Paolo Aluffi

Post-thyroidectomy superior laryngeal nerve injury

Abstract Voice dysfunction after thyroidectomy may be caused by damage to laryngeal nerves or lesions to strap muscles with laryngo-tracheal movement impairment. Injury to an external branch of the superior laryngeal nerve (EBSLN) is sometimes difficult to recognize clinically and its electromyographic incidence ranges from 0% to 58%. In this study we evaluated, 12–18 months postoperatively, 45 patients who had undergone thyroid surgery (6 total lobectomy, 5 subtotal thyroidectomy, and 34 total thyroidectomy), using a subjective interview, laryngeal videostroboscopy and spectrographic analysis with a multidimensional voice program. Vocal parameters included fundamental frequency, jitter, shimmer, noise-to-harmonic-ratio (NHR) and degree of sub-harmonics. Laryngeal electromyography (LEMG) of the cricothyroid (CT) muscles was performed in 21 subjects with voice problems (35 EBSLNs) using a modified method for the CT recording. In 3 patients of this group (14%) LEMG documented a unilateral EBSLN injury. Easy voice fatigue and decreased pitch range were the most common symptoms after surgery. Average values of vocal parameters pre- and post-operatively in patients without neural damage (n = 42) were: jitter 0.64% and 0.78%, shimmer 3.25% and 3.54%, and NHR 0.12% and 0.13%, respectively (P > 0.05). Acoustic analysis revealed altered patterns in some patients with no objective evidence of damage to EBSLNs, suggesting an extralaryngeal cause of vocal dysfunction, such as laryngo-tracheal fixation or lesions to strap muscles. We conclude that laryngeal videostroboscopy and spectrographic analysis are very useful to assess voice problems after thyroidectomy, including in patients without LEMG-proven neural lesions, in order to suggest early speech rehabilitation, especially in professional voice users.

Voice quality after treatment for T1a glottic carcinoma--radiotherapy versus laser cordectomy.

The purpose of this study was to assess the anatomic and functional outcomes and compare the voice quality in patients affected by T1a glottic carcinoma treated with curative intent with radiotherapy or laser cordectomy. Fifty-seven cases were analysed: 27 after curative radiotherapy and 30 after laser cordectomy. All patients were studied with videolaryngostroboscopy, voice analysis by narrow spectrogram, and vocal parameters (Jitter, Shimmer, noise/harmonic ratio, and diplophonia). Videolaryngostroboscopy showed severe glottic inadequacy in 25% of cases treated with radiation and insufficient compensation ‘ventricular band’ or ‘with arytenoid hyperadduction’ in 65% of cases after surgery. Severe dysphonia on the electro-acoustic analysis of voice was observed in 25% of cases after radiation and 70% after laser (p<0.001). Fundamental frequency and vocal parameters showed more favourable results in the radiation group (p<0.001). Voice assessment showed better results after radiotherapy compared with laser cordectomy. Voice outcome should be carefully considered in the treatment decision for T1 glottic carcinoma.

Demonstration of Multiple HPV Types in Laryngeal Premalignant Lesions Using Polymerase Chain Reaction and Immunohistochemistry

Recent evidence has shown that human papillomavirus (HPV) is involved in both the development of carcinoma and in premalignant mucosal lesions of the oral cavity. This study examined the relationship of HPV infection to some pathological features in precancerous lesions of the larynx, not examined extensively so far. Fifty formalin‐fixed paraffin‐embedded tissue sections containing human laryngeal precancerous lesions were screened for the presence of HPV infection by polymerase chain reaction, and for capsid protein expression by immunohistochemistry with polyclonal antibody directed against the L1 protein. The presence of HPV DNA was detected in 28 of 50 specimens (56%), including 9/12 cases with mild dysplasia (75%), 3/6 cases with moderate dysplasia (50%), and 7/11 cases with severe dysplasia (64%). Multiple HPV infections, containing two or three types, were detected in 17 of the 28 HPV‐positive lesions (60%). Of 21 cases with keratosis and no dysplasia, 11 were positive for HPV DNA (52%) and 4 showed L1 staining (36%). By contrast, L1 positivity was revealed only in two lesions with moderate dysplasia, confirming that fully productive HPV infection is strictly dependent on epithelial differentiation and surface keratinization. The probability that HPV is a cofactor in the malignant progression of these lesions is suggested by the fact that 3/4 patients who developed cancer within 50 months were positive for HPV DNA. J. Med. Virol. 59:110–116, 1999.

Altered patterns of the interferon-inducible gene IFI16 expression in head and neck squamous cell carcinoma: immunohistochemical study including correlation with retinoblastoma protein, human papillomavirus infection and proliferation index.

Aims:  To investigate whether the expression of interferon (IFN)‐inducible gene IFI16 is inversely related to proliferative activity in vivo, we compared immunohistochemical reactivity of IFI16 in a series of head and neck squamous cell carcinomas (HNSCCs) with their proliferation index and the cell cycle regulator pRb. As human papillomavirus (HPV) infection is manifested by changes in the function or expression level of host genes such as IFN‐inducible genes, we also investigated the presence of HPV DNA to determine whether head and neck cancers associated with HPV DNA can be distinguished from tumours that are presumably transformed by other mechanisms.

CO2 LASER POSTERIOR VENTRICULOCORDECTOMY FOR THE TREATMENT OF BILATERAL VOCAL CORD PARALYSIS

Abstract We reviewed our clinical experience between 1991 and 1997 concerning use of the CO2 laser for posterior ventriculocordectomy (PVC) for the treatment of bilateral vocal cord paralysis. Pre- and postoperative functional evaluation was assessed in a prospective setting. In all, 41 patients (33 females and 8 males) underwent an endoscopic CO2 laser PVC. Pre- and postoperative pulmonary function tests documented a significant statistical improvement in the parameters considered. Sixteen of 21 previously tracheostomized patients were decannulated within 15 months of operation. In no case was a postoperative tracheostomy required. We found no evidence of subclinical aspiration among our cases. Evaluation of vocal parameters by spectrographic analysis was assessed in 20 patients and revealed a postoperative reduction in voice quality. Laser CO2 PVC seems to be an effective and reliable surgical procedure that allows for rapid decannulation and gives stable results with a low incidence of revision surgery and functional failures.

Peripheral Facial Nerve Palsy: How Effective Is Rehabilitation?

Objective To review the current literature to assess the effectiveness of rehabilitation treatment for peripheral facial nerve palsy. Data Sources A review of the literature was conducted using the following database: PubMed, EMBASE, PEDro, and Scopus. All randomized or quasi randomized controlled trials, case control, cohort studies and case series greater than 6 published between 1990 and 2010 in the English language were included. Study Selection All types of peripheral facial nerve palsy were included. We considered all the exercises or rehabilitation programs provided by a physiotherapy in outpatient or home setting and excluded trials in which a drug therapy or surgical intervention was investigated. Three reviewers independently selected the articles. Data Extraction To rate the methodological quality of the studies the American Academy of Neurology classification of evidence for therapeutic intervention (Classes I–IV) was applied. Conclusion Peripheral injury of the VIIth cranial nerve can have serious repercussions on the patient’s functioning and quality of life. The recovery rate is related to the preservation of the nerve and to the cause of palsy. We obtained a third level of recommendation (level C); mime therapy could be effective to improve functional outcome in these patients. Evidence of specific treatment addressed to specific cause is lacking; likewise, no evidence is available on timing of intervention with respect to time of onset. Well-designed randomized controlled trials are required to evaluate the effect of rehabilitation in patients with facial palsy.

Rosai-Dorfman disease of the larynx.

We present a case of an 81-year-old man with a history of worsening dysphonia of six months duration. A year before a sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) was diagnosed on a submandibular lymph node biopsy. On presentation the patient showed a mass in the left subglottic area with a modest reduction in the airway space. The patient underwent an endoscopic CO2 laser excision of the mass, without post-operative complications. Histopathological examination and electron microscope images confirmed the previous diagnosis of Rosai-Dorfman disease. The clinical and pathological features of this entity are discussed.

