The incidence of vocal fold motion impairment after primary thyroid and parathyroid surgery for a single high-volume academic surgeon determined by pre- and immediate post-operative fiberoptic laryngoscopy.

BACKGROUND: Vocal fold motion impairment (VFMI) is a well-recognized complication of thyroid and parathyroid surgery. Preoperative counseling requires a thorough understanding of the incidence, risk factors, and value of early diagnosis of postoperative VFMI. Our objective is to describe the incidence of and risk factors for VFMI for a single high-volume academic surgeon, and to assess the utility of immediate postoperative fiberoptic laryngoscopy (FOL) in early diagnosis of VFMI. METHODS: Retrospective cohort study of patients undergoing primary thyroid and parathyroid procedures by a single high-volume surgeon at an academic tertiary care center. All patients underwent preoperative and immediate postoperative FOL. The primary outcome was incidence of VFMI, either temporary (<1 year) or permanent (1 year or more). The unit of analysis was number of recurrent laryngeal nerves (RLN) at risk. Risk factors for VFMI were analyzed using logistic regression, reporting unadjusted and adjusted odds ratios (OR and aOR) and 95% confidence intervals (CI). RESULTS: The study population comprised 1547 patients undergoing 1580 procedures for a total of 2527 nerves at risk, excluding the 27 nerves found to have motion impairment on preoperative FOL. Sixty-seven new incidents of VFMI were identified on postoperative FOL, with an additional six new incidents detected after voice complaints prompted FOL upon follow-up. Thus, the incidence of postoperative VFMI was 2.9% of RLNs at risk (73 of 2527). The sensitivity and negative predictive value of immediate postoperative FOL were 92% and 99.8% respectively. Permanent VFMI occurred in 9 cases (0.4%), 3 of which were from intentional RLN transection for malignancy. Odds of VFMI were significantly lower after parathyroidectomy (aOR = 0.1, 95%CI = 0.01-0.8 compared with hemithryoidectomy) and higher with central neck dissection (aOR = 2.4, 95CI = 1.0-5.9). Among cases of malignancy, odds of VFMI increased significantly with increasing T-stage (adjusted ptrend<0.001). CONCLUSION: VFMI is rare and usually temporary after primary thyroid and parathyroid procedures, with increased risk associated with larger primary malignancies and the inclusion of central neck dissection. Immediate postoperative FOL is useful for early detection of VFMI that may allow for clear definition of temporary and permanent immobility rehabilitation especially if there is evidence to support early intervention.

Voice outcomes following reoperative central neck dissection for recurrent/persistent thyroid cancer.

OBJECTIVES/HYPOTHESIS: We aimed to assess voice outcomes following reoperative central neck dissection (RCND) to characterize postoperative voice difficulties experienced, determine the natural progression of vocal recovery, and identify risk factors for the development of voice disorders postoperatively. STUDY DESIGN: Prospective cohort study. METHODS: Consecutive patients with recurrent/persistent thyroid cancer who were deemed appropriate candidates for RCND were eligible for participation in this study. A battery of voice evaluation measures was administered both preoperatively and 2 to 4 weeks postoperatively. RESULTS: Twenty consecutive patients were included. Postoperatively, six (30%) new incidents of vocal fold motion impairment (VFMI) were identified, with two (10%) being due to intentional recurrent laryngeal nerve (RLN) transection. On 1-year follow-up, two patients had full restoration of vocal fold mobility and four had persistent VFMI. No preoperative voice/laryngeal exam factors were predictive of postoperative VFMI. Clinically relevant change in postoperative Voice Handicap Index score was absent in all patients without VFMI and present in five of six patients with VFMI (P=.0004). Patients with VFMI had significantly poorer overall dysphonia grade, less glottic closure, and elevated jitter in contrast to those individuals without VFMI. Patients with malignant tissue in the remnant thyroid were four times more likely to develop VFMI than those with central neck lymph node metastases alone (P=.06). CONCLUSION: Patients undergoing RCND are at risk for postoperative VFMI, even when the RLN is anatomically preserved, with subsequent impact on quality of life. Presence of malignant disease in the remnant thyroid appears to be the best predictor for postoperative VFMI. LEVEL OF EVIDENCE: 2b.

The prognostic implications from molecular testing of thyroid cancer.

Thyroid cancer is the most common endocrine malignancy and its incidence has increased over the past few decades. Most patients with thyroid cancer have an excellent prognosis, but there is a 15% recurrence rate within 10 years after initial treatment and mortality is possible. To date, there are no prospective, well-defined data supporting the use of molecular markers alone to decide the extent of treatment of patients with thyroid cancer or to predict the individual prognosis of these patients. Molecular markers are promising in the development of new targeted therapies particularly for radioiodine-refractory and unresectable thyroid cancers.

