Joseph Brennan

Prevalence and patterns of intraoperative nerve monitoring for thyroidectomy

Objective To estimate the patterns of use of intraoperative recurrent laryngeal nerve (RLN)-monitoring devices during thyroid surgery by otolaryngologists in the United States. Methods A questionnaire was mailed to 1685 randomly selected otolaryngologists, representing approximately half of all otolaryngologists currently practicing in the United States. Topics covered included training history and current practice setting, use and characteristics of use of RLN monitoring during thyroid surgery, as well as history of RLN injury and/or subsequent lawsuits. X 2 test was used to examine associations between monitor usage and dependent variables, and odds ratios calculated by logistic regression were used to refine the magnitude of these associations. RESULTS: A total of 685 (40.7%) of questionnaires were returned, and 81 percent (555) of respondents reported performing thyroidectomy. Of those, only 28.6 percent (159) reported using intraoperative monitoring for all cases. Respondents were 3.14 times more likely to currently use intraoperative monitoring if they used it during their training. Surgeons currently using intraoperative RLN monitoring during thyroidectomy were 41 percent less likely to report a history of permanent RLN injury. Further information about surgeon background and rationale for decisions regarding RLN monitor usage are discussed. Conclusions Presently, the majority of otolaryngologists in the United States do not report regular usage of RLN monitoring in their practices. Surgeon background and training, more so than surgical volume, significantly influenced the use of intraoperative RLN monitoring.

Prospective analysis of the efficacy of continuous intraoperative nerve monitoring during thyroidectomy, parathyroidectomy, and parotidectomy

OBJECTIVE: Continuous intraoperative electromyographic monitoring was prospectively performed in all parotidectomies, thyroidectomies, and parathyroidectomies over approximately 5 years to assess the efficacy of this technology. STUDY DESIGN AND SETTING: Continuous intraoperative nerve monitoring with perioperative nerve assessment was performed. The postresection minimal stimulation level of the nerves was determined to evaluate if this level would predict nerve function postoperatively. RESULTS: Forty-four parotidectomies and 70 thyroid/parathyroid operations were performed with 140 nerves at risk (44 facial, 96 recurrent laryngeal). The incidence of temporary facial paralysis was 15.9% (7 of 44) and the incidence of permanent paralysis was 0%. The incidence of temporary recurrent laryngeal nerve paralysis in terms of nerves at risk was 1.0% (1 of 96), and the incidence of permanent recurrent laryngeal nerve paralysis was 0%. All patients with normally functioning facial and recurrent laryngeal nerves postoperatively had minimal stimulation levels less than or equal to 0.4 mA. CONCLUSION: Continuous intraoperative nerve monitoring was associated with extremely low rates of temporary and permanent nerve paralysis in our series of 140 nerves at risk as compared to the rates documented in the literature.

Lymph node micrometastases in head and neck cancer: a review.

ALFIO FERLITO, MAXINE PARTRIDGE, JOSEPH BRENNAN and HIROYUKI HAMAKAWA From the Department of Otolaryngology—Head and Neck Surgery, Uni×ersity of Udine, Udine, Italy, Department of Maxillofacial Surgery, King’s College Hospital, London, UK, Department of Otolaryngology—Head and Neck Surgery, Wilford Hall Medical Center, Lackland Air Force Base, Texas, USA and Department of Oral and Maxillofacial Surgery, Ehime Uni×ersity School of Medicine, Ehime, Japan

Experience of First Deployed Otolaryngology Team in Operation Iraqi Freedom: The Changing Face of Combat Injuries

OBJECTIVES: In September, 2004, an Air Force otolaryngology team was deployed to Iraq as a member of the multispecialty head and neck team, which had historically consisted of neurosurgery, ophthalmology, and oral surgery. We examined our operative and outpatient experience to determine if otolaryngology would be a critical component of this new head and neck team. STUDY DESIGN AND SETTING: Between September 7, 2004, and January 22, 2005, we collected data on all otolaryngology operative procedures and outpatient visits at the Air Force Theater Hospital at Balad Air Base, Iraq. RESULTS: One hundred fifty-nine patients underwent 257 operative procedures with the 3 most common procedures being complex facial laceration repair, tracheostomy, and neck exploration for penetrating neck trauma. In the otolaryngology clinic, we examined and treated 529 patients from throughout the Middle East. CONCLUSIONS: The otolaryngology team proved to be a critical component of the Air Force multispecialty head and neck team. EBM rating: C-4

Patterns of Use of Facial Nerve Monitoring During Parotid Gland Surgery

OBJECTIVE: To determine current patterns of use of facial nerve monitoring during parotid gland surgery by otolaryngologists in the United States. STUDY DESIGN AND SETTING: A questionnaire encompassing surgeon training background, practice setting, patterns of facial nerve monitor usage during parotid gland surgery, and history of permanent facial nerve injury or legal action resulting from parotid surgery was mailed to 3139 otolaryngologists in the United States. Associations between facial nerve monitor usage and dependent variables were examined by using the χ 2 test. Magnitudes of the associations were determined from odds ratios calculated using logistic regression. RESULTS: A 49.3% questionnaire response rate was achieved. Sixty percent of respondents who perform parotidectomy employed facial nerve monitoring some or all of the time. Respondents were 5.6 times more likely to use the monitor in practice if they used it in training and 79% more likely to use it if they performed more than 10 parotidectomies per year. Respondents were 35% less likely to have a history of inadvertent nerve injury if they performed more than 10 parotidectomies per year. Surgeons who employed monitoring in their practice were 20.8% less likely to have a history of a parotid surgery-associated lawsuit. Additional information regarding surgeon demographics, types of nerve monitors used, and reasons for and against monitor usage are discussed. CONCLUSION: Permanent facial nerve paralysis after parotidectomy occurs in 0-7% of cases. Currently, a majority of otolaryngologists in the United States are employing facial nerve monitoring during parotid surgery some or all of the time, even though no studies to date have demonstrated improved outcomes with its use. Physician training background and surgery caseload were significant factors influencing usage of facial nerve monitoring in this study.

