RESUMO
El trabajo original que publica en esta edición el equipo multidisciplinario del Hospital Fernández merece la siguiente reflexión: La pandemia por SARS-CoV-2 puso a nuestro sistema de salud ante un desafío inédito. La falta de previsión de las autoridades ante este evento que se extendió primero por el hemisferio norte se sumó a una infraestructura deteriorada e insuficiente. Frente a semejante reto, el personal de salud en su conjunto respondió con su capacidad de trabajo, intelectual y, en muchos casos, con su propia vida para poder salvar a la mayor cantidad posible de enfermos. Nunca será reconocido suficientemente este esfuerzo
Assuntos
Traqueotomia , Transtornos de Deglutição , Doenças da Laringe , Traumatismos do Nervo LaríngeoAssuntos
Estenose da Valva Aórtica , Cardiopatias/complicações , Traumatismos do Nervo Laríngeo/etiologia , Paralisia das Pregas Vocais/etiologia , Alcoolismo , Estenose da Valva Aórtica/complicações , Cardiopatias/diagnóstico , Insuficiência Cardíaca , Rouquidão/diagnóstico por imagem , Rouquidão/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome , Paralisia das Pregas Vocais/diagnóstico por imagemRESUMO
INTRODUCTION: Swallowing and voice alterations may manifest in patients with thyroid disease, especially after thyroidectomy. OBJECTIVE: To identify the prevalence of patients with complaints of swallowing disorders after thyroidectomy and to evaluate patients' perceptions regarding swallowing before and after the procedure. METHODS: A prospective longitudinal study was performed with 26 consecutive patients undergoing a private service thyroidectomy, in which the presence of swallowing dysfunction was evaluated using validated questionnaires that addressed the perception of swallowing by patients before (on the day of surgery) and after the surgery (on the first postoperative day). RESULTS: Of the 26 patients, 18 (69.2%) were subjected to total thyroidectomy and 8 to partial thyroidectomy. Analysis of the domains of the Swallowing Handicap Index questionnaire showed higher scores when evaluated on the first postoperative day, demonstrating a significant worsening in swallowing after the procedure. The same result was demonstrated for the final score of swallowing perception, with 15.3 and 30.8% of patients reporting moderate alterations before and after the thyroidectomy, respectively, and 11.5% reporting the alterations as severe. Swallowing and vocal symptoms on the first postoperative day were more prevalent in the procedure than previously mentioned. Eight patients (30.8%) noted swallowing alterations before the procedure, compared with 80.8% (21 cases) after thyroidectomy. CONCLUSION: There was a prevalence of 42.3% in swallowing complaints on the first postoperative day, regardless of the lesion in the laryngeal innervation, and this prevalence was significantly higher than that prior to the procedure.
Assuntos
Traumatismos do Nervo Laríngeo , Distúrbios da Voz , Deglutição , Humanos , Estudos Longitudinais , Percepção , Estudos Prospectivos , Tireoidectomia/efeitos adversos , Distúrbios da Voz/diagnóstico , Distúrbios da Voz/epidemiologia , Distúrbios da Voz/etiologiaAssuntos
Traumatismos do Nervo Laríngeo/história , Canto , Nódulo da Glândula Tireoide/história , Tireoidectomia/efeitos adversos , Pessoas Famosas , História do Século XIX , História do Século XX , Humanos , Itália , Traumatismos do Nervo Laríngeo/etiologia , Música , Nódulo da Glândula Tireoide/cirurgiaAssuntos
Humanos , História do Século XIX , História do Século XX , Tireoidectomia/efeitos adversos , Nódulo da Glândula Tireoide/história , Traumatismos do Nervo Laríngeo/história , Canto , Nódulo da Glândula Tireoide/cirurgia , Pessoas Famosas , Traumatismos do Nervo Laríngeo/etiologia , Itália , MúsicaRESUMO
Abstract Introduction: Dysphonia is a common symptom after thyroidectomy. Objective: To analyze the vocal symptoms, auditory-perceptual and acoustic vocal, videolaryngoscopy, the surgical procedures and histopathological findings in patients undergoing thyroidectomy. Methods: Prospective study. Patients submitted to thyroidectomy were evaluated as follows: anamnesis, laryngoscopy, and acoustic vocal assessments. Moments: pre-operative, 1st post (15 days), 2nd post (1 month), 3rd post (3 months), and 4th post (6 months). Results: Among the 151 patients (130 women; 21 men). Type of surgery: lobectomy + isthmectomy n = 40, total thyroidectomy n = 88, thyroidectomy + lymph node dissection n = 23. Vocal symptoms were reported by 42 patients in the 1st post (27.8%) decreasing to 7.2% after 6 months. In the acoustic analysis, f0 and APQ were decreased in women. Videolaryngoscopies showed that 144 patients (95.3%) had normal exams in the preoperative moment. Vocal fold palsies were diagnosed in 34 paralyzes at the 1st post, 32 recurrent laryngeal nerve (lobectomy + isthmectomy n = 6; total thyroidectomy n = 17; thyroidectomy + lymph node dissection n = 9) and 2 superior laryngeal nerve (lobectomy + isthmectomy n = 1; Total thyroidectomy + lymph node dissection n = 1). After 6 months, 10 patients persisted with paralysis of the recurrent laryngeal nerve (6.6%). Histopathology and correlation with vocal fold palsy: colloid nodular goiter (n = 76; palsy n = 13), thyroiditis (n = 8; palsy n = 0), and carcinoma (n = 67; palsy n = 21). Conclusion: Vocal symptoms, reported by 27.8% of the patients on the 1st post decreased to 7% in 6 months. In the acoustic analysis, f0 and APQ were decreased. Transient paralysis of the vocal folds secondary to recurrent and superior laryngeal nerve injury occurred in, respectively, 21% and 1.3% of the patients, decreasing to 6.6% and 0% after 6 months.
Resumo Introdução: A disfonia é um sintoma comum após a tireoidectomia. Objetivo: Analisar os sintomas vocais, auditivo-perceptivos e acústica vocal, videolaringoscopia, procedimento cirúrgico e achados histopatológicos em pacientes submetidos à tireoidectomia. Método: Estudo prospectivo. Pacientes submetidos à tireoidectomia foram avaliados da seguinte forma: anamnese, laringoscopia e avaliações vocais acústicas. Momentos: pré-operatório, 1ª avaliação pós (15 dias), 2ª avaliação pós (1 mês), 3ª avaliação pós (3 meses) e 4ª avaliação pós-operatória (6 meses). Resultados: Dos 151 pacientes, 130 eram mulheres e 21, homens. Tipos de cirurgia: lobectomia + istmectomia n = 40, tireoidectomia total n = 88, tireoidectomia + dissecção de linfonodo n = 23. Sintomas vocais foram relatados por 42 pacientes na 1ª avaliação pós-operatória (27,8%), reduzidos para 7,2% após 6 meses. Na análise acústica, f0 e APQ estavam diminuídos nas mulheres. As videolaringoscopias mostraram que 144 pacientes (95,3%) tiveram exames normais no momento pré-operatório. Paralisia das cordas vocais foi diagnosticada em 34 pacientes na 1ª avaliação pós-operatória, 32 do nervo laríngeo recorrente (lobectomia + istmectomia - n = 6; tireoidectomia total - n = 17; tireoidectomia total + dissecção de linfonodos - n = 9) e 2 do nervo laríngeo superior (lobectomia + istmectomia - n = 1; tireoidectomia total + dissecção de linfonodos - n = 1). Após 6 meses, 10 pacientes persistiram com paralisia do nervo laríngeo recorrente (6,6%). Histopatologia e correlação com paralisia das cordas vocais: bócio coloide nodular (n = 76; paralisia n = 13), tireoidite (n = 8; paralisia n = 0) e carcinoma (n = 67; paralisia n = 21). Conclusão: Os sintomas vocais, relatados por 27,8% dos pacientes na 1ª avaliação pós-operatória, diminuíram para 7% em 6 meses. Na análise acústica, f0 e APQ diminuíram. A paralisia transitória de cordas vocais secundária à lesão do nervo laríngeo recorrente e nervo laríngeo superior ocorreu, respectivamente, em 21% e 1,3% dos pacientes, reduziu-se para 6,6% e 0% após 6 meses.
Assuntos
Humanos , Masculino , Criança , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Adulto Jovem , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/epidemiologia , Tireoidectomia/efeitos adversos , Distúrbios da Voz/etiologia , Doenças da Laringe/etiologia , Fatores de Tempo , Qualidade da Voz/fisiologia , Brasil/epidemiologia , Fatores Sexuais , Paralisia das Pregas Vocais/etiologia , Paralisia das Pregas Vocais/fisiopatologia , Paralisia das Pregas Vocais/epidemiologia , Distúrbios da Voz/fisiopatologia , Distúrbios da Voz/epidemiologia , Doenças da Laringe/fisiopatologia , Doenças da Laringe/epidemiologia , Estudos Prospectivos , Traumatismos do Nervo Laríngeo/etiologia , Traumatismos do Nervo Laríngeo/fisiopatologia , Traumatismos do Nervo Laríngeo/epidemiologia , Laringoscopia/métodos , Laringe/lesões , Laringe/patologiaRESUMO
INTRODUCTION: Dysphonia is a common symptom after thyroidectomy. OBJECTIVE: To analyze the vocal symptoms, auditory-perceptual and acoustic vocal, videolaryngoscopy, the surgical procedures and histopathological findings in patients undergoing thyroidectomy. METHODS: Prospective study. Patients submitted to thyroidectomy were evaluated as follows: anamnesis, laryngoscopy, and acoustic vocal assessments. Moments: pre-operative, 1st post (15 days), 2nd post (1 month), 3rd post (3 months), and 4th post (6 months). RESULTS: Among the 151 patients (130 women; 21 men). Type of surgery: lobectomy+isthmectomy n=40, total thyroidectomy n=88, thyroidectomy+lymph node dissection n=23. Vocal symptoms were reported by 42 patients in the 1st post (27.8%) decreasing to 7.2% after 6 months. In the acoustic analysis, f0 and APQ were decreased in women. Videolaryngoscopies showed that 144 patients (95.3%) had normal exams in the preoperative moment. Vocal fold palsies were diagnosed in 34 paralyzes at the 1st post, 32 recurrent laryngeal nerve (lobectomy+isthmectomy n=6; total thyroidectomy n=17; thyroidectomy+lymph node dissection n=9) and 2 superior laryngeal nerve (lobectomy+isthmectomy n=1; Total thyroidectomy+lymph node dissection n=1). After 6 months, 10 patients persisted with paralysis of the recurrent laryngeal nerve (6.6%). Histopathology and correlation with vocal fold palsy: colloid nodular goiter (n=76; palsy n=13), thyroiditis (n=8; palsy n=0), and carcinoma (n=67; palsy n=21). CONCLUSION: Vocal symptoms, reported by 27.8% of the patients on the 1st post decreased to 7% in 6 months. In the acoustic analysis, f0 and APQ were decreased. Transient paralysis of the vocal folds secondary to recurrent and superior laryngeal nerve injury occurred in, respectively, 21% and 1.3% of the patients, decreasing to 6.6% and 0% after 6 months.
Assuntos
Doenças da Laringe/etiologia , Complicações Pós-Operatórias , Tireoidectomia/efeitos adversos , Distúrbios da Voz/etiologia , Adolescente , Adulto , Idoso , Brasil/epidemiologia , Criança , Feminino , Humanos , Doenças da Laringe/epidemiologia , Doenças da Laringe/fisiopatologia , Traumatismos do Nervo Laríngeo/epidemiologia , Traumatismos do Nervo Laríngeo/etiologia , Traumatismos do Nervo Laríngeo/fisiopatologia , Laringoscopia/métodos , Laringe/lesões , Laringe/patologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Estudos Prospectivos , Fatores Sexuais , Fatores de Tempo , Paralisia das Pregas Vocais/epidemiologia , Paralisia das Pregas Vocais/etiologia , Paralisia das Pregas Vocais/fisiopatologia , Distúrbios da Voz/epidemiologia , Distúrbios da Voz/fisiopatologia , Qualidade da Voz/fisiologia , Adulto JovemRESUMO
BACKGROUND: This study investigated whether visual localization of the external branch of the superior laryngeal nerve (EBSLN) coincides with its localization via intraoperative neuro-monitoring (IONM) during thyroidectomy and whether its use influences the frequency of injuries. METHODS: A prospective, comparative, cross-sectional, observational study was performed in 240 superior thyroid poles. The metrics were visual identification of the EBSLN and its corroboration with IONM. The frequency of EBSLN injuries was also determined. Statistical analysis was achieved via kappa and chi-square tests, as well as odds ratios (OR). RESULTS: Of the 240 superior thyroid poles, IONM identified 234 (97.5%) EBSLN, whereas 190 (79.1%) were identified visually: OR = 10.35 [CI 4.37-24.65] p < 0.0001. Of the 190 EBSLN identified visually, 150 were confirmed through IONM. Indeed, their structure corresponded to an EBSLN to yield a kappa with a linear weighting value of 0.362. The standard error was 0.0467 [CI 0.2686-0.4554], indicating a fair agreement between the visual and IONM classification. CONCLUSION: IONM identified 97.5% of EBSLN cases. It was higher than the visual identification. There were no injuries to EBSLN identified through IONM.
