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Poster Design & Printing by Genigraphics ® - 800.790.4001 UTILITY OF ULTRASONOGRAPHY IN EVALUATING VOCAL CORD MOBILITY AFTER THYROID AND PARATHYROID SURGERY Laura Pelaez, MD 1 ; Daniel B Noel 1 ; Rohan R Walvekar, MD 1 1 Department of Otolaryngology Head & Neck Surgery, LSU Health Sciences Center, New Orleans, LA UTILITY OF ULTRASONOGRAPHY IN EVALUATING VOCAL CORD UTILITY OF ULTRASONOGRAPHY IN EVALUATING VOCAL CORD MOBILITY AFTER THYROID AND PARATHYROID SURGERY MOBILITY AFTER THYROID AND PARATHYROID SURGERY Laura Pelaez, MD Laura Pelaez, MD 1 1 ; Daniel B Noel ; Daniel B Noel 1 1 ; Rohan R Walvekar, MD ; Rohan R Walvekar, MD 1 1 1 1 Department of Otolaryngology Head & Neck Surgery, Department of Otolaryngology Head & Neck Surgery, LSU Health Sciences Center, New Orleans, LA LSU Health Sciences Center, New Orleans, LA INTRODUCTION DISCUSSION RESULTS Table 1. Summary of results Figure 1.Postoperative USG. Figure 2. Postoperative USG. Seventeen patients with a mean age of 49.6 years (range13 – 75) underwent a total of 18 procedures. The procedures included parathyroidectomy (5/18), hemithyroidectomy (9/18), and total thyroidectomy (4/18). Endoscopic video-assisted in 33% and 67% were open procedures. Pathology included papillary carcinoma, follicular adenoma, multinodular adenomatous hyperplasia, lymphocytic thyroiditis, parathyroid adenoma and atypical parathyroid adenoma. The pre-operative VCF was normal in all 17 patients. In 17 procedures, the RLN was localized and stimulated intra-operatively. In one patient undergoing a total thyroidectomy, the RLN were identified but had an inconsistent nerve stimulation. Initial stimulation at 1 mA was negative. However, at the end of the procedure both nerves stimulated appropriately. Ultrasonography was performed in the operating room in 17/18 cases. In one patient, the ultrasonography was performed after the patient was transferred to the recovery unit. On ultrasonography, bilateral VCF was recorded as “Normal” in all 18 procedures and visualization of vocal cord mobility was possible without any difficulty or patient discomfort in all patients. The postoperative USG finding correlated with good voice quality and normal bilateral VCF on follow up FL in 99.95% of cases.. Recurrent Laryngeal Nerve Palsy (RLNP) is a recognized possible complication following thyroid and parathyroid surgery and may result in significant comorbidity to the patient. Assessment of the VCF is of vital importance in both the preoperative and postoperative evaluation of patients undergoing this type of surgery. Early diagnosis of RLNP is crucial since it can help avoid complications like aspiration pneumonia, and is vital in giving the patient the best chance for full recovery. Currently, the gold standard diagnostic tool for VCF impairment is FL. Although highly sensitive and specific, FL poses certain challenges that prevent it from being a readily available tool to all surgeons. FL is only possible when a physician trained in laryngoscopy is available, and it can be very challenging in the immediate postoperative period because of pooling of secretions in the oropharynx and the patients being less cooperative after surgery. In addition, FL is invasive, requires topical anesthesia and is often very uncomfortable for the patient. Endocrine surgeons, endocrinologists, and head and neck surgeons use the USG routinely to diagnose thyroid and parathyroid lesions and are familiar with using the ultrasound in office and operative settings. Our preliminary study has shown that USG provides a very accurate assessment of VCF that strongly correlates with postoperative FL findings. USG is easy, non-invasive, comfortable and cost effective. We propose that USG be used routinely for the postoperative evaluation of VCF by all physicians performing thyroid and parathyroid surgery. All patients undergoing thyroid and parathyroid surgery by a single