CONCEPTS FOR THE HEAD AND NECK SURGEON
| SUBSTERNAL GOITER: WHO NEEDS SURGERY? —Elise Brett, MD, Assistant Clinical Professor of Medicine and
Endocrinology, Mount Sinai School of Medicine, New York City
|
| Substernal goiter: extension of cervical gland most common; can also be primary retrosternal goiter from ectopic thyroid
tissue; unilateral or bilateral; occurs most often in anterior mediastinum, but can also be posterior; usually develops
from toxic or nontoxic multinodular goiter; patients predominantly older women; may be symptomatic or asymptomatic;
symptoms caused by compression of mediastinal structures; imaging—chest x-ray shows mediastinal soft tissue mass
with displacement of trachea and esophagus; computed tomography (CT) shows displacement of trachea and esophagus
and compression of tracheal lumen
|
| Nonsurgical treatment: study compared high-dose radioiodine (>100 µCi/g thyroid tissue) to high-dose levothyroxine
(2.5 µg/kg body weight) in patients with nontoxic multinodular goiter; radioiodine—decrease in size 44% at 2 yr, no
change in bone density; levothyroxine—median decrease in size 7% at 1 yr and 1% at 2 yr; 16 patients were nonresponders;
10 patients developed symptoms of thyrotoxicosis, and 1 developed atrial fibrillation; levothyroxine associated
with decrease in bone density of 4% at 2 yr; effect of radioiodine on substernal and cervical components—
size of gland increased in 2 patients; 4 patients had small decrease in size of substernal, compared to cervical, component;
concluded radioiodine moderately effective in reducing size of substernal goiter; radioiodine associated with decrease in
size of gland of 40% to 60% at 2 yr; high doses—used because glands have low uptake of radioiodine, but often require
inpatient treatment and associated with increased risk for adverse effects
|
 | Recombinant human thyroid-stimulating hormone (rhTSH): used to increase radioiodine uptake and to lower required
dose of radioiodine; study found uptake doubled at 24 hr with small dose of rhTSH; study looking at higher doses of
rhTSH found 4-fold increase in radioiodine uptake at 72 hr; another study found rhTSH associated with improvement
in size of gland of 40% to 60% at 1 yr; safety—study found rhTSH increased size of normal gland by >30% in 3 days
(can cause acute respiratory symptoms in patients with large goiters); study looked at free thyroxine (T4 ) levels after
treatment with rhTSH or radioiodine treatment alone; free T4 levels rose above upper limit of normal at 1 wk of rhTSH
(may lead to thyrotoxicosis or worsen cardiac disease)
|
| Surgery: treatment of choice because of high risk for compressive symptoms and unexpectedly high risk for cancer (most
studies found >10% of patients with intrathoracic multinodular goiter had thyroid cancer); substernal nodules difficult to
follow because they cannot be monitored by ultrasonography (US) or biopsied; transient hypocalcemia most common
complication; low rate of permanent hypothyroidism after surgery; surgery associated with high risk for transient vocal
cord paralysis, but low risk for permanent recurrent laryngeal nerve injury; low risk for thoracotomy
|
| HYPOCALCEMIA: PREVENTION DURING THYROID SURGERY —Robert Sofferman, MD, Professor of Surgery and
Chairman, Division of Otolaryngology, University of Vermont College of Medicine, Burlington
|
| Blood supply: inferior thyroid artery supplies most blood to superior and inferior parathyroid glands, with contribution
from superior thyroid artery
|
| Technique for parathyroid preservation: use magnifying loop; dissect into capsule of thyroid gland first to optimize
identification; dissect parathyroid gland from anterior to posterior and separate from thyroid gland to avoid vascular
supply; consider anything yellow in thyroid gland as parathyroid tissue (often just fat around parathyroid gland; can lead
to better preservation of parathyroid tissue); approach recurrent laryngeal nerve from lateral direction; when using bipolar
cautery, stay right on capsule of thyroid gland; always check color of parathyroid glands before closing; darkly venous
or black gland may require reimplantation, but slightly ischemic or mottled gland may not; if patient has had surgery on
other side and parathyroids look marginal, consider making small nick with scalpel or needle in antivascular border to
check for venous blood
|
| Techniques to avoid: proximal ligation of inferior thyroid artery (ligate vessel beyond point where parathyroid blood supply
originates); placing clamps on superior pole vessels above level of thyroid (come down onto anterior face of thyroid,
then ligate each individual vessel anteriorly; avoids going to main trunk where superior laryngeal nerve may be injured);
cauterizing near parathyroid gland (cauterize vessels on thyroid capsule and work toward parathyroid); removing normal
parathyroid glands during parathyroidectomy (if uncertain, take biopsy and send to pathology); gland probably not hyperplastic
if reasonable complement of fat present (except in elderly patient); disturbing blood supply while exploring other parathyroid
areas (can devascularize normal parathyroid gland)
|
| Intraoperative parathyroid hormone (PTH) level: during parathyroidectomy—used to demonstrate resolution
of hyperparathyroid state; keep excised parathyroids sterile and on ice in operating room in case autotransplantation becomes
necessary; obtain parathyroid assay after removal of adenoma; below-normal PTH level not necessarily reason for
reimplantation (suppression of function by hormone-secreting parathyroid adenoma can result in low intraoperative PTH
level); during thyroidectomy—consider reimplantation of parathyroid if uncertain whether parathyroid glands removed
during previous right thyroid lobectomy; consider reimplantation of parathyroid if intraoperative PTH level below normal
during thyroidectomy (patient usually euparathyroid before surgery)
|
| Measurement of parathyroid microcirculation: laser Doppler flowmetry—infrared laser at 780 nm penetrates
1.5 mm into tissue; measures flow of red blood cells (RBCs) in mm/min per 100 g of tissue; study—measured ischemia in
41 parathyroid glands removed during parathyroidectomy; median preremoval value of 67 mm/min decreased to 7 mm/min
(values <10 mm/min indicate ischemia); study—measured ischemia in 71 parathyroid glands manipulated during thyroidectomy
without dissection into thyroid capsule; median decrease in blood supply 31 mm/min; no patient developed permanent
hypocalcemia
|
| HYPOPHARYNGEAL CANCER: CONTEMPORARY MANAGEMENT —Randal S. Weber, MD, Hubert L. and Olive
Stringer Distinguished Professor and Chairman, Department of Head and Neck Surgery, University of Texas M.D. Anderson
Cancer Center, Houston
|
| Physical assessment: determine—epicenter and sites of tumor extension (postcricoid, esophageal introitus, apex of
pyriform sinus, tonsillar fossa, or base of tongue); whether hemilarynx fixed or laryngeal crepitus present (loss of laryngeal
crepitus indicates extension into esophageal introitus); adenopathy—subdigastric node and jugular chain main sites
of drainage; consider retropharyngeal and paratracheal nodes on ipsilateral side of pyriform sinus and upper mediastinal
lymphatics; positive retropharyngeal nodes in 44% of patients with pharyngeal wall cancer (include retropharyngeal
lymph nodes in treatment plan); ipsilateral lymphatic spread more common if medial wall of pyriform sinus involved; bilateral
lymphatic spread common if tumor involves anterior lateral walls of pyriform sinus, postcricoid region, or posterior
pharyngeal wall; jugular chain of lymph nodes main site of involvement; lymphatic vessels drain to medial and
lateral retropharyngeal nodes; consider retropharyngeal node metastasis if patient presents with pain beginning at occiput
that radiates to apex of orbit, and obtain imaging of retropharyngeal nodes
|
| Presentation, imaging, and staging: tumors often grade 3 and poorly differentiated on presentation; skip or multifocal
lesions common; look for second primary tumor; pyriform sinus most common site of origin; diagnostic imaging—
determine cartilage destruction (most likely to occur in posterior lamina of thyroid cartilage for pyriform sinus cancers);
CT preferred (motion sensitivity of magnetic resonance imaging [MRI] inappropriate in these patients); barium swallow
helpful in assessing function of hypopharynx; staging—T4a and T4b stages added to staging system; T4b tumors may
invade prevertebral space or encase carotid artery and are unresectable
|
| Patterns of spread: hypopharynx cancers—can extend into esophageal introitus and proximal cervical esophagus, but
extensive esophageal involvement rare; skip lesions and party wall involvement between esophagus and trachea rare;
cancers in cervical esophagus—frequently extend up to level of cricopharyngeus muscle, making laryngeal preservation
difficult during cervical esophagectomy; extension into thoracic esophagus common; skip lesions and party wall involvement
common if tracheal wall involved; superior extension of tumor often precludes laryngeal preservation
|
| Preoperative management: endoscopy—used to determine if flap required during reconstruction, if tumor resectable,
and tumor extent; assess cervical trachea with rigid or flexible bronchoscopy; assess skip lesions with esophagoscopy
for percutaneous endoscopic gastrostomy (PEG) placement (avoid PEG placement if considering gastric pull-up);
patient selection—patient must be good candidate for multihour operation; avoid operating on patient without reconstructive
options; surgery contraindicated in patient who has had multiple abdominal procedures or has no vessel access
in neck because of prior treatment
|
| Surgical management: general—preserve one jugular vein (to avoid having to stage neck); if performing bilateral
neck dissection, preserve one jugular vein to prevent cerebral edema or blindness and to provide vein for reconstruction;
obtain frozen sections of surgical margins; options for resection—consider endoscopic resection, partial pharyngectomy
