DISORDERS OF THE HEAD AND NECK: MODES OF MANAGEMENT
| TRANSNASAL ESOPHAGOSCOPY —Gregory N. Postma, MD, Professor, Department of Otolaryngology, Head
and Neck Surgery, Medical College of Georgia, Augusta
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| Introduction: gastroesophageal reflux and extraesophageal reflux common; in series of patients with extraesophageal
reflux, ≈50% of patients with extraesophageal complaints have some degree of esophageal pathology; 75% to
90% of complications of flexible endoscopy sedation-related; since no sedation involved in transnasal esophagoscopy
(TNE), complication rate essentially zero; TNE device—has working channel and audiovisual controls; ability
to suction, shoot water, and insufflate air; 60 cm long; retroflexes in stomach to view bottom of esophagus;
distal chip system or fiberoptic system
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| Head and neck indications: diagnosis—screening; biopsies (no complications seen); speaker prefers to perform
panendoscopy if patient on coumadin; performing primary and secondary tracheoesophageal punctures (TEPs); delivering
flexible laser beam and dilating strictures; all studies to date (n=6) show no differences in diagnostic yield
between traditional sedated esophagoscopy and unsedated TNE, with majority of patients preferring TNE; for biopsy,
1.8-mm cup goes through working channel to obtain sample (brush sometimes used); since all head and neck
cancer patients who have had radiation therapy have pathologic degrees of reflux, and some develop Barrett’s
esophagus, use TNE to follow patients prospectively; also, fungal infections, esophagitis (particularly after radiation
therapy), and strictures (rate 40%); advantages—effective way to perform panendoscopy without taking patient
to operating room (OR); appropriate for sick patients and cost-effective; other applications—tracheoscopy and
bronchoscopy; also used in high narrow strictures of cervical esophagus after irradiation and chemotherapy; used to
look at anastomosis after reconstruction for head and neck cancer; used to excise and ablate tissue for palliation; dilations
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| Procedures: anesthesia—same as for transnasal esophagoscopy; lidocaine and oxymetazoline (Afrin) in nose and
topical 4% or 2% lidocaine through working channel in area being worked on; TEP—performed in clinic; neopharynx
blown up with air; prosthesis no longer put in directly; dilations—over-wire Savory dilators no longer used; concentric
radial expansion balloons used to dilate strictures with guide wire under direct vision; well tolerated by ≈75%
of patients; in-office laser therapy—most common indications papilloma and chronic granulomas; also used in leukoplakia
of larynx and for cancer palliation; ablate granulation tissue to maintain airways; standard safety guidelines for
OR used; effective for nasopharyngeal stenosis
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| OUTPATIENT THYROID AND PARATHYROID SURGERY —David J. Terris, MD, Porubsky Distinguished Professor
and Chair, Department of Otolaryngology, Head and Neck Surgery, Medical College of Georgia, Augusta
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| Trends in hospital stays: preoperative admission rare; same-day tonsillectomy standard of care; outpatient cholecystectomy
common; overnight admission for parathyroidectomy denied
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| Conventional surgery: involves subplatysmal flap elevation (not necessary; takes extra time, increases rate of seroma
formation, and prolongs wound-healing process); also 4-gland exploration, drains, and calcium monitoring;
inpatient hospitalization (2-3 days)
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| Justification for outpatient surgery: smaller incisions; less invasive (less dissection and disruption of tissue
planes); no subplatysmal flaps; Harmonic technology
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| Use of drains: speaker not comfortable sending patient home with drain; used to avoid expanding hematoma and
prevention of seroma; 98% of surgeons use drains routinely after thyroid surgery; forgoing drains—prospective
randomized trial showed no difference whether drain used; meta-analyses also showed no difference; of 28 papers
published, none supports use of drains in thyroid surgery
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| Calcium supplementation: routinely given orally after total thyroidectomy to achieve outpatient surgery; taper
over 3 wk; 1.8 g/day in 3 divided doses for first week, 1.2 g in second week, and 600 mg for third week; given by
speaker for thyroid and parathyroid surgery; speaker feels no need to add vitamin D to regimen, although high rate
of vitamin D deficiency in northern states and Southeast
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| Benefits of outpatient surgery: lower charges; convalescence in home environment; decreased exposure to nosocomial
organisms; patient who has surgery immediately immunocompromised (drop in white blood cell count with general
anesthesia); minimizes opportunity for medical errors