Assuntos
Monitorização Neurofisiológica Intraoperatória/métodos , Nervos Laríngeos , Tireoidectomia , Percepção Visual , Adolescente , Adulto , Idoso , Distribuição de Qui-Quadrado , Estudos Transversais , Feminino , Humanos , Traumatismos do Nervo Laríngeo/etiologia , Traumatismos do Nervo Laríngeo/prevenção & controle , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Fatores de Risco , Tireoidectomia/efeitos adversos , Resultado do Tratamento , Adulto JovemRESUMO
One of the most significant complication of thyroid surgery is injury of the recurrent laryngeal nerve. Injury of the external branch of the superior laryngeal nerve is a less obvious but occasionally significant problem. Recently, neuromonitoring during thyroidectomy has received considerable attention because of literature encouraging its use, but there is no consensus about its advantages and utility. A critical assessment of the literature on neuromonitoring was conducted in order to define its effectiveness, safety, cost-effectiveness and medical-legal impact. Available data does not show results superior to those obtained by traditional anatomical methods of nerve identification during thyroid surgery. Data about cost-effectiveness is scarce. The literature shows inconsistencies in methodology, patient selection and randomization in various published studies which may confound the conclusions of individual investigations. The current recommendation for use in "high risk" patients should be assessed because definition heterogeneity makes identification of these patients difficult. As routine use of neuromonitoring varies according to geography, its use should not be considered to be the standard of care.
Assuntos
Complicações Intraoperatórias/prevenção & controle , Monitorização Neurofisiológica Intraoperatória , Traumatismos do Nervo Laríngeo/prevenção & controle , Glândula Tireoide/cirurgia , Tireoidectomia/efeitos adversos , Eletromiografia/métodos , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Traumatismos do Nervo Laríngeo/etiologia , Tireoidectomia/métodos , Paralisia das Pregas Vocais/etiologia , Paralisia das Pregas Vocais/prevenção & controleRESUMO
Neuromonitoring in thyroid surgery has been employed to make nerve identification easier and decrease the rates of laryngeal nerve injuries. Several individual randomized controlled trials (RCTs) have been published, which did not identify statistical differences in the rates of recurrent laryngeal nerve (RLN) or external branch of the superior laryngeal nerve (EBSLN) injuries. The objective of this report is to perform meta-analysis of the combined results of individual studies to measure the frequency of RLN and EBSLN injuries in patients who underwent thyroidectomy with routine neuromonitoring in comparison with common practice of search and identification. RCTs comparing routine neuromonitoring versus no use in patients who underwent elective partial or total thyroidectomy were evaluated. Outcomes measured were temporary and definitive palsy of the RLN and EBSLN. A systematic review and meta-analysis was done using random effects model. GRADE was used to classify quality of evidence. Six studies with 1,602 patients and 3,064 nerves at risk were identified. Methodological quality assessment showed high risk of bias in most items. Funnel plot did not reveal publication bias. The risk difference for temporary RLN palsy, definitive RLN palsy, temporary EBSLN palsy, and definitive EBSLN palsy were -2% (95% confidence interval -5.1 to 1); 0% (-1 to 1); -9% (-15 to -2) and -1% (-4 to 2), respectively. Quality was rated low or very low in most outcomes due to methodological flaws. Meta-analysis did not demonstrate a statistically significant decrease in the risk of temporary or definitive RLN injury and definitive EBSLN injury with the use of neuromonitoring. The neuromonitoring group had a statistically significant decrease in the risk of temporary EBSLN injury.
