Is Routine Central Neck Dissection Necessary for the Treatment of Papillary Thyroid Microcarcinoma?

Objectives

It remains unclear as to whether routine central neck dissection (CND) is necessary when performing surgery to treat patients with papillary thyroid microcarcinoma (PTMC). To determine the necessity for routine CND in PTMC patients, we reviewed the clinicopathologic and laboratory data of the patients of PTMC.

Methods

Between September 2001 and July 2005, 101 patients with PTMC and clinical N0 disease were retrospectively reviewed. The study cohort was devided into groups: the total thyroidectomy plus CND group (the CND group, N=48) and the total thyroidectomy without CND group (the no CND group, N=53). The serum stimulated thyroglobulin (Tg) levels were measured after surgery and prior to radioactive iodine ablation therapy (RAI) and at 6-12 months after RAI. Pathology, the Tg levels and recurrence data were compared between the 2 groups.

Results

Central nodal metastases were found in 18 of the 48 CND patients (37.5%). The incidence of Tg levels >5 ng/mL at RAI was higher in the no CND patients and in the 18 node-positive CND patients compared with the 30 node-negative CND patients (22-24% vs. 3%, respectively, P=0.020-0.058). The difference when performing a similar comparison using a >2 ng/mL Tg threshold level showed no significance (10-11% vs. 4%, respectively, P>0.1). Two of the no CND patients and one node-positive CND patient had recurrences in the thyroid bed or lateral neck during a mean follow-up of 24 months.

Conclusion

The data showed that occult metastasis to the central neck is common in PTMC patients. A CND provides pathologic information about the nodal metastases, and it potentially provides guidance for planning the postoperative RAI. However, the long-term benefit of CND on recurrence and survival remains somewhat questionable.     

Level V Lymph Node Dissection in Oral and Oropharyngeal Carcinoma Patients with Clinically Node‐Positive Neck: Is it Absolutely Necessary?

OBJECTIVES: Postoperative shoulder dysfunction has been significantly associated with any dissection of level V secondary to traction or with ischemic injury to the spinal accessory nerve. The aim of this study was to determine whether the dissection of level V lymph node pads is absolutely necessary in therapeutic neck dissection as a treatment for oral and oropharyngeal squamous cell carcinoma (OOSCC) patients with clinically N+ neck. STUDY DESIGN: Retrospective chart review. METHODS: We performed a retrospective analysis of 93 OOSCC patients who underwent surgical treatment of the primary lesion along with a simultaneous comprehensive neck dissection from January 1992 to December 2003. Of these, only one patient had a clinically positive neck node at level V. During the neck dissection, the contents of the level V lymph nodes were dissected, labeled, and processed separately from the remainder of the major neck dissection specimen. We studied the incidence of pathologic metastasis to level V lymph nodes. In addition, we also evaluated several potential risk factors for metastatic disease in the level V lymph nodes such as sex, age, T stage, N stage, histologic grade, and presence of other positive lymph nodes. RESULTS: A total of 96 comprehensive neck dissections were performed in this series. The prevalence of metastases in the level V lymph nodes was 5% (5 of 93) in ipsilateral and 0% (0 of 3) in contralateral necks. One case with clinically positive node at level V had a pathologic positive node in level II, III, IV, and V. Occult metastasis rate of ipsilateral level V was 4% (4 of 92). There was a statistically significant association between level V metastases and a positive N stage above N2b (P=.01). The presence of metastasis in other multiple neck levels, particularly the combined neck levels II, III, and IV, also have a statistically significant association with level V metastasis (P=.023). CONCLUSION: Level V lymph node pads may be preserved in modified neck dissections on OOSCC patients with clinically N+ neck below the nodal stage N2a.     

Conversion from Selective to Comprehensive Neck Dissection: Is It Necessary for Occult Nodal Metastasis? 5-Year Observational Study

Objectives

To compare the therapeutic results between selective neck dissection (SND) and conversion modified radical neck dissection (MRND) for the occult nodal metastasis cases in head and neck squamous cell carcinoma.

Methods

Forty-four cases with occult nodal metastasis were enrolled in this observational cohort study. For twenty-nine cases, SNDs were done and for fifteen cases, as metastatic nodes were found in the operative field, conversion from selective to MRNDs type II were done. Baseline data on primary site, T and N stage, extent of SND, extracapsular spread of occult metastatic node and type of postoperative adjuvant therapy were obtained. We compared locoregional control rate, overall survival rate and disease specific survival rate between two groups.