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| Contraindications to outpatient surgery: preoperative and intraoperative evaluation of patient indicates drain
necessary; patient medically infirm, has large dead space, or known bleeding dyscrasia (drain necessary)
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| Previous reports: Steckler first to describe outpatient thyroidectomy (lobectomies only); Mowschenson described
lobectomy and total thyroidectomy; LoGerfo described locoregional anesthesia and outpatient thyroid surgery
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| Changes in thyroid surgery: marking while patient sitting up in holding area (cosmetic purpose); minimal neck extension
(shoulder rolls or thyroid pillow no longer used); marked neck extension causes posterior cervical neck pain
unnecessarily and makes recurrent laryngeal nerve more difficult to locate; nerve monitoring now performed routinely;
use of elevators helpful to accomplish atraumatic dissection during thyroid surgery; speaker no longer identifies
and ligates superior thyroid artery or vein individually (takes whole upper pedicle as single bundle with Harmonic device
and stays on capsule); dissection perpendicular to recurrent laryngeal nerve to identify nerve (previously parallel
to nerve); topical skin adhesive (Dermabond) instead of sutures
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| Summary: calcium supplementation and avoidance of drains allows performance of outpatient surgery; technology
and minimally invasive approaches minimize risk for postoperative hemorrhage; outpatient thyroid surgery safe
and cost-effective in selected patients; in outpatient surgery center, no reimbursement for disposable items (unlike
hospitals)
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| RECURRENT LARYNGEAL NERVE INJURIES —Dr. Postma
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| Incidence: fairly low in major centers; higher risk in thyroid cancer, Graves’ disease, large goiters, and those who
need reoperation; surgery overtaking cancer as number one cause of unilateral vocal cord immobility, with thyroid
surgery leading cause (anterior cervical approaches to cervical spine second leading cause); surgery represents
slightly over one-third of causes of bilateral paralysis (followed by cancer, with intubation injury third); most cases
of intubation injury probably posterior glottic stenosis and not bilateral vocal fold immobility due to neurogenic
reasons; endocrine surgery leading surgical cause
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| Symptoms of glottal insufficiency: variable dysphonia; effortful phonation; vocal fatigue; diplophonia (2-tone
quality to voice); dysphagia; frank aspiration; in attempt to compensate, high-pitched voice results (strained hyperfunctional
sound); loss of high-pitch range in singers; shortness of breath
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| Diagnosis: flexible examination critical (patient more relaxed, less splinting, and more likely to see subtle vocal fold
motion abnormalities); findings—want to see vocal processes touching before supraglottic hyperfunction; in normal
individual, almost complete glottal closure when vocal processes touching; simplest approach “e sniff” maneuver
(patient relaxed, with flexible scope in nose; saying the letter “e” brings cords together and then sniffing strongest
stimulus to abducting vocal folds); look for symmetry and closure pattern; often see sphincteric closure because patient
trying too hard; not done on purpose (patient compensating); concept of “unloading”—have patient take deep
breath and hum; able to view glottis; majority of patients have supraglottic hyperfunction due to incomplete closure
of larynx; careful examination required before referral to speech therapist
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| Laryngeal electromyography (EMG): controversial; provides diagnostic and prognostic information; speaker always
performs left side first, regardless of pathology; monopolar electrodes; speaker has patient perform “e sniff”
maneuver, looking for synkinesis; speaker often uses head lift to ascertain location; recruitment depends on volitional
effort; electrical silence and vocal cord immobility rare; almost all individuals reinnervate after neurologic injury,
but become synkinetic, ie, keep tone, but lose motion; no correlation between vocal fold position and status of
superior laryngeal nerve (SLN); in about two-thirds of cases, speaker able to determine prognosis based on EMG;
speaker does not perform EMG if it will not be helpful or will not change management; detailed EMGs necessary in
legal cases
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| Unilateral cord: planned—in general, speaker prefers, if removing nerve, to fix problem during surgery (usually by
performing injection augmentation during thyroidectomy); suture placed in muscular process of arytenoid and
pulled anteriorly; laryngoplasty and arytenoid reduction performed 2 wk later under local anesthesia with sedation;
in nonprofessional vocalist, injection of immobile cord (or soon-to-be immobile cord if nerve removed) at same sitting;
