Surgery

Post-thyroidectomy hypocalcemia: Impact on length of stay

July 20, 2015     Joe Grainger, FRCS; Mohammed Ahmed, MRCP; Rousseau Gama, FRCPath; Leonard Liew, FRCS; Harit Buch, FRCP; Ronald J. Cullen, FRCS
article

Abstract

Hypocalcemia is a recognized complication following thyroid surgery. Variability in the definition of hypocalcemia and different opinions on its management can lead to unnecessary patient morbidity and longer hospital stays as a result of inappropriate or untimely treatment. Therefore, we developed a management guideline for the recognition and treatment of post-thyroidectomy hypocalcemia, and we conducted a retrospective study to assess its impact on length of stay (LOS). Between April 1, 2007, and March 31, 2009, 29 adults had undergone a total or completion thyroidectomy at our large district general hospital. Of this group, postoperative hypocalcemia (defined as a serum calcium level of <2.00 mmol/L) developed in 13 patients (44.8%) during the first 3 postoperative days. Our guideline went into effect on July 1, 2009, and from that date through June 30, 2010, 18 more adults had undergone a total or completion thyroidectomy. Of that group, hypocalcemia developed in 7 patients (38.9%); the guideline was actually followed in 5 of these 7 cases (71.4%). In the preguideline group, the development of hypocalcemia increased the mean LOS from 2.0 days to 7.0 days (p < 0.001). The management of postoperative hypocalcemia in these cases was highly variable and was dictated by variations in practice rather than patient needs. In the postguideline group, postoperative hypocalcemia increased the mean LOS from 2.7 days to only 3.7 days (p = 0.07). While the difference between LOS in the two hypocalcemic groups did not reach statistical significance, we believe it merely reflects the relatively small number of patients rather than any lack of guideline efficacy. The implementation of a simple flowchart guideline for the management of postoperative hypocalcemia in our hospital has resulted in more uniform management and a reduced LOS.

Cricotracheal resection

June 4, 2015     Amanda Hu, MD, FRCSC; James McCaffrey, MD; Al Hillel, MD
article

As much as half of the trachea can be resected with a low incidence of anastomotic complications.

Neuropathic pain from a nasal valve suspension suture

June 4, 2015     Tyler P. Swiss, DO; Douglas S. Ruhl, MD, MSPH; Scott B. Roofe, MD, FACS
article

Surgeons should maintain a high index of suspicion when a patient who has undergone nasal valve suspension complains of postoperative neuropathic pain.

Large Haller cell mucocele leading to maxillary sinusitis

April 27, 2015     Jae-Hoