Lisa A. Orloff

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

American Thyroid Association statement on outpatient thyroidectomy.

BACKGROUND The primary goals of this interdisciplinary consensus statement are to define the eligibility criteria for outpatient thyroidectomy and to explore preoperative, intraoperative, and postoperative factors that should be considered in order to optimize the safe and efficient performance of ambulatory surgery. SUMMARY A series of criteria was developed that may represent relative contraindications to outpatient thyroidectomy, and these fell into the following broad categories: clinical, social, and procedural issues. Intraoperative factors that bear consideration are enumerated, and include choice of anesthesia, use of nerve monitoring, hemostasis, management of the parathyroid glands, wound closure, and extubation. Importantly, postoperative factors are described at length, including suggested discharge criteria and recognition of complications, especially bleeding, airway distress, and hypocalcemia. CONCLUSIONS Outpatient thyroidectomy may be undertaken safely in a carefully selected patient population provided that certain precautionary measures are taken to maximize communication and minimize the likelihood of complications.

Adult Subglottic Stenosis : Management With Laser Incisions and Mitomycin-C

Objectives/Hypothesis: To assess the efficacy of endoscopic laser radial incisions with mitomycin‐C application (ELRM) in managing adult subglottic stenosis (SGS).

Lack of Association of BRAF Mutation With Negative Prognostic Indicators in Papillary Thyroid Carcinoma: The University of California, San Francisco, Experience

IMPORTANCE Papillary thyroid carcinoma (PTC) is the most common endocrine neoplasm. B-type raf kinase (BRAF) V600E mutation has been proposed as a negative prognostic indicator in PTC, and patients harboring it should receive more aggressive initial therapy. OBJECTIVE To assess the significance of BRAF V600E mutation in PTC in the largest US sample to date. DESIGN We identified patients from our institutions pathology archives diagnosed as having PTC and meeting criteria for BRAF mutation testing. Medical records were analyzed for BRAF status (positive or negative) and a list of standardized clinicopathologic features. PARTICIPANTS A total of 429 patients with PTC at an academic medical center. MAIN OUTCOMES AND MEASURES Clinicopathologic features in patients with PTC with and without BRAF mutation. RESULTS Of 429 cases with PTC, 314 (73.2%) were positive for the BRAF mutation and 115 (26.8%) tested negative. BRAF mutation was significantly associated with tumor margin positivity (P = .03) and lymph node metastasis (P = .002) on univariate analysis but not on multivariate study. BRAF mutation was a predictor of male sex (odds ratio [OR], 3.2; 95% CI, 1.4-7.2), total thyroidectomy (OR, 2.6; 95% CI, 1.1-6.2), and a negative predictor of follicular variant PTC (OR, 0.1; 95% CI, 0.1-0.4). There was no significant association between BRAF positivity and tumor multicentricity, lymphovascular invasion, extranodal extension, central neck involvement, advanced stage (stage III or IV), and distant metastasis. CONCLUSIONS AND RELEVANCE BRAF V600E mutation has been extensively studied in relation to negative prognostic indicators in PTC, with no consistent relationship emerging. Two recent meta-analyses showed an overall association between BRAF status and aggressive disease features and called for tailoring treatment plans in patients accordingly. In this, the largest US study to date, BRAF status was not significantly associated with most clinicopathologic features suggestive of more aggressive disease.

Management of invasive well-differentiated thyroid cancer: an American Head and Neck Society consensus statement. AHNS consensus statement.

Invasive differentiated thyroid cancer (DTC) is relatively frequent, yet there is a paucity of specific guidelines devoted to its management. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to provide clinical consensus statements based on review of the literature, synthesized with the expert opinion of the group.

Electrophysiologic facial nerve monitoring during parotidectomy.

Facial nerve monitoring is an adjunctive method available to a surgeon during parotid surgery to assist with the functional preservation of the facial nerve. This review describes the goals, applications, technique, and benefits of electrophysiologic facial nerve monitoring during parotid surgery. A review and analysis of the relevant medical literature related to electrophysiologic facial nerve monitoring during parotid surgery are included.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY DISEASE STATE CLINICAL REVIEW: POSTOPERATIVE HYPOPARATHYROIDISM - DEFINITIONS AND MANAGEMENT

Abbreviations: BID = bis in die DSPTC = diffuse sclerosing papillary thyroid cancer FNA = fine-needle aspiration HT = Hashimoto thyroiditis iPTH = intact parathyroid hormone 25OHD = 25-hydroxy vitamin D PTH = parathyroid hormone TPO = thyroid peroxidase US = ultrasonography

