INCIDENCE OF RECURRENT LARYNGEAL NERVE PALSY IN CERVICAL ANASTOMOSIS AFTER ESOPHAGECTOMY FOR CARCINOMA ESOPHAGUS

Objective: To study the incidence of Recurrent Laryngeal Nerve Palsy (RLNP) in cervical anastomosis after esophagectomy for carcinoma of the esophagus. Study Design: Prospective observational study. Place and Duration of Study: Military Hospital’s Thoracic surgery departments, Combined Military Hospital Rawalpindi, Combined Military Hospital Lahore and Combined Military Hospital Multan, from Jan 2010 to Sep 2020. Methodology: Designated proformas were used to collect data. Histopathologically proven, operable cases of carcinoma esophagus with normal phonation were included, all of which underwent cervical anastomosis. All cases of benign pathologies and per-operative macroscopically advanced loco-regional disease were excluded. Recurrent laryngeal nerve (RLN) was identified in all cases and follow-up of 6 months for recovery period was executed. Results: 220 cases were included out of which 121 (55%) were males while 99 (45%) females. The age range was 14-81 years (mean is 38.7 ± 16.78). Out of 29 (13.6%) cases underwent minimally invasive esophagectomy (MIE) while thoracophreno laparotomy was performed in 100 (45.4%) cases, McKeown in 46 (20.9%) and Trans-hiatal esophagectomy (THE) in 45 (20.4%) patients. Recurrent Laryngeal Nerve Palsy was found in 19 patients (8.6%), tracheal injury in 3 (1.3%) and bronchial injury in 1 (0.4%) patient. Recurrent Laryngeal Nerve Palsy was transient in 14 cases and permanent damage persisted in 5 patients. Conclusion: Recurrent Laryngeal Nerve Palsy after esophagectomy is related to increased morbidity due to respiratory complications. With Sharp dissection technique, adequate surgical skill and equipment, the incidence of Recurrent Laryngeal Nerve Palsy can be decreased. In our study, it is less............

Study to assess proper timing of laryngoscopy in post-thyroid surgery patients to detect recurrent laryngeal nerve injury

Background: Thyroid surgeries are commonly done nowadays for benign and malignant conditions. Recurrent laryngeal nerve palsy (RLNP) is an important and potentially catastrophic complication of thyroid surgery. The purpose of the study was to determine the impact of rigid endoscopy (Hopkins rod-lens telescope) performed at different time intervals on the diagnosis of RLNP in post-thyroid surgery patients. Aims and Objectives: To assess Proper Timing of Laryngoscopy in Post-thyroid Surgery patients to Detect RLN Injury. Materials and Methods: Rigid endoscopy was performed postoperatively at day 0 (T0), at 2nd day post-op (T1), and day 14 (T2). For patients with RLNP, repeated examinations were performed at 2 months (T3), 6 months (T4), and 12 months (T5). Results: The study included 50 patients of thyroid swelling with different diagnoses. Overall, 35 patients appeared for postoperative laryngoscopic examination of the vocal folds at our center, providing 61 nerves at risk. RLNP rate was 8.1% at T0, 11.5% at T1, 9.8% at T2, 8.1% at T3, 4.9% at T4, and 3.3% at T5. T1 was significantly superior to all other time intervals in terms of diagnosis of RLNP but statistically not significant. Conclusion: Rigid endoscopy is essential for the detection of vocal cord paralysis after thyroidectomy. We report different time evaluation criteria of vocal cord morbidity with great and significant variability of results. Second day post-op inspection of the larynx (T1) is suggested.

Hoarseness in an older adult: Ortner syndrome

A detailed examination in an older adult presenting with chronic hoarseness is mandatory to exclude an upper aerodigestive tract malignancy. We describe a 71-year-old chronic smoker with essential hypertension who presented with hoarseness and vocal fatigue for 5 months. Laryngoscopic examination showed left vocal fold paralysis with phonation gap. No growth was seen at all laryngeal and hypopharyngeal subsites. The rest of the head and neck, chest, upper limbs and neurovascular examination were unremarkable. A plain chest radiograph demonstrated a cause for the left recurrent laryngeal nerve palsy. The diagnosis, complications and definitive management of the underlying cause and resultant voice problem will be discussed.

Bilateral Recurrent Laryngeal Nerve Palsy following Total Thyroidectomy in Triple A Syndrome, an Unexpected but Critical Complication

Introduction. Triple “A” syndrome (TAS) is a rare autosomal recessive disorder that presents in childhood with achalasia cardia, alacrima, ACTH-resistant adrenal insufficiency, with sensorimotor and autonomic polyneuropathy developing later in the course of the disease. Case Presentation. An adult white male affected by this syndrome underwent an uneventful total thyroidectomy for malignancy and suffered delayed bilateral recurrent laryngeal nerve palsy in the early postoperative hours. The palsy spontaneously resolved after a five-week course. Conclusion. Given the rarity of this severe condition and the absence of surgical or medical causes identifiable, there is possibility that it is the neurological involvement caused by TAS that predisposed the patient to this adverse outcome, precipitated by standard manipulations during surgery.

Tracheal and Cricotracheal Resection With End-to-End Anastomosis for Locally Advanced Thyroid Cancer: A Systematic Review of the Literature on 656 Patients

Airway involvement by advanced thyroid carcinoma (TC) constitutes a negative prognosticator, besides being a critical clinical issue since it represents one of the most frequent causes of death in locally advanced disease. It is generally agreed that, for appropriate laryngo-tracheal patterns of invasion, (crico-)tracheal resection and primary anastomosis [(C)TRA] is the preferred surgical technique in this clinical scenario. However, the results of long-term outcomes of (C)TRA are scarce in the literature, due to the rarity of such cases. The relative paucity of data prompts careful review of the available relevant series in order to critically evaluate this surgical technique from the oncologic and functional points of view. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement on the PubMed, Scopus, and Web of Science databases. English-language surgical series published between January 1985 and August 2021, reporting data on ≥5 patients treated for TC infiltrating the airway by (C)TRA were included. Oncologic outcomes, mortality, complications, and tracheotomy-dependency rates were assessed. Pooled proportion estimates were elaborated for each end-point. Thirty-seven studies were included, encompassing a total of 656 patients. Pooled risk of perioperative mortality was 2.0%. Surgical complications were reported in 27.0% of patients, with uni- or bilateral recurrent laryngeal nerve palsy being the most common. Permanent tracheotomy was required in 4.0% of patients. Oncologic outcomes varied among different series with 5- and 10-year overall survival rates ranging from 61% to 100% and 42.1% to 78.1%, respectively. Five- and 10-year disease specific survival rates ranged from 75.8% to 90% and 54.5% to 62.9%, respectively. Therefore, locally advanced TC with airway invasion treated with (C)TRA provides acceptable oncologic outcomes associated with a low permanent tracheotomy rate. The reported incidence of complications, however, indicates the need for judicious patient selection, meticulous surgical technique, and careful postoperative management.

Post-thyroidectomy complications in southwestern Saudi Arabia: a retrospective study of a 6-year period

BACKGROUND: Thyroidectomy is the surgical removal of all or part of the thyroid gland for non-neoplastic and neoplastic thyroid diseases. Major postoperative complications of thyroidectomy, including recurrent laryngeal nerve injury, hypocalcemia, and hypothyroidism, are not infrequent. OBJECTIVE: Summarize the frequency of surgical complications of thyroidectomy. DESIGN: Retrospective. SETTING: Secondary health facility in southwestern Saudi Arabia. PATIENTS AND METHODS: We collected data from the records of patients who were managed for thyroid diseases between December 2013 and December 2019. MAIN OUTCOME MEASURE: Complications following thyroidectomy. SAMPLE SIZE: 339 patients, 280 (82.6%) females and 59 (17.4%) males. RESULTS: We found 311 (91.7%) benign and 28 (8.3%) malignant thyroid disorders. Definitive management included 129 (38.1%) total thyroidectomies, 70 (20.6%) hemithyroidectomies, 10 (2.9%) subtotal thyroidectomies and 5 (1.5%) near-total thyroidectomies with 125 (36.9%) patients treated non-surgically. The overall complication rate was 11.3%. There were 4 (1.9%) patients with recurrent laryngeal nerve palsy, 16 (7.5%) patients with temporary hypoparathyroidism, 1 (0.5%) patient with paralysis of the external branch of the superior laryngeal nerve and 3 (1.4%) patients with wound hematoma. CONCLUSION: The rate of complications following thyroidectomy is still high. There is a need for emphasis on comprehensive measures to control the high rate of complications. LIMITATIONS: Retrospective design and no long-term follow up to monitor late complications. CONFLICT OF INTEREST: None.

Outcomes of esophagectomy for patients with esophageal squamous cell carcinoma accompanied by recurrent laryngeal nerve palsy at diagnosis

Background Hoarseness is one of the classical symptoms in patients with locally advanced thoracic esophageal squamous cell carcinoma (ESCC), and it results from recurrent laryngeal nerve palsy, which is caused by nodal metastasis along the recurrent laryngeal nerve or by main tumors. We reviewed the short-term and long-term results of esophagectomy for patients with locally advanced ESCC and hoarseness at diagnosis. Patients Patients who initially presented with hoarseness from recurrent laryngeal nerve palsy between 2009 and 2018 and underwent esophagectomy for thoracic ESCC were eligible for this study. Pharyngolaryngectomy or cervical ESCC were exclusionary. Results A total of 15 patients were eligible, and 14 underwent resection of the recurrent laryngeal nerves. The remaining patient had nerve-sparing surgery. Nine patients (60%) had post-operative complications ≥ Clavien–Dindo class II and, pulmonary complications were most common. Two patients (13%) died in the hospital. The 5-year overall survival rate for all patients was 16%. Age (≤ 65 years), cT1/T2 tumor, and remarkably good response to neoadjuvant treatment were likely related to longer survival; however, these relationships were not statistically significant. Conclusions Esophagectomy for ESCC patients who are diagnosed with recurrent laryngeal nerve paralysis at initial presentation could be a treatment option if the patient is relatively young, has a cT1/T2 tumor, or shows a remarkably good response to neoadjuvant treatment. However, clinicians should be aware of the possibility of postoperative pulmonary complications, which were frequently observed with the procedure.