Kai-Pun Wong

A prospective, assessor-blind evaluation of surgeon-performed transcutaneous laryngeal ultrasonography in vocal cord examination before and after thyroidectomy

INTRODUCTIONnTranscutaneous laryngeal ultrasonography (TLUSG) is a promising alternative to direct laryngoscopy in assessing perioperative vocal cord function. This study sought to evaluate the accuracy of TLUSG in assessing vocal cord function.nnnMETHODSnAltogether, 204 patients underwent TLUSG and direct laryngoscopy before and after elective thyroidectomy. For both examinations, vocal cord movements were independently graded. Grade I meant both vocal cords had normal movement; grade II meant ≥1 vocal cord had decreased movement; and grade III meant ≥1 vocal cord had no movement. Grade II or III on direct laryngoscopy was defined as vocal cord paresis or palsy (VCP). To assess accuracy, TLUSG findings were correlated with direct laryngoscopy findings.nnnRESULTSnNo patient had preoperative VCP, and 17 had unilateral postoperative VCP. The overall postoperative VCP rate was 5.1%. TLUSG failed to assess VCs in 11 (5.4%) postoperative patients. Of these, 2 had VCP and 9 had no VCP on direct laryngoscopy. Postoperative TLUSG had a sensitivity, specificity, positive predictive value, and negative predictive value of 93.3%, 97.8%, 77.8%, and 99.4%, respectively. Of the 175 patients with grade I on TLUSG, only 1 (<1%) had grade II VCP on direct laryngoscopy.nnnCONCLUSIONnTLUSG is a promising, noninvasive tool for selecting patients to undergo direct laryngoscopy before and after thyroidectomy.

Use of radiofrequency ablation in benign thyroid nodules: a literature review and updates.

Successful thermal ablation using radiofrequency has been reported in various tumors including liver or kidney tumors. Nonsurgical minimally invasive ablative therapy such as radiofrequency ablation (RFA) has been reported to be a safe and efficient treatment option in managing symptomatic cold thyroid nodules or hyperfunctioning thyroid nodules. Pressure and cosmetic symptoms have been shown to be significantly improved both in the short and long terms after RFA. For hyperfunctioning thyroid nodules, RFA is indicated for whom surgery or radioiodine are not indicated or ineffective or for those who refuse surgery or radio-iodine. Improvement of thyroid function with decreased need for antithyroid medications has been reported. Complication rate is relatively low. By reviewing the current literature, we reported its efficacy and complications and compared the efficacy of RFA relative to other ablative options such as ethanol ablation and laser ablation.

The importance of sonographic landmarks by transcutaneous laryngeal ultrasonography in post-thyroidectomy vocal cord assessment

INTRODUCTIONnDuring examination of the vocal cords (VC) using transcutaneous laryngeal ultrasonography (TLUSG), 3 sonographic landmarks (namely, false VC [FC], true VC [TC], and arytenoids [AR]) are often seen. However, it remains unclear which landmark provides a more reliable assessment and whether seeing more landmarks improves the diagnostic accuracy and reliability.nnnMETHODSnWe evaluated prospectively 245 patients from 2 centers. One assessor from each center performed all TLUSG examinations and their findings were validated by direct laryngoscopy. All 3 sonographic landmarks were routinely visualized whenever possible. The rate of visualization and diagnostic accuracy between the 3 landmarks were compared.nnnRESULTSnEighteen patients suffered postoperative VC palsy (VCP). Both centers had comparable visualization or assessability rate of ≥ 1 sonographic landmark (94.9 and 95.3%; P = 1.000) and 100% sensitivity on postoperative TLUSG. The rates of FC, TC, and AR visualization were 92.7%, 36.7%, and 89.8%, respectively. The sensitivity, specificity, and diagnostic accuracy and the proportion of true positives, false positives, and true negatives between using 1, 2, landmarks and 3 landmarks were comparable (P > .05).nnnCONCLUSIONnEach sonographic landmark had similar reliability and diagnostic accuracy. Identifying all 3 sonographic landmarks was not mandatory and visualizing normal movement in one of the sonographic landmarks would be sufficient to exclude VCP.