Assuntos
Complicações Intraoperatórias/prevenção & controle , Monitorização Neurofisiológica Intraoperatória/métodos , Traumatismos do Nervo Laríngeo/prevenção & controle , Doenças da Glândula Tireoide/cirurgia , Tireoidectomia , Paralisia das Pregas Vocais/etiologia , Humanos , Traumatismos do Nervo Laríngeo/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , RiscoRESUMO
PURPOSE OF REVIEW: Laryngeal nerve injuries are among the most important complications of thyroidectomy. Recently, the use of neuromonitoring has been increasingly employed in order to predict and document nerve function at the end of thyroidectomy. RECENT FINDINGS: There is much controversy in recent studies concerning neuromonitoring in thyroid surgery. Some authors believe that the method does not bring any additional reduction in the paralysis rate of the laryngeal nerves. Other researchers defend its use only in selected cases and in very specific situations. Finally, some much respected surgeons advocate the routine use of neuromonitoring in all thyroidectomies. SUMMARY: In this review, we try to present relevant recent publications dealing with this still controversial subject, emphasizing the advantages and disadvantages of neuromonitoring in thyroidectomy.
Assuntos
Traumatismos do Nervo Laríngeo/prevenção & controle , Monitorização Intraoperatória , Tireoidectomia , Estimulação Elétrica , Humanos , Traumatismos do Nervo Laríngeo/etiologia , Monitorização Intraoperatória/efeitos adversos , Tireoidectomia/efeitos adversosRESUMO
BACKGROUND: In ancient times, operations on the thyroid gland caused unacceptable morbidity and mortality. Only after the landmark work of Kocher, the technical principles of thyroidectomy were solidly established, and are still valid nowadays. METHODS: Revision article on practical suggestions to decrease morbidity associated with thyroidectomy, as well as warning against common pitfalls that the surgeon may encounter. RESULTS: The following subjects are objectively addressed: how to manage upper airway obstruction, how to avoid non-esthetic scars and how to recognize the most prevalent anatomic variations concerning the recurrent nerve, the external branch of the superior laryngeal nerve and the parathyroid glands, in order to decrease operative morbidity. CONCLUSION: The Head and Neck Surgeon must be fully aware of the complex anatomy of the central visceral compartment of the neck, as well as must be prepared to handle some complications of thyroidectomy that can be life-threatening.
Assuntos
Complicações Intraoperatórias/prevenção & controle , Traumatismos do Nervo Laríngeo , Traumatismos do Nervo Laríngeo Recorrente , Doenças da Glândula Tireoide/cirurgia , Humanos , Hipoparatireoidismo/prevenção & controle , Glândulas Paratireoides/lesõesRESUMO
UNLABELLED: Vocal alterations after thyroidectomy are generally related to laryngeal nerve injury or laryngotracheal mobility disorders caused by postoperative fibrosis or strap muscle lesion. AIM: this study aims to evaluate the frequency of vocal and rima glottidis disorders after thyroidectomy. MATERIALS AND METHOD: This is a prospective study based on 35 patients submitted to thyroidectomy under local anesthesia and hypnosedation. All patients underwent voice auditory perception evaluation, voice acoustic tests and videolaryngostroboscopy preoperatively, and at one week and at 30 days postoperatively. Bilateral cricothyroid muscle electromyography was performed on the thirtieth day after surgery to confirm the presence of injury in the external branch of the superior laryngeal nerve. RESULTS: 14.3% of the patients presented posterior glottis deviation before surgery and normal electromyography findings. Transient and permanent vocal alteration occurred in 25.7% and 14.2% of the patients respectively. CONCLUSION: voice disorders evaluated after voice auditory perceptive evaluation and voice acoustic tests were more intense in the group with superior laryngeal nerve external branch injury than in the injury-free dysphonic patient group. Oblique glottis can be present in normal patients; however its onset after thyroidectomy is indicative of superior laryngeal nerve external branch lesion.
