Background
During the SARS‐CoV‐2 pandemic, tracheostomy may be required for COVID‐19 patients requiring long‐term ventilation in addition to other conditions such as airway compromise from head and ...neck cancer. As an aerosol‐generating procedure, tracheostomy increases the exposure of health care workers to COVID‐19 infection. Performing surgical tracheostomy and tracheostomy care requires a strategy that mitigates these risks and maintains the quality of patient care.
Methods
This study is a multidisciplinary review of institutional tracheostomy guidelines and clinical pathways. Modifications to support clinical decision making in the context of COVID‐19 were derived by consensus and available evidence.
Results
Modified guidelines for all phases of tracheostomy care at an academic tertiary care center in the setting of COVID‐19 are presented.
Discussion
During the various phases of the COVID‐19 pandemic, clinicians must carefully consider the indications, procedural precautions, and postoperative care for tracheostomies. We present guidelines to mitigate risk to health care workers while preserving the quality of care.
Background
The use of ultrasound‐guided ablation procedures to treat both benign and malignant thyroid conditions is gaining increasing interest. This document has been developed as an international ...interdisciplinary evidence‐based statement with a primary focus on radiofrequency ablation and is intended to serve as a manual for best practice application of ablation technologies.
Methods
A comprehensive literature review was conducted to guide statement development and generation of best practice recommendations. Modified Delphi method was applied to assess whether statements met consensus among the entire author panel.
Results
A review of the current state of ultrasound‐guided ablation procedures for the treatment of benign and malignant thyroid conditions is presented. Eighteen best practice recommendations in topic areas of preprocedural evaluation, technique, postprocedural management, efficacy, potential complications, and implementation are provided.
Conclusions
As ultrasound‐guided ablation procedures are increasingly utilized in benign and malignant thyroid disease, evidence‐based and thoughtful application of best practices is warranted.
Surgical management of thyroid cancer requires careful consideration of the recurrent laryngeal nerve and its impact on glottic function. Management of the compromised recurrent laryngeal nerve is a ...complex task, requiring synthesis of multiple elements. The surgeon must have an appreciation for preoperative recurrent laryngeal nerve function, intraoperative anatomic and electromyographic information, disease characteristics, and relevant patient factors. Preoperative clinical evaluation including preoperative laryngoscopy and assessment of recurrent laryngeal nerve risk is essential to formulating a surgical plan and providing appropriate patient counseling. Intraoperative neuromonitoring information has significant implications for surgical management of the injured or invaded recurrent laryngeal nerve and informs strategy with respect to staging of bilateral surgery. Disease characteristics and patient-related factors, including patient preference, must be considered with intraoperative decision-making. Multidisciplinary discussion and patient communication are essential for effective management and successful surgical outcome.
Background
Ultrasonography has become an essential tool for the evaluation and management of thyroid and parathyroid diseases. Its applications extend beyond neck endocrine conditions to a multitude ...of pathologies within the head and neck region.
Objectives
Our study aimed to: (1) provide a broad review of neck ultrasonography and key findings in neck endocrine diseases; (2) support skilled performance office-based diagnostic ultrasonography and its varied applications.
Materials and methods
A review of the current literature was supplemented with clinical examples of key ultrasonographic findings.
Results
Current applications and key findings of ultrasonography in the diagnosis and management of neck endocrine conditions are reviewed.
Conclusion
Ultrasonography is a fundamental component in the evaluation and management of neck endocrine diseases. The reader is encouraged to use this review to enhance office-based performance and application of ultrasonography.
Surgical treatment of advanced thyroid malignancy can be morbid, compromising normal functions of the upper aerodigestive tract. There is a paucity of guidelines dedicated to the management of ...advanced disease. In fact, there is not even a uniform definition for advanced thyroid cancer currently. The presence of local invasion, bulky cervical nodes, distant metastases or recurrent disease should prompt careful preoperative evaluation and planning. Surgical strategy should evolve from multidisciplinary discussion that integrates individual disease characteristics and patient preference. Intraoperative neuromonitoring has important applications in surgery for advanced disease and should be used to guide surgical strategy and intraoperative decision-making. Recent paradigm shifts, including staged surgery and use of neoadjuvant targeted therapy hold potential for decreasing surgical morbidity and improving clinical outcomes. Modern surgical planning provides optimal treatment for each patient through a tailored approach based on exact extent and type of disease as well as incorporating appreciation of surgical complications, patient preferences and intraoperative findings.