Graves’ Ophthalmopathy as an Indication Increased the Risk of Hypoparathyroidism After Bilateral Thyroidectomy

BackgroundStudies have evaluated the effect of thyroidectomy on the course of Graves’ ophthalmopathy (GO) but it is unclear how GO as an indication might affect surgical outcomes. We aimed to evaluate the impact of this indication on surgical outcomes in Graves’ disease (GD).MethodsFrom 1995 to 2008, 329 patients with GD underwent thyroidectomy. Patients were stratified into two groups, namely, those with GO as indication (GO) and those with non-GO indication (non-GO). Outcomes were compared between the groups and outcomes with significance were further analyzed by multivariate analyses to determine independent factors.ResultsThe GO group was significantly older (Pxa0<xa00.001), had more males (Pxa0<xa00.001), and fewer relapses (Pxa0<xa00.001) than the non-GO group. It also had a higher proportion of total/near-total thyroidectomy (Pxa0<xa00.001), despite a shorter operating time (Pxa0=xa00.024) and less blood loss (Pxa0=xa00.010). When only total/near-total thyroidectomy was considered, the GO group had significantly more permanent hypoparathyroidism than the non-GO group (9.2 vs. 1.6%, Pxa0=xa00.038), but the rate of permanent hypoparathyroidism was similar in the two groups when only those with parathyroid autotransplantation were considered. Other complications were similar between the two groups. By multivariate analysis, GO as indication was an independent risk factor for temporary (OR 1.97, Pxa0=xa00.033) and permanent hypoparathyroidism (OR 4.76, Pxa0=xa00.007).ConclusionGO as a surgical indication (i.e., unstable or active GO requiring ophthalmic treatment or follow-up) was associated with increased risk of temporary and permanent hypoparathyroidism after bilateral thyroidectomy. Routine parathyroid autotransplantation may reduce the risk of permanent hypoparathyroidism in this select patient group.

The Role of Prophylactic Central Neck Dissection in Differentiated Thyroid Carcinoma: Issues and Controversies

Prophylactic central neck dissection (pCND) in differentiated thyroid carcinoma (DTC) is one of the most controversial surgical subjects in recent times. To date, there is little evidence to support the practice of pCND in patients with DTC undergoing total thyroidectomy. Although the recently revised American Thyroid Association (ATA) guideline has clarified many inconsistencies regarding pCND and has recommended pCND in high-risk patients, many issues and controversies surrounding the subject of pCND in DTC remain. The recent literature has revealed an insignificant trend toward lower recurrence rate in patients with DTC who undergo total thyroidectomy and pCND than those who undergo total thyroidectomy alone. However, this was subjected to biases, and there are concerns whether pCND should be performed by all surgeons who manage DTC because of increased surgical morbodity. Performing a unilateral pCND may be better than a bilateral pCND given its lower surgical morbidity. Further studies in this controversial subject are much needed.

Assessing the Validity of Transcutaneous Laryngeal Ultrasonography (TLUSG) After Thyroidectomy: What Factors Matter?