surgeon (RRW) at Our Lady of the Lake Regional Medical Center, Baton Rouge with the LSU Department of Otolaryngology between January 2011 to September of 2011 were included in the study. Data was collected in a prospective fashion and analyzed retrospectively. Clinical, demographic, surgical data, pathological data, subjective voice assessments, and vocal cord status was documented (Table1). The assessment of vocal cord function was done at three time points. A routine preoperative evaluation with FL in the office. The second time point included an immediate peri-operative ultrasound examination to document vocal cord function. The ultrasound was performed by the attending surgeon (RRW) or the ENT Resident with the attending present. The procedure was performed either in the operating room immediately after extubation or in the recovery room. Perioperative voice and swallow functions were also recorded and were based on subjective assessments. The third point of evaluation was the routine post-operative FL in the office at the first follow up visit. USG provides a non-invasive and accurate estimate of VCF immediately after thyroid and parathyroid surgery and empowers the surgeon with information that can be used to prognosticate postoperative recovery. USG for VCF assessment is technically easy, cost effective, and comfortable for the patients. It can be easily adapted into the practice by physicians in various levels of training and experience and consequently we propose that it should be routinely utilized for evaluation of post thyroidectomy and parathyroidectomy vocal cord mobility. Surgery of the thyroid and parathyroid glands is performed routinely for the treatment of conditions such as nodular thyroid goiter, hyperthyroidism, thyroid cancer, Hashimoto’s disease, parathyroid adenoma and hyperplasia. The recurrent laryngeal nerve (RLN) is at high risk during thyroid and parathyroid surgery with a reported incidence of permanent nerve damage of 1–3% and temporary RLN injury in 5–8%8. Unilateral RLN paralysis may result in a breathy voice, aspiration in the early postoperative period, and swallowing dysfunction. Bilateral RLN palsy can result in airway compromise requiring an emergent tracheostomy. Consequently, an accurate assessment of post- operative vocal cord status is important and allows for prediction of postoperative recovery following any neck surgery that puts the RLN at risk. Fiber-optic laryngoscopy is widely considered the gold standard for detecting post-operative RLN palsy as it allows visualization of the vocal cords in 99% of cases following thyroidectomy. This procedure, however, is invasive, requires topical anesthesia, a physician trained in performing this procedure, and additionally is often uncomfortable for the patient. This is especially true if the assessment of vocal cord function needs to be performed in the immediate postoperative period. Our study proposes the use of ultrasonography in vocal cord assessment and aims to measure its accuracy in doing so following thyroid and parathyroid surgery. METHODS AND MATERIALS Hanna, B. and Brooker, D. (2008), A preliminary study of simple voice assessment in a routine clinical setting to predict vocal cord paralysis after thyroid or parathyroid surgery. Clinical Otolaryngology, 33: 63–66. Kundra, Pankaj, Vinoth Kumar, Krishnamachari Srinivasan, Surianarayanan Gopalakrishnan, and Sudeep Krishnappa. "Laryngoscopic Techniques to Assess Vocal Cord Mobility following Thyroid Surgery." ANZ Journal of Surgery 80.11 (2010): 817-21. Print. Wagner, H. E., and Ch. Seiler. "Recurrent Laryngeal Nerve Palsy after Thyroid Gland Surgery."British Journal of Surgery 81.2 (1994): 226-28. Print. Farrag, Tarik Y., Robin A. Samlan, Frank R. Lin, and Ralph P. Tufano. "The Utility of Evaluating True Vocal Fold Motion Before Thyroid Surgery." The Laryngoscope 116.2 (2006): 235-38. Print. Lacoste, L., J. Karayan, MS Lehuedé, D. Thomas, M. Goudou-Sinha, P. Ingrand, J. Barbier, and