with laryngeal preservation, extended supraglottic laryngectomy, supracricoid with hemilaryngopharyngectomy,
and total laryngopharyngectomy; laser resection—select small superficial tumors in line of sight; indicated for tumors
in medial or anterior pyriform sinus and arytenoepiglottic folds; contraindicated if cord fixed, in interarytenoid disease, if
tumor extends into apex of pyriform, in retrocricoid disease, or disease in opposite arytenoid; supracricoid
hemilaryngopharyngectomy—can preserve one arytenoid if cord unfixed and if apex of pyriform sinus uninvolved;
study gave patients preoperative chemotherapy, modified radical neck resection, with hemithyroidectomy and paratracheal
lymph node dissection; closure uses strap muscles to reconstitute pharynx (significant risk for pharyngeal stenosis
if combined with radiotherapy); posterior pharyngeal wall tumors (study)—patients with intermediate-stage tumors
received resection and reconstruction with radial forearm flap; flap produces fixation during swallowing and can impede
propulsion of food into esophageal introitus; removal of pharyngeal plexus results in loss of coordinated reflex mechanisms
of swallowing; associated with poor functional outcome and inadequate disease control; all required postoperative
irradiation; major resection not compatible with safe laryngeal preservation; laryngopharyngectomy for advanced hypopharyngeal
cancer (study)—overall survival rate 30%; 80% of patients required radiotherapy; concluded that partial
or radical surgery with radiotherapy provides poor disease control and survival
|
| Improving outcome: consider radiotherapy for early-stage disease (treats regional and retropharyngeal lymphatic vessels
with good outcome); consider postoperative chemo- and radiotherapy for high-risk patients, postoperative adjuvant chemotherapy
to treat occult distant metastases, targeted chemo- and radiotherapy for organ preservation, and organ-sparing surgery;
avoid organ preservation treatment in patients who require tracheostomy or g-tube at presentation;
chemoradiotherapy for advanced disease—patients with advanced tumors received platinum-based chemotherapy and
radiotherapy; overall survival rate 44%; laryngeal preservation (study)—similar survival rate in patients treated with total
or partial laryngectomy and radiotherapy or surgery and chemotherapy, but surgery and chemotherapy resulted in laryngeal
preservation in half of patients; local control worse for patients receiving chemoradiation
|
| ALCOHOL WITHDRAWAL FOLLOWING SURGERY: STANDARD CARE PROTOCOL —Christopher D. Landsford,
MD, Lecturer, University of Michigan Health System, Ann Arbor
|
| Alcohol withdrawal syndrome (AWS): Michigan protocol—separates AWS symptoms into 3 distinct groupings,
allowing each to be addressed with specific pharmacologic approach; medications used only when symptoms manifest;
requires frequent assessment of patients for symptoms of AWS; type A—central nervous system (CNS) excitation; manifested
by anxiety, dysphoria, and enhanced reaction to abrupt stimuli; evaluate patient for class 2 hemorrhagic shock, hypoglycemia,
or generalized anxiety disorder prior to therapy; lorazepam primary treatment; type B—adrenergic
hyperactivity; manifested by fever, chills, diaphoresis, hypertension, and tachycardia; most likely to be associated with
significant morbidity and mortality; treated with clonidine; type C—delirium manifested by attention deficit, disorientation,
and hallucinations; begins within 5 days of sobriety; characterized by waxing and waning sensitivity to stimuli; differential
diagnosis includes overall causes of mental status changes, hepatic encephalopathy, or overly aggressive use of
lorazepam; treated with haloperidol; protocol—identify at-risk patients with CAGE (feeling need to cut down, annoyed
by criticism, guilty about drinking, and eye opener) questionnaire; preprinted orders available for physicians to review
and sign; postoperatively, patients given thiamine, folic acid, and multivitamin daily; nursing assessment performed q2h
using AWS indicator; treat positive type A score with lorazepam (1 to 2 mg) qh as needed until score 0 or until patient
calm and cooperative; positive type B score requires differential diagnosis from treating physician; treat with clonidine if
symptoms correlate with AWS; use blood pressure parameters to prevent hypertension; patient with positive type C score
first treated nonpharmacologically, then with haloperidol; lorazepam stopped; recommend full 24-hr course of haloperidol
after discontinuation of lorazepam
|
Educational Objectives
| The goal of this program is to educate the listener about the surgical management of substernal goiter, prevention of hypocalcemia
during thyroid surgery, management of hypopharyngeal cancer, and alcohol withdrawal following surgery. After
hearing and assimilating this program, the clinician will be better able to:
|
| 1. Discuss the advantages of the surgical management of substernal goiter.
