Erivelto Martinho Volpi

Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: International standards guideline statement

Intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery has gained widespread acceptance as an adjunct to the gold standard of visual nerve identification. Despite the increasing use of IONM, review of the literature and clinical experience confirms there is little uniformity in application of and results from nerve monitoring across different centers. We provide a review of the literature and cumulative experience of the multidisciplinary International Neural Monitoring Study Group with IONM spanning nearly 15 years. The study group focused its initial work on formulation of standards in IONM as it relates to important areas: 1) standards of equipment setup/endotracheal tube placement and 2) standards of loss of signal evaluation/intraoperative problem‐solving algorithm. The use of standardized methods and reporting will provide greater uniformity in application of IONM. In addition, this report clarifies the limitations of IONM and helps identify areas where additional research is necessary. This guideline is, at its forefront, quality driven; it is intended to improve the quality of neural monitoring, to translate the best available evidence into clinical practice to promote best practices. We hope this work will minimize inappropriate variations in monitoring rather than to dictate practice options. Laryngoscope, 121:S1–S16, 2011

External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: International Neural Monitoring Study Group standards guideline statement.

Intraoperative neural monitoring (IONM) during thyroid surgery has gained widespread acceptance as an adjunct to the gold standard of visual identification of the recurrent laryngeal nerve (RLN). Contrary to routine dissection of the RLN, most surgeons tend to avoid rather than routinely expose and identify the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy or parathyroidectomy. IONM has the potential to be utilized for identification of the EBSLN and functional assessment of its integrity; therefore, IONM might contribute to voice preservation following thyroidectomy or parathyroidectomy. We reviewed the literature and the cumulative experience of the multidisciplinary International Neural Monitoring Study Group (INMSG) with IONM of the EBSLN. A systematic search of the MEDLINE database (from 1950 to the present) with predefined search terms (EBSLN, superior laryngeal nerve, stimulation, neuromonitoring, identification) was undertaken and supplemented by personal communication between members of the INMSG to identify relevant publications in the field. The hypothesis explored in this review is that the use of a standardized approach to the functional preservation of the EBSLN can be facilitated by application of IONM resulting in improved preservation of voice following thyroidectomy or parathyroidectomy. These guidelines are intended to improve the practice of neural monitoring of the EBSLN during thyroidectomy or parathyroidectomy and to optimize clinical utility of this technique based on available evidence and consensus of experts.

Continuous intraoperative neuromonitoring in thyroid surgery: Safety analysis of 400 consecutive electrode probe placements with standardized procedures

Continuous intraoperative neuromonitoring (C‐IONM) is a new technology and it is appropriate to analyze its safety.

Leiomiossarcoma primário da glândula tireoide

Despite the fact that 15% to 20% of sarcomas occur in the head and neck and 80% in adults, only 0.014% are primary thyroid leiomyosarcomas. To the best of our knowledge, only 16 cases have been reported around the world, none in South America. Cytologic diagnosis is challenging and these tumors may be mistaken by more common ones such as anaplastic or medullary carcinomas. The treatment of choice for thyroid leiomyosarcomas is not well established yet because of its poor prognosis. Radical surgery associated with chemoradiotherapy has not been effective and did not improve survival rates. The authors report a case of primary thyroid leiomyosarcoma in a young male, who has been submitted to total thyroidectomy and selective neck dissection. Extensive literature review was performed by the authors. The patient received adjuvant radiotherapy, presenting good postoperative course. After four years evolution, there was no local recurrence or distant metastasis.

Ancient schwannoma of the vagus nerve, resection with continuous monitoring of the inferior laryngeal nerve.

Schwannomas (neurinomas, neurilemmomas) are benign, single, slow-growing encapsulated tumors that originate in the sheath of cranial or spinal nerves, and that rarely undergo malignant transformation. Descriptions have shown that about 25% of cases occur in the head and neck; there are only 95 references of vagus nerve involvement. These tumors appear mostly between the third and fifth decades of life; there is no sex predominance. The clinical picture usually consists of a relatively pain-free bulge in the neck; the differential diagnosis should be made with other parapharyngeal tumors or neoplasms in the jugular foramen. The senile schwannoma (SS) is a rare variant that was first described by Ackrman and Taylor in 1951; its features are: wide areas of hyalinized matrix, hypercellularity with nuclear polymorphism and cell hyperchromatism. A microscopic description of SS in serial and histological sections reveals two cell types: the Antoni type A or fasciculated type (elongated cells, arranged in intertwining bundles in various directions or in a spiral layout), and the Antoni type B or reticular type (polymorphic cells that define small vacuoles, giving the tumor a honeycomb aspect). Antoni type B cells predominate in SS. Absence of mitosis is the main feature that differentiates a SS from a malignant schwannoma. Twelve cases of head and neck SSs have been described so far, of which one involved the vagus nerve. Surgery is the treatment of choice; there is a high rate of vagus nerve injury during this procedure. There are descriptions of resections of vagus nerve schwannomas associated with neurostimulation and observation of esophageal6 contractions or endoscopic visualization of the larynx. The current article is the first case report of resection of a vagus nerve schwannoma under continuous electrophysiological monitoring of the recurrent laryngeal nerve.

Tireoidectomia vídeo assistida: experiência de 120 casos

BACKGROUND: The objective of this paper is to describe a 120 cases experience in the video-assisted technique, performed by the same surgical team. METHODS: Between september 2004 and february 2006, 120 video-assisted thyroidectomies has been performed - 119 females and 1 male. Age: 19 - 58, median 34 years. Indications: suspicion of malignancy, without any cervical surgery, radiotherapy, thyroid volume under 20 cc and nodules under 3 cm. RESULTS: Surgery time: 25 - 180, median time 85 minutes for total and 59 minutes for parcial thyroidectomy. The incision: 1,6 - 3,5cm, median 2,5cm. Four conversions to conventional technique are related. Nerve palsy was observed in 5,8%. There was no hypoparathyroidism or hematoma in this series. All patients were released in the first postoperative day. CONCLUSION: The video assisted approach is a safe procedure, and its complication index is similar to the conventional technique, with advantages in incision size and postoperative evolution. However, more studies are needed to confirm these findings.

The learning progression of diagnostic sialendoscopy

INTRODUCTION Sialendoscopy is becoming the gold standard procedure for diagnosis and treatment of Salivary Gland Inflammatory Diseases. OBJECTIVE To evaluate the learning progression of a single surgeon to implement and perform diagnostic sialendoscopy: to estimate how many procedures were necessary to achieve better results; if it was higher rate of complications in the beginning. METHODS Retrospective analysis involving 113 consecutive sialendoscopies performed from 2010 to 2013. According to a descriptive analysis of the factors related to surgeons experience, the casuistic was divided into two groups: group (A) comprising the first 50 exams, and group (B) the last 63. Groups were then compared concerning demographic and peri-operative aspects. RESULTS In Group A, failure to catheterize papilla were 22% versus 3% in B (p=0.001). Failure to complete examination was 30% in group A versus 6% in B (p=0.001), and necessity to repeat exams was 22% in group A versus 10% in B (p=0.058). The complication rates were 18% in group A, and 10% in B (p=0.149). Operative time was slightly shorter in group B (56 versus 41 min, p=0.045). CONCLUSION We found better outcomes after the first 50 diagnostic sialendoscopies. Complication rates were statistically the same between early and late groups of experience with sialendoscopy.

International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal: INMSG LOS Part 1

This publication offers modern, state‐of‐the‐art International Neural Monitoring Study Group (INMSG) guidelines based on a detailed review of the recent monitoring literature. The guidelines outline evidence‐based definitions of adverse electrophysiologic events, especially loss of signal, and their incorporation in surgical strategy. These recommendations are designed to reduce technique variations, enhance the quality of neural monitoring, and assist surgeons in the clinical decision‐making process involved in surgical management of recurrent laryngeal nerve. The guidelines are published in conjunction with the INMSG Guidelines Part II, Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer–Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data.

International neuromonitoring study group guidelines 2018: Part II: Optimal recurrent laryngeal nerve management for invasive thyroid cancer-incorporation of surgical, laryngeal, and neural electrophysiologic data: INMSG Loss of Signal Guidelines: Part II

The purpose of this publication was to inform surgeons as to the modern state‐of‐the‐art evidence‐based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real‐time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision‐making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal.

Morbidity of Prophylactic Node Dissection in Thyroid Cancer

Objective: Determine if the implementation of prophylactic neck dissection of the central compartment as a routine procedure increases the risk of injury over the recurrent laryngeal nerve and parathyroid glands in patients with clinical stage T1N0M0 compared with patients who underwent total thyroidectomy only. Method: Retrospective study of 46 patients undergoing total thyroidectomy plus prophylactic central lymph node dissection for papillary cancer with preoperative staging T1N0M0 from March 2008 to July 2010. The outcomes were compared with 107 patients in the same conditions and period undergoing total thyroidectomy alone. Results: The 2 groups (with and without neck dissection) were similar in age, gender, pathologic features, and completeness of thyroidectomy. Of the 46 patients who underwent neck dissection, 6 (13.0%) had vocal fold paralysis with one (2.1%) permanent. In patients who underwent only total thyroidectomy, 9 (8.4%) had transient paralysis, with no cases of permanent paralysis. Regarding hypoparathyroidism 15 patients (32.6%) had transient and 2 (4.3%) had permanent among those who underwent neck dissection, but in patients who underwent only total thyroidectomy, the total rate of hypoparathyroidism was 7.4% (8 cases) with 2 cases (1.8%) of permanent hypoparathyroidism. Conclusion: Even though the prophylactic neck dissection of the central compartment did not cause a statistically significant increase in injuries on the recurrent laryngeal nerve, its realization is associated with high rates of hypoparathyroidism. These results make it difficult to indicate this procedure as a routine treatment for early thyroid tumors.