Necessity of routine ipsilateral hemithyroidectomy during laryngopharyngectomy for pyriform sinus cancer.

PURPOSE: The aim of this study was to revisit the role of hemithyroidectomy in the treatment of pyriform sinus cancer by determining the incidence of thyroid gland invasion by the tumor. MATERIALS AND METHODS: Medical records of 27 patients with pyriform sinus cancer who underwent laryngopharyngectomy with ipsilateral hemithyroidectomy from 1999 to 2010 at a National Cancer Institute-designated comprehensive cancer center were retrospectively reviewed. Computed tomographic scans of the neck, operative notes, and surgical specimens were examined to determine the presence of thyroid gland invasion by imaging, clinical appearance, and pathology. RESULTS: There were 19 male and 8 female patients (age range, 44-79 years; mean, 59.9 years). Most of the cases (85%) had advanced-stage disease. Extralaryngeal spread of tumor with thyroid cartilage invasion was noted in the computed tomographic scans of 5 patients; however, there was no radiologic evidence of thyroid gland invasion in any patient. No gross thyroid gland invasion by the tumor was appreciated in any patient during surgery. No histologic evidence of tumoral invasion of the thyroid gland was found in any of 27 surgical specimens. CONCLUSIONS: Results of this study suggest that thyroid gland invasion by pyriform sinus cancer is not common. Therefore, a routine ipsilateral hemithyroidectomy may not be necessary in the treatment of every patient with pyriform sinus cancer, unless there is evidence of thyroid gland invasion.

Preliminary report of laryngeal phonation during mechanical ventilation via a new cuffed tracheostomy tube.

OBJECTIVE: To study the safety, efficacy, patient tolerance, and patient satisfaction of the Blom Tracheostomy Tube and Speech Cannula (Pulmodyne, Indianapolis, Indiana), a new device that allows the patient to speak while the tracheostomy tube cuff is fully inflated. METHODS: With 10 tracheostomized mechanically ventilated patients we recorded ventilator settings and physiologic variables at baseline with patient's usual tracheostomy tube, then with the Blom Tracheostomy Tube and the Blom standard (non-speech) cannula, and then during three 30-min trials of the Blom Speech Cannula. During the Blom Speech Cannula trials we assessed the subjects' success in phonation (eg, sentence length and volume). RESULTS: Nine of the 10 subjects achieved sustained audible phonation and were very satisfied with the device. CONCLUSIONS: The Blom Speech Cannula appears to be safe, effective, and well tolerated in tracheostomized mechanically ventilated patients while maintaining full cuff inflation.

Safety of audiology direct access for medicare patients complaining of impaired hearing.

BACKGROUND: Allowing Medicare beneficiaries to self-refer to audiologists for evaluation of hearing loss has been advocated as a cost-effective service delivery model. Resistance to audiology direct access is based, in part, on the concern that audiologists might miss significant otologic conditions. PURPOSE: To evaluate the relative safety of audiology direct access by comparing the treatment plans of audiologists and otolaryngologists in a large group of Medicare-eligible patients seeking hearing evaluation. RESEARCH DESIGN: Retrospective chart review study comparing assessment and treatment plans developed by audiologists and otolaryngologists. STUDY SAMPLE: 1550 records comprising all Medicare eligible patients referred to the Audiology Section of the Mayo Clinic Florida in 2007 with a primary complaint of hearing impairment. DATA COLLECTION AND ANALYSIS: Assessment and treatment plans were compiled from the electronic medical record and placed in a secured database. Records of patients seen jointly by audiology and otolaryngology practitioners (Group 1: 352 cases) were reviewed by four blinded reviewers, two otolaryngologists and two audiologists, who judged whether the audiologist treatment plan, if followed, would have missed conditions identified and addressed in the otolaryngologist's treatment plan. Records of patients seen by audiology but not otolaryngology (Group 2: 1198 cases) were evaluated by a neurotologist who judged whether the patient should have seen an otolaryngologist based on the audiologist's documentation and test results. Additionally, the audiologist and reviewing neurotologist judgments about hearing asymmetry were compared to two mathematical measures of hearing asymmetry (Charing Cross and AAO-HNS [American Academy of Otolaryngology-Head and Neck Surgery] calculations). RESULTS: In the analysis of Group 1 records, the jury of four judges found no audiology discrepant treatment plans in over 95% of cases. In no case where a judge identified a discrepancy in treatment plans did the audiologist plan risk missing conditions associated with significant mortality or morbidity that were subsequently identified by the otolaryngologist. In the analysis of Group 2 records, the neurotologist judged that audiology services alone were all that was required in 78% of cases. An additional 9% of cases were referred for subsequent medical evaluation. The majority of remaining patients had hearing asymmetries. Some were evaluated by otolaryngology for hearing asymmetry in the past with no interval changes, and others were consistent with noise exposure history. In 0.33% of cases, unexplained hearing asymmetry was potentially missed by the audiologist. Audiologists and the neurotologist demonstrated comparable accuracy in identifying Charing Cross and AAO-HNS pure-tone asymmetries. CONCLUSIONS: Of study patients evaluated for hearing problems in the one-year period of this study, the majority (95%) ultimately required audiological services, and in most of these cases, audiological services were the only hearing health-care services that were needed. Audiologist treatment plans did not differ substantially from otolaryngologist plans for the same condition; there was no convincing evidence that audiologists missed significant symptoms of otologic disease; and there was strong evidence that audiologists referred to otolaryngology when appropriate. These findings are consistent with the premise that audiology direct access would not pose a safety risk to Medicare beneficiaries complaining of hearing impairment.