Surgical considerations and controversies in thyroid and parathyroid surgery

The techniques of thyroid surgery have been fully elucidated in several surgical texts and atlases. This article discuss surgical pearls of thyroid and parathyroid surgery. We discuss preoperative, intraoperative, and postoperative considerations and controversies for both procedures.

Importance of molecular analysis in detecting cervical lymph node metastasis in head and neck squamous cell carcinoma

Because of the impact of nodal status on treatment and survival in squamous cell carcinoma of the head and neck, accurate staging of cervical lymph nodes is critical. This article explores the value of molecular analyses in the detection of cervical lymph node metastasis.

Penetrating Neck Trauma in Operation Iraqi Freedom

Objectives. To examine the surgical outcomes of penetrating neck trauma patients in Operation Iraqi Freedom (OIF) and compare treatment and perioperative survival to historical data with low-velocity penetrating neck trauma seen in a noncombat clinical setting. Study Design. Case series with chart review. Setting. Air Force Theater Hospital at Balad Air Base, Iraq. Subjects and Methods. The surgical management of penetrating neck trauma by 6 otolaryngologists deployed over a 30-month period at the United States Air Force Theater Hospital in Balad, Iraq, was retrospectively reviewed. The presenting signs and symptoms, operative findings, and outcomes of patients who underwent neck exploration for high-velocity penetrating neck trauma were determined. A treatment algorithm defining the management of both high-velocity and low-velocity penetrating neck trauma is recommended. Results. One hundred and twelve neck explorations for penetrating neck trauma were performed in OIF over 30 months. Ninety-eight percent of these neck injuries were due to high-velocity projectiles. In patients, zone 1 injuries occurred in 10%, zone 2 injuries in 77%, zone 3 injuries in 5%, combined zone 1/2 injuries in 5%, and combined zone 2/3 injuries in 3%. The positive exploration rate (patients with intraoperative findings necessitating surgical repair) was 69% (77/112). The mortality of patients undergoing neck exploration for high-velocity penetrating neck trauma was 3.7%. Conclusions. The perioperative mortality and the positive exploration rate for high-velocity penetrating neck trauma by deployed surgeons in OIF are very comparable to those rates seen in civilian centers managing low-velocity penetrating neck trauma.

The Joint Facial and Invasive Neck Trauma (J-FAINT) Project, Iraq and Afghanistan 2003-2011

Objective Define the number and type of facial and penetrating neck trauma injuries sustained in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Study Design Retrospective database study. Setting Tertiary care level I trauma center. Subjects and Methods The Joint Theater Trauma Registry (JTTR) was queried for data from OIF and OEF from January 2003 to May 2011. Information on demographics; type and severity of facial, neck, and associated trauma injures; and impact on overall mortality was recorded. Results There were 37,523 discrete facial and penetrating neck injuries that occurred in 7177 service members. There were 25,834 soft tissue injuries and 11,689 facial fractures. The most common soft injury sites were the face/cheek (48%), neck/larynx/trachea (17%), and mouth/lip (12%). The maxilla (25%), mandible (21%), and orbit (19%) were the most common facial fracture sites. The most common mechanism of injury was penetrating (49.1%), followed by blunt (25.7%), blast (24.2%), and other/unknown/burn (1%). Injuries were associated with an overall mortality rate of 3.5%. The highest risks for mortality were treatment at a level IIa facility, female sex, prehospital intubation, and blast injury. Most injuries were mild to moderate. Conclusion Facial and penetrating neck trauma are common in modern warfare. Most injuries are minor to moderate and survivable. Training and potential body armor updates can be made. Medical personnel deploying to support OIF and OEF could benefit from specific training in the management of facial and penetrating neck injuries. A surgeon skilled in managing these injuries would likely be beneficial in a deployed setting.

Isolated posterior table frontal sinus fractures do not form mucoceles in a goat model.

Objective The goal of this study was to investigate how patency of the nasofrontal outflow tract would affect frontal sinus healing in the setting of displaced, comminuted, posterior table fractures in the adult goat (Capra hircus). Study Design Prospective animal study. Subjects and Methods Posterior table fractures were created in 20 adult goats. The nasofrontal outflow tract was left patent in 10 goats (Group 1) and obstructed in 10 (Group 2). Gross, radiologic, and histologic evaluation were carried out six months postoperatively. Results One of nine subjects subjects (11%) in Group 1 developed a mucocele while eight of 10 (80%) in Group 2 developed mucoceles (P = 0.004). No subjects (100%) in Group 1 had gross, radiologic, or histologic evidence of mucosal ingrowth into the posterior table, while two of 10 (20%) in Group 2 showed evidence of mucosal ingrowth into, but not through, the posterior table. In both groups 100% of the subjects had gross and histologic evidence of intact posterior tables abutting the dura. Conclusion An occluded nasofrontal outflow tract leads to an increased mucocele formation rate at six months. In an unobstructed nasofrontal outflow tract there is no gross, radiologic, or histologic evidence of mucosal ingrowth into the posterior table at six months. These findings would suggest that not all comminuted, significantly displaced posterior table fractures need to be surgically addressed if the nasofrontal outflow tract is patent.