[Contribution of neuromonitoring to the safety of tracheal extubation after total thyroidectomy. Prospective study with needle electrodes]. / Contribución de la neuroestimulación a la seguridad en la extubación traqueal tras tiroidectomía total. Estudio prospectivo con electrodos de aguja.

INTRODUCTION AND OBJECTIVES: Bilateral laryngeal paralysis cause serious respiratory complications. In thyroid surgery, neuromonitoring helps in identifying the recurrent laryngeal nerve, reports on its functioning at the end of surgery, supports decision making, and may reduce the risk of bilateral paralysis. Our objective was to estimate the influence of neuromonitoring in operative strategy and extubation safety in total thyroidectomy. METHODS: A non-randomized prospective study was conducted on 210 patients undergoing total thyroidectomy (420 laryngeal nerves stimulated included). We collected qualitative neuromonitoring variables (presence or absence of final signal after stimulation of the vagus nerve), and postoperative indirect laryngoscopy (normal motility or paralysis), performed until 3rd day after the surgery. RESULTS: The accuracy of the test was 99.5% (95% CI 98.3 to 99.9). The positive predictive value was 100% (95% CI 99.1 to 100), which showed the high ability of neuromonitoring to predict paralysis in case of loss of signal, and the negative predictive value was 99.5% (95% CI 98.3 to 99.9), which indicated its predictive capacity for normal motility when there is a normal signal. CONCLUSIONS: In our group of patients, recurrent laryngeal nerve monitoring was useful in total thyroidectomy as it provided information on the prognosis of laryngeal motility, and helped in making decisions during surgery when there was signal loss. Due to the risk of serious respiratory complications due to bilateral recurrent laryngeal nerve paralysis, we opted for the performing of the 2-stage total thyroidectomy in case of signal loss in the first lobectomy. Thereby, neuromonitoring contributed to the safety of the airway in tracheal extubation, aiding in the prevention of a possible bilateral laryngeal paralysis.

[Hemostasis and neuromonitoring as patient safety measures in thyroid surgery]. / Influencia de las técnicas de hemostasia quirúrgica y la neuromonitorización intraoperatoria en la incidencia de eventos adversos en cirugía de tiroides.

INTRODUCTION: The most frequent adverse effects after thyroidectomy are hemorrhage, recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, and airway complications. OBJECTIVES: To evaluate if improvement actions introduced in thyroidectomy have an influence on monitored sentinel events after surgery of thyroid gland. METHOD: A retrospective study of 954 patients subjected to thyroidectomy during the period 1997 to 2011. The hemostasis techniques used were, conventional ligature and mono or bipolar electrocoagulation in period A (1997-2006), and the Harmonic Ultracision(®) technology was used exclusively during periods B (2006-2010) and C (2011). The identification the RLN was performed visually in periods A-B and by intraoperative neuromonitoring in period C. RESULTS: On comparing periods A and B + C, there was a significant reduction in the incidence of bleeding from 1.92% to 0.24% (P=.007), and postoperative complications in the airway that required tracheotomy from 1.28% to 0% (P=.012). The reductions in the incidence of RLN paralysis (from 1.32% to 0.8%, P=.45) and hypoparathyroidism (from 1.1% to 0.6%, P=.42) were not statistically significant. The number of annual events decreased from period A (odds ratio=3.51) to C (odds ratio=0.39). CONCLUSIONS: Technical improvements in hemostasis, and identification of RLN, increase patient safety in thyroid surgery.

[Commentaries on the complication of vestibular diseases]. / Comentarios sobre minusvalía en patología vestibular.

Handicap of the patient with vestibular disease can be measured by means of scales and questionnaires. The utility of a questionnaire developed and validated in Spanish language is commented (CEMPV). The CEMPV consists of 46 questions distributed in three scales (emotional, functional and organic) whose obtained scores are related to diverse degrees of handicap (global, emotional, functional and organic). The CEMPV is self-employed and evaluates the evolution of the patient and allows to accredit the results obtained between different investigators.

[Subglottic pleomorphic adenoma]. / Adenoma pleomorfo subglótico.