AbstractIntroductionnAlthough transcutaneous laryngeal ultrasound (TLUSG) is an excellent, noninvasive way to assess vocal cord (VC) function after thyroidectomy, some patients simply have “un-assessable” or “inaccurate” examination. Our study evaluated what patient and surgical factors affected assessability and/or accuracy of postoperative TLUSG.MethodsFive hundred eighty-one consecutive patients were analyzed. All TLUSGs were done by one operator using standardized technique, whereas direct laryngoscopies (DL) were done by an independent endoscopist to confirm TLUSG findings. Their findings were correlated. TLUSG was “unassessable” if ≥1 VC could not be clearly visualized, whereas it was “inaccurate” if the TLUSG and DL findings were discordant. Demographics, body habitus, neck anthropometry, and position of incision were correlated with assessability and accuracy of TLUSG.ResultsTwenty-nine (5.0xa0%) patients had “unassessable” VCs; among the “assessable” patients, 29 (5.3xa0%) patients had “inaccurate” TLUSG. More than one-third (38.5xa0%) of VC palsies (VCPs) were “inaccurate.” Older age (odds ratio [OR]xa0=xa01.055, 95xa0% confidence interval [CI] 1.016–1.095, pxa0=xa00.005), male sex (ORxa0=xa013.657, 95xa0% CI 2.771–67.315, pxa0=xa00.001), taller height (ORxa0=xa01.098, 95xa0% CI 1.008–1.195, pxa0=xa00.032), and shorter distance from cricoid cartilage to incision (ORxa0=xa00.655, 95xa0% CI 0.461–0.932, pxa0=xa00.019) were independent factors for “unassessable” VCs, whereas older age (ORxa0=xa01.028, 95xa0% CI 1.001–1.056, pxa0=xa00.040) was the only factor of incorrect assessment.ConclusionsOlder age, male sex, tall in height, and incision closer to the thyroid cartilage were independent contributing factors for unassessable VCs, whereas older age was the only contributing factor for inaccurate postoperative TLUSG. Because more than one-third of VCPs were actually normal, patients labeled as such on TLUSG would benefit from laryngoscopic validation.Although transcutaneous laryngeal ultrasound (TLUSG) is an excellent, noninvasive way to assess vocal cord (VC) function after thyroidectomy, some patients simply have “un-assessable” or “inaccurate” examination. Our study evaluated what patient and surgical factors affected assessability and/or accuracy of postoperative TLUSG. Five hundred eighty-one consecutive patients were analyzed. All TLUSGs were done by one operator using standardized technique, whereas direct laryngoscopies (DL) were done by an independent endoscopist to confirm TLUSG findings. Their findings were correlated. TLUSG was “unassessable” if ≥1 VC could not be clearly visualized, whereas it was “inaccurate” if the TLUSG and DL findings were discordant. Demographics, body habitus, neck anthropometry, and position of incision were correlated with assessability and accuracy of TLUSG. Twenty-nine (5.0xa0%) patients had “unassessable” VCs; among the “assessable” patients, 29 (5.3xa0%) patients had “inaccurate” TLUSG. More than one-third (38.5xa0%) of VC palsies (VCPs) were “inaccurate.” Older age (odds ratio [OR]xa0=xa01.055, 95xa0% confidence interval [CI] 1.016–1.095, pxa0=xa00.005), male sex (ORxa0=xa013.657, 95xa0% CI 2.771–67.315, pxa0=xa00.001), taller height (ORxa0=xa01.098, 95xa0% CI 1.008–1.195, pxa0=xa00.032), and shorter distance from cricoid cartilage to incision (ORxa0=xa00.655, 95xa0% CI 0.461–0.932, pxa0=xa00.019) were independent factors for “unassessable” VCs, whereas older age (ORxa0=xa01.028, 95xa0% CI 1.001–1.056, pxa0=xa00.040) was the only factor of incorrect assessment. Older age, male sex, tall in height, and incision closer to the thyroid cartilage were independent contributing factors for unassessable VCs, whereas older age was the only contributing factor for inaccurate postoperative TLUSG. Because more than one-third of VCPs were actually normal, patients labeled as such on TLUSG would benefit from laryngoscopic validation.

Determining the Learning Curve of Transcutaneous Laryngeal Ultrasound in Vocal Cord Assessment by CUSUM Analysis of Eight Surgical Residents: When to Abandon Laryngoscopy.

Transcutaneous laryngeal ultrasonography (TLUSG) is a promising alternative to laryngoscopy in vocal cords (VCs) assessment which might be challenging in the beginning. However, it remains unclear when an assessor can provide proficient TLUSG enough to abandon direct laryngoscopy . Eight surgical residents (SRs) without prior USG experience were recruited to determine the learning curve. After a standardized training program, SRs would perform 80 consecutive peri-operative VCs assessment using TLUSG. Performances of SRs were quantitatively evaluated by a composite performance score (lower score representing better performance) which comprised total examination time (in seconds), VCs visualization, and assessment accuracy. Cumulative sum (CUSUM) chart was then used to evaluate learning curve. Diagnostic accuracy and demographic data between every twentieth TLUSG were compared. 640 TLUSG examinations had been performed by 8 residents. 95.1xa0% of VCs could be assessed by SRs. The CUSUM curve showed a rising pattern (learning phase) until 7th TLUSG and then flattened. The curve declined continuously after 42nd TLUSG (after reaching a plateau). Rates of assessable VCs were comparable in every twentieth cases performed. It took a longer time to complete TLUSG in 1st–20th than 21st–40th examinations. (45 vs. 32s, pxa0=xa00.001). Although statistically not significant, proportion of false-negative results was higher in 21st–40th (2.5xa0%) than 1st–20th (0.6xa0%), 41st–60th (0.7xa0%), and 61st–80th (0.7xa0%) TLUSG performed. After a short formal training, surgeons could master skill in TLUSG after seven examination and assess vocal cord function consistently and accurately after 40 TLUSG.

Using Transcutaneous Laryngeal Ultrasonography (TLUSG) to Assess Post-thyroidectomy Patients' Vocal Cords: Which Maneuver Best Optimizes Visualization and Assessment Accuracy?

