Ezzeddin Elsheikh

Thyroidectomy with late identification of recurrent laryngeal nerve

INTRODUCTION The basic procedure in thyroid surgery is total lobectomy with routine identification of the recurrent laryngeal nerve (RLN). This entails anatomic localization of the inferior thyroid artery (ITA) in the lower tracheoesophageal groove. Because of the importance and great concern surrounding the RLN, surgeons usually start with its localization, which may be strenuous to the beginner and time consuming. Because the nerve lies constantly beneath the thyroid gland, it should be dissected from its surrounding tissue to uncover the nerve in its bed. Does this justify doing thyroid surgery by dissection in the extracapsular plane with late identification of the RLN? The aim of this work was to remove the gland with dissection along the thyroid capsule without initial identification of the RLN in de novo cases diagnosed as benign goiter.

Voice Changes after Late Recurrent Laryngeal Nerve Identification Thyroidectomy.

OBJECTIVES To assess voice changes in patients after thyroidectomy where the recurrent laryngeal nerve (RLN) was found late in the thyroid dissection and where the RLN was not injured (late RLN identification technique). METHODS This study was conducted on 64 patients who underwent thyroidectomy by late RLN identification technique. Voice was assessed preoperatively, 1 week, 3 months, and 6 months after surgery using the voice assessment protocol and Voice Problem Self-Assessment Scale. The study group was divided into two subgroups (hemithyroidectomy: N = 13 and total thyroidectomy: N = 51). Voice assessments of both subgroups were then compared with a control group (N = 20) of patients who recently underwent extracervical surgeries. RESULTS All voice analysis differences between the control group and the individual study subgroup were nonsignificant. Dysphonia in the study group was significantly worse at 1 week and 3 months postoperatively but became nonsignificant at 6 months postoperatively. The deviations from the preoperative acoustic analysis were significant only in the first week postoperative comparison for fundamental frequency, noise-to-harmonic ratio, and maximal phonation time and thereafter became nonsignificant. Significant Voice Problem Self-Assessment Scale mean score increase (worsening) was also detected only at first week postoperatively. CONCLUSION Minimal voice changes were reported early after late RLN identification thyroidectomy in absence of RLN injury and disappeared gradually in a few months. Those changes are comparable with that of other extracervical surgeries, making thyroidectomy with late RLN identification a relatively safe technique as regard voice.

Choanal atresia: Histochemical, immunohistochemical and ultrastructure study of the nasal mucosa

OBJECTIVES To study the nasal mucosal changes in cases with choanal atresia at the light and electron microscope and to compare the results with the normal side in unilateral cases. STUDY DESIGN Cross sectional study. SETTING Tertiary University hospital, departments of Otolaryngology and pathology. METHODS Sixteen patients diagnosed to have choanal atresia (seven bilateral and nine unilateral); ranging in age from 3 days to 9 years; were included in this study. During surgical repair, a biopsy of the inferior turbinate mucosa was taken. Biopsy from patent side in unilateral choanal atresia was also taken (as a control). Then biopsies were subjected to histopathological, histochemical, immunohistochemical and ultrastructure studies. RESULTS The nasal mucosa in choanal atresia side (weather unilateral or bilateral) showed distorted cilia, marked increase of mucous submucosal glands associated with marked reduction of goblet cell density and lymphocytic cellular infiltration. The patent side (control) showed normal respiratory epithelium with obviously noted intra-epithelial goblet cells. Submucosal glands were less in number and activity than in the atretic side. CONCLUSIONS Choanal atresia showed a condition of the nasal mucous membrane with characteristic excessive nasal tenacious secretion; mostly actively secreted besides some effect of lack of drainage due to interrupted cilia. Further studies are required to evaluate the impact of atresia repair on detected features.

Posterior Pharyngeal Flap for Velopharyngeal Insufficiency Patients: A New L-Shaped Flap.

Objective:To describe and assess the results of central inset L-shaped posterior pharyngeal flap (PF) for treatment of velopharyngeal incompetence. Methods:This study included 12 patients who were diagnosed as persistent velopharyngeal insufficiency. L-shaped central inset superiorly based PF was harvested from oropharynx and inserted into the soft palate through a transverse full-thickness palatal incision 1 cm behind the posterior margin of the hard palate, then the flap was spread 1 cm horizontally and 1 cm in the anteroposterior direction in soft palate. Before and after surgery, patients were assessed by examination, video: nasoendoscopy, and speech assessment. Results:Postoperative speech assessment showed significant improvement in the nasal emission, resonance, intraoral pressure, and articulation defects. Grade 4 velopharyngeal valve closure (complete closure) could be achieved in all patients. No patients showed dehiscence (partial or total) of the flap and no obstructive sleep apnea reported. Conclusions:The new used L-shaped PF could properly correct velopharyngeal functions (closure and speech) in patients with persistent velopharyngeal insufficiency with no reported complication.

False Computed Tomography Findings in Bilateral Choanal Atresia

Introduction Choanal atresia (CA) is a challenging surgical problem defined as a failure in the development of communication between the nasal cavity and nasopharynx. Objective The objective of this study is to describe computed tomography (CT) findings in cases with bilateral choanal atresia. Methods The study involved performing axial and coronal non-contrast CT scanning with 2–3 mm sections on14 neonates that had bilateral CA. We used fiberoptic nasal endoscopy to confirm the diagnosis. We evaluated coronal CT to study the skull base area in such neonates. Results This study included 14 neonates with bilateral CA; with mean age of 7 ± 3.5 days. Mixed atretic plates were found in 12 (85.7%) cases while two (14.3%) had pure bony atresia. Isolated CA was detected in 9 cases (64.3%) and 5 (35.7%) cases had associated anomalies. Coronal CT showed soft tissue density in the nasal cavity that appeared to extend through an apparent defect in the nasal roof (cribriform plate), falsely diagnosed by radiologists as associated encephalocele. At the time of surgical repair, all patients showed thick tenacious mucous secretions in both nasal cavities and revealed no encephalocele. Nasal roof remained intact in all cases. Conclusion The thick secretion of bilateral CA could give a false encephalocele appearance on the CT. It is highly recommended to perform proper suction of the nasal cavity of suspected CA cases just before CT scanning.

