Place of total thyroidectomy in rhinolaryngologists' surgical treatment of thyroid disease

Total thyroidectomy is more frequently performed and is becoming more widely accepted as the treatment of choice for more surgical diseases of the thyroid gland. Improvement in anesthesia, presurgical and postoperative care, as well as more meticulous surgical technique, have decreased the complications associated with this operation. As is demonstrated, morbidity and complications of total thyroidectomy are no more frequent nor severe than when subtotal thyroidectomy is performed. This allows boadening of the indications for total thyroidectomy to include more cases which will be better controlled, but for which total thyroidectomy had been withheld because of the fear of increased morbidity.     

The treatment of metastatic thyroid disease

1. Removal of all resectable disease commensurate with reasonable morbidity and mortality is the initial treatment of all thyroid carcinoma. 2. Patients with no evidence of recurrent metastatic well-differentiated thyroid carcinoma should be placed on suppressive doses of Synthroid. 3. 131I is utilized for nonresectable and for distant metastatic well-differentiated thyroid carcinoma. External radiation therapy and chemotherapy are utilized in recurrent or metastatic thyroid carcinomas that do not concentrate 131I.     

The treatment of well-differentiated thyroid cancer

The management of well differentiated thyroid cancer continues to generate considerable debate and controversy regarding diagnostic evaluation, extent of surgery, and postoperative adjuvant therapy and follow-up. The fine-needle aspiration biopsy has been routinely used for diagnostic evaluation of thyroid nodule. Understanding prognostic factors and risk group analysis is extremely crucial in the overall management of thyroid cancer regarding the extent of thyroidectomy and adjuvant therapy. Patients in the low-risk group do extremely well and can be treated with lobectomy alone while those in the high-risk group invariably require total thyroidectomy due to the need of adjuvant radioactive iodine treatment. Thyroglobulin appears to be a good tumor marker in patients who have undergone total thyroidectomy during follow-up. One of the major nuances in the management of thyroid cancer is the availability of recombinant TSH which can be used for radioactive iodine dosimetry during the follow-up of patients with well differentiated thyroid cancer. This prevents patients from becoming hypothyroid for an extended period of time which directly affects their quality of life. Understanding poorly differentiated thyroid cancer is extremely crucial as an important histologic prognostic factor and generally being nonradioavid tumors. PET scan is useful in the follow-up of these patients to evaluate the extent of distant metastasis.     

伴有心脏疾病的甲状腺癌患者围手术期临床治疗经验

目的 探讨伴有心脏疾病的甲状腺癌患者围手术期临床治疗经验.方法 以2014年4月至2018年2月在首都医科大学附属北京安贞医院耳鼻咽喉头颈外科收治的伴有心脏疾病的39例甲状腺癌患者为研究对象进行回顾性分析,其中男25例,女14例;年龄在59~75岁,平均年龄(67.3±6.2)岁.围手术期临床监测指标包括:心脏超声左心室射血分数(LVEF)、冠状动脉(冠脉)CT显示的血管狭窄程度、实验室检查超敏肌钙蛋白I(TNI)、B型利钠肽(BNP)、纤维蛋白原降解产物、凝血指标等.50%≤LVEF<60%的26例;40%≤LVEF<50%的10例;36%≤LVEF<40%的3例.术前冠脉CT检查显示无3支冠脉狭窄>75%,搭桥血管通畅,支架术后冠脉通畅.0≤BNP<100 ng/L的患者27例,100 ng/L≤BNP<400 ng/L的患者7例,400 ng/L≤BNP<700 ng/L的患者5例.围手术期用药包括采用低分子肝素替代口服抗凝等.对于LVEF<40%的3例患者及400≤BNP<700 ng/L的5例患者,应用强心、利尿、营养心肌治疗1周.以SPSS 17.0软件对数据进行统计分析.结果 39例患者均在全麻下顺利完成甲状腺癌根治术,其中全甲状腺切除32例,腺叶及峡部切除7例;侧颈清扫23例(40侧).39例患者中1例术后3 d出现心衰,给予强心、利尿等治疗2周后好转出院.余38例未发生围手术期心脏相关事件及脑血管、肺脏血栓.0≤BNP<100 ng/L且50%≤LVEF<60%组与0≤BNP<100 ng/L且36%≤LVEF<50%组麻醉准备时间差异有统计学意义(t=-8.884,P<0.001).结论 术前应用多指标充分评估心脏功能,参考心脏超声与冠脉CT检查结果,进行改善心脏功能治疗;做好伴有心脏疾病的甲状腺癌患者围手术期的风险评估与管理,可安全施行规范的甲状腺癌手术.     