Pleomorphic adenoma is the most common tumor of major salivary glands, but it is unusual into the larynx. The AA. expose a case of a 74-year-old man who consulted for dysphonia and diagnosed as having a subglottic pleomorphic adenoma. The patient needed an urgent tracheotomy owing to the dyspnoea. Removal of the tumor was made through direct laryngoscopy. Literature on pleomorphic laryngeal adenoma is reviewed.

[Solitary extramedullary plasmacytoma of the rhinopharynx]. / Plasmocitoma extramedular solitario de rinofaringe.

Solitary extramedullary plasmacytoma involving the nasopharynx is very rare. A case of asymptomatic extramedullary plasmacytoma in the nasopharynx in a 69-year-old man is presented. Radiotherapy was the treatment (60 Gy). In this patient two neoplasms of B series are associated (lymphoproliferative B Kappa syndrome and extramedullary plasmacytoma).

[Disability and vestibular pathology]. / Minusvalía y patología vestibular.

OBJECTIVE: To probe the ability in differentiate the handicap degree among patients with peripheral vestibular illness by means of a questionnaire carefully thought with this purpose. DESIGN: Prospective study covering 2 years (May 1st. 1991 till May the 1st. 1996). FIELD OF STUDY: Patients from the Health Area of Zamora, ambulatory attended at Otolaryngology Department, complaining of peripheral vestibular troubles. INDIVIDUALS INCLUDED: 60 patients diagnosed as paroxitic positional vertigo or Ménière's disease, lasting the discomfort either 6 weeks or less or 2 years or more, the totality split into 4 groups, of 15 individuals each. SCORING: Analysis of the performed scores of the first valuation by means of the Questionnaire for Assessment of the Disability in Vestibular Pathology (Q.A.D.V.P.). Descriptive statistics were performed for each group and each scale. RESULTS: Patients with more than 2 years of evolvement present themselves, usually, with higher scores in both emotional and functional scales if compared with those resulting from patients suffering from paroxistic positional vertigo. CONCLUSIONS: The Q.A.D.V.P. is a measure instrument very useful, by allowing the differentiation of several degrees of disabled people of our studied samples.

[Fronto-ethmoidal mucocele: endoscopic fronto-orbital approach]. / Mucoceles frontoetmoidales: abordaje combinado endoscópico y frontoorbitario.

OBJECTIVE: To revise the references of surgical approach of the mucocele into frontal sinus. DESIGN: A retrospective study. STUDY SUBJECTS: Three patients with mucocele frontal and orbitary encroachment were treated with endoscopic and associated external approach. The follow-up period has been between 22 and 36 months. RESULTS: Combined approach allow marsupialization and adequate repermeabilization of the nasofrontal duct. CONCLUSIONS: Endoscopy surgery is the choice method in treatment of mucoceles, but the access has to be completed by an external approach when the lateral wall of the frontal sinus is extended or the mucocele exterioriced.

[Treatment review in rhinocerebral mucormycosis]. / Revisión del tratamiento en la mucormicosis rinocerebral.

The rhinocerebral mucormycosis is the more common form produced by Rhizopus, a genus of fungi. It's a serious infective disease with high mortality, that needs a precocious medical treatment. Amphotericin B is the choice medical treatment, but liposomal amphotericine B in recent years is a better drug, due to minor renal toxicity and greater tisular diffusion. Even can not to treat all affected areas it's necessary an extensive surgical treatment according to individual characteristics and disease evolution. A 56-year-old man with rhinocerebral mucormycosis, caused by Rhizopus, who was treated with liposomal-amphotericin B and extensive rhino-orbital surgery is presented.

[Ischemia of the anterior vestibular artery (Lindsay-Hemenway syndrome). Review and comments]. / Isquemia de la arteria vestibular anterior (síndrome de Lindsay-Hemenway). Revisión y comentarios.