|
| 2. Describe techniques used to prevent hypocalcemia during thyroid surgery.
|
| 3. Evaluate the efficacy of surgery, radiotherapy, and chemoradiation for hypopharyngeal cancer.
|
| 4. Identify a patient with alcohol withdrawal syndrome (AWS).
|
| 5. Treat a head and neck cancer patient with AWS.
|
Discussed on This Program
Clonidine HCl [Catapres, Duraclon]
Haloperidol [Haldol, Haldol Decanoate 50, Haldol Decanoate 100]
Lorazepam [Ativan, Lorazepam Intensol]
Recombinanl human thyroid-stimulating hormone (Thyrotropin alfa) [Thyrogen]
Suggested Reading
Batori M et al: Substernal goiters. Eur Rev Med Pharmacol Sci. 9:355, 2005; Bonnema SJ et al: Does radioiodine
therapy have an equal effect on substernal and cervical goiter volumes? Evaluation by magnetic resonance imaging. Thyroid
. 12:313, 2002; Chalian AA et al: Design and impact of intraoperative pathways for head and neck resection and reconstruction.
Arch Otolaryngol Head Neck Surg. 128:892, 2002; Clayman GL et al: Laryngeal preservation for
advanced laryngeal and hypopharyngeal cancers. Arch Otolaryngol Head Neck Surg. 121:219, 1995; Erbil Y et al:
Surgical management of substernal goiters: clinical experience of 170 cases. Surg Today. 34:732, 2004; Fewins J et al:
Complications of thyroid and parathyroid surgery. Otolaryngol Clin North Am. 36:189, 2003; Neyman KM et al: Alcohol
withdrawal prophylaxis in patients undergoing surgical treatment of head and neck squamous cell carcinoma. Laryngoscope
. 115:786, 2005; Peters LJ et al: Evaluation of the dose for postoperative radiation therapy of head and neck
cancer: first report of a prospective randomized trial. Int J Radiat Oncol Biol Phys. 26:3, 1993; Proctor MD et al: Intraoperative
parathyroid hormone testing: what have we learned? Laryngoscope. 113:706, 2003; Shirinian MH et al:
Laryngeal preservation by induction chemotherapy plus radiotherapy in locally advanced head and neck cancer: the M. D.
Anderson Cancer Center experience. Head Neck. 16:39, 1994; Sofferman RA: Surgical management of primary hyperparathyroidism:
review of my experience at the University of Vermont. Arch Otolaryngol Head Neck Surg. 124:1056,
1998; Weber RS et al: Paratracheal lymph node dissection for carcinoma of the larynx, hypopharynx, and cervical
esophagus. Otolaryngol Head Neck Surg. 108:11, 1993; Yom SS et al: Survival impact of planned restaging and early
surgical salvage following definitive chemoradiation for locally advanced squamous cell carcinomas of the oropharynx and
hypopharynx. Am J Clin Oncol. 28:385, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs Brett, Sofferman, and Weber were recorded at the 15th annual Multidisciplinary Management of Head and Neck
Cancer and Thyroid and Parathyroid Diseases, sponsored by the Departments of Otolaryngology at the Albert Einstein
College of Medicine and Beth Israel Medical Center and held April 9-17, 2005, in New York City. Dr. Lansford was recorded
at the annual combined Otolaryngological Spring Meetings (COSM) of the American Head and Neck Society
(AHNS), held May 15-16, 2005, in Boca Raton, Florida. The Audio-Digest Foundation thanks the speakers and the sponsors
for their cooperation in the production of this program.
|