Results

Among the 29 patients who underwent SND, only one patient had a nodal recurrence which occurred in the contralateral undissected neck. On the other hand, among the 15 patients who underwent conversion MRND, two patients had nodal recurrences which occurred in previously undissected neck. According to the Kaplan Meier survival curve, there was no statistically significant difference for locoregional control rate, overall survival rate and disease specific survival rate between two groups (P=0.2719, P=0.7596, and P=0.2405, respectively).

Conclusion

SND is enough to treat occult nodal metastasis in head and neck squamous cell carcinoma and it is not necessary to convert from SND to comprehensive neck dissection.     

Is Dissection of Level IV Necessary in Patients With T1‐T3 N0 Tongue Cancer?

OBJECTIVE: Dissection of the lower jugular level of lymph nodes (level IV), as part of an elective neck dissection, has been advocated recently for all patients with oral tongue cancer because of the possibility of "skip metastases" to levels III and IV. The current study was undertaken to evaluate the need to perform a dissection of level IV in patients with oral tongue cancer with no clinical evidence of nodal metastases. METHODS: Fifty-one patients with T1-3, N0 squamous cell carcinoma of the oral tongue were treated with a partial glossectomy and a selective neck dissection of levels I, II, and III. When enlarged nodes were encountered during surgery in level II or III, the dissection was extended to include the nodes in level IV. Involvement of level IV was determined either by the presence of carcinoma on pathological examination or by the development of recurrence in the untreated level IV during a follow-up period of at least 2 years. RESULTS: Level IV was resected as part of the specimen in 17 of the 51 patients and metastatic tumor was found in this level in only one patient. At an average follow-up of 4.1 years, only one patient recurred at level IV, which had been addressed at the initial neck dissection. Consequently, the rate of metastases to undissected level IV was 2%. CONCLUSIONS: Metastases to level IV lymph nodes is rare in patients with T1-T3, N0 oral tongue cancer. Dissection of these nodes only when there is intraoperative suspicion of metastases in levels II or III does not increase the risk or recurrence of tumor in the neck.     

Is Lack of Placement of Drains After Thyroidectomy With Central Neck Dissection Safe? A Prospective,Randomized Study

OBJECTIVE: Selective use of drains after thyroidectomy has been suggested in the literature. Although the safety of thyroidectomy without drains has been reviewed, there is little specific data available to identify the safety of thyroidectomy combined with central neck dissection (CND) without drains. This study aims to determine the feasibility and safety of thyroidectomy without drains, especially in cases of combined CND. STUDY DESIGN: Prospective, randomized study. MATERIALS AND METHODS: One hundred ninety-eight consecutive thyroidectomized patients were enrolled in this study. Drain group (n = 101) consisted of 41 hemithyroidectomies (HT), 28 total thyroidectomies (TT), and 32 total TT with CND. No-drain group (n = 97) consisted of 42 HT, 18 TT, and 37 TT with CND. The following variables were examined: perioperative complications (hemorrhage, hematoma, seroma), intraoperative bleeding, operation time, volume of resected thyroid gland, time of hospital discharge after operation, duration of drain placement, and total amount of drainage (drain group). RESULTS: There were no significant differences in age, sex, volume of resected thyroid gland, types of operation, operation time, and histopathlologic diagnosis between two groups. In the drain group, overall perioperative complications occurred in seven (7/101, 6.9%) patients. In the no-drain group, overall perioperative complications occurred in nine (10/97, 10.3%) patients. There was no significant difference in overall perioperative complications between the drain and no-drain groups, even in cases of performing CND. Time of hospital discharge after operation was significantly shorter in the no-drain group than the drain group (P < .05). CONCLUSIONS: We conclude that thyroidectomy without drains is safe and effective even in combination with CND and appears to confer several advantages over the routine drainage method. In addition, we achieved significant reduction of hospital stay, which led to a reduction in costs for the patients.     

Hoarseness: Is It Really Laryngopharyngeal Reflux?

