Should we routinely expose recurrent laryngeal nerve(s) during thyroid surgery?

OBJECTIVE: To compare the frequency of recurrent laryngeal nerve(s) (RLNs) palsy after various thyroid procedures with and without identification of recurrent laryngeal nerve during the operation. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Surgery, Military Hospital, Rawalpindi, from August 2008 to April 2010. METHODOLOGY: Patients undergoing indirect laryngoscopy with normal vocal cords and those with carcinoma and re-do surgery having normal vocal cord were included in the study. Patients with hoarseness of voice, abnormal vocal cord movements and with solitary nodule in the isthmus were excluded. These patients were randomly divided into 2 groups of 50 each using random number tables. RLN was identified by exposing the inferior thyroid artery and traced along its entire course in group-A. Whereas, in group-B, nerves were not identified during the operations. Immediate postoperative direct laryngoscopy was performed by a surgeon with the help of an anaesthesiologist for the assessment of vocal cords. Patients with persistent hoarseness of voice were followed-up with indirect laryngoscopy at 3 and 6 months. RESULTS: Temporary unilateral recurrent laryngeal nerve palsies occurred in 2 (4%) patients in group-A where the voice and cord movements returned to normal in 6 months. In group-B, it occurred in 8 (16%) patients, 2 bilateral (4%) injuries requiring tracheostomy and 6 unilateral injuries (12%). Among the 2 bilateral recurrent laryngeal nerve injuries, the tracheostomy was removed in one case after 6 months with persistent hoarseness of voice but no respiratory difficulty during routine activities. Tracheostomy was permanent in the other case. Among the 6 cases of unilateral nerve injuries, the voice improved considerably in 4 cases within 6 months but in 2 cases hoarseness persisted even after 6 months. Frequency of recurrent laryngeal nerve palsies was significantly lower in group-A as compared to group-B (p = 0.046). CONCLUSION: For safe thyroid surgery, recurrent laryngeal nerve(s) should be routinely exposed in its entire course.

Spontaneous nephrocutaneous fistula in tuberculous pyelonephritis.

A rare case of spontaneous nephrocutaneous fistula with renal tuberculosis is presented here. A 70 years old male with neglected stones in right kidney was investigated for discharging sinus right lumbar region of three months duration. Excretory urography revealed non-functioning right kidney and an impacted stone right upper ureter and a small stone in renal pelvis. The patient was successfully treated by nephroureterectomy and excision of the fistulous track followed by anti-tuberculous treatment. Histopathology of the specimen revealed renal tuberculosis. Though the incidence of various forms of tuberculosis is very high in this part of the world, presence of nephrocutaneous fistula is still uncommon.

Halothane induced fulminant hepatic failure.

A rare case of halothane-induced fulminant hepatic failure is reported in a 22 years old male, who developed fever, jaundice, coma and deranged coagulation profile, 2 days after undergoing laparotomy under halothane anaesthesia. Despite all supportive care, he died of fulminant hepatic failure, 6 days after surgery. Postmortem liver biopsy revealed massive predominantly centrilobular hepatic necrosis.