Ottavio Cavicchi

Transient hypoparathyroidism following thyroidectomy : A prospective study and multivariate analysis of 604 consecutive patients

Objectives The purpose of this study was to identify the risk factors for postoperative transient hypoparathyroidism in a group of patients undergoing thyroid surgery. Study Design A prospective study was conducted on 604 patients undergoing thyroid surgery. Subjects and Methods Gender, final diagnosis, extent of resection, biology of pathology, intrathoracic involvement, surgery for recurrent multinodular goiter, and presence and number of parathyroid glands in a surgical specimen were analyzed as risk factors for postoperative transient hypoparathyroidism. The chi-square test and a logistic regression analysis were applied. RESULTS: On logistic regression analysis, only the extent of surgery constituted an independent variable for transient hypoparathyroidism (P = 0.001). Conclusion The extent of surgery to central and/or lateral neck lymph nodes is responsible for a high rate of transient hypoparathyroidism owing to a high probability of unplanned parathyroidectomy or parathyroid gland devascularization.

The value of neurostimulation and intraoperative nerve monitoring of inferior laryngeal nerve in thyroid surgery

Objective: To determine the accuracy of neurostimulation with laryngeal palpation (NSLP) and intraoperative neuromonitoring (IONM) to predict the postoperative function of recurrent laryngeal nerve (RLN) in thyroid surgery. Study Design: Historical cohort study. Subjects and Methods: A retrospective case control study with 993 patients. The control group (799 patients with 1450 nerves at risk) included patients who underwent NSLP and the case group (194 patients with 354 nerves at risk) consisted of those who underwent NSLP in association with IONM. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and accuracy were calculated for NSLP and IONM, with nerve palsy as the target outcome. Results: A significant difference in nerve injury between the case and the control group (P = 0.31) was not observed. The presence or absence of laryngeal twitch (LT) (P < 0.0001) and the acoustic response to electrical stimulation (P = 0.003) were significantly associated with nerve function at the end of the surgery. Conclusion: Our results indicate that NSLP is a safe and reliable intraoperative method of RLN monitoring. Moreover our data confirm that IONM is not a helpful tool to reduce the rate of palsy in thyroid surgery.

Clinical Significance of BRAF Mutation in Thyroid Papillary Cancer

Objective To correlate the presence of BRAF V600E mutation with clinicopathological parameters. Study Design Case-control study. Setting BRAF mutation represents the most common oncogenic event in sporadic papillary thyroid cancer (PTC). There are, however, significant discrepancies regarding the overall frequency and its relationship with clinicopathological parameters of poor outcome. We analyzed BRAF mutation in a cohort of patients affected by PTCs to identify its association with clinical variables. Subjects and Methods We analyzed retrospectively a series of 304 patients, treated for PTC from 1999 to 2011 at Bologna University Hospital. We searched BRAF mutation by reverse transcription polymerase chain reaction (PCR) followed by PCR and direct sequencing. Results BRAF mutation was found in 77.4% of classical PTCs, 31.9% of the follicular variant, and 72.2% of high tall cell PTCs, being significantly associated, at univariate analysis, with recurrence, stage, multicentricity, histologic subtype, extrathyroidal extension, nodule dimension, body mass index, and American Thyroid Association (ATA) risk stratification. Furthermore, higher T, but not N or M, stage was associated with BRAF mutation. In the multivariate analysis, the BRAF mutation was significantly associated only with the ATA risk stratification, in turn showing a significant negative association with recurrence-free survival time with Cox multivariate analysis. Conclusion Our results indicate that BRAF mutation identifies a subset of PTC with increased risk of recurrence. The presence of BRAF mutation might be a valuable diagnostic and prognostic marker of the disease. To confirm the diagnostic usefulness of this marker, further studies should be carried out.

Minimally invasive nonendoscopic thyroidectomy.

OBJECTIVES: Minimal-access thyroid surgery, using various techniques, is increasingly being reported. The present study reviews our experience with thyroid surgery using a minimally invasive approach (MIT). STUDY DESIGN: Between October 2002 and December 2004, a prospective nonrandomized study of patients undergoing thyroid surgery was performed to evaluate the variables that might condition the indications to minimally invasive nonendoscopic approach. RESULTS: 296 patients underwent thyroid surgery; 46 of these were eligible for MIT through a 2.5- to 3-cm incision. There was one case of transient inferior laryngeal nerve palsy and no postoperative definitive hypoparathyroidism. MIT was converted to conventional thyroidectomy only in two cases. Cosmetic results were considered excellent by all patients. CONCLUSIONS: Minimal-access thyroid surgery is a safe and feasible alternative to conventional thyroid surgery in selected cases. The advantage that this technique offers, in addition to low morbidity, is an improved cosmetic result.

Laryngeal neuromonitoring and neurostimulation versus neurostimulation alone in thyroid surgery: A randomized clinical trial

The aim of this study was to assess a prospective, randomized clinical trial (RCT) comparing neurostimulation with laryngeal palpation (NSLP) of recurrent laringeal nerve (RLN) alone with NSLP associated with laryngeal neuromonitoring (LNM) to evaluate the ability of LNM in reducing the rates of RLN palsy.