Objective
Endotracheal tube (ETT) surface electrodes are used to monitor the vagus nerve (VN), recurrent laryngeal nerve (RLN), and external branch of the superior laryngeal nerve (EBSLN) during ...thyroid and parathyroid surgery. Alternative nerve monitoring methods are desirable when intubation under general anesthesia is not desirable or possible. In this pilot study, we compared the performance of standard ETT electrodes to four different noninvasive cutaneous recording electrode types (two adhesive electrodes and two needle electrodes) in three different orientations.
Methods
The VN was stimulated directly during thyroid and parathyroid surgery using a Prass stimulator probe. Electromyographic (EMG) responses for each patient were recorded using an ETT plus one of the following four cutaneous electrode types: large‐foot adhesive, small‐foot adhesive, long‐needle and short‐needle. Each of the four electrode types was placed in three orientations: (1) bilateral, (2) ipsilateral mediolateral, and (3) ipsilateral craniocaudal.
Results
Four surgical cases were utilized for data collection with the repetitive measures obtained in each subject. Bilateral electrode orientation was superior to ipsilateral craniocaudal and ipsilateral mediolateral orientations. Regardless of electrodes type, all amplitudes in the bilateral orientation were >100 μV. When placed bilaterally, the small‐foot adhesive and the long‐needle electrodes obtained the highest EMG amplitudes as a percentage of ETT amplitudes.
Conclusion
Cutaneous electrodes could potentially be used to monitor the VN during thyroid and parathyroid procedures. Different electrode types vary in their ability to record amplitudes and latencies. Bilateral orientation improves EMG responses in all electrode types. Additional validation of cutaneous electrodes as an alternative noninvasive method to monitor the VN is needed.
Electronic consultation (eConsult) systems have enhanced access to specialty expertise and enhanced care coordination among primary care and specialty care providers, while maintaining high primary ...care provider (PCP), specialist and patient satisfaction. Little is known about their impact on the efficiency of specialty care delivery, in particular surgical yield (percent of ambulatory visits resulting in a scheduled surgical case).
Retrospective cohort of a random selection of 150 electronic consults from PCPs to a safety-net general surgery clinic for the three most common general surgery procedures (herniorrhaphy, cholecystectomy, anorectal procedures) in 2014. Electronic consultation requests were reviewed for the presence/absence of consult domains: symptom acuity/severity, diagnostic evaluation, concurrent medical conditions, and attempted diagnosis. Logic regression was used to examine the association between completeness of consult requests and scheduling an ambulatory clinic visit. Surgical yield was also calculated, as was the percentage of patients requiring unanticipated healthcare visits.
In 2014, 1743 electronic consultations were submitted to general surgery. Among the 150 abstracted, the presence of consult domains ranged from 49% to 99%. Consult completeness was not associated with greater likelihood of scheduling an ambulatory visit. Seventy-six percent of consult requests (114/150) were scheduled for a clinic appointment and surgical yield was 46%; without an eConsult system, surgical yield would have been 35% (p=0.07). Among patients not scheduled for a clinic visit (n=36), 4 had related unanticipated emergency department visits.
Econsult systems can be used to safely optimize the surgical yield of a safety-net general surgery service.
Objectives
Neoadjuvant targeted therapy has emerged as a promising treatment strategy for locally aggressive thyroid cancer. Its impact on tumor and adjacent tissues remains a nascent area of study. ...Here we report on a series of six subjects with locally advanced thyroid cancer and recurrent laryngeal nerve (RLN) paralysis who experienced recovery of RLN function with neoadjuvant treatment and describe the morphologic and electrophysiologic characteristics of these recovered nerves.