Therapeutic Sialendoscopy for the Management of Radioiodine Sialadenitis

OBJECTIVE To describe our experience with therapeutic sialendoscopy for radioiodine (iodine 131 [(131)I]) sialadenitis. DESIGN Retrospective medical chart review. SETTING Academic tertiary referral center. PATIENTS The study included 11 patients who underwent therapeutic sialendoscopy for the treatment of (131)I sialadenitis after failing medical management. INTERVENTIONS Therapeutic sialendoscopy with dilation and irrigation of the ductal system was performed in all patients. MAIN OUTCOME MEASURES Patient-reported frequency and severity of symptoms. RESULTS Our series included 9 women and 2 men (mean age, 51 years; age range, 35-65 years). A total of 23 parotid glands and 5 submandibular glands were treated. Sialendoscopy was possible in all patients, except one in whom the Stensen duct could not be cannulated. Typical endoscopic findings included pale ductal mucosa, thick mucous plugs, ductal debris, and stenosis of the duct. Most patients (91%) reported improvement of symptoms after a single procedure. Complete resolution of symptoms, with sustained benefit, was reported by 6 patients (54%) at a mean follow-up of 18 months. Partial improvement of symptoms, with some persistent intermittent episodes of pain or swelling, was reported by 4 patients (36%). One patient reported no subjective symptomatic improvement after 2 procedures and subsequently underwent a parotidectomy. CONCLUSIONS Sialendoscopy is useful for the improvement of symptoms due to radioiodine-induced sialadenitis in patients who are refractory to conservative medical therapy. Therapeutic sialendoscopy appears to provide effective and sustained symptom improvement in most patients in our experience.

Dopamine and norepinephrine in the alimentary tract changes after chemical sympathectomy and surgical vagotomy

The aim of this study was to examine the distribution of dopamine and norepinephrine in the proximal alimentary tract of the rat and to assess the contributions of sympathetic and vagal fibers to the tissue concentrations of both catecholamines. Tissues were extracted in perchloric acid and the catecholamines were separated by high pressure liquid chromatography and detected electrochemically. In untreated rats (controls) both catecholamines were concentrated in the gastric muscle but norepinephrine levels were 6-8 times higher (corpus, dopamine 35 +/- 7 ng . g-1, norepinephrine 265 +/- 50 ng . g-1, mean +/- SE, n = 6). In the mucosa norepinephrine concentrations were 10-12 times higher (corpus, dopamine 12 +/- 3 ng . g-1, norepinephrine 140 +/- 26 ng . g-1). Chemical sympathectomy (6 hydroxydopamine, 100 mg . kg-1 ip 3 days) significantly reduced dopamine concentrations in muscle and norepinephrine in muscle, mucosa, pylorus and duodenum. In all tissues the effects on norepinephrine were greater. Surgical vagotomy significantly reduced dopamine concentrations in the gastric muscle, but not the mucosa. Norepinephrine concentrations in the stomach of vagotomized rats were significantly reduced only in the pylorus. Differences in the relative concentrations of dopamine and norepinephrine in gastric tissues of the normal rat and differences in the effects of sympathectomy and vagotomy suggest that dopamine and norepinephrine exist, to an extent, in separate populations of cells and that dopamine is not merely a precursor of norepinephrine. Gastric mucosal dopamine, which was mainly unaffected by either treatment, may exist in APUD cells.

Botulinum toxin in the treatment of first bite syndrome

F irst bite syndrome (FBS) following surgery of the parapharyngeal space is a well known but poorly understood complication. I Most theories on the pathology of FBS revolve around the concept of sympathetic denervation of the parotid gland with subsequent hypersensitivity of myoepithelial cells to parasympathetic neurotransmitters. This hypersensitivity is thought to elicit a supramaximal contraction of myoepithelial cells during the first bite of a meal that subsides with continued masticatory action? Although the intricacies of FBS pathways may not be fully understood, the concept that pain is elicited ultimately with myoepithelial contraction led us to hypothesize that paralysis of these myoepithelial filaments with botulinum toxin may result in relief of symptoms associated with FBS. We report the first documented use of botulinum toxin in the treatment of FBS. This case report was approved by the University of California, San Francisco Committee on Human Research (lRB). The patient is a 53-year-old woman with a history of right neck lymphangioma. She had undergone four operations for surgical resection in 1984, 2004, 2005, and 2006. In 2005, resection included mandibular osteotomies and parapharyngeal space dissection (Fig I). After this operation, she developed a Homers syndrome and complaints of intense radiating pain in the preauricular region upon the first bite of each meal that improved with subsequent masticatory movements. She was given the diagnosis of first bite syndrome and was treated medically with aggressive pain management including multiple narcotics and neurotrophic drugs. She also tried therapeutic acupuncture but gained little relief from her symptoms. She elected to undergo tympanic neurectomy in 2007, which initially provided her with what she described as 50% relief from her symptoms. However, much of her pain returned over the next few months and she elected to undergo a second tympanic neurectomy with laser ablation of the promontory six months later, which provided no further relief of symptoms. Four months later, she was evaluated in our office and continued to have severe pain with first bite. A lemon drop