Functional and manofluorographic outcomes after transoral endoscopic pharyngoesophageal diverticulostomy.

OBJECTIVES: To investigate functional and manofluorographic findings of patients with pharyngoesophageal diverticulum before and after transoral endoscopic pharyngoesophageal diverticulostomy (TEPD) and to comment on outcomes relative to predictors of successful treatment and pathogenesis of pharyngoesophageal diverticulum. DESIGN: Retrospective medical record review. SETTING: Academic center. PATIENTS: Thirty patients underwent TEPD between July 1, 1997, and June 30, 2007, and met the study inclusion criteria. According to the depth of their pharyngoesophageal diverticulum, patients were categorized as having small (<20 mm) or large (>or=20 mm) diverticula. INTERVENTION: Manofluorography before and 6 months after TEPD. MAIN OUTCOME MEASURES: Functional and manofluorographic findings before and 6 months after surgery. RESULTS: Functional Outcome Swallowing Scale stage was significantly decreased in patients after surgery. Videofluoroscopy demonstrated normal swallowing coordination and a significant decrease in pouch depth after surgery (from 29.62 to 4.78 mm). Manometry confirmed normal swallowing coordination and showed significant mean postoperative pressure reductions in the following: cricopharyngeal (CP) resting pressure (from 16.23 to 9.26 mm Hg), CP midbolus pressure (from 32.86 to 19.26 mm Hg), intrabolus pressure gradient across the CP region (from 22.48 to 10.16 mm Hg), and CP peak clearing pressure (from 41.98 to 26.99 mm Hg). The mean preoperative intrabolus pressure gradient across the CP region and the mean postoperative CP nadir were significantly greater in patients having large diverticula. CONCLUSIONS: Statistically significant decreases in functional and objective measures occurred after TEPD. High CP midbolus pressure and high intrabolus pressure gradient across the CP region are reliable objective indicators of patients who might benefit from TEPD and are appropriate variables for follow-up after surgery. There was no manofluorographic evidence of abnormal swallowing coordination in this small series. Our study supports the hypothesis that anatomical hypopharyngeal wall weakness has a major role in the pathogenesis of pharyngoesophageal diverticulum.

Manofluorographic and functional outcomes after endoscopic laser cricopharyngeal myotomy for cricopharyngeal bar.

OBJECTIVE: To investigate the manofluorographic and functional outcomes after endoscopic laser cricopharyngeal myotomy (ELCPM) for cricopharyngeal (CP) bar. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: Review of patients undergoing ELCPM between 2001 and 2007 was undertaken to determine the demographic, clinical, and manofluorographic findings before and six months after surgery. Two groups were established according to pharyngeal driving pressures: normal pressure group (> 55 mm Hg) and low pressure group (< 55 mm Hg). RESULTS: Fourteen patients underwent ELCPM for CP bar without a concomitant head and neck or Zenker's procedure. There were no major surgical complications. All 14 patients improved at least one stage on the Functional Outcome Swallowing Scale (FOSS) after surgery. There was a statistically significant decrease in the FOSS stages after surgery. Videofluoroscopy demonstrated a significant postoperative increase in the mean cross-sectional CP opening (CP-area) from 32.75 to 123.52 mm(2). Manofluorographic pressure recordings showed a significant postoperative decrease in the intrabolus pressure gradient across the cricopharyngeal region (IB-Gra) from 25.44 to 13.22 mm Hg. Despite significant overall results, the change in the IB-Gra showed no difference between the patient groups. CONCLUSION: Subjective (FOSS) and objective manofluorographic (CP-area, IB-Gra) improvement in CP bar patients occurred after ELCPM. We suggest IB-Gra as a reliable objective indicator for patients who might benefit from ELCPM and as an appropriate parameter for follow-up after surgery. However, continued research on a larger patient population is required to enhance our understanding of CP bar and predictors of outcome after treatment of CP bar dysphagia.

Anterior cervical osteophyte dysphagia: manofluorographic and functional outcomes after surgery.