To assess vocal cord (VC) movement with transcutaneous laryngeal ultrasound (TLUSG), three maneuvers, namely passive (quiet respiration), active (phonation), and Valsalva maneuvers have been described. It remains unclear which maneuver or using more maneuvers provides better visualization and assessment accuracy. We prospectively evaluated 342 post-thyroidectomy patients from two centers. They underwent TLUSG with direct laryngoscopic (DL) validation afterwards. During TLUSG, patients were instructed to perform all three maneuvers (passive, active, and Valsalva). VC visualization rate and accuracy between three maneuvers were compared. Visualization rate tended to be higher in Valsalva maneuver than that in other two maneuvers (92.1xa0% vs. passive: 91.5xa0%; active: 89.8xa0%). While 19 patients had post-operative VC palsy, passive maneuver had lower test specificity than active (94.3 vs. 97.6xa0%, pxa0=xa00.01) and Valsalva maneuvers (94.3 vs. 97.4xa0%, pxa0=xa00.02). In assessable VCs, passive maneuver has a higher ability to differentiate between mobile VCs and VC palsy (Area under ROC curve—passive: 0.942, active: 0.863, Valsalva: 0.893). TLUSG with more maneuvers did not improve sensitivity or specificity. On applying TLUSG as a screening tool (i.e., only selected patient with “unassessable” VCs or VCP on TLUSG for DL), Valsalva maneuver (85.96xa0%) saved more patients from DL than passive (81.87xa0%) or active (84.81xa0%) maneuver. Passive maneuver has a higher ability to differentiate VC palsy from normal. Using TLUSG as a screening tool, Valsalva was the preferred maneuver as it was more specific, had high visualization rate, and saved more patients from DL.

A Comparison of Surgical Morbidity and Scar Appearance Between Gasless, Transaxillary Endoscopic Thyroidectomy (GTET) and Minimally Invasive Video-Assisted Thyroidectomy (VAT)

BackgroundThe gasless, transaxillary endoscopic thyroidectomy (GTET) and minimally invasive video-assisted thyroidectomy (VAT) are both well-recognized endoscopic thyroid procedures, but how their postoperative outcomes are compared remains unclear. The present study was designed to compare surgical morbidities/complications and scar appearance between GTET and VAT at our institution.MethodsOf the 141 patients eligible for endoscopic thyroidectomy, 96 (68.1xa0%) underwent GTET and 45 (31.9xa0%) underwent VAT. Patient demographics, indications, operative findings, pain scores on days 0 and 1, and surgical morbidities were compared between the two groups. At 6xa0months after surgery, all patients were asked about their satisfaction on the cosmetic result by giving a score (Patient Satisfaction Score or PSS) and their scar appearance was assessed by the 11 domains in the Patient and Observer Scar Assessment Scale (POSAS).ResultsGTET was associated with a significantly longer operating time (84 vs. 148xa0min, pxa0=xa00.005), higher pain scores on days 0 and 1 (2.9 vs. 2.3, pxa0=xa00.042 and 2.2 vs. 1.7, pxa0=xa00.033, respectively), overall recurrent laryngeal nerve (RLN) injury (6.3 vs. 0xa0%, pxa0=xa00.043), and overall morbidity rates (12.5 vs. 2.2xa0%, pxa0=xa00.049) than VAT. The actual individual score for the 11 domains in POSAS and for PSS remained similar between the two groups. They remained similar even when patients with morbidity were excluded.ConclusionsGTET was a technically more challenging procedure and was associated with longer hospital stay, longer operating time, more immediate pain, and increased overall RLN injury and morbidity than VAT. The 6-month POSAS and PSS were similar between the two procedures.

New Molecular Targeted Therapy and Redifferentiation Therapy for Radioiodine-Refractory Advanced Papillary Thyroid Carcinoma: Literature Review

Although the majority of papillary thyroid carcinoma could be successfully managed by complete surgical resection alone or resection followed by radioiodine ablation, a small proportion of patients may develop radioiodine-refractory progressive disease which is not amenable to surgery, local ablative treatment or other treatment modalities. The use of FDG-PET/CT scan for persistent/recurrent disease has improved the accuracy of restaging as well as cancer prognostication. Given that patients with RAI-refractory disease tend to do significantly worse than those with radioiodine-avid or non-progressive disease, an increasing number of phase I and II studies have been conducted to evaluate the efficacy of new molecular targeted drugs such as the tyrosine kinase inhibitors and redifferentiation drugs. The overall response rate of these drugs ranged between 0–53%, depending on whether the patients had been previously treated with these drugs, performance status and extent of disease. However, drug toxicity remains a major concern in administration of target therapies. Nevertheless, there are also ongoing phase III studies evaluating the efficacy of these new drugs. The aim of the review was to summarize and discuss the results of these targeted drugs and redifferentiation agents for patients with progressive, radioiodine-refractory papillary thyroid carcinoma.