INTRODUCTION: The Lindsay and Hemenway syndrome is produced by ischemia in the territory of the anterior vestibular artery and is characterized by an initial episode of acute vertigo followed by benign paroxysmal positional vertigo and decreased or abolished caloric response. OBJECTIVE: To determine the incidence of anterior vestibular artery syndrome in patients with benign paroxysmal positional vertigo. DESIGN: A 3-year retrospective study (January 1994 to December 1996). SETTING: Patients with benign paroxysmal positional vertigo of the Zamora and Salamanca (Spain) health districts seen in two outpatients clinics. STUDY SUBJECTS: Ninety-eight patients with benign paroxysmal positional vertigo. RESULTS: Sixteen patients diagnosed as anterior vestibular artery syndrome were revised (16.3%). CONCLUSIONS: Although the literature is scarce, the incidence of Lindsay-Hemenway syndrome seems to be underestimated.

[Questionnaire for disability assessment in vestibular pathology]. / Cuestionario para la evaluación de la minusvalía en patología vestibular (CEMPV).

The QADVP (questionnaire for assessment of disabled by vestibular pathology) is self-employed and consists of a series of 46 questions divided into 3 scales (emotional, functional and organic) from which direct and proportionate scores (both for each scale and as a whole for the full questionnaire) are gained. The aim of the paper is to show its application-way, the outcome of assessments and the disability degree drawn out from the scores. A prospective study fulfilled within 2 years term (May, 1st 1994 until May, 1st 1996) between patients of the Health Area of Zamora, seen at the ENT outpatients Department. The validation's study (reliability, homogeneity and discriminatory power in each scale and of the whole questionnaire) was made from a sample of 30 patients suffering of recurring-paroxysmal vestibular disease of several etiologies. In order to establish the handicap degree the questionnaire was employed in 60 patients suffering postural-paroxysmal vertigo or Ménière disease, grouped in 4 homogenous sets after the evolutive time. The series in each scale and globally for the whole questionnaire make sharp 4 levels of handicap (from I to IV). Zero degree is equivalent to absence of vestibular disorder. The QADVP is a measuring tool allowing: assessment several degrees of incapacity, to control the development of the disorder and try therapeutic changes.

[Comments on the treatment of rhinocerebral mucormycosis]. / Comentarios sobre el tratamiento en la mucormicosis rinocerebral.

Rhinocerebral mucormycosis is a serious infectious disease with a high mortality rate that requires early medical treatment. Liposomal amphotericin B is the medical treatment of choice because of its low renal toxicity and good tissue diffusion. Surgical treatment is necessary, even if all affected areas cannot be reached. The surgical indication should be based on individual characteristics and disease evolution. The case of a 56-year-old man with rhinocerebral mucormycosis caused by Rhizopus and treated with liposomal amphotericin B and extensive rhino-orbital surgical treatment is commented.

[Anxiety and vertigo]. / Ansiedad y vértigo.

AIM OF THE STUDY: To determinate the prevalence of anxiety associated with vertigo of vestibular origin. DESIGN: A retrospective study. SETTING: Patients from Salamanca's University Hospital (Neuro-Otology). PATIENTS: 138 patients with asymptomatic vestibular dysfunction (group A: with filiated disease and group B: with unfiliated disease). INSTRUMENTATION: Structured anamnese and STAI questionnary (State-Trait-Anxiety-Scale) were realized in the whole collective. RESULTS: Anxiety (elevated score in STAI-scale) was detected in 48.6% patients and more differences between groups A and B were not significant. With logistic regression anxiety is related with previous symptomatological experiences and subjective global incapacity. Anxiety is clearly connected with the symptoms in the intercritic periods. CONCLUSION: Anxiety is associated with vestibular disease and it follows a parallel course.

[The anamnesis in old people with equilibrium disorder]. / La anamnesis en el anciano con patología del equilibrio.

Equilibratory troubles in aged individuals are the consequence of changes in vestibular, visual, proprioceptive, neuro-muscular and skeletal systems. Often related as well, to iatrogenic effects induced by pharmacological treatments. Its assessment is not easy at all because elderly population undergo physiological inability and so offer great difficulties in both diagnosis and management. At least informative data related to the equilibration must be collected: feelings, positional and postural unleashing factors, evolutive pattern, intercrises symptoms, cochlear and neurologic findings. Pharmacological treatments, associated pathologies and psycho-affective conditions as well. In the anamnestic model proposed by the AA. other helpful data in order to arouse clinical suspicion on vasculocerebral and vertebrobasilaris pathologies are contemplated. A sample concerning 51 patients more than 70-year-old with the gained descriptive results in detailed.