Assuntos
Disfonia/etiologia , Traumatismos do Nervo Laríngeo , Tireoidectomia/efeitos adversos , Adulto , Idoso , Anestesia Local , Disfonia/diagnóstico , Eletromiografia , Feminino , Humanos , Hipnose Anestésica , Laringoscopia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Índice de Gravidade de Doença , Tireoidectomia/métodos , Adulto JovemRESUMO
BACKGROUND: The extent of surgical treatment for well-differentiated thyroid cancer is based on non-oncological reasons related to morbidity and oncological reasons related to risk factors and cancer staging. We undertook this study to evaluate if the surgical extent for the treatment of well-differentiated thyroid cancer has a relationship with increased morbidity. METHODS: A cross-sectional, comparative, retrospective study was conducted in 823 thyroidectomies done over 5 years with systematized surgical technique. Subjects were grouped in two groups: G1 with differentiated thyroid cancer; G2 with benign thyroid disease. Studied variables were definitive hypocalcemia (DH), recurrent laryngeal nerve lesion (RLN) and external branch of superior laryngeal nerve lesion (EBSLN). Variables were measured 6 months after surgery and evaluation was also done as to the training of the surgeon: expert vs. surgical resident. Statistical analysis was done by central tendency measures and chi(2), with p >0.05 as significant. RESULTS: We studied 766 women and 57 men with an average age of 42 years (range: 16-89 years). In G1 there were 195 cases all with total thyroidectomies (TT), 4 (2.05%) DH, 2 (1.02%) RLN, 3 (1.53%) EBSLN. In 45 cases, surgery was performed by the resident. G2 included 628 cases, 56 TT and 572 unilateral hemithyroidectomies with 7 (1.1%) DH, 9 (1.43%) RLN and 3 (0.47%) EBSLN. In 134 cases, surgery was performed by the resident. Comparing these results, no differences were documented in terms of cancer diagnosis and who performed the surgery, expert surgeon or surgical resident (p >0.05). CONCLUSIONS: There is no reason to limit the extent of surgery for treatment of well-differentiated thyroid cancer, based on morbidity.
Assuntos
Adenocarcinoma Folicular/cirurgia , Carcinoma Papilar/cirurgia , Complicações Pós-Operatórias/epidemiologia , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Hipoparatireoidismo/epidemiologia , Hipoparatireoidismo/etiologia , Internato e Residência , Traumatismos do Nervo Laríngeo , Masculino , Pessoa de Meia-Idade , Traumatismos do Nervo Laríngeo Recorrente , Estudos Retrospectivos , Doenças da Glândula Tireoide/cirurgia , Tireoidectomia/efeitos adversos , Tireoidectomia/métodos , Distúrbios da Voz/epidemiologia , Distúrbios da Voz/etiologiaRESUMO
OBJECTIVE: To establish the frequency and degree of postthyroidectomy injury of the external branch of the superior laryngeal nerve (EBSLN) by means of electromyography and to assess whether intraoperative identification of the nerve and the presence of malignancy influence morbidity. PATIENTS AND METHODS: Prospective, randomized, blind study. Comparison of 100 superior thyroid poles subjected to surgery because of benign and malignant disease, divided in three groups: G1, thyroidectomies, without searching for the EBSLN; G2, thyroidectomies, searching for the EBSLN; G3, Control, lobes, contralateral to the lobectomy, not surgically manipulated. The electromyographic function of the EBSLN was assessed in all cases, classifying the degree of injury and clinically assessing its function. Central tendency measures were used, as well as X (2) and multiple variance analysis. RESULTS: In G1, with 50 dissections of the superior pole, 25 injuries were found in 15 patients (10 bilateral and 5 unilateral). In G2, EBSLN injury was found after 13 explorations of the superior pole in 8 patients (5 bilateral and 3 unilateral). G3 patients did not present EBSLN injury. X (2) among groups and degree of injury revealed that intraoperative identification of the EBSLN decreases its injury. No evidence were found that injury frequency is increased by the presence of thyroid malignancy, extracapsular infiltration, or size of tumor. Clinical manifestations of hoarseness were present in 14% of G1 patients and 8% of G2 patients. DISCUSSION: The rate of EBSLN injury increased when not exploring and/or identifying it expressly. The presence of cancer, extracapsular extension, or size of the thyroid tumor exerted no influence on the frequency of injury; localization of the nerve was the only factor affecting injury. Hoarseness correlated with the degree of injury. CONCLUSION: EBSLN must be localized expressly to decrease the risk of injury.