Single-Stage Repair of Palatal Fistula and Velopharyngeal Incompetence by the New L Flap

Objective: To describe and assess the results of use of the new L-shaped posterior pharyngeal flap for repair of both palatal fistula and velopharyngeal incompetence. Methods: This study included 10 patients who were diagnosed to have soft palate fistula and persistent velopharyngeal insufficiency (VPI). L-shaped superiorly based pharyngeal flap was harvested from oropharynx and inserted into the soft palate closing the fistula after fistula trimming. The palatal part of the flap (transverse limb) was spread 1 cm horizontally and 1 cm in the anteroposterior direction in soft palate at fistula site closing it without tension. Prior to and after surgery, patients were assessed by examination, video-nasoendoscopy, and speech assessment. Results: Closure of the palatal fistula could be achieved in all patients. Postoperative speech assessment showed significant improvement in the nasal emission, resonance, intraoral pressure, and articulation defects. Grade 4 velopharyngeal valve closure (complete closure) could be achieved in all patients. No patients showed dehiscence (partial or total) of the flap and no obstructive sleep apnea reported. Conclusion: The new used L-shaped pharyngeal flap could properly close palatal fistula and correct velopharyngeal functions (closure and speech) in patients with persistent VPI with no reported significant complication and without the need for palatal dissection or flaps.

Impact of Successful Choanal Atresia Repair on the Nasal Mucosa: A Preliminary Study

Introduction  The main histological features of the nasal mucosa in choanal atresia are distorted cilia, marked increase of mucous submucosal glands associated with marked reduction of goblet cell density, and lymphocytic cellular infiltration. Objective  To study the nasal mucosal changes in cases of choanal atresia after successful repair compared with pre-repair mucosal histological features. Methods  Tissue samples were taken from the inferior turbinate of 3 patients (1 bilateral and 2 unilateral) who were successfully operated. Then, the biopsies were subjected to histopathological, histochemical and immunohistochemical studies. After that, the results were compared with pre-repair findings in the choanal atresia side and in the normal side. Results  Four biopsies (4 repaired choanal atresia sides) of the mucosa of the inferior turbinate revealed that 1 patient (who had a bilateral choanal atresia repaired), after achieving a patent choana for 8 months, had not completely recovered a normal nasal mucosa. The other 2 patients, after 18 and 23 months of achieving a patent choana, showed normal nasal cavities. Conclusion  The main histological features of the nasal mucosa in choanal atresia could be reversed by surgery, making the patients regain their choanal patency, with their mucosae changing back to normal gradually with time.

Superior parathyroid gland approach to the recurrent laryngeal nerve

The superior parathyroid gland is known to be almost constant in its location under the false thyroid capsule. Could it be a landmark to point to the site of incision of the false thyroid capsule and find the plane of the recurrent laryngeal nerve (RLN) during thyroidectomy?

Two- versus Three-Point Internal Fixation of Displaced Zygomaticomaxillary Complex Fractures

Despite the high frequency of the zygomaticomaxillary complex (ZMC) fractures, there is no consensus among facial reconstructive surgeons regarding the best surgical management; thus, surgical choice for ZMC fractures is still challenging. This study included 40 patients with displaced ZMC fracture. Twenty patients were treated with open reduction and internal fixation (OR/IF) using two-point fixation technique (at infraorbital margin and zygomaticofrontal buttress region) and the remaining 20 patients were treated with OR/IF using three-point fixation technique (at frontozygomatic suture, infraorbital margin, and zygomatico maxillary buttress). The results of both types of ZMC fractures repair were then statistically compared. No statistical differences between the two types regarding malar eminence asymmetry; projection (forward displacement) and width (medial displacement) in axial CT; inferior displacement; superior displacement and width (medial displacement) in coronal CT; angle of displacement (outward displacement) in 3D CT; masseter and temporalis muscles power electromyography; actual duration of surgery; and patient satisfaction. On the other hand, the total cost of the used plates and screws was significantly higher with three-point repair than two-point repair (p = 0.003). Moreover, postoperative CT lateral zygoma displacement was statistically significantly better in three-point fixation. Two-point fixation modality for displaced ZMC fractures is as effective as three-point method in fixation and prevents postreduction rotation or clinical displacement with significantly lower cost.

Isolated Osteoma of the Ascending Process of the Maxilla.

Background:Osteoma, the most common benign tumor of the paranasal sinuses, most commonly originates within the frontal sinus, followed by the ethmoid, the maxillary sinus, and finally sphenoid. Only 2 cases of osteomas of the nasal bones were previously reported. This study describes the first reported osteoma of the ascending process of maxilla and describes its management. Methodology:A 20-year-old man was presented with left painless hard nasal swelling. Computed tomography (CT) scan showed well-circumscribed hyperdense bony mass originating from the outer surface of the left ascending process of maxilla. This mass was removed through lateral nasal incision. Results:The mass was histopathologically proved to be compact osteoma and was removed totally with no reported operative or postoperative complication. Conclusions:A case of osteoma of ascending process of maxilla was reported and could be safely removed. This directs surgeon attention to osteoma as a cause of nasal bone swelling because early diagnosis allows easy and safe removal of the osteoma.