The treatment of thyroid cancer. The role of fine-needle aspiration cytology

A series of 960 fine-needle aspiration biopsies of thyroid lesions are reported. The primary indication is the presence of a solitary thyroid mass. Aspiration biopsy is accomplished using a 23-gauge needle and a commercially available syringe pistol equipped with a 20.0-mL syringe. Sensitivity for the presence of a thyroid neoplasm, specificity for the absence of a thyroid neoplasm, predictive value of a positive diagnosis for a thyroid neoplasm, and diagnostic efficiency are all over 90% in this series. Eight percent of the aspirates were unsatisfactory. Use of fine-needle aspiration biopsy for the diagnosis of thyroid conditions reduces thyroid surgery significantly for nonneoplastic disease. It is cost-effective and essentially free of complications.     

The surgical treatment of Ménière's disease.

Ménière's disease is more common than was generally believed in the past. Stahle has calculated the incidence of Ménière's disease in Sweden. Using the same incidence for the United States, there ought to be 97,000 hospitalized inpatients with Ménière's disease of all ages in the whole population. The increased understanding of inner ear physiology and pathology during the past decade has changed the indication for operation towards an early intervention for preserving the hearing function. For the purposes of analyzing results, patients with Ménière's disease were divided into the following classes according to the hearing loss only: 1. Near normal hearing (no more than 10 db loss at 500, 1,000, 2,000). 2. Ascending audiogram, fluctuating (500 more than 10 db more than 2,000). 3. Flat audiogram, fluctuating (500 not 10 db different than 2,000). 4. Flat audiogram, non-fluctuating (500 not 10 db different than 2,000). 5. Other, more extreme hearing loss, non-fluctuating (2,000 10 db more than 500). In this study, 33 patients with early Ménière's disease had a subarachnoid endolymphatic shunt operation. Two patients belonged to Class 1 and 31 patients to Class 2. All had well-visualized vestibular aqueducts on polytomography and most had a positive glycerin test done in conjunction with transtympanic electrocochleography. During the first postoperative year, two patients in Class 2 improved to Class 1 (normal hearing). The other 29 in Class 2 remained in Class 2. None was worse as regards hearing. Most were completely relieved or improved as regards vertigo. Early surgical drainage in Ménière's disease is effective and safe and should be performed prior to irreversible dilatation of the membranous labyrinth. Patients in Classes 3, 4, and 5, with excessive and widespread hydrops of the membranous labyrinth, should have a vestibular nerve section.     

甲状腺癌侵及气管的外科处理

目的:探讨侵及气管的甲状腺癌的外科处理方法及疗效。方法:回顾性分析了1975年～1999年共收治的侵及气管的甲状腺癌71例,根据侵及程度分三类:仅侵及气管外膜;侵及气管软骨;侵及气管全层并突入管腔引起呼吸困难。术中分别行切除气管外膜、气管壁开窗造瘘、部分气管切除及全喉切除术。其中17例未分化癌患者术后均行放疗。甲状腺滤泡癌及乳头滤泡癌患者均行碘~(131)治疗。结果:分化型甲状腺癌,1年生存率94.4％,3年生存率88.9％,5年生存率85.2％,10年生存率31.5％。未分化型患者17例均在1年内死亡。结论:侵及气管的甲状腺癌在全身状态允许的条件下是可以采用外科手术治疗的,但未分化型甲状腺癌的预后较差。     

Conservative surgical management of invasive differentiated thyroid cancer

The majority of well differentiated thyroid carcinoma are tumours of low grade malignancy. Laryngotracheal invasion by well differentiated thyroid carcinoma is an uncommon occurrence. The surgical management of patients with thyroid cancer invading the upper airway has primarily been by total laryngectomy. Other surgeons recommend in selected cases partial laryngeal and/or tracheal resection. A total of 122 patients with thyroid carcinoma were treated in our department between 1967 and 1982. Only seven patients with well differentiated tumours had airway invasion. In these seven patients we used a partial laryngeal and/or tracheal resection. In three of the patients with tracheal invasion a myoperichondrial flap was used for closing the tracheal defect. A partial resection of the larynx and trachea, and end to end anastomosis between the trachea and the remaining part of the larynx was performed in another four patients. The techniques used and a long-term follow-up are presented (Table I).     

重视甲状腺癌手术治疗的规范化

甲状腺手术的历史最早可以追溯到公元1000年,有资料记载Albucaais当时曾成功地切除过甲状腺肿,但文献记载第一例有完整记录的甲状腺手术完成于1595年.1872年,瑞士的Kocher完成了第一例甲状腺切除术,到1901年Kocher共完成2000例甲状腺手术.     