Accuracy of PTH assay and corrected calcium in early prediction of hypoparathyroidism after thyroid surgery

Objective To evaluate the accuracy of the intraoperative parathyroid hormone (ioPTH) and 6-hour PTH (6hPTH) assay in predicting transient hypoparathyroidism after thyroidectomy. Study Design A nonrandomized prospective study was conducted on patients undergoing thyroid surgery. Subjects and Methods Of 138 patients undergoing thyroid surgery, intraoperative PTH was measured 10 minutes after gland removal. Serum calcium, magnesium, inorganic phosphorus, albumin, and PTH levels were assayed 6 and 16 hours after surgery and daily until patient discharge. Results The development of postoperative hypocalcemia was associated with low ioPTH (P < 0.0001) and 6hPTH (P < 0.0001) values, and the decline of PTH from baseline (P < 0.0001). The cutoff for percentage decline of ioPTH and 6hPTH (55.7% and 379%, respectively) was more accurate than an absolute value. Accuracy, and positive and negative predictive values were 88 percent, 63 percent, and 100 percent for ioPTH and 75 percent, 46 percent, and 100 percent for 6hPTH, respectively. Conclusion With the use of ioPTH decline in association with 16-hour corrected calcium, it is possible to distinguish early normocalcemic patients from hypocalcemic ones in most cases.

ANTEROLATERAL THIGH FREE FLAP FOR TRACHEAL RECONSTRUCTION AFTER PARASTOMAL RECURRENCE

Stomal recurrence after total laryngectomy is 1 of the most serious issues in head and neck surgery, both because of the complexity of its management and because of its morbidity. Prior to the introduction of free‐tissue transfer, mediastinal tracheostomy has been the standard reconstructive procedure with high rate of complications. The ideal reconstructive solution to these problems must provide well‐vascularized soft tissues that can cover the defect after resection and also allow suturing of the tracheal remnant to skin edges without tension.

Branchial cyst of the parapharyngeal space: report of a case and surgical approach considerations

IntroductionNeoplasms arising within the parapharyngeal space are rare and represent approximately 0.5% of all head and neck tumors. The majority of these lesions consist of minor salivary gland tumors, tumors of the deep lobe of the parotid gland, and tumors of neurogenic origin (paragangliomi and schwannomi), while branchial cysts are extremely rare. Despite advances in radiographic images, surgical excision remains the definitive technique for the diagnosis of parapharyngeal space tumors.Results and discussionThe authors report a case of branchial cyst of the parapharyngeal space excised through a combined transcervical–transmandibular approach and discuss the several surgical techniques proposed to approach this type of tumors.

Benign cystic teratoma of the parotid gland

An 18-year-old female was observed for a swelling in the left retromandibular area. The patient stated that her mass had been present since childhood. The patient was otherwise asymptomatic, and no other signs were revealed by physical examination. The history did not reveal any other significant pathology regarding the patient or her family. An ultrasound examination showed a hyperechogenic area (1 cm diameter) with an internal anechogenic area located in the central part of the parotid gland. A subsequent fine-needle aspiration revealed many squamous cells; T1 and T2 weighted MR images demonstrated a small (8 mm) hyperintense wellcapsulated lesion occupying the posteroinferior portion of the left parotid gland. On the basis of these findings, the patient was scheduled for a parotidectomy. The surgical procedure permitted the identification of a lesion with both a cystic and a cartilaginous component located within the parotid gland (Fig 1A). The cartilaginous portion appeared to be in continuity with the pointer, and the cystic portion was immediately below. The tumor was dissected from the pointer and resected en bloc with the remnant of the superficial part of the gland and the adherent portion of the deep lobe. The facial nerve was identified and anatomically preserved and was normally responsive to electric stimulation at the end of the procedure. The patient was discharged after 3 days. No complications were observed at follow-up. Gross examination revealed the presence of a graybrownish tissue, mostly constituted of a cystic lesion containing a yellowish pultaceous material. At the superior end of this cyst, a round-shaped chondroid mass was observable. Histologic examination led to the diagnosis of a “mature cystic teratoma of the salivary gland with dermoid cyst-like components” (Fig 1B).

Intraoperative intermittent neuromonitoring of inferior laryngeal nerve and staged thyroidectomy: our experience

PurposeTo evaluate the reliability of intermittent intraoperative neuromonitoring (I-IONM) through recurrent laryngeal nerve (RLN) stimulation and laryngeal palpation in predicting postoperative vocal cord palsy and to examine the reliability of this technique in providing useful information in the decision to perform a staged surgery in initially planned total thyroidectomy.MethodsThis was a retrospective cohort study of patients who underwent thyroid surgery at the ENT Department of the University of Bologna from January 2014 to June 2017. In all cases, preoperative and postoperative laryngoscopy was performed. All surgeries were conducted with I-IONM and RLN simultaneous laryngeal palpation (NSLP) to detect contraction (laryngeal twitch) of the posterior crico-arytenoid muscle. The incidence of vocal cord palsy was calculated for nerves at risk. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were calculated with a confidence interval determined at 95% level.ResultsSeven hundred and sixteen patients were enrolled in the study. The incidence of vocal cord palsy was 3.16%. Specificity of I-IONM in predicting vocal cord paralysis was 99.1% and sensitivity was 90%. The NPV was 99.7% and PPV 78.3%. Two-stage thyroidectomy (ST) was performed in 22 cases (22/570: 3.85%). Six patients (27.3%) were false positive and 16 true positive (72.7%) at I-IONM.ConclusionHigh sensitivity and specificity values confirm the validity of I-IONM with NSLP in predicting postoperative normal vocal cord function. Our results confirm that I-IONM may safely guide an ST overall in benign thyroid diseases and in low-grade malignancies.