if unplanned—majority of surgeons perform nerve-nerve repairs; only controversy what nerve to use; majority
use recurrent laryngeal nerve (RLN); speaker recommends injecting cord at same time
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| Future directions: ongoing research looking at various trophic agents applied to nerves to promote nerve repair;
include basic fibroblast growth factor and brain-derived neurotrophic factor; also growth factors attached to virus
vectors for injection
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| Indications for surgery: life-altering symptoms; most patients with glottal insufficiency do not require surgery
(depends on vocal requirements)
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 | Watchful waiting: speaker does not advocate waiting for 12 mo; need to be aggressive and manage problem early
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| Speech therapy
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| Injection laryngoplasty: several options; speaker prefers fat, voice gel, and calcium hydroxyapatite; 10 different injectables
available commercially; fat—easy to obtain; autologous tissue; has good consistency; use suction cannula
to remove, then wash in saline, and load into Bruning syringe for injection; results variable (15%-40% long-
term [≈2 yr] yields); every patient told further procedure may be necessary; preferred by speaker for professional
vocalists; calcium hydroxyapatite in carboxymethylcellulose carrier—not permanent in all patients; durable; data
show good outcomes 1 yr after injection in majority of participants; be careful with injections (inject deep in muscle);
about two-thirds of patients get single injection anterolateral to vocal process, down deep; about one-third
need second injection around mid cord; everyone overinjected (carrier substance dissolves in few months); voice
gel—carboxymethylcellulose alone; used by speaker instead of absorbable gelatin sponge (Surgifoam); simple to
inject and has temporary effects (2-3 mo); speaker does not perform per oral injections often (only for botulinum
toxin type A and cidofovir); 3 percutaneous techniques; speaker prefers thyrohyoid approach (needle driven in at
thyroid notch and both vocal folds injected)
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| Medialization laryngoplasty: able to tune voice; easy to perform bilaterally; performed with sedation; controversy
about implant materials (speaker switched to expanded polytetrafluoroethylene [Gore-Tex]); key point—avoid
overcorrection of vocal cord, particularly anteriorly; always fixate implants; visual and auditory feedback; speaker’s
techniques—18-gauge needle used to drill through thyroid ala; intravenous (IV) catheter or 27-gauge needle then
used to determine location (should not miss vocal folds); #15 blade or drill used to make small hole; Kerrison
rongeur used for rest of window; antibiotic-soaked Gore-Tex layered into window; look and listen during procedure;
real-time fiberoptic visualization; with Gore-Tex—procedure faster; less swelling and less likely to overcorrect
anterior commissure than with Silastic; easy revision surgery; easy learning curve
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| Indications for injection laryngoplasty: for small glottal gaps (unless patient performing artist); bowing, paresis,
and immobility with small gap; vocal cord scarring from previous cancer; temporary relief; fine tuning after
laryngoplasty; faster (not >15 min); preferred in children and adults with control issues (under general anesthesia);
dysphagia (address cricopharyngeus muscle); concern about neck incision
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| Laryngeal framework surgery: preferred in large glottal gaps, for most vocal professionals (poor anesthetic
risk), and if any airway concerns
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| Surgeon’s preference: time—injection laryngoplasty faster; general anesthesia if patient unreasonable or whines
and squirms during evaluation
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| Patient factors: anticoagulation status; study showed no complications with injection augmentation in participants
on warfarin (Coumadin) and clopidogrel (Plavix); radiation therapy controversial (injection preferred); psychiatric
concerns
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| Laryngeal reinnervation: controversial; varied results (some spectacular); speaker uses only in very young patients
and professional singers; injection augmentation performed at same time (takes 6-9 mo to be effective)
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| Approach to patient: select surgical patient carefully; many patients with impaired glottic closure do not require surgery;
if patient >50 or 55 yr of age, augment both vocal cords
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Suggested Reading
Alía P et al: Postresection parathyroid hormone and parathyroid hormone decline accurately predict hypocalcemia
after thyroidectomy. Am J Clin Pathol 127:592, 2007; Amin M et al: Hands-on training methods for vocal fold injection
education. Ann Otol Rhinol Laryngol 116:1, 2007; Amin MR: Thyrohyoid approach for vocal fold augmentation.
Ann Otol Rhinol Laryngol 115:699, 2006; Bailleux S et al: Thyroid surgery and recurrent laryngeal nerve
monitoring. J Laryngol Otol 120:566, 2006; Cahill RA et al: Parathormone response to thyroid surgery. Am J Surg
191:453, 2006; Cantarella G et al: Airway resistance and airflow dynamics after fat injection into vocal folds. Ann
Otol Rhinol Laryngol 115:810, 2006; Chou FF et al: Neurorrhaphy of the recurrent laryngeal nerve. J Am Coll Surg
197:52, 2003; Fleischer S et al: Office-based laryngoscopic observations of recurrent laryngeal nerve paresis and
paralysis. Ann Otol Rhinol Laryngol 114:488, 2005; Halum SL et al: Laryngeal electromyography for adult unilateral
vocal fold immobility: a survey of the American Broncho-Esophagological Association. Ann Otol Rhinol Laryngol
114:425, 2005; Hartl DM et al: Laryngeal aerodynamics after vocal fold augmentation with autologous fat vs thyroplasty
in the same patient. Arch Otolaryngol Head Neck Surg 131:696, 2005; Kumar VV et al: Evaluation of middle
and distal esophageal diverticuli with transnasal esophagoscopy. Ann Otol Rhinol Laryngol 114:276, 2005;
McCrystal DJ et al: Cricotracheal separation: a review and a case with bilateral recovery of recurrent laryngeal
nerve function. J Laryngol Otol 120:497, 2006; Munin MC et al: Utility of laryngeal electromyography in predicting
recovery after vocal fold paralysis. Arch Phys Med Rehabil 84:1150, 2003; Pothier DD: The use of drains following
thyroid and parathyroid surgery: a meta-analysis. J Laryngol Otol 119:669, 2005; Sharma A et al: Transnasal
flexible laryngo-oesophagoscopy: an evaluation of the patient's experience. J Laryngol Otol 120:24, 2006; Stavrakis
AI et al: Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery. Surgery 142:887,
2007; Tanna N et al: Foreign body reaction to calcium hydroxylapatite vocal fold augmentation. Arch Otolaryngol
Head Neck Surg 132:1379, 2006; Xu W et al: Value of laryngeal electromyography in diagnosis of vocal fold immobility.
Ann Otol Rhinol Laryngol 116:576, 2007.
Educational Objectives
| The goal of this program is to improve the management of head and neck disorders. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Cite the indications for and advantages of transnasal esophagoscopy.
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| 2. Describe the justifications, benefits, and contraindications of outpatient thyroid and parathyroid surgery.
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| 3. Implement the latest improvements in outpatient thyroid and parathyroid surgery.
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| 4. Recognize glottic insufficiency, based on symptoms, laryngoscopy, and laryngeal electromyography.
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| 5. Review the treatment options for glottic insufficiency.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Terris is
a director for thyroid courses at Ethicon Endo-Surgery and consultant for instrument development at Medtronic Xomed. Dr.
Postma is on the Speakers’ Bureau for Kay Pentax and Olympus. The planning committee reported nothing to disclose.
Acknowledgements
Dr. Postma’s lecture on transnasal esophagoscopy was recorded at the Fifth Annual Porubsky Symposium, Chief Resident
Graduation and Alumni Weekend, held June 22-23, 2007, in Augusta, GA, and sponsored by the Medical College of Georgia
School of Medicine, Department of Otolaryngology and Division of Continuing Education. Dr. Terris’ and Dr. Postma’s lectures
on recurrent laryngeal nerve injuries were recorded at Minimally Invasive Surgical Management of Thyroid and Parathyroid
Disorders, held November 1-3, 2007, in Augusta, GA, and sponsored by the Medical College of Georgia School of
Medicine Department of Otolaryngology and Division of Continuing Education. The Audio-Digest Foundation thanks Drs.
Postma and Terris and the Medical College of Georgia for their cooperation in the production of this program.
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