CLINICAL AND MOLECULAR FEATURES OF MUCOSA-ASSOCIATED LYMPHOID TISSUE (MALT) LYMPHOMAS OF SALIVARY GLANDS

To analyze clinical features and to discuss the modality of investigation and treatment of a series of mucosa‐associated lymphoid tissue (MALT) lymphomas. To investigate the prevalence of aberrant promoter methylation, responsible for gene inactivation, in a selected panel of genes potentially involved in the pathogenesis of B‐cell malignancies as O6‐methylguanine‐DNA methyltransferase (MGMT), p73, death‐associated protein kinase (DAP‐k).

Factores pronósticos de hipoparatiroidismo definitivo tras tiroidectomía total

Introduccion y objetivo La hipocalcemia tras tiroidectomia total constituye la mayor complicacion, en la mayoria de los casos, transitoria, en relacion con un dano funcional de las paratiroides u otros factores reversibles. Se trata de un estudio sobre 67 pacientes sometidos a tiroidectomia total para identificar posibles factores clinicos, anatomopatologicos y quirurgicos predictivos de hipocalcemia definitiva tras tiroidectomia total. Metodos Recogida de valores plasmaticos de calcio en el periodo postoperatorio y factores como edad, sexo, funcionalidad tiroidea, diagnostico anatomopatologico definitivo, extirpacion accidental de las paratiroides y su autotrasplante, reintervencion para identificar factores de riesgo para el desarrollo de hipoparatiroidismo definitivo. Las comparaciones han sido efectuadas entre los pacientes con hipocalcemia y concentraciones normales de calcemia postoperatoria. Resultados La hipocalcemia aguda transitoria ha sido identificada en 25/67 pacientes (43,3 %). El hipoparatiroidismo definitivo ha sido identificado en 8 (11 %) pacientes. Conclusiones En nuestro estudio ha supuesto que una calcemia despues de 24 h de la intervencion quirurgica inferior a 7,5 mg/dl sea un factor altamente pronostico de hipoparatiroidismo definitivo; esta determinacion es un parametro fiable, economico, rapido y muy predictivo del desarrollo de hipoparatiroidismo definitivo. No se han encontrado asociaciones estadisticamente significativas con otros factores, como funcionalidad tiroidea, histologia, extirpacion accidental o autotrasplante de las paratiroides, asi que podemos afirmar que una atenta manipulacion de las paratiroides conservando cuidadosamente la vascularizacion glandular representa un factor de fundamental importancia para garantizar una normal funcionalidad paratiroidea postoperatoria.

Papillary thyroid carcinoma identified after Sistrunk procedure: Report of two cases and review of the literature

Thyroglossal duct cysts represent the most common congenital cervical malformations. Carcinomas arising in the thyroglossal duct cysts are rare neoplasms characterized by a relatively non aggressive behavior with rare lymph node spread. Approximately 1% of thyroglossal cysts contain a carcinoma. The most frequent histological type is papillary carcinoma, accounting for about 80% of cases. Currently, most authors agree about their primary origin ex novo from ectopic thyroid tissue in the cyst. In most cases the diagnosis of thyroglossal duct carcinoma (TDC) is not made until histopathological examination has been performed on a resected cyst without any suspected clinical sign of malignancy. The definition of the correct surgical treatment for these carcinomas is still controversial; most authors maintain that resection of a TDC with the Sistrunk procedure can be considered oncologi-cally adequate when dealing with a differentiated carcinoma without extracapsular invasion and/or lymph node metastases and with a normal thyroid. We present two cases of papillary thyroid carcinoma identified after resection of a thyroglossal cyst according to the Sistrunk procedure and managed with different surgical approaches according to the different sites of the tumors. In addition, we discuss appropriate therapeutic strategies in light of the most recent data in the literature.