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Riedel's thyroiditis (RT) represents one type of IgG4-related thyroid disease (IgG4RTD) and the diagnosis involves quantitative immunohistochemistry showing dense lymphoplasmacellular inflammatory infiltrate consisting of IgG4-positive plasma cells with storiform fibrosis and obliterative phlebitis. We report a case of RT with progressive enlargement of the anterior neck, severe dysphagia, odynophagia, and dyspnea. The patient underwent surgical decompression of the airway, protection tracheotomy, and gastrostomy for nutritional intake 6 months after first symptoms. Complete resolution occurred after surgical treatment combined with prednisolone. Immunostaining revealed IgG4-positive plasma cells 12/HPF (high-power field) and the IgG4/IgG ratio 25%, values that were disproportionate to the intensity of the patient's symptoms. As to this case and the few cases described and analyzed in the literature, our impression is that there is no relation between the intensity of symptoms in RT with the total number of IgG4-positive plasma cells and the IgG4/IgG ratio, but more studies are needed.
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SUMMARY: The role of systemic inflammatory response as a prognostic factor has been proposed in a variety of cancers. The purpose of this study was to investigate the prognostic value of the pretreatment neutrophil-to-lymphocyte ratio (NLR) in the incidence of pharyngocutaneous fistula (PCF) in patients who underwent total laryngectomy. We conducted a retrospective cohort analysis of 141 patients with squamous cell carcinoma of larynx who underwent total laryngectomy from 2009 to 2015. The incidence of PCF was 49.6%. A higher risk of 23% was observed among patients with NLR > 2.5 for the occurrence of PCF (p = 0.007). Patients with laryngeal squamous cell carcinoma who present elevated values in the ration > LR> (> 2.5) presented a higher risk of developing pharyngocutaneous fistula in the postoperative setting of total laryngectomy.
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Fístula Cutânea/sangue , Fístula/sangue , Laringectomia , Linfócitos , Neutrófilos , Doenças Faríngeas/sangue , Complicações Pós-Operatórias/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/cirurgia , Estudos de Coortes , Fístula Cutânea/epidemiologia , Feminino , Fístula/epidemiologia , Humanos , Incidência , Neoplasias Laríngeas/cirurgia , Contagem de Leucócitos , Contagem de Linfócitos , Masculino , Pessoa de Meia-Idade , Doenças Faríngeas/epidemiologia , Valor Preditivo dos Testes , Prognóstico , Estudos RetrospectivosRESUMO
INTRODUCTION: Postsurgical hypoparathyroidism normally occurs a short time after thyroid surgery in form of two clinical syndromes of different etiology and prognosis. The first is transitory and might spontaneously recover within a few weeks or months. The second is permanent and needs a definitive treatment. Only few cases of hypoparathyroidism clinically evident after many years from surgery have been reported. CASE REPORT: A case of hypoparathyroidism clinically evident only three and a half years after surgery is reported. Our findings and review of a few cases reported by medical literature suggest the existence of a third form of postsurgical hypoparathyroidism, characterized by a late beginning.
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In spite of increasing experience with skull base surgery, some of the guidelines for indications for operations may vary according to the institution. One-hundred two patients underwent craniofacial oncologic resections at our institution from 1982 to 1995. A retrospective analysis of the indications for and contraindications to these procedures was undertaken. The main indications for malignant tumors were skin lesions with direct invasion of the anterior or lateral skull base (69%) and nasal-paranasal sinus tumors (21%). The main indications for benign tumors were glomus lesions (26%), menigiomas (22%), and fibro-osseous lesions of the anterior skull base (19%). The main contraindications were extensive invasion of the central nervous system, invasion of the cavernous sinus and/or internal carotid artery by aggressive malignancies, and bilateral orbital invasion in a nonblind patient. Also, 6 patients had their procedures interrupted during craniotomy for several reasons - extensive central nervous system invasion (2 cases), bilateral orbital invasion (1), lack of brain retraction (1), lack of histologic diagnosis during the operation (1), and purulent discharge at the frontal sinus (1). Craniofacial oncologic operations are extensive surgical procedures that have to be properly indicated in order to obtain low levels of morbidity and mortality. The selection of cases is of paramount importance. In some instances, it seems advisable even to interrupt these operations in the first phase.
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Craniotomia/métodos , Seleção de Pacientes , Neoplasias da Base do Crânio/cirurgia , Adulto , Contraindicações , Craniotomia/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Neoplasias da Base do Crânio/diagnóstico por imagem , Neoplasias da Base do Crânio/patologia , Tomografia Computadorizada por Raios XRESUMO
The charts of 58 patients with squamous-cell carcinomas of the lower lip, treated at the General Hospital of the University of São Paulo Medical School from January 1980 to December 1989, were retrospectively analyzed. In addition to regular demographic data, all available information was collected regarding: smoking and drinking habits; sun exposure; clinical stage; macroscopic features of the primary lesions; type of treatment; and follow-up. A meticulous pathological analysis, comprising the histologic differentiation grade, maximal tumor thickness, sun elastosis, perineural spread, vascular and muscular invasion, surgical margins, peritumoral inflammatory infiltrate, and positive lymph nodes, with or without extracapsular spread, was undertaken as well. The evaluation of the overall 5-year survival showed significant statistical differences, with prognostic implications, for the following variables: maximal tumor thickness, T-stage and positive nodes.