J. Fusciardi. "A comparison of direct, indirect, and fiberoptic laryngoscopy to evaluate vocal cord paralysis after thyroid surgery." Thryoid 6 (1996): 17-21. Sidhu, Stan, Raymond Stanton, Sharam Shahidi, John Chu, Simon Chew, and Peter Campbell. "Initial experience of vocal cord evaluation using grey-scale, real-time, B-mode ultrasound."ANZ Journal of Surgery 71 (2001): 737-39. Sirikc, A., E. Karatas, C. Durucu, T. Baglam, Y. Bayazit, A. Ozkur, S. Sonmezisik S, and M. Kanlikama. "Noninvasive assessment of benign lesions of vocal folds by means of ultrasonography." Annals of Otology, Rhinology, and Laryngology 116 (2007): 827-31. J.-P. Jeannon, A. A. Orabi, G. A. Bruch, H. A. Abdalsalam, R. Simo. “Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review” Int J Clin Pract. 2009 Apr;63(4):624-9. CONCLUSIONS REFERENCES ABSTRACT Objective: To determine the utility of ultrasonography (USG) in determining vocal cord function (VCF) following thyroid and parathyroid surgery. Study Design: Prospective, Observational Study. Methods: Patients undergoing thyroid and parathyroid surgery by a single surgeon (RRW) at a tertiary care facility from January 2011 to September 2011 were included. VCF was documented with preoperative fiberoptic laryngoscopy (FL). An immediate perioperative ultrasound examination was performed after extubation. VCF was documented as “Normal” or “Abnormal”. Postoperative voice and FL in follow up examination were documented. Results: Seventeen patients with a mean age of 49.6 years (range 13 – 75) underwent a total of 18 procedures. The procedures included parathyroidectomy (5/18), hemithyroidectomy (9/18), and total thyroidectomy (4/18). 33% were endoscopic video-assisted and 67% were open procedures. The preoperative VCF was normal in 17 patients. Bilateral VCF was visualized without patient discomfort in all patients. The postoperative USG finding correlated with good voice quality and normal bilateral VCF on follow up FL in 99.95% of cases. Conclusions: USG provides a non-invasive and accurate estimate of VCF immediately after thyroid and parathyroid surgery. USG for VCF assessment is technically easy and can be easily adapted into the practice by physicians in various levels of training and experience. CONTACT Laura Pelaez, MD Department of Otolaryngology Louisiana State University New Orleans, LA [email protected] (504)568-4785 ABSTRACT Objective: To determine the utility of ultrasonography (USG) in determining vocal cord function (VCF) following thyroid and parathyroid surgery. Study Design: Prospective, Observational Study. Methods: Patients undergoing thyroid and parathyroid surgery by a single surgeon (RRW) at a tertiary care facility from January 2011 to September 2011 were included. VCF was documented with preoperative fiberoptic laryngoscopy (FL). An immediate perioperative ultrasound examination was performed after extubation. VCF was documented as “Normal” or “Abnormal”. Postoperative voice and FL in follow up examination were documented. Results: Seventeen patients with a mean age of 49.6 years (range 13 – 75) underwent a total of 18 procedures. The procedures included parathyroidectomy (5/18), hemithyroidectomy (9/18), and total thyroidectomy (4/18). 33% were endoscopic video-assisted and 67% were open procedures. The preoperative VCF was normal in 17 patients. Bilateral VCF was visualized without patient discomfort in all patients. The postoperative USG finding correlated with good voice quality and normal bilateral VCF on follow up FL in 99.95% of cases. Conclusions: USG provides a non-invasive and accurate estimate of VCF immediately after thyroid and parathyroid surgery. USG for VCF assessment is technically easy and can be easily adapted into the practice by physicians in various levels of training and experience. CONTACT Laura Pelaez, MD Department of Otolaryngology Louisiana State University New Orleans, LA [email protected] (504)568-4785