甲状腺癌的外科治疗分析

目的 探讨甲状腺癌的外科治疗相关问题。方法 对28例经手术治疗的甲状腺癌患者的临床资料进行回顾性分析。结果 术中常规快速冰冻切片病理诊断,术后常规病理切片确诊,术中、术后病理不符2例;乳头状癌22例,滤泡状癌2例,淋巴瘤1例,乳头状癌合并低分化癌1例,髓样癌1例,小细胞癌1例;扩大甲状腺全切2例,甲状腺全切8例,腺叶加峡部切除10例,一侧腺叶、峡部加对侧腺叶大部切除术7例,肿物局部切除1例;双侧颈清术5例,单侧颈清术6例。本组无手术死亡,术后新发现声嘶1例,出现抽搐2例。甲状腺全切者常规甲状腺素替代治疗。结论 术中冰冻切片病理检查有助于甲状腺癌的诊断和术式选择;病理类型、癌肿侵犯范围是决定手术范围的重要因素。     

Surgical treatment of substernal thyroid disease

The thyroid surgeon must have a full understanding of the anatomy and surgical approaches to the mediastinum. Although most benign substernal goiters may be removed by a transcervical approach, the surgeon needs to know indications for transclavicular and median sternotomy approaches. When there is direct evidence of extension of thyroid cancer into the mediastinum, the possibility of median sternotomy should be considered. This is certainly mandated when disease extends to the inferior mediastinum. Superior mediastinal node dissection is usually easy to approach transcervically. Unilateral extension of the disease may be accessed readily with a transclavicular approach for most cases. Careful dissection of the recurrent laryngeal nerve as well as parathyroids is essential to diminish postoperative morbidity. The morbidity is a reflection of the experience and technical skills of the surgeon as well as the extent of the disease. The best results for resection of substernal thyroid disease are obtained by the experienced thyroid surgeon, not the occasional operator.     

原发性甲状旁腺功能亢进的诊治

简而言之,原发性甲状旁腺功能亢进是指由于甲状旁腺组织自身病变所致甲状旁腺过度分泌甲状旁腺激素.其本质是甲状旁腺细胞钙受体对血清游离钙敏感性下降而降低了对甲状旁腺激素分泌的抑制作用.     

舌根癌的手术治疗

目的：探讨舌根癌的手术治疗方法。方法：舌根癌患者21例，经舌骨咽切开进路11例，下颌骨部分切除进路7例，下唇、下颌骨、舌正中切开进路3例。结果：3例下唇、下颌骨、舌正中切开者出现语言功能障碍，吞咽困难；余18例口腔功能均正常。随访2～5年，失访2例，2年生存18例，3年生存13例，5年生存5例。结论：经舌骨咽切开进路对吞咽功能及语言功能的影响较小，是一种值得推广的术式。     

原发性甲状旁腺功能亢进的临床特点及其外科治疗

目的　探讨原发性甲状旁腺机能亢进症的临床特点及其外科处理方法。方法　回顾性分析2000年1月～2014年12月在我科手术治疗的25例原发性甲状旁腺功能亢进症患者的临床资料,外科治疗方式以及术后随访情况。结果　24例患者均在术前确诊,1例甲状旁腺癌术中冰冻明确。2例双侧下甲状旁腺瘤行双侧探查及双侧下甲状旁腺瘤切除,18例单侧甲状旁腺瘤行单侧探查及切除;4例甲状旁腺增生行双侧探查加双侧甲状旁腺大部切除,仅保留0.5枚甲状旁腺,1例甲状旁腺癌行患侧甲状腺和甲状旁腺全切除、峡部切除、健侧甲状腺近全切除和患侧颈部中央区淋巴结清扫术。所有患者术后均恢复良好,甲状旁腺功能亢进症状得到有效控制,随访6个月～10年,无复发。结论　影像学和实验室检查是诊断甲状旁腺亢进的有效方法,及时进行外科手术治疗可减少骨关节和泌尿系统损害等严重并发症的发生。     

The treatment and outcome analysis of primary squamous cell carcinoma of the thyroid

Objectives

Primary squamous cell carcinoma (SCC) of the thyroid is a rare disease. It usually presents with locally advanced disease and has an overall poor prognosis. In this study, we investigated the characteristics and outcomes of patients with SCC of the thyroid, and reported our experience with chemotherapy with lenvatinib in the treatment of SCC of the thyroid.