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Carcinoma de Células Escamosas , Neoplasias Labiais , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Feminino , Seguimentos , Humanos , Neoplasias Labiais/mortalidade , Neoplasias Labiais/patologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Análise de SobrevidaRESUMO
BACKGROUND: A prospective trial was undertaken to investigate the advantages and disadvantages of stapled skin closure versus conventional nylon sutures in head and neck surgery. PATIENTS AND METHODS: The study included 20 consecutive patients who underwent extensive surgery in which their skin was closed with staples. Another group of 20 matched patients receiving a noncontinuous nylon suture closure was followed in parallel. RESULTS: The complications recorded occurred in 5 patients in the stapled group and 3 in the sutured group. Analysis of cosmetic results showed 16 patients (80%) in the stapled group with good wound appearance and 17 (85%) in the sutured group. The mean closure time was 5 minutes for the stapled group and 25 minutes for the sutured group. Cost was $19.75 for conventional closure and $22.00 for mechanical suture. CONCLUSION: The use of skin staples speeds up closure time by 80%, yields similar cosmetic results with no increase in complications, although at a slightly higher cost.
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Procedimentos Cirúrgicos Dermatológicos , Cabeça/cirurgia , Pescoço/cirurgia , Grampeadores Cirúrgicos , Adulto , Idoso , Estudos de Casos e Controles , Custos e Análise de Custo , Estética , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Nylons , Cuidados Pós-Operatórios , Complicações Pós-Operatórias , Estudos Prospectivos , Radioterapia , Fístula das Glândulas Salivares/etiologia , Pele/patologia , Grampeadores Cirúrgicos/efeitos adversos , Grampeadores Cirúrgicos/economia , Infecção da Ferida Cirúrgica/etiologia , Suturas/efeitos adversos , Suturas/economia , Fatores de TempoRESUMO
BACKGROUND: Intraoperative injury to the external branch of the superior laryngeal nerve (EBSLN) can result in significant postoperative voice problems. This injury can be avoided by intraoperative nerve identification. The EBSLN has a close anatomic relationship with the superior thyroid pedicle. According to the previous anatomic classification, the type 2b nerve, which crosses the vessels below the superior thyroid pole and is considered high risk, is found in 14% to 20% of persons with normal or slightly enlarged thyroid glands. OBJECTIVE: To analyze the frequency of this type 2b nerve in a population with large goiters and to compare it with the previously mentioned proportions. DESIGN: Nonrandomized prospective study. PATIENTS AND METHODS: During a 15-month period, patients with large uninodular or multinodular goiters were entered in the study. The EBSLN was searched with the help of a nerve stimulator and the type was annotated. If the patient had to be submitted to a bilateral thyroidectomy, each superior thyroid pole, with the correspondent nerve, was considered as a separate unit. RESULTS: Nine patients, all women, underwent surgery. The average size of the goiters was 10.9 cm x 7.3 cm x 5.0 cm, and the average weight of the specimens was 431 g. There were four bilateral procedures, totalling 13 nerves analyzed. Seven (54%) were type 2b. CONCLUSION: The frequency of the type 2b EBSLN is considerably higher in large goiters. This finding suggests that it is even more advisable to try to positively identify the nerve in these situations, in order to prevent its injury, which is permanent and troublesome for voice professionals.
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Bócio Nodular/patologia , Nervos Laríngeos/patologia , Adulto , Idoso , Estimulação Elétrica/instrumentação , Feminino , Bócio Nodular/cirurgia , Humanos , Cuidados Intraoperatórios , Complicações Intraoperatórias/prevenção & controle , Músculos Laríngeos/inervação , Traumatismos do Nervo Laríngeo , Pessoa de Meia-Idade , Contração Muscular , Tamanho do Órgão , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Glândula Tireoide/inervação , Glândula Tireoide/patologia , Tireoidectomia/métodos , Distúrbios da Voz/prevenção & controleRESUMO
The charts of 81 patients who underwent skull base surgery between 1982 and 1993 were reviewed retrospectively. Data relative to demographic aspects, clinical stage, previous treatment, surgical approach, type of reconstruction, histology, extent of disease, complications, and follow-up were analyzed. The craniofacial approach for the anterior fossa was used in 53% of patients, the lateral skull base approach in 12%, and a combination of both in 17. Malignant tumors were diagnosed in 58 patients (72%), and histologically benign tumors in the remaining 23 (28%). Forty-one patients (51%) had skin cancer. There was dural invasion in 31 patients (38%), and 32 (40%) underwent microsurgical flap reconstruction. From the malignant group, 31 (53%) were alive with no evidence of disease (NED), and 6 (10%) were alive with disease. From the benign group, 19 (83%) were alive NED. The most common complications were cerebrospinal-fluid fistula (10%) and flap necrosis (9%). Statistical analyses of survival showed significantly different rates associated with histologic types (P = 0.0002), type of reconstruction (P = 0.0039), and previous treatment (P = 0.0018).