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Page 1: Laura Pelaez, MD Department of Otolaryngology Head & · PDF fileDepartment of Otolaryngology Head & Neck Surgery, ... after thyroid and parathyroid surgery. USG for ... Pelaez Research

Poster Design & Printing by Genigraphics® - 800.790.4001

UTILITY OF ULTRASONOGRAPHY IN EVALUATING VOCAL CORD MOBILITY AFTER THYROID AND PARATHYROID SURGERY

Laura Pelaez, MD1; Daniel B Noel1; Rohan R Walvekar, MD1

1Department of Otolaryngology Head & Neck Surgery, LSU Health Sciences Center, New Orleans, LA

UTILITY OF ULTRASONOGRAPHY IN EVALUATING VOCAL CORD UTILITY OF ULTRASONOGRAPHY IN EVALUATING VOCAL CORD MOBILITY AFTER THYROID AND PARATHYROID SURGERYMOBILITY AFTER THYROID AND PARATHYROID SURGERY

Laura Pelaez, MDLaura Pelaez, MD11; Daniel B Noel; Daniel B Noel11; Rohan R Walvekar, MD; Rohan R Walvekar, MD11

11Department of Otolaryngology Head & Neck Surgery, Department of Otolaryngology Head & Neck Surgery, LSU Health Sciences Center, New Orleans, LALSU Health Sciences Center, New Orleans, LA

INTRODUCTION DISCUSSIONRESULTS

Table 1. Summary of results

Figure 1.Postoperative USG. Figure 2. Postoperative USG.

Seventeen patients with a mean age of 49.6 years (range13 – 75) underwent a total of 18 procedures. The procedures included parathyroidectomy (5/18), hemithyroidectomy (9/18), and total thyroidectomy (4/18). Endoscopic video-assisted in 33% and 67% were open procedures. Pathology included papillary carcinoma, follicular adenoma, multinodular adenomatous hyperplasia, lymphocytic thyroiditis, parathyroid adenoma and atypical parathyroid adenoma.The pre-operative VCF was normal in all 17 patients. In 17 procedures, the RLN was localized and stimulated intra-operatively. In one patient undergoing a total thyroidectomy, the RLN were identified but had an inconsistent nerve stimulation. Initial stimulation at 1 mA was negative. However, at the end of the procedure both nerves stimulated appropriately. Ultrasonography was performed in the operating room in 17/18 cases. In one patient, the ultrasonography was performed after the patient was transferred to the recovery unit. On ultrasonography, bilateral VCF was recorded as “Normal” in all 18 procedures and visualization of vocal cord mobility was possible without any difficulty or patient discomfort in all patients. The postoperative USG finding correlated with good voice quality and normal bilateral VCF on follow up FL in 99.95% of cases..

Recurrent Laryngeal Nerve Palsy (RLNP) is a recognized possible complication following thyroid and parathyroid surgery and may result in significant comorbidity to the patient. Assessment of the VCF is of vital importance in both the preoperative and postoperative evaluation of patients undergoing this type of surgery. Early diagnosis of RLNP is crucial since it can help avoid complications like aspiration pneumonia, and is vital in giving the patient the best chance for full recovery.Currently, the gold standard diagnostic tool for VCF impairment is FL. Although highly sensitive and specific, FL poses certain challenges that prevent it from being a readily available tool to all surgeons. FL is only possible when a physician trained in laryngoscopy is available, and it can be very challenging in the immediate postoperative period because of pooling of secretions in the oropharynx and the patients being less cooperative after surgery. In addition, FL is invasive, requires topical anesthesia and is often very uncomfortable for the patient. Endocrine surgeons, endocrinologists, and head and neck surgeons use the USG routinely to diagnose thyroid and parathyroid lesions and are familiar with using the ultrasound in office and operative settings. Our preliminary study has shown that USG provides a very accurate assessment of VCF that strongly correlates with postoperative FL findings. USG is easy, non-invasive, comfortable and cost effective.We propose that USG be used routinely for the postoperative evaluation of VCF by all physicians performing thyroid and parathyroid surgery.

