Hossam Eldin Mohamed

Assessment of Vocal Fold Function Using Transcutaneous Laryngeal Ultrasonography and Flexible Laryngoscopy.

IMPORTANCE Evaluation of preoperative and postoperative vocal fold function is important in patients undergoing thyroid or parathyroid surgical procedures. Transcutaneous laryngeal ultrasonography (TLUSG) has been proposed as a promising noninvasive technique and alternative to flexible fiberoptic laryngoscopy. OBJECTIVE To determine whether TLUSG can be an alternative to flexible laryngoscopy in evaluating vocal fold function. DESIGN, SETTING, AND PARTICIPANTS A prospective study was performed from March 1, 2013, to July 31, 2014. Patients who were scheduled to undergo thyroid or parathyroid surgery by a single surgeon at a North American, university-based tertiary care center and who agreed to undergo preoperative and postoperative TLUSG and flexible fiberoptic laryngoscopy were enrolled. Patients were divided into 2 groups: nonoverweight (body mass index [calculated as weight in kilograms divided by height in meters squared] <25) and overweight or obese (body mass index ≥ 25). Follow-up was completed on February 28, 2015, and data were analyzed from March 1, 2013, to February 28, 2015. INTERVENTIONS Preoperative and postoperative TLUSG and flexible fiber optic laryngoscopic assessments of vocal fold function. MAIN OUTCOMES AND MEASURES The findings of TLUSG and flexible fiber optic laryngoscopy were compared for all patients and each body mass index group to assess the accuracy of TLUSG in assessing vocal fold function. RESULTS A total of 250 patients (500 vocal folds) underwent evaluation, of whom 208 (83.2%) were women and with a mean (SD) age of 52.7 (14.3) years. On flexible fiberoptic laryngoscopy findings, 13 patients had preoperative vocal fold paralysis (VFP), and 14 postoperative new incidents of VFP were identified. Only 7 (53.9%) of the preoperative cases of VFP and 15 (55.6%) of the postoperative cases of VFP were identified by TLUSG. The sensitivity, specificity, and accuracy of preoperative TLUSG were 53.8%, 50.5%, and 50.6%, respectively; for postoperative TLUSG, 55.6%, 38.7%, and 39.6%, respectively. In the nonoverweight group, the preoperative TLUSG sensitivity, specificity, and accuracy were 100%, 70.0%, and 70.5%, respectively; in the overweight-obese group, 45.4%, 43.4%, and 43.5%, respectively (odds ratio, 3.16; 95% CI, 2.06-4.84; P < .001). Postoperative visualization of the vocal folds was more challenging, with a sensitivity, specificity, and accuracy of 83.3%, 55.6%, and 56.8%, respectively, in the nonoverweight group, and 47.6%, 32.6%, and 33.4%, respectively, in the overweight-obese group (odds ratio, 2.62; 95% CI, 1.75-3.94; P < .001). CONCLUSIONS AND RELEVANCE When evaluation of vocal fold function is indicated in patients undergoing thyroid and parathyroid surgery, TLUSG should not be considered as an alternative to the current practice of flexible fiberoptic laryngoscopy. Adequate ultrasonographic visualization of the vocal folds and arytenoids is challenging, especially in overweight and obese patients and in the postoperative setting.

Electrophysiologic identification and monitoring of the external branch of superior laryngeal nerve during thyroidectomy

The aim of the study is to examine the correlation between weight, gender, and race with external branch of superior laryngeal nerve (EBSLN) visualization. Furthermore, we compared normative EBSLN neural‐monitoring values to those of the recurrent laryngeal nerve (RLN).