Assuntos
Eletromiografia , Complicações Intraoperatórias/prevenção & controle , Nervos Laríngeos/anatomia & histologia , Tireoidectomia/métodos , Adolescente , Adulto , Idoso , Envelhecimento/fisiologia , Método Duplo-Cego , Feminino , Humanos , Músculos Laríngeos/anatomia & histologia , Músculos Laríngeos/inervação , Traumatismos do Nervo Laríngeo , Masculino , Pessoa de Meia-Idade , Caracteres Sexuais , Glândula Tireoide/patologia , Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/cirurgiaRESUMO
OBJECTIVE: This study evaluates some "intrinsic risk factors" for a surgical injury of the external branch of superior laryngeal nerve (EBSLN) based on its anatomic relationship with the thyroid gland. STUDY DESIGN AND SETTING: Seventy-two neck dissections were performed in 36 fresh human adult cadavers. Every EBSLN was dissected and categorized using Cernea's classification. All data regarding gender, ethnicity, stature, side of the neck, and volume of hemi thyroid were collected and statistically analyzed by the chi(2)-test and analysis of variance. RESULTS: Although no statistical differences were observed between genders (P = 0.3770), ethnicities (P = 0.9780) or sides of the neck (P = 0.2523), statistical significance was reached regarding the nerve type when the groups were divided by stature (P = 0.0006) and glandular volume (P = 0.0007). CONCLUSION: Individual stature and volume of the hemi thyroid gland are probably involved in risk of the surgical EBSLN injury. SIGNIFICANCE: Surgeons should be aware of these anatomic findings in order to obtain a good voice-related outcome in the thyroidectomies.
Assuntos
Complicações Intraoperatórias , Traumatismos do Nervo Laríngeo , Nervos Laríngeos/anatomia & histologia , Glândula Tireoide/anatomia & histologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
Knowledge of the topographic anatomy is essential to prevent iatrogenic damage of the superior laryngeal nerve (SLN) in carotid endarterectomy (CEA). The purpose of this study was to analyze the anatomic relationship between the SLN and carotid arteries in order to prevent iatrogenic nerve injury. Anatomic dissections similar to CEA were performed bilaterally in 50 fresh human adult cadavers. The topography of the SLN was analyzed regarding its relationship with the carotid arteries. Furthermore, the distance between the external branch of the SLN and the point of bifurcation of the common carotid artery (dCAB) was analyzed regarding effects of gender, ethnicity, individual stature and side of the neck. The SLN was always located adjacent and posterior to the carotid arteries.The dCAB ranged from 20.3 mm below the point of bifurcation of the common carotid artery to 50.9 mm above this level (average 10.3 mm above). Most dissections (75%) showed the external branch of the SLN emerging from behind the carotid artery above the arterial bifurcation; in only 10% of cases did this nerve emerge from the artery below that anatomic reference. Based on Student's t-test, there were no significant differences in the dCAB between genders ( P=0.237), ethnicities ( P=0.410) and sides of the neck ( P=0.872). Moreover, tall stature was not significantly correlated with a shorter dCAB (linear regression: R(2)=0.009, P=0.357). We conclude that most SLNs were located above the carotid artery bifurcation, but anatomic variations occurred in 25% of the dissections. The dCAB was unaffected by gender, ethnicity, individual stature and side of the neck.
Assuntos
Endarterectomia das Carótidas , Nervos Laríngeos/anatomia & histologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artéria Carótida Primitiva/anatomia & histologia , Endarterectomia das Carótidas/efeitos adversos , Etnicidade , Feminino , Humanos , Complicações Intraoperatórias , Traumatismos do Nervo Laríngeo , Masculino , Pessoa de Meia-Idade , Caracteres SexuaisRESUMO
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.
Assuntos
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
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.
Assuntos
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
In the present retrospective study we examine the complications arising from simple goiter operations based on the analysis of 2,035 cases. The mortality rate is extremely low (0.3%). The most typical intraoperative complications - such as unilateral vocal cord paralysis (1.6%) and permanent parathyroprival hypocalcemia (0.4%) were observed to occur much more frequently in cases of subtotal thyroidectomy than in those of partial resection. - As a result of the introduction of synthetic reabsorbent sewing materials, healing problems have been drastically reduced (0.4%). Hypothyreosis and goiter recurrence can be avoided in cases of subtotal thyroidectomy by life-long and individually adjusted administration of thyroid hormones (rate of incidence in our study 3.1%). - In our view a subtotal thyroidectomy is indicate in cases where malignity is suspected (one or more cold nodules).