All patients undergoing thyroid and parathyroid surgery by a single surgeon (RRW) at Our Lady of the Lake Regional Medical Center, Baton Rouge with the LSU Department of Otolaryngology between January 2011 to September of 2011 were included in the study. Data was collected in a prospective fashion and analyzed retrospectively. Clinical, demographic, surgical data, pathological data, subjective voice assessments, and vocal cord status was documented (Table1). The assessment of vocal cord function was done at three time points. A routine preoperative evaluation with FL in the office. The second time point included an immediate peri-operative ultrasound examination to document vocal cord function. The ultrasound was performed by the attending surgeon (RRW) or the ENT Resident with the attending present. The procedure was performed either in the operating room immediately after extubation or in the recovery room. Perioperative voice and swallow functions were also recorded and were based on subjective assessments. The third point of evaluation was the routine post-operative FL in the office at the first follow up visit.

USG provides a non-invasive and accurate estimate of VCF immediately after thyroid and parathyroid surgery and empowers the surgeon with information that can be used to prognosticate postoperative recovery.USG for VCF assessment is technically easy, cost effective, and comfortable for the patients.It can be easily adapted into the practice by physicians in various levels of training and experience and consequently we propose that it should be routinely utilized for evaluation of post thyroidectomy and parathyroidectomy vocal cord mobility.

Surgery of the thyroid and parathyroid glands is performed routinely for the treatment of conditions such as nodular thyroid goiter, hyperthyroidism, thyroid cancer, Hashimoto’s disease, parathyroid adenoma and hyperplasia. The recurrent laryngeal nerve (RLN) is at high risk during thyroid and parathyroid surgery with a reported incidence of permanent nerve damage of 1–3% and temporary RLN injury in 5–8%8. Unilateral RLN paralysis may result in a breathy voice, aspiration in the early postoperative period, and swallowing dysfunction. Bilateral RLN palsy can result in airway compromise requiring an emergent tracheostomy. Consequently, an accurate assessment of post-operative vocal cord status is important and allows for prediction of postoperative recovery following any neck surgery that puts the RLN at risk.

Fiber-optic laryngoscopy is widely considered the gold standard for detecting post-operative RLN palsy as it allows visualization of the vocal cords in 99% of cases following thyroidectomy. This procedure, however, is invasive, requires topical anesthesia, a physician trained in performing this procedure, and additionally is often uncomfortable for the patient. This is especially true if the assessment of vocal cord function needs to be performed in the immediate postoperative period.

Our study proposes the use of ultrasonography in vocal cord assessment and aims to measure its accuracy in doing so following thyroid and parathyroid surgery.

METHODS AND MATERIALS

Hanna, B. and Brooker, D. (2008), A preliminary study of simple voice assessment in a routine clinical setting to predict vocal cord paralysis after thyroid or parathyroid surgery. Clinical Otolaryngology, 33: 63–66. Kundra, Pankaj, Vinoth Kumar, Krishnamachari Srinivasan, Surianarayanan Gopalakrishnan, and Sudeep Krishnappa. "Laryngoscopic Techniques to Assess Vocal Cord Mobility following Thyroid Surgery." ANZ Journal of Surgery 80.11 (2010): 817-21. Print.Wagner, H. E., and Ch. Seiler. "Recurrent Laryngeal Nerve Palsy after Thyroid Gland Surgery."British Journal of Surgery 81.2 (1994): 226-28. Print.Farrag, Tarik Y., Robin A. Samlan, Frank R. Lin, and Ralph P. Tufano. "The Utility of Evaluating True Vocal Fold Motion Before Thyroid Surgery." The Laryngoscope 116.2 (2006): 235-38. Print.Lacoste, L., J. Karayan, MS Lehuedé, D. Thomas, M. Goudou-Sinha, P. Ingrand, J. Barbier, and J. Fusciardi. "A comparison of direct, indirect, and fiberoptic laryngoscopy to evaluate vocal cord paralysis after thyroid surgery." Thryoid 6 (1996): 17-21.Sidhu, Stan, Raymond Stanton, Sharam Shahidi, John Chu, Simon Chew, and Peter Campbell. "Initial