OBJECTIVE/HYPOTHESIS: This study will test the hypothesis that proton pump inhibitor (PPI) use is prevalent among patients referred for hoarseness and will assess the ultimate diagnosis and factors associated with patients' voice outcomes. STUDY DESIGN: Retrospective review of patients in a tertiary care voice clinic. METHODS: Patients with a primary diagnosis of hoarseness, who were taking or had taken PPIs in the previous 2 months and referred to a tertiary care voice clinic, were identified. The dosage and length of PPI administration, patient report of gastroesophageal reflux (GER), presence of findings suggesting muscle tension dysphonia (MTD), patient demographics, diagnosis, chronicity of symptoms, interventions, follow-up, and outcome were determined. RESULTS: Of 299 patients, 264 met the inclusion criteria. The mean age was 47.2 years, with a range of 18 to 89 years, with 26.7% male and 73.3% female. Among patients referred for voice problems, 148 (56.1%) had previously tried PPIs or were currently on PPI treatment; 44 (29.7%) stopped taking their PPI because of continued hoarseness, and 104 (70.3%) had persistent hoarseness and associated throat complaints despite continued PPI treatment. Among patients who quit taking their PPI because of continued voice complaints, 79.5% did not have traditional GER symptoms of heartburn or regurgitation. The most common treatment after referral was voice therapy, with an overall voice therapy response rate of 62.7%. CONCLUSIONS: PPI use is prevalent among patients referred because of persistent hoarseness. Whether patients have GER or MTD may influence patients' voice outcomes in response to PPI treatment.     

Endoscopic Endonasal Management of Pseudotumor Cerebri: Is it Effective?

PURPOSE: To study the efficacy and safety of endoscopic endonasal optic nerve fenestration for the management of idiopathic intracranial hypertension (IIH). DESIGN: A prospective study at a tertiary care center. PATIENTS AND METHODS: All patients with a final diagnosis of IIH from July 2001 to March 2005 were included and subjected to detailed neuro-ophthalmologic examination and endoscopic endonasal optic nerve fenestration. Postoperative visual acuity and the perimetry was compared with the preoperative status, and the results were analyzed using the chi2 test. RESULTS:: Of the 18 patients included in the study, 17 had improvement in vision postoperatively. Fifteen patients had visual deterioration in the other eye as well, and of these, 12 had improvement, obviating the need for surgery on the other side. Complications were minimal and in the form of synechiae in two of the cases. DISCUSSION: A number of procedures have been described for the management of this entity, and each is associated with a significant morbidity; therefore, there was a need for a minimally invasive procedure. The procedure adopted in the series is minimally invasive and is associated with a 94.5% success rate and minimal morbidity. CONCLUSIONS: Endoscopic endonasal optic nerve fenestration is a safe, minimally invasive, and extremely effective procedure for the management of IIH.     

Sublingual Gland Resection in Squamous Cell Carcinoma of the Floor of Mouth: is it Necessary?

OBJECTIVES: Little evidence exists to guide surgeons in the management of the sublingual glands (SLG) not macroscopically involved by squamous cell carcinoma of the floor of mouth and oral tongue. This study aims to determine the frequency with which the SLG is invaded, to identify variables predicting for SLG invasion and the morbidity associated with it's resection in entirety. STUDY DESIGN: Retrospective cohort study. METHODS: A review of 164 patients treated for oral cavity cancer at a tertiary institution with a large volume of head and neck malignancy was performed. Demographic data, rates of surgical complications and follow up information was recorded. Pathologic review of resected material in this group yielded 134 specimens in the region of the SLG. A detailed analysis of 63 specimens in which the SLG was included was carried out. RESULTS: The median age was 58 years, mean follow up was 2.2 years, and there were 44 males and 19 females. Seventeen cases (27%) demonstrated histopathological SLG invasion. In patients with SLG involvement, this was evident at the time of surgery in 15 patients (88%). Microscopic SLG invasion, without macroscopic evidence at surgery, was present in only 4.2% of patients undergoing SLG resection. Clinical and pathological T stage (p = 0.023 and 0.005) and tumor thickness (p = 0.015) predicted for SLG invasion. Total SLG resection significantly increased the post-operative wound complication rate from 14% in patients without SLG resection to 25% (p = 0.05). CONCLUSION: Total SLG resection in early stage and thin squamous cell carcinoma of the floor of mouth and oral tongue provides minimal oncologic benefit and is associated with increased perioperative morbidity due to neck wound complications.     

Is the Canine Fossa Puncture Approach Really Necessary for the Severely Diseased Maxillary Sinus during Endoscopic Sinus Surgery?

Objectives: To evaluate the necessity of canine fossa puncture (CFP) by comparing the symptom scores and postoperative computed tomography (CT) findings between patients with severe maxillary sinus disease who underwent CFP and those who underwent maxillary sinus clearance through a middle meatal antrostomy (MMA). Study Design: A prospective, randomized study. Materials and Methods: Fourteen patients met the inclusion criteria for each of the CFP and MMA groups. In both groups, all diseased sinuses were addressed in the same manner using the same surgical techniques; the only difference was management of the maxillary sinus. Most of the patients completed the Sinonasal Outcome Test 20 (SNOT‐20) and visual analogue scales (VAS) for the six main symptoms preoperatively and 3, 6, and 12 months postoperatively. The Lund‐Mackay scores for the maxillary sinus and for all sinuses were calculated from the preoperative CT scan and another scan taken 12 months postoperatively. The mucosal thickening as a percentage of the total volume of the maxillary sinus was also evaluated on the postoperative CT scans, and complications related to both procedures were investigated. Results: Twenty‐four patients completed the follow‐up, questionnaires, and postoperative CT scans and were included in the analysis: 11 CFP patients and 13 MMA patients. All of the patients had chronic rhinosinusitis with nasal polyposis (NP). There were no significantdifferences in polyp extent or Lund‐Mackay score for the maxillary sinus and for all sinuses on the pre‐ and postoperative CT scans between the groups. The volume of mucosal thickening also did not differ significantly between the groups on the postoperative CT scans. The SNOT‐20 and VAS scores improved significantly 3, 6, and 12 months after the procedure in both groups. However, there were no significant differences between the two groups except for the VAS for postnasal drip 3 months postoperatively, which was better in the CFP group. Six of 11 patients in the CFP group experienced one or more complications after the procedure, although all of the symptoms resolved spontaneously within 3 months. In the MMA group, three patients had bleeding from the branches of the sphenopalatine artery during widening of the ostium, which was controlled intraoperatively with suction cauterization. Conclusions: We could not find any benefits of the CFP procedure over the conventional MMA method in the present study. Although CFP is a useful method for removing severe mucosal disease that cannot be reached through the MMA, it does not guarantee a better subjective or objective surgical outcome in patients who have accompanying NP.     

Is Nasal Packing Necessary Following Endoscopic Sinus Surgery?

OBJECTIVES/HYPOTHESIS: To determine the necessity of nasal packing or hemostatic agents or both following endoscopic sinus surgery. STUDY DESIGN: Retrospective review of cases in a tertiary care sinus practice at an academic medical center. METHODS: Records of 165 patients undergoing 169 endoscopic sinus surgeries were reviewed to determine the presence of adjunctive nasal procedures, the use of nasal packing or hemostatic agents or both, blood loss during surgery, and the incidence of bleeding complications following surgery. RESULTS: The median estimated blood loss during surgery was 50.0 mL (range, 5-1000 mL). In four surgeries (2.4%) hemostatic agents were placed in the nose at the conclusion of surgery, 19 (11.2%) had packing, and 147 (87.0%) had no material left in the nose. No patients had bleeding complications postoperatively. There was a significant decrease in the use of packing or hemostatic agents or both over time. CONCLUSION: Placement of nasal packing or other hemostatic agents or both within the nasal cavity is not necessary in the majority of endoscopic sinus surgeries. The risks, costs, and discomforts associated with these interventions can often be avoided.     

Post-tonsillectomy late haemorrhage: Is it a preferably night-time event?

Aim

To evaluate the relationship between the incidence of late post-tonsillectomy haemorrhage and its prevalence in a definite period of the day.

Study design and setting

This retrospective study was carried out in the Ear Nose Throat (ENT) Unit of Giannina Gaslini Institute, Genoa, Italy on children operated for adenotonsillectomy (AT) or tonsillectomy (T) between January 2003 and February 2008. We considered in the study all the post-tonsillectomy late haemorrhages irrespective of their severity and for each case we evaluated whether they recurred in the day-time (B) (between 9.00 a.m. and 9.00 p.m.) or in the night-time (A) (between 9.00 p.m. and 9.00 a.m.). Finally we considered the number of haemorrhages per hour in the whole day.

Results

Out of 3306 patients undergoing elective adenotonsillectomy or tonsillectomy, post-operative late haemorrhage occurred in 59 (1.78%). We noted that 42 episodes (71.2%) occurred in the night-time and 17 (28.8%) in the day-time. The average time from the operation was 8.4 days.A statistically significant difference (p = 0.002) was found when comparing the frequencies of night-time and day-time haemorrhages.We did not observe any significant difference in the distribution per hour of the haemorrhages.

Conclusions

The incidence of post-tonsillectomy late haemorrhage in our study population was 1.78%. A statistically significant difference was found between night-time and day-time haemorrhages. Even though no significant distribution of haemorrhages per hour was observed, we underline that we recorded 32 (54.2%) events in 2 periods of the day: from 10 p.m. to 1 a.m. and from 6 to 9 a.m.