The presentation of lymph nodes in Hashimoto’s thyroiditis on ultrasound

BACKGROUND Comprehensive neck ultrasound (US) examination has become an essential component of preoperative workup for patients with thyroid cancer. Regional cervical lymph nodes may be involved in cases of Hashimotos thyroiditis (HT). This study seeks to examine the sonographic pattern of lymph nodes in patients with HT. METHODS This is a retrospective study looking at patients with confirmed diagnoses of HT on final surgical pathology who underwent preoperative comprehensive neck US. We compared preoperative ultrasound for patients with HT to euthyroid patients with goiter. Data collected included number, size and ultrasonographic features of cervical lymph nodes. RESULTS We included a total of 417 patients: 202 patients with HT in the study group, and 215 patients with goiter and euthyroid status in the control group. Patients with HT had a higher number of total cervical lymph nodes than the control group (2.00±2.35 vs. 0.76±1.36 mm; P<0.0001), most notably in cervical levels III and IV (P<0.05 for both). CONCLUSIONS HT seems to be associated with an ultrasonographic pattern of increased number of enlarged cervical lymph nodes, particularly in levels III, and IV.

A Prospective Study Comparing the Efficacy and Surgical Outcomes of Harmonic Focus Scalpel Versus LigaSure Small Jaw in Thyroid and Parathyroid Surgery

Background. The use of sealing devices has been established in thyroid surgeries. Recently, LigaSure Small Jaw (LS), a new device that utilizes bipolar energy, was approved by the Food and Drug Administration for use in different head and neck procedures. The purpose of this study is to assess the efficiency and safety of LS use in thyroid surgery compared to Harmonic Focus Scalpel (HS), a well-established device. Methods. A prospective study was conducted to compare the efficacy of LS versus the HS. We evaluated 301 patients who underwent surgery at a North American academic institution. Patients were allocated into two groups according to LS or HS use. All patients underwent vocal cord assessment using direct laryngoscopy preoperatively and postoperatively. Analyses were performed to examine the difference in perioperative outcomes resulting from the utilization of either device. Results. No difference was seen in operative time between both groups (124.20 ± 68.44 minutes in HS vs 125.20 ± 72.13 minutes in LS, P = .99). Overall complications were similar between both groups (22.86% in HS vs 13.84% in LS, P = .05). However, LS use was also associated with a lower incidence of postoperative transient hypocalcemia as compared to the HS (P = .025). No significant difference was found between both groups regarding the incidence of recurrent laryngeal nerve injury (P = .52). Conclusion. The use of the LS is safe, feasible, and is associated with comparable outcomes to HS. Both intraoperative and postoperative variables were similar between both devices. Future larger studies are warranted to further investigate the effect on postoperative transient hypocalcemia.

Remote access thyroid surgery

Robot assisted thyroid surgery has been the latest advance in the evolution of thyroid surgery after endoscopy assisted procedures. The advantage of a superior field vision and technical advancements of robotic technology have permitted novel remote access (trans-axillary and retro-auricular) surgical approaches. Interestingly, several remote access surgical ports using robot surgical system and endoscopic technique have been customized to avoid the social stigma of a visible scar. Current literature has displayed their various advantages in terms of post-operative outcomes; however, the associated financial burden and also additional training and expertise necessary hinder its widespread adoption into endocrine surgery practices. These approaches offer excellent cosmesis, with a shorter learning curve and reduce discomfort to surgeons operating ergonomically through a robotic console. This review aims to provide details of various remote access techniques that are being offered for thyroid resection. Though these have been reported to be safe and feasible approaches for thyroid surgery, further evaluation for their efficacy still remains.

Robotic thyroidectomy and parathyroidectomy: An initial experience with retroauricular approach.

New approaches for robotic‐assisted thyroidectomy were recently described. The purpose of this study was to present the report of our initial experience using a retroauricular approach for thyroid and parathyroid surgeries.

