Surgery

Protracted hypocalcemia following post-thyroidectomy lumbar rhabdomyolysis secondary to evolving hypoparathyroidism

March 2, 2015     Usman Y. Cheema, MD; Carrie N. Vogler, PharmD, BCPS; Joshua Thompson, PharmD; Stacy L. Sattovia, MD, FACP; Srikanth Vallurupalli, MD
article

Abstract

Rhabdomyolysis is characterized by skeletal muscle breakdown. It is a potential cause of serious electrolyte and metabolic disturbances, acute kidney insufficiency, and death. Recently, rhabdomyolysis has been increasingly recognized following certain surgical procedures. We discuss the case of a morbidly obese 51-year-old woman who developed postoperative rhabdomyolysis of the lumbar muscles following a prolonged thyroidectomy for a large goiter. We discuss how her morbid obesity, the supine surgical position, the duration of surgery (including prolonged exposure to anesthetic agents), and postoperative immobility contributed to the development of rhabdomyolysis. Immediately after surgery, the patient developed hypocalcemia, which was likely due to rhabdomyolysis since her serum parathyroid hormone level was normal. Later, however, persistent hypocalcemia despite resolution of the rhabdomyolysis raised a suspicion of iatrogenic hypoparathyroidism, which was confirmed by a suppressed parathyroid hormone level several days after surgery. In post-thyroidectomy patients with risk factors for rhabdomyolysis, maintaining a high degree of clinical suspicion and measuring serum creatine kinase and parathyroid hormone levels can allow for an accurate interpretation of hypocalcemia.

Streamlined bilateral otologic surgery: How I do it

March 2, 2015     Tara E. Brennan, MD; Miriam I. Redleaf, MD
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Abstract

Bilateral simultaneous otologic surgery is being performed more commonly among otologists. The benefits of performing bilateral simultaneous cochlear implants in the pediatric population, in particular, have become increasingly recognized as the safety and efficacy of this operation have been recognized in the literature. Here we present a streamlined method of performing bilateral simultaneous otologic surgery that emphasizes midline placement of facial nerve electrodes and a method of sterile preparation and draping that affords direct exposure to both ears at one time, without the need to turn the head or adjust the drapes multiple times throughout the operation. Our approach facilitates frequent and efficient alternation between ears throughout the operation, optimizing efficiency of motion and instrumentation for the surgeon, and reducing overall operative and general anesthesia time for the patient.

Previous gastric bypass surgery complicating total thyroidectomy

March 2, 2015     Bianca Alfonso, MD; Adam S. Jacobson, MD; Eran E. Alon, MD; Michael A. Via, MD
article

Abstract

Hypocalcemia is a well-known complication of total thyroidectomy. Patients who have previously undergone gastric bypass surgery may be at increased risk of hypocalcemia due to gastrointestinal malabsorption, secondary hyperparathyroidism, and an underlying vitamin D deficiency. We present the case of a 58-year-old woman who underwent a total thyroidectomy for the follicular variant of papillary thyroid carcinoma. Her history included Roux-en-Y gastric bypass surgery. Following the thyroid surgery, she developed postoperative hypocalcemia that required large doses of oral calcium carbonate (7.5 g/day), oral calcitriol (up to 4 μg/day), intravenous calcium gluconate (2.0 g/day), calcium citrate (2.0 g/day), and ergocalciferol (50,000 IU/day). Her serum calcium levels remained normal on this regimen after hospital discharge despite persistent hypoparathyroidism. Bariatric surgery patients who undergo thyroid surgery require aggressive supplementation to maintain normal serum calcium levels. Preoperative supplementation with calcium and vitamin D is strongly recommended.

Cochlear implantation leading to successful stapedectomy in the contralateral only-hearing ear

March 2, 2015     Samantha J. Mikals, MD; Gerald I. Schuchman, PhD; Joshua G.W. Bernstein, PhD; Arnaldo L. Rivera, MD
article

Abstract

Cochlear implants have recently begun to be offered to patients with single-sided deafness (SSD). Implantation in these patients has led to good results in suppressing ipsilateral tinnitus and in providing audiologic benefits in terms of speech perception in noise and localization. One previously unreported benefit of cochlear implantation in patients with SSD is the restoration of functional hearing in the previously deaf ear, which may allow for surgical opportunities in the contralateral hearing ear. We report a case in which cochlear implantation in the deaf left ear of a 50-year-old man allowed for surgical intervention in the previously only-hearing right ear, which in turn led to the restoration of normal middle ear function. Further studies may be warranted to consider the surgical candidacy of the contralateral only-hearing ear as another potential indication for cochlear implantation in patients with SSD.

Absence of the long process of the incus

February 2, 2015     Christina H. Fang, BS; Robert W. Jyung, MD
article

A definitive diagnosis of an ossicular defect, such as absence of the incus long process, requires an exploratory tympanotomy.

Contralateral hearing loss after vestibular schwannoma excision: A rare complication of neurotologic surgery

January 19, 2015     Robert H. Deeb, MD; Jack P. Rock, MD; Michael D. Seidman, MD, FACS
article

Abstract

We report a rare case of contralateral hearing loss after vestibular schwannoma excision in a 48-year-old man who underwent surgery via a suboccipital approach for removal of a nearly 2-cm lesion involving the right cerebellopontine angle. Postoperatively, the patient awoke with bilateral deafness, confirmed by both audiometry and spontaneous otoacoustic emissions. The patient was treated aggressively with high-dose intravenous steroids, vitamins E and C, and oxygen. Over the next several months he had gradual recovery of most of the hearing in his left (unoperated) ear. Contralateral hearing loss may develop after vestibular schwannoma excision; multiple pathophysiologic mechanisms for this occurrence have been proposed.

Endoscopic view of nasopharyngeal scarring

January 19, 2015     Joseph P. Mirante, MD, FACS; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS
article

A finding of fibrous or scar tissue in the nasopharynx usually indicates previous trauma or surgery in the area. The most common iatrogenic cause is adenoidectomy.

Glottic myxoma presenting as chronic dysphonia: A case report and review of the literature

January 19, 2015     Christopher G. Tang, MD; Daniel L. Monin, MD; Balaram Puligandla, MD; Raul M. Cruz, MD
article

Abstract

Myxomas of the vocal fold are rare benign tumors often presenting with chronic dysphonia and less frequently with airway obstruction. The current consensus is that all laryngeal myxomas should be totally excised with clear margins to prevent recurrences. The recommendation for complete excision, however, has to be balanced with consideration of preserving vocal fold phonatory and sphincteric function. We report a case of vocal fold myxoma recurring twice after subtotal excision via two surgical approaches. This case illustrates a benign lesion with potential for recurrence and the need for a balanced treatment approach.

Sinus transillumination, then and now

December 19, 2014     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS
article

In recent years, a new use has been found for transillumination in sinus surgical procedures involving balloon dilation. In these procedures, it is used to identify a sinus and to confirm that the balloon has entered the sinus correctly.

Cerebrospinal fluid leaks following septoplasty

December 19, 2014     Naren N. Venkatesan, MD; Douglas E. Mattox, MD; John M. Del Gaudio, MD
article

We conducted a retrospective review to identify the characteristics of cerebrospinal fluid (CSF) leak in patients who had undergone septoplasty and in selected patients who had experienced a spontaneous CSF leak. CSF leak is a known but infrequently reported complication of septoplasty; to the best of our knowledge, only 4 cases have been previously published in the literature. A review of our institution's database revealed 3 cases of postseptoplasty CSF leak. We reviewed all the available data to look for any commonalities among these 7 cases. In addition, we reviewed 6 cases of spontaneous CSF leak selected from our database for the same purpose. For all patients, we noted the side of the cribriform plate defect, its size and, for the postseptoplasty cases, the interval between the septoplasty and the leak repair. Overall, we found that leaks were much more common on the right side than on the left. The sizes of the leaks in the 2 postseptoplasty groups were comparable (mean: 14.0 x 6.4 mm). The interval between septoplasty and leak repair ranged from 2.5 to 20 years in our cases and from 3 days to 22 weeks in the previously published cases. All 3 of the postseptoplasty patients in our database presented with clear rhinorrhea. Two of the 3 patients had meningitis; 1 of these 2 also had pneumocephalus. Of the 6 cases of spontaneous CSF leaks, 4 occurred on the right and 2 on the left; the average size of the defect was 5.8 mm in the greatest dimension. The finding that cribriform plate defects after septoplasty were typically right-sided likely reflects the prevalence of left-sided surgical approaches. Also, the fact that the defects were larger in the postseptoplasty cases than in the spontaneous cases is likely attributable to the torque effect toward the thin skull base that occurs when the perpendicular plate is twisted during septoplasty.

Iatrogenic fracture of the superomedial orbital rim during frontal trephine irrigation

December 19, 2014     Douglas Angel, MD; Rebecca Zener, MD; Brian W. Rotenberg, MD, MPH, FRCSC
article

Frontal sinus trephination (FST) has numerous applications in the treatment of acute and chronic sinus disease. This procedure involves making an incision at the medial aspect of the supraorbital rim and then drilling the sinus's anterior table. Placement of a frontal trephine allows for irrigation of the frontal recess in order to evacuate the frontal sinus in a minimally invasive manner. Orbital injury is a rare complication of FST. We present a case of previously unreported orbital compartment syndrome secondary to iatrogenic fracture of the superomedial orbital rim as a complication of frontal trephine irrigation. We also review the literature on the applications of FST and its associated complications, and we discuss orbital compartment syndrome as a complication of sinus surgery.

Management of soft palate agenesis in Nager syndrome with an elongated, superiorly based pharyngeal flap

October 17, 2014     Oneida A. Arosarena, MD; Troy Hemme, DO
article

Abstract

Nager syndrome, or preaxial acrofacial dysostosis, is associated with aberrant development of the first and second branchial arch structures, as well as abnormal development of the limb buds. It is a rare disorder, and its clinical manifestations have not been completely defined. Absence of the soft palate has been reported in patients with Nager syndrome. In this report we describe the use of an elongated, superiorly based pharyngeal flap for the treatment of severe velopharyngeal insufficiency in a patient with Nager syndrome and absence of the soft palate. We also describe the dysmorphisms associated with Nager syndrome and present a differential diagnosis for the condition.

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