The Effect of Patient Positioning on Intraoperative Neuromonitoring During Thyroid and Parathyroid Surgery

Background Intraoperative neuromonitoring (IONM) has been accepted as a routine adjunct among surgeons who perform thyroid and parathyroid surgeries. Thyroid and parathyroid surgeries use various patient positioning strategies that have poorly understood effects on IONM. The aim of this study was to compare IONM signals between the transaxillary and transcervical approaches. Methods In this retrospective cohort study, we evaluated 463 adult patients who underwent a total of 502 procedures. The procedures performed included total thyroidectomy, right or left hemithyroidectomy, and parathyroidectomy. Vagus nerve and recurrent laryngeal nerve (RLN) latency and amplitude measurements were analyzed intra-operatively. The distances between the vagus nerve and the trachea were measured via ultrasound during transaxillary procedures. Results Compared to the transcervical approach, the right vagus nerve latency was significantly decreased in the transaxillary approach. Transaxillary surgery was not associated with increased latency or decreased amplitude on IONM. The distance between the vagus nerve and trachea was significantly decreased post-positioning during transaxillary approaches. Discussion Despite differences in patient positioning, a transaxillary approach was not associated with increased stress on the vagus nerve or RLN, according to IONM data. The decreased right vagus nerve latency associated with a transaxillary approach highlights the importance of considering patient positioning and laterality while interpreting IONM data.

Diagnosis and Management of Giant Esophageal Fibrovascular Polyp With Hypopharyngeal Pedicle

Background: Fibrovascular polyps (FVPs) with hypopharyngeal pedicles (hFVPs) are the rare intraluminal benign tumours of the upper aerodigestive tract, and their accurate diagnosis and optimal management are challenging. Purpose: The present retrospective study attempted to explore the optimal diagnosis and treatment of hFVPs. Research Design: The clinical records of 2 patients with giant, irregularly shaped hFVPs, who underwent several failed surgical procedures after inaccurate diagnosis, were reviewed. Finally, the patients were correctly diagnosed and successfully treated at Capital Medical University Beijing Friendship Hospital in different years, 2018 and 2020. Results: Case 1 was of a 43-year-old woman with 2 months of progressive dysphagia. Gastroenterologists overlooked the origin of her FVP, and decided to sever its narrowest point in the oesophagus through endoscopy. However, upon unsuccessful removal of the mass, a gastrotomy procedure was performed to extract the mass 7 days later. Symptoms recurred 3 months after the treatment, and a fibreoptic laryngoscopy confirmed hFVP in the patient at our department. A transcervical approach was used to sever the hypopharyngeal pedicle, achieve haemostasis and remove the oesophageal tumour. No recurrence was detected during the 2-year follow-up period after the treatment. Case 2 was of a 32-year-old man with dysphagia who had previously undergone transthoracic and transcervical oesophagotomy procedures within a gap of 3 months for the removal of FVP causing dysphagia. The hypopharyngeal pedicle was not diagnosed in the patient. The symptoms of dysphagia recurred 4 years after the treatment, and a fibreoptic laryngoscope confirmed hFVP at our department. The tumour was removed successfully through the transcervical approach. No recurrence was detected during the 6-months follow-up after surgery. Conclusion: In conclusion, the transcervical approach is suitable for achieving haemostasis and removing giant, irregularly shaped hFVPs.

A case report of a huge euthyroid goiter with retrosternal extension

Massive goiter with retrosternal extension is most frequently found in the anterior mediastinum; however, 10%–15% of the cases are found in the posterior mediastinum. It may induce symptoms caused by tracheal, esophageal, and recurrent laryngeal nerve compression. Surgery for such a huge mass requires a high degree of experience to avoid serious complications, particularly if it weighs >500 g. Herein, we report the case of a 64-year-old man who complained of neck swelling which was gradually increasing in size during the past 19 years and breathing difficulty that worsened during the past years. A 31 × 16 cm heterogeneous enhancing mass that expanded the thyroid gland with retrosternal extension, pushing the main vessels posterolaterally and compressing the trachea, was detected during computed tomography of the neck and chest. Total thyroidectomy was performed safely via a transcervical approach. The recovery period was uneventful, and the patient was discharged 5 days later. Given the rarity of a massive goiter that pushes the main vessels and compresses the trachea in the posterior mediastinum, this case report emphasizes the treatment options and outcome of this condition.

Current Therapeutic Approaches to Subglottic Stenosis in Patients With GPA: A Systematic Review

Background: The management of subglottic stenosis (SGS) in granulomatosis patients with polyangiitis (GPA) has no clear guidelines. This systematic review aimed to identify different surgical techniques and evaluate the outcomes of applied procedures. Methods: An electronic search was performed using 3 major databases, CINAHL, PubMed, and Clinical key, to include relevant studies published from the databases from inception through January 2017. All primary studies reporting treatment of SGS in cases with GPA were included. Articles were excluded if not relevant to the research topic or if they were duplicates, review articles, editorials, short comments, unpublished data, conference abstracts, case reports, animal studies, or non-English studies. Results: Thirteen papers were included in our systematic review with a total of 267 cases for the qualitative review Endoscopic approaches showed favorable outcomes with the need to use multiple procedures to achieve remission. The open transcervical approach showed excellent results mainly after failure of other endoscopic techniques. Tracheostomy was necessary for severe respiratory obstruction symptoms. Medical treatment was essential for stabilizing the active disease and therefore may enhance the success rate postoperatively. Conclusion: Subglottic stenosis in patients with GPA requires a multidisciplinary approach to provide optimal management regarding disease activity, grade of stenosis, and severity of symptoms.

Classic Eagle’s Syndrome: Styloidectomy via the Transcervical Approach

Eagle’s syndrome was first described by Watt Eagle in 1937, as a syndrome of vague orofacial and cervical pain. He reported two variants, classic styloid and stylocarotid artery syndrome. Eagle’s syndrome is a non-perceived and underdiagnosed clinical condition of the head and neck. This anomalous entity presents with neck pain, globus sensation, difficulty in turning the head, dysphagia, odynophagia and various other symptoms occurring as a result of irritation to the nearby structures. The surgical management of Eagle’s syndrome consists of two major approaches: the transoral and the transcervical approaches. We report a case of classic bilateral elongated styloid process syndrome, treated with transcervical styloidectomy for painful left elongated styloid process. This gave permanent relief to the patient. The transcervical surgical approach for resection of elongated styloid process in patients with Eagle’s syndrome appears to be safe and effective, although the risk for transient marginal mandibular nerve weakness is notable.

Needle in the Haystack: Wire Bristle Foreign Body Presenting Deep Within the Tongue Base

Objectives: To report a case of ingested wire bristle embedded within the extrinsic musculature of the tongue requiring a transcervical approach for removal and to provide a revised algorithm for the management of ingested wire bristles. Methods: The clinical record of 1 patient who ingested a grill brush wire bristle was reviewed. A literature review was also conducted to refine a treatment algorithm for managing ingested wire bristles. Results: We present a case of a 53-year-old male who accidentally ingested a grill brush wire bristle. After multiple unsuccessful endoscopic attempts at removal, the wire bristle migrated deep into the extrinsic musculature of the tongue, necessitating a transcervical approach for adequate visualization and retrieval. Conclusions: This is the first case reported of a wire bristle migrating deep into the tongue musculature that was successfully removed via a transcervical approach. Our proposed algorithm provides a comprehensive approach to the management of ingested wire bristles, specifically in cases where endoscopic retrieval is not feasible.