Methods
This is a multicenter retrospective review. Descriptive analysis was conducted to examine the following parameters for recovered nerves: (1) nerve morphology, characterized as Type A (involving epineurium only) versus Type B (extending beyond epineurium); (2) proximal stimulability (normal vs. abnormal vs. absent); and (3) surgical management (resection vs. preservation).
Results
Six subjects with unilateral VFP were identified. Median time to return of VF mobility was 3 months (range 2–13.5). All nerves (100%) were noted to have Type A morphology at surgery. Proximal stimulability was normal in four subjects (66.7%), abnormal in one (16.7%), and absent in one (16.7%). Nerves that had improvement of function through neoadjuvant therapy were able to be surgically preserved in five subjects (83.3%).
Conclusions
This represents the first characterization of RLNs that have recovered function with neoadjuvant treatment of locally advanced thyroid cancer. Although much remains unknown, our findings indicate carcinomatous neural invasion is a reversible process and recovered nerves may demonstrate normal morphology and electrophysiologic activity.
Level of Evidence
4 Laryngoscope, 134:3415–3419, 2024
Objective
To investigate a possible link between breast and thyroid cancer.
Methods
A multicenter retrospective review of patients in the electronic medical records of six Accrual to Clinical Trial ...(ACT) institutions with both breast cancer and thyroid carcinoma. Each center queried its data using a predefined data dictionary. Information on thyroid and breast cancer included dates of diagnosis, histology, and patient demographics.
Results
A random‐effects model was used. There were 4.24 million women's records screened, 44 605 with breast cancer and 11 846 with thyroid cancer. The relative risks observed at each institution ranged from 0.49 to 13.47. The combined risk ratio (RR) estimate was 1.77 (95% confidence interval: 0.50–5.18).
Conclusion
There was no association between the risk of developing thyroid cancer and being a breast cancer survivor compared to no history of breast cancer, but the range of relative risks among the participating institutions was wide. Our findings warrant further study of more institutions with larger sample size. Additionally, further analysis of the significance of regional RR differences may be enlightening.
Oncocytic (Hürthle cell) thyroid carcinoma is a follicular cell-derived neoplasm that accounts for approximately 5% of all thyroid cancers. Until recently, it was categorized as a follicular thyroid ...carcinoma, and its management was standardized with that of other differentiated thyroid carcinomas. In 2022, given an improved understanding of the unique molecular profile and clinical behavior of oncocytic thyroid carcinoma, the World Health Organization reclassified oncocytic thyroid carcinoma as distinct from follicular thyroid carcinoma. The International Thyroid Oncology Group and the American Head and Neck Society then collaborated to review the existing evidence on oncocytic thyroid carcinoma, from diagnosis through clinical management and follow-up surveillance.
Given that oncocytic thyroid carcinoma was previously classified as a subtype of follicular thyroid carcinoma, it was clinically studied in that context. However, due to its low prevalence and previous classification schema, there are few studies that have specifically evaluated oncocytic thyroid carcinoma. Recent data indicate that oncocytic thyroid carcinoma is a distinct class of malignant thyroid tumor with a group of distinct genetic alterations and clinicopathologic features. Oncocytic thyroid carcinoma displays higher rates of somatic gene variants and genomic chromosomal loss of heterozygosity than do other thyroid cancers, and it harbors unique mitochondrial DNA variations. Clinically, oncocytic thyroid carcinoma is more likely to have locoregional (lymph node) metastases than is follicular thyroid carcinoma-with which it was formerly classified-and it develops distant metastases more frequently than papillary thyroid carcinoma. In addition, oncocytic thyroid carcinoma rarely absorbs radioiodine.
The findings of this review suggest that the distinct clinical presentation of oncocytic thyroid carcinoma, including its metastatic behavior and its reduced avidity to radioiodine therapy, warrants a tailored disease management approach. The reclassification of oncocytic thyroid carcinoma by the World Health Organization is an important milestone toward developing a specific and comprehensive clinical management for oncocytic thyroid carcinoma that considers its distinct characteristics.
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