BACKGROUND: Our aim was to investigate the clinical and manofluorographic findings of patients with anterior cervical osteophyte (ACO) dysphagia before and after surgery. METHODS: Chart review including manofluorography (MFG) data of patients undergoing ACO removal was undertaken. RESULTS: Thirteen patients underwent transcervical ACO removal over a 10-year period. A postoperative hematoma was the only surgical complication. Overall, there was a significant postoperative decrease in Functional Outcome Swallowing Scale (FOSS). MFG data showed an elevated preoperative intrabolus pressure gradient across the osteophyte (IB-Gra), 39.78 mm Hg, and IB-Gra significantly decreased to 19 mm Hg 6 months after surgery. CONCLUSION: Functional (FOSS) and objective MFG (IB-Gra) improvements occurred in patients who had ACO dysphagia and underwent surgery. These findings support high IB-Gra as a reliable objective indicator for surgical intervention for ACO dysphagia and IB-Gra as an appropriate parameter for follow-up after ACO removal. In selected patients, ACO removal by anterolateral-transcervical approach is a safe and highly effective treatment.

Computed tomographic angiography with three-dimensional reconstruction for transoral laser microsurgery.

OBJECTIVE: To identify major arteries in relationship to large pharyngeal tumors during transoral laser microsurgery. STUDY DESIGN: Case series with planned data collection. SETTING: Mayo Clinic, Jacksonville, Florida. SUBJECTS AND METHODS: We developed a new technique that combines three-dimensional CT angiography and enhanced soft-tissue neck CT for evaluation of pharyngeal tumors before transoral laser microsurgery. Data from CT angiography were used to create three-dimensional images of the tumor and adjacent arterial branches to better orient the surgeon to the spatial relationships of major arteries and pharyngeal tumors. Included were selected patients who had large tumors involving the pharynx and who underwent transoral laser microsurgery. RESULTS: Eighteen patients were studied from June 2008 through January 2009. Tumor enhancement was absent or modest in four of 18 patients. Three of these four patients had superficial squamous cell carcinomas and one had adenoid cystic carcinoma. The remaining 14 patients had good tumor enhancement. The tumor involved the lingual artery in three and displaced the lingual or facial artery in two of these 14 patients. One anomalous right inferior thyroid artery was identified. Compared with routine enhanced soft-tissue neck CT, three-dimensional CT angiography greatly enhanced the anatomical relationships of the major arteries. In one patient, the surgeon's approach was changed after three-dimensional CT angiography demonstrated an encased lingual artery. CONCLUSION: Three-dimensional CT angiography was useful in identifying the anatomical orientation of major arteries and the planning of transoral laser microsurgery to treat tumors involving the pharynx.

Evaluation of taste after underlay technique myringoplasty using whole-mouth gustatory test: smokers versus non-smokers.

The aim of this prospective non-randomized study was to evaluate the alterations in taste sensation after myringoplasty and to investigate the influence of smoking on taste. Ninety-six patients who underwent myringoplasty and 43 healthy controls were examined. Whole-mouth gustatory test solutions were sucrose (sweet); sodium chloride (salty taste); citrate (sour) taste; and quinine hydrochloride (bitter). Sucrose, citric acid, and sodium chloride recognition thresholds were high in the early postoperative period; however, they were regressed to the preoperative status in course of time. No difference was found between preoperative, early/late postoperative taste recognition thresholds of smoker and non-smoker patients. Underlay myringoplasty has little but transient effect on taste recognition in the early postoperative period. This impairment is completely recovered within 6 months. Furthermore, smoking has no effect on the taste recognition of patients with permanent tympanic membrane perforation and has no influence on the alterations in taste recognition thresholds after myringoplasty. We believe that this study will supply some additional aspects in the scope of taste disturbances due to ear surgery and smoking.

Current diagnosis and treatment of laryngocele in adults.

OBJECTIVE: To evaluate the treatment outcome of a series of laryngoceles and to comment on the current diagnosis and management of laryngoceles. STUDY DESIGN AND SETTING: A retrospective review of charts, radiological and histopathological notes, videolaryngostroboscopic records, and acoustic voice analyses of patients with laryngocele treated over a 10-year period was undertaken. RESULTS: Seven patients had internal laryngoceles; one had external; another one had combined laryngocele. Patients with internal laryngocele underwent endoscopic CO2 laser resection, while those with external or combined laryngocele were treated via external approach. Quality of voice was improved and no recurrences were encountered during the follow-up. No evidence of laryngeal cancer was found on the histological examinations. CONCLUSION: Endoscopic CO2 laser resection of internal laryngocele provides a reliable and cost-effective method that minimizes hospitalization and the need for tracheotomy. We believe that advances in the applications of laser in microlaryngosurgery will alter the traditional management of all type of laryngoceles.