The significance of enlarged cervical lymph nodes in diagnosing thyroid cancer

INTRODUCTION We aim to investigate the significance of enlarged cervical lymph nodes (ECLN) identified by initial surgeon-performed ultrasound (US) as a tool for determining the risk of malignancy in the patients presenting with suspicious thyroid nodules. METHODS Radiological and surgical reports were retrospectively reviewed for the patients with suspicious thyroid nodules who underwent thyroidectomy and preoperative comprehensive neck US. Ultrasonographic features of the identified cervical lymph nodes were correlated with the final pathology report. Patients with malignancy other than papillary thyroid cancer (PTC) were excluded. RESULTS The study consisted of 440 patients. On final pathology, PTC was found in 142 patients (32.3%), the remaining 298 (67.7%) exhibited benign findings. ECLN (>1 cm) were found in 66 (46.5%) patient with PTC compared to only 53 (17.8%) patients with benign nodules (P < 0.001). Of the 119 patients with ECLN, 54.6% had benign appearing ECLN with no suspicious features, 26.1% had one suspicious feature, and 19.3% had more than one suspicious features. Benign appearing ECLN had a positive predictive value (PPV) of 41.54%, negative predictive value (NPV) of 59.02%, sensitivity of 51.92%, and specificity of 48.65% in predicting malignancy as opposed to the absence of ECLN. While as opposed to benign looking ECLN, ECLN with only one suspicious feature had a PPV of 70.97%, NPV of 50.00%, sensitivity of 33.33%, and specificity of 83.02%, and ECLN with two or more suspicious feature had a PPV of 73.91%, NPV of 48.96%, sensitivity of 25.76%, and specificity of 88.68%. CONCLUSION ECLN are associated with an increased likelihood of thyroid malignancy in the patients undergoing evaluation of a suspicious nodule. The risk of malignancy in thyroid nodules increases with the presence of suspicious ultrasonographic features on cervical lymph nodes.

Robotic trans‐axillary and retro‐auricular thyroid surgery

Remote access approaches for thyroid surgery using surgical incisions placed outside the neck, including the axillary, chest and the retro-auricular region have gained interest due to the social stigmatization of young females with a visible neck scar. These novel approaches have been reported to be safe and feasible approaches for thyroid surgery in a select group of patients. Herein, we will discuss different aspects of the current robotic approaches. J. Surg. Oncol. 2015; 112:243–249.

Different surgical approaches in parathyroid adenoma resections

Three patients were referred to our clinic for the management of a persistent symptomatic primary hyperparathyroidism. Pre-operative imageological localization revealed evidence of an adenoma. Here we are presenting three videos demonstrating the different surgical approaches of parathyroid adenoma resection, with the use of an intraoperative gamma probe and nerve monitoring.

Concomitant thyroid disease and primary hyperparathyroidism in patients undergoing parathyroidectomy or thyroidectomy

BACKGROUND Thyroid abnormalities have been found intraoperatively during parathyroidectomy and have resulted in concomitant thyroidectomy. The identification of concomitant disease is important prior to primary operation in order to minimize reoperations. This study investigates the incidence of concomitant primary hyperparathyroidism (PHPT) and thyroid nodular disease in patients undergoing thyroidectomy or parathyroidectomy. METHODS We performed a retrospective review of prospectively gathered data for 621 patients who underwent thyroidectomy, parathyroidectomy, or both at Tulane Medical Center. Information obtained included initial referral, initial thyroid stimulating hormone (TSH), initial parathyroid hormone (PTH), fine needle aspiration (FNA) results, ultrasound results, type of operation performed, final diagnosis, and final pathology. RESULTS Among the 400 patients referred primarily for thyroid disease, 13.50% underwent a thyroidectomy and parathyroidectomy (PTX) simultaneously and 10.75% received a final diagnosis of thyroid and concomitant parathyroid disease. Among the 103 patients referred primarily for parathyroid disease, 26.21% underwent a PTX and thyroidectomy and 24.27% received a final diagnosis of both thyroid and parathyroid disease. Patients referred primarily for parathyroid disease were more likely to receive a final diagnosis of both parathyroid and thyroid disease and were more likely to undergo a combined operation. CONCLUSIONS Concomitant thyroid and parathyroid disease occur and preoperative analysis is important to avoid increased complications from reoperations.