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Neoplasias Cranianas/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Encefálicas/cirurgia , Criança , Dura-Máter/cirurgia , Feminino , Humanos , Masculino , Neoplasias Meníngeas/cirurgia , Pessoa de Meia-Idade , Estudos Retrospectivos , Neoplasias Cutâneas/cirurgia , Neoplasias Cranianas/mortalidade , Taxa de SobrevidaRESUMO
Since last decade, myocutaneous flaps have appeared among the most versatile and safest options for the reconstruction of defects caused by large oncological resections, in the head and neck area. Undoubtedly, the myocutaneous flap of the pectoralis major muscle is the most widespread and accepted, due to the long experience obtained through its use. Nevertheless, it presents some restrictions related not only to its rotation arch, but also to the esthetic consequences for the donor site in females. Over the last years, there has been a growing interest in the posterior trapezius myocutaneous flap (PTMF), which proved to be a valuable alternative for reconstruction in selected cases. The experience of the Department of Head and Neck Surgery, at the University of São Paulo Medical School-Hospital das Clínicas, using this technique, is reported here in a detailed description.
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Carcinoma Basocelular/cirurgia , Carcinoma de Células Escamosas/cirurgia , Neoplasias de Cabeça e Pescoço/cirurgia , Retalhos Cirúrgicos/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transplante de PeleRESUMO
Seventy-six patients underwent preoperative vocal evaluation and were randomized into 3 groups: (1) those with the superior thyroid pole dissected by the first author, with the external branch of the superior laryngeal nerve (EBSLN) identified by means of a nerve stimulator; (2) those patients whose dissection was executed by a resident, with no nerve search; and (3) those whose dissection was undertaken by the first author, without any nerve search. Postoperative analysis consisted of voice evaluation and electromyography of the cricothyroid muscle. No lesion occurred in patients in group 1. Twenty-eight percent of patients in group 2 and 12% in group 3 experienced a complete lesion of the EBSLN (p = 0.0123). When the patients in group 1 were compared with the patients with 62 nerves corresponding to nonoperated thyroid lobes, patients in group 1 exhibited no increased risk, whereas a significantly increased hazard was evident in both groups 2 (p = 0.0002776) and 3 (p = 0.0346393). In this study, effective prevention of iatrogenic EBSLN lesions during thyroidectomies was achieved only by the intraoperative identification of the nerve with the nerve stimulator.
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Complicações Intraoperatórias/prevenção & controle , Traumatismos do Nervo Laríngeo , Tireoidectomia , Adulto , Estimulação Elétrica , Eletromiografia , Feminino , Humanos , Cuidados Intraoperatórios , Nervos Laríngeos/anatomia & histologia , Nervos Laríngeos/fisiologia , Masculino , Fonação , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de TempoRESUMO
Iatrogenic lesions of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomies are not infrequent due to the possibility of anatomic variations of the relationships of this nerve with the superior thyroid vessels. Therefore, based on an anatomic analysis of 30 superior thyroid poles from 15 fresh cadavers, a new classification of the EBSLN was proposed, considering the jeopardy during a thyroidectomy. Thirty-seven percent of the nerves were type 2, ie, crossing the superior thyroid pedicle less than 1 cm above the superior thyroid pole. It is notable that 20% were type 2b, ie, crossing the vessels below the upper border of the pole, having been considered "high risk." This incidence was comparable with other series, which found dangerous anatomic variations of the EBSLN in the range of 15% to 68%, confirming that a significant proportion of these nerves might be at risk during surgery on the superior thyroid pole.
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Nervos Laríngeos/anatomia & histologia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , TireoidectomiaRESUMO
Twenty-six patients with head and neck tumors were submitted to 27 microvascular reconstructive procedures. In 15, the mandible was reconstructed using the rib (4), iliac crest (7), and scapula (4). Nine patients underwent craniofacial reconstructions with the latissimus dorsi (5), rectus abdominis (2), greater omentum (2), and scapular (1) flaps. Two patients received a jejunum (1) and a stomach plus greater omentum (1) flaps for pharyngoesophageal reconstruction. Three illustrative cases, one from each group, are presented in detail. Good results were obtained in 22 patients (85%), with both functional and morphological rehabilitation. There were five flap losses (two in the same patient) due to thrombosis of the microvascular anastomoses. There was no operative mortality, and the average operative time was 11 hours. The good results observed in these very advanced cases show that there is a place for these complex procedures in the treatment of selected cases of head and neck tumors.