â€¯40.5 for conventional VFI and RL-VFI (P = .004). The mean preference scores were 4.2 ±â€¯1.3 and 8.7 ±â€¯1.3 for conventional VFI and RL-VFI (P = .004). CONCLUSION: SBT program using RL-VFI might improve the comfort levels of trainees for VFI with CT approach. It would be helpful for trainees to practice VFI before trying it on actual patients. LEVEL OF EVIDENCE: N/A.

Application of Attachable Magnetic Nerve Stimulator in Intraoperative Facial Nerve Monitoring during Ear Surgery.

We developed an attachable magnetic nerve stimulator (AMNS) that connects the metallic instruments to a neurophysiological monitoring unit for monitoring the facial nerve (FN) during ear surgery and present our experiences with intraoperative neuromonitoring (IONM) of the FN using AMNS. The FN in 20 patients who underwent tympanomastoidectomy for chronic ear disease was examined. The electromyography (EMG) amplitudes of the FN using AMNS were assessed. The EMG amplitudes of the FN at 1.00-mA stimulation during drilling were 265 ± 64 µV in the orbicularis oris and 288 ± 57 µV in the orbicularis oculi. The EMG amplitudes using AMNS attached to the surgical instruments under 0.35-mA stimulus at the tympanic segment of the FN were 196 ± 43 µV in the orbicularis oris and 197 ± 41 µV in the orbicularis oculi. The application of continuous stimulation with burr and surgical instruments using the AMNS is feasible and effective for FN stimulation and identification.

Septal Cartilage Traction Suture Technique for Correction of Caudal Septal Deviation.

OBJECTIVE: Correction of the caudal septum deviation is the most difficult part of the septoplasty and a common cause of revision septoplasty. The purpose of this study was to present authors' preliminary results in the treatment of patients with caudal septal deviation using the septal cartilage traction suture technique. STUDY DESIGN: Prospective, single center, observational study. MATERIALS AND METHODS: Sixty-seven patients with a caudal septal deviation underwent septal cartilage traction suture technique with endonasal septoplasty. After removal of excessive caudal cartilage, the caudal L-strut was sutured at two or more points using 5-0 Vicryl on the modified Killian incision site. Subjective outcomes using visual analog scales (VAS) and Nasal Obstruction Symptom Evaluation (NOSE) scale, objective endoscopic examination, and acoustic rhinometry data were assessed. RESULTS: There was significant symptomatic improvement in the VAS and NOSE scale at 1, 3, and 6 months postsurgery. Complete correction in the endoscopy was observed in the 91.0% of patients at 3 months postsurgery. The results of acoustic rhinometry increased from 0.3 and 4.3 preoperatively to 0.7 and 7.7 at 3 months postoperatively. Furthermore, no patient experienced septal hematoma, septal perforation, and loss of nasal tip support at 6 months follow-up. CONCLUSIONS: The septal cartilage traction suture technique obtained significant improvement in subjective and objective outcomes in patients with caudal septal deviation. This technique is a simple, safe, and effective method to treat caudal septal deviation. LEVEL OF EVIDENCE: 4 Laryngoscope, 2020.

Development of a Novel Intraoperative Neuromonitoring System Using an Accelerometer Sensor in Thyroid Surgery: A Porcine Model Study.

OBJECTIVES: The sensitivity and positive predictive value of widely used intraoperative neuromonitoring (IONM) using electromyography (EMG) of the vocalis muscle in thyroid surgery are controversial. Thus, we developed a novel IONM system with an accelerometer sensor that uses the piezoelectric effect instead of EMG to detect laryngeal twitching. The objective of this study was to evaluate the feasibility and safety of this novel IONM system during thyroid surgery in a porcine model. METHODS: We developed an accelerometer sensor that uses the piezoelectric effect to measure laryngeal twitching in three dimensions. This novel accelerometer sensor was placed in the anterior neck skin (transcutaneous) or postcricoid area. Stimulus thresholds, amplitude, and latency of laryngeal twitching measured using the accelerometer sensor were compared to those measured through EMG of the vocalis muscle. RESULTS: The amplitudes of the accelerometer sensor at the anterior neck and postcricoid area were significantly lower than those of EMG because of differences in the measurement method used to evaluate laryngeal movement. However, no significant differences in stimulus thresholds between the EMG endotracheal tube and transcutaneous or postcricoid accelerometer sensors were observed. CONCLUSION: Accelerometer sensors located at the anterior neck or postcricoid area were able to identify laryngeal twitching. The stimulus intensity measured with these sensors was equivalent to that from conventional vocalis EMG. Our novel IONM system with an accelerometer sensor that checks changes in surface acceleration can be an alternative to EMG of the vocalis muscle for IONM in the future.

The efficacy of cotton ball packing after endoscopic sinus surgery: A prospective, randomized, controlled trial.

OBJECTIVE: The blocking of airflow into sinonasal cavity may decrease postoperative crusting and the development of adhesions. The purpose of this study was to investigate the efficacy of cotton ball packing in patients following endoscopic sinus surgery (ESS). METHODS: Thirty nine patients with chronic rhinosinusitis requiring the same extent of ESS were included. As a part of postoperative care, the patients were instructed to perform a nasal saline irrigation and apply a nasal spray in each nostril, and then informed to put a cotton ball in a one side of nostril, and the other side was kept to be empty as a control. Patients' subjective symptoms, patients' pain while receiving sinonasal cavity debridement, time required to perform debridement, and postoperative wound healing were evaluated. RESULTS: Although cotton ball packing resulted in less discomfort for postnasal drip, rhinorrhea, headache, and facial pain than no packing, there were no statistically significant differences between the groups. The cotton ball packing was associated with significantly less pain on while performing postoperative debridement, therefore less time was needed to perform debridement. The cotton ball packing appears to improve wound healing within the sinus cavities up to 1 month postoperatively. CONCLUSION: The use of the cotton ball packing after ESS results in significantly less formation of crusts and adhesions, leading to decreasing pain and time during postoperative debridement and promoting faster wound healing.