experience of vocal cord evaluation using grey-scale, real-time, B-mode ultrasound."ANZ Journal of Surgery 71 (2001): 737-39.Sirikc, A., E. Karatas, C. Durucu, T. Baglam, Y. Bayazit, A. Ozkur, S. Sonmezisik S, and M. Kanlikama. "Noninvasive assessment of benign lesions of vocal folds by means of ultrasonography." Annals of Otology, Rhinology, and Laryngology 116 (2007): 827-31.J.-P. Jeannon, A. A. Orabi, G. A. Bruch, H. A. Abdalsalam, R. Simo. “Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review” Int J Clin Pract. 2009 Apr;63(4):624-9.

CONCLUSIONS

REFERENCES

ABSTRACT

Objective: To determine the utility of ultrasonography (USG) in determining vocal cord function (VCF) following thyroid and parathyroid surgery. Study Design: Prospective, Observational Study.Methods: Patients undergoing thyroid and parathyroid surgery by a single surgeon (RRW) at a tertiary care facility from January 2011 to September 2011 were included. VCF was documented with preoperative fiberoptic laryngoscopy (FL). An immediate perioperative ultrasound examination was performed after extubation. VCF was documented as “Normal”or “Abnormal”. Postoperative voice and FL in follow up examination were documented. Results: Seventeen patients with a mean age of 49.6 years (range 13 – 75) underwent a total of 18 procedures. The procedures included parathyroidectomy (5/18), hemithyroidectomy (9/18), and total thyroidectomy (4/18). 33% were endoscopic video-assisted and 67% were open procedures. The preoperative VCF was normal in 17 patients. Bilateral VCF was visualized without patient discomfort in all patients. The postoperative USG finding correlated with good voice quality and normal bilateral VCF on follow up FL in 99.95% of cases.Conclusions: USG provides a non-invasive and accurate estimate of VCF immediately after thyroid and parathyroid surgery. USG for VCF assessment is technically easy and can be easily adapted into the practice by physicians in various levels of training and experience.

CONTACT

Laura Pelaez, MDDepartment of OtolaryngologyLouisiana State UniversityNew Orleans, LA

[email protected](504)568-4785

ABSTRACT

Objective: To determine the utility of ultrasonography (USG) in determining vocal cord function (VCF) following thyroid and parathyroid surgery. Study Design: Prospective, Observational Study.Methods: Patients undergoing thyroid and parathyroid surgery by a single surgeon (RRW) at a tertiary care facility from January 2011 to September 2011 were included. VCF was documented with preoperative fiberoptic laryngoscopy (FL). An immediate perioperative ultrasound examination was performed after extubation. VCF was documented as “Normal”or “Abnormal”. Postoperative voice and FL in follow up examination were documented. Results: Seventeen patients with a mean age of 49.6 years (range 13 – 75) underwent a total of 18 procedures. The procedures included parathyroidectomy (5/18), hemithyroidectomy (9/18), and total thyroidectomy (4/18). 33% were endoscopic video-assisted and 67% were open procedures. The preoperative VCF was normal in 17 patients. Bilateral VCF was visualized without patient discomfort in all patients. The postoperative USG finding correlated with good voice quality and normal bilateral VCF on follow up FL in 99.95% of cases.Conclusions: USG provides a non-invasive and accurate estimate of VCF immediately after thyroid and parathyroid surgery. USG for VCF assessment is technically easy and can be easily adapted into the practice by physicians in various levels of training and experience.

CONTACT

Laura Pelaez, MDDepartment of OtolaryngologyLouisiana State UniversityNew Orleans, LA

[email protected](504)568-4785