[Detection of primary tumor in cervical lymph node metastases of unknown origin]. / Detección del tumor primario en metástasis ganglionares cervicales de origen desconocido.

OBJECTIVE: To determine the incidence of cervical metastases of cancer of unknown origin and the probability of locating the primary tumor. DESIGN: A three-year prospective study (January 1992 to December 1994). SETTING: Patients of the Zamora (Spain) health district who were seen in the head and neck oncology unit of the Virgen de la Concha Hospital for malignant neck tumor. STUDY SUBJECTS: Seventy-nine patients with lymphatic carcinomatous metastases in neck. RESULTS: A primary tumor of the pharynx, larynx, or oral cavity was found in 56 cases (70.9%). No primary tumor was located in 12 patients (15.2%). The primary tumor was an asymptomatic tumor of the chest, abdomen, or pelvis in 11 cases (13.9%) (3 pulmonary, 2 renal, 2 prostatic, 1 vesical, 1 gastric, and 2 esophageal). The probability of locating the primary tumor by clinical examination and noninvasive methods was p = 0.95. CONCLUSIONS: The diagnostic strategy for cervical metastases of an unknown primary was reviewed. The probability of locating the primary tumor depended on diagnostic phase.

[Validity of videolaryngoscopy in detecting laryngeal structural changes]. / Validez de la videolaringoscopia en la detección de lesión estructural laríngea.

STUDY OBJECTIVE: To determinate the validity of videolaryngoscopy on diagnose of laryngeal diseases versus other laryngoscopic methods. DESIGN: Retrospective study covering 2 years (1992 and 1993). SETTING: 267 were the consulting patients because of dysphony. This collective was ranged in 2 groups. Group A included those hoarse individuals in whom was detected a growth, confirmed afterwards by means of direct laryngoscopy, biopsy and pathologists examination of a smear. Group B was formed for dysphonics with no organic changes seen through indirect laryngoscopy. INTERVENTIONS: All patients underwent indirect laryngoscopy (laryngeal mirror) and videolaryngoscopy. Patients showing an organic lesion underwent, also, suspension direct laryngoscopy, biopsy and histopathological control (reference's measurement). In all laryngoscopic procedures were determinated presence or absence of laryngeal changes (organic or functional) and the glottic area involved. RESULTS: In 156 patients direct laryngoscopies were performed. Organic lesion could be confirmed in 154 cases. The relative sensibility of videolaryngoscopy versus laryngeal mirror account for 0.4 and its negative predictive value for 0.26. The correlation videolaryngoscopy direct laryngoscopy results in 1. CONCLUSIONS: Videolaryngoscopy is a method with major sensibility and negative predictive value as indirect laryngoscopy with mirror. But the latter is indispensable in diagnosis of laryngeal organic lesions and must be done prior to microlaryngoscopie direct examination.

[Asymptomatic thoracic and abdominal tumors with lymph nodes metastasis as a reason for consultation]. / Tumores torácicos y abdominales asintomáticos con metástasis ganglionar cervical como motivo de consulta.

OBJECTIVE: To determine the incidence of metastatic cancer to the neck from asymptomatic primary tumors in thorax, abdomen or pelvis. DESIGN: Two years term (January 1992 to December 1993) retrospective study. PATIENTS AND METHOD: Presentation of 57 patients with a neck mass which through puntion-aspiration (FNB), cervicotomy and biopsy confirmed any type of carcinoma. RESULTS: In 39 cases (68.42%) a primary tumor either in the pharynx or mouth were affirmative of growth; in other 10 (17.54%) the site of the primary remainded unknown; and 8 cases (14.04%) the primary tumor even asymptomatic could be localized inside the thorax or abdomen (3 pulmonary, 2 kidney, 1 stomach, 1 prostate and 1 esophagus). In other 2 occurrences, a cervicofacial association existed (1 case a synchronic growth of the hypopharynx-prostate, the other one cavum pharyngis and lung). COMMENTS: Cases diagnosed as asymptomatic thoracic or abdominal tumors are commented and its bibliography reviewed. The same as diagnostic strategy in hidden primaries aiming to the probability of ascertain the sitting in each diagnostic stage.