Transoral robotic resection of lingual thyroid: case report.

OBJECTIVE: We present a case of large, symptomatic lingual thyroid which was successfully and safely removed via a transoral approach, using the da Vinci robotic system, in an academic medical centre in Singapore. CASE REPORT: A 17-year-old female adolescent presented with a large lingual thyroid causing upper airway obstruction. She underwent robotic, minimally invasive, transoral resection using the da Vinci system. Post-operative recovery was uneventful; she was able to commence oral feeding almost immediately, and was discharged from hospital on the fourth post-operative day. CONCLUSION: It is surgically feasible and safe to undertake transoral robotic resection of a large lingual thyroid. This approach may allow faster recovery and shorter hospitalisation for patients. Surgical safety requires a full understanding of the intralingual neurovascular anatomy.

Long-term results of endoscopic resection of nasopharyngeal tumours.

Traditional open approaches to the nasopharynx either provide limited access and risk significant morbidity. Here we describe our experience with endoscopic resection of nasopharyngeal tumours. Retrospective chart review was performed for all patients who underwent endoscopic nasopharyngeal resection from September 1993 to January 2007 at a tertiary rhinology centre. Six patients underwent endoscopic nasopharyngectomy for tumours arising from or involving the nasopharynx. The mean age was 49.8 years (range 23 - 70). The sex distribution was five males and one female. Four tumours were malignant and two were benign. The mean disease-free and overall survival for malignant tumors was 90.75 months (range 66 - 120 months). None of the benign tumors recurred. The endoscopic nasopharyngectomy technique may be successfully used for resection of tumors arising from or involving the nasopharynx with good efficacy and a decrease in morbidity when compared to open approaches.

10th Yahya Cohen Memorial Lecture: Clinical predictors in obstructive sleep apnoea patients with computer-assisted quantitative videoendoscopic upper airway analysis.

AIM: To identify the clinical predictors and assist surgeons in their clinical management of obstructive sleep apnoea (OSA) - a prospective study with a new approach to analyse the static and dynamic upper airway morphology between patients with OSA and normal subjects. To introduce a new method of assessment for surgical outcome. MATERIALS AND METHODS: Quantitative computer-assisted videoendoscopy (validated with upper airway magnetic resonance imaging) was performed in 49 (43 males, 6 females) patients with OSA and compared with 39 (22 males, 17 females) controls (apnoea-hypopnoea index <5). Absolute cross-sectional areas, transverse and longitudinal diameters at the retro-palatal and retro-lingual levels were measured during end of quiet respiration and during Mueller's manoeuvre in the erect and supine positions, allowing us to study static and dynamic morphology (collapsibility) of the upper airway. We analysed 3744 parameters. RESULTS: In males, retro-palatal and retro-lingual areas during Mueller's manoeuvre in the supine position of 0.7981 cm2 [receiver operating characteristics (ROC) = 0.9284, positive predictive value (PPV) = 86.05%, negative predictive value (NPV) = 84.62%] and 2.0648 cm2 (ROC = 0.8183, PPV = 76%, NPV = 83.33%), respectively, were found to be good predictors/ cut-off values for OSA. Retro-palatal area measured in the supine position during Mueller's manoeuvre (AS1M) and collapsibility of retro-palatal area in the supine position calculated (CAS1) were found to have significant correlations with severity of OSA. In females, areas measured during Mueller's manoeuvre in the supine position of 0.522 cm2 at retropalatal level (ROC = 1, 100% PPV and NPV) and transverse diameter at retro-lingual level during erect Mueller's manoeuvre of 1.1843 cm (ROC = 0.9056, PPV = 100%, NPV = 83.33%) were found to be predictive. All measurements at the retro-palatal level and in the supine position had higher predictability. Area measurements obtained during Muller's manoeuvre were more predictive (ROC >0.9910) than resting measurements (ROC >0.8371). Several gender and anatomical-site specific formulas with excellent predictability (ROC close or equal to 1) were also devised. Examples of surgical outcome assessment were introduced. CONCLUSION: Upper airway Mueller's studies are predictive and useful (independent samples t-test/Mann Whitney U test, ROC) in identifying patients with OSA. With these gender and anatomical-site specific OSA predictors/formulas and this innovative clinical method, we hope to assist other surgeons with quantitative clinical diagnosis, assessment, surgical planning and outcome assessment tools for OSA patients.

Quantitative computer-assisted digital-imaging upper airway analysis for obstructive sleep apnoea.

This was a prospective study of a new objective method which quantitatively analyses the upper airways in patients with obstructive sleep apnoea (OSA). Video-nasopharyngoscopic examinations of the upper airways of 45 patients were carried out with an endoscopic calibrator. Images of the upper airway during quiet respiration and Mueller's manoeuvre in erect and supine positions were digitized by computer to generate the actual dimensions of obstructive sites. Measurements by the new method were validated by comparing 90 pairs of videoendoscopic images with upper airway magnetic resonance imaging (MRI) measurements at two identical levels. Quantitative precision is 100% for the retropalatal level and 95.6% for the retrolingual level with a tolerance of 0.5 cm(2) between the two methods. The absolute mean of the difference between the two methods of measurement is 0.08 cm(2) at the retropalatal level and 0.18 cm(2) at the retrolingual level. The agreement between the digital-imaging videoendoscopic and MRI measurements was 93.3% for the retropalatal level and 95.6% for the retrolingual level. Quantitative computer-assisted digital imaging is a reliable, cost-effective clinical method of upper airway evaluation in OSA patients. This method allows us to examine the dynamic and static morphology objectively, measure surgical outcomes of upper airway, opening up new avenues for OSA management.

Adriamycin-induced cardiomyopathy aggravated by cis-platinum nephrotoxicity requiring dialysis.

Complications of chemotherapy for a synovial sarcoma in an eight-year old boy included cisplatinum nephrotoxicity and adriamycin cardiotoxicity. The resultant renal failure and fluid overload necessitated peritoneal dialysis. Intractable hypomagnesemia was also a prominent feature.