Ottavio Piccin

European position paper on drug-induced sedation endoscopy (DISE)

BackgroundAlthough drug-induced sedation endoscopy (DISE) represents the most widespread diagnostic tool for upper airway endoscopic evaluation of snoring and obstructive sleep apnea hypopnea syndrome (OSAHS), many controversies exist about how to perform the sedation, the indications for DISE, and how to report DISE findings. The present position paper reports on a consensus as proposed by a group of European experts in the field of DISE after discussion during a recent dedicated meeting.MethodsThe authors have evaluated all the available evidence reported in the literature and have compared experience among various departments in leading European centers in order to provide a standardization of the DISE procedure and an in-depth insight in the main aspects of this technique.ResultsA proposal of the DISE procedure standardization has been achieved with a general agreement concerning the terminology, indications, contraindications, required preliminary examinations, setting, technical equipment required, staffing, local anesthesia and nasal decongestion, patient positioning, basis and special diagnostic maneuvers, and the applied sedation drugs and observation windows. Otherwise, no consensus has been reached on a scoring and classification system.ConclusionsAlthough consensus has been reached on several aspects of the DISE procedure, some topics remain open to future research, such as a better analysis of the importance of positional aspects during DISE and a further comparison of the differences in degree, level and pattern of upper airway collapse observed during DISE versus during natural sleep and awake endoscopy. Finally, a universally accepted scoring and classification system is lacking.

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.

One-phase management of severe obstructive sleep apnea: Tongue base reduction with hyoepiglottoplasty plus uvulopalatopharyngoplasty

OBJECTIVES: To describe the results of a 1 phase surgical procedure for the treatment of severe obstructive sleep apnea (OSA) attributable to tongue base obstruction. STUDY DESIGN AND SETTING: A retrospective nonrandomized study at S Orsola Malpighi University Hospital of Bologna, Italy. METHODS: Ten male patients affected by severe OSA (mean apnea/hypopnea index [AHI] of 54.7), underwent uvulopalatopharyngoplasty (UPPP) associated with tongue base reduction and hyoepiglottoplasty (TBRHE). The indications to this surgical procedure were based on the presence of hyolingual abnormalities and absence of craniofacial deficiencies determined by preoperative assessment. RESULTS: Mean AHI decreased from 54.7 + 11.5 to 9.4 + 5.4 whereas the mean low SaO2 value went from 77% + 6.2 to 90.7% + 3 and the time of sleep with SaO2 < 90% improved from 53% + 17.2 to 7.3% + 8. The overall success rate was 100%. CONCLUSIONS AND SIGNIFICANCE: TBRHE is an effective and safe treatment in patients with severe OSA attributable to tongue base obstruction and in absence of craniofacial deficiencies.

Functional expansion pharyngoplasty in the treatment of obstructive sleep apnea.

INTRODUCTION Continuous positive airway pressure is usually prescribed as first-line treatment in preventing the upper airway collapse in patients with obstructive sleep apnea syndrome (OSAS), but long-term treatment adherence represents an evident problem. Among the variety of surgical procedures described to expand the pharyngeal lumen, uvulopalatopharyngoplasty (UPPP) remains the most frequently performed technique for the treatment of retropalatal obstruction. Uvulopalatopharyngoplasty was first described by Fujita in 1981, and basically consists of a tonsillectomy, trimming of the soft palate and uvula, and suturing of the tonsillar pillars. Due to its low success rate and the considerable morbidities involved, the role of this technique has been questioned since the 1990s, and in the last two decades many modifications of UPPP have been proposed. The recent evolution regarding the techniques of pharyngoplasty has been focused on the concept of obtaining the expansion and stabilization of the pharyngeal airspace through the treatment of lateral pharyngeal wall (LPW) collapse rather than through ablation of the redundant pharyngeal soft tissue. The role of LPW in the pathogenesis of OSAS has been demonstrated by Schwab. The narrowing of the LPW appears to be the sole independent risk factor for OSAS. The aim of this article is to present a new surgical technique, functional expansion pharyngoplasty (FEP), which represents a conservative modification of expansion sphincter pharyngoplasty (ESP), as described by Pang and Woodson. Applying the original technique, which includes a superolateral incision of the soft palatal mucosa to expose the anterior arching fibers of the palatoglossus muscle bilaterally, and the preparation of a dorsal palatal flap, we experienced dehiscence of the rotated palatopharyngeus muscle and troubles related to palate incisions, such as globus sensation and dry throat. The FEP technique involves splinting of the LPW and advancement of the soft palate. This is obtained by means of the supero-lateral repositioning of the palatopharyngeus muscle, with a less aggressive and more ‘‘physiologic’’ approach to the LPW and soft palate, in order to both increase pharyngeal airspace and decrease pharyngeal collapse without undermining velum muscles, and in doing so avoiding scarring of the velum.

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.

Modified Hyoid Suspension Technique in the Treatment of Multilevel Related Obstructive Sleep Apnea

Objective Using the Hörmann technique of hyoid suspension in sleep apnea surgery, a steel wire is placed through the thyroid cartilage and slung around the hyoid bone. However, we experienced thyroid cartilage fracture by steel wire traction. A modification is presented to avoid thyroid cartilage fracture. Study Design Case series with chart review. Setting University hospital. Subjects and Methods Twenty-seven patients affected by obstructive sleep apnea syndrome underwent Hörmann hyoid suspension. In 2 patients, the steel wire caused a fracture of the thyroid cartilage. The technique was therefore modified in 25 subsequent patients. The wire is threaded through an adaptation titanium miniplate placed on the surface of the thyroid cartilage. Results The apnea-hypopnea index decreased from 43.1 to 10.9/h. Nineteen patients (76%) met the criteria for a successful outcome. No complications related to this modification were noted. Conclusions The Hörmann hyoid suspension is a procedure that advances the hyoid bone to expand the airway, and its effectiveness has been proven previously. The modified hyoid suspension presented here promises similar results without the risk of serious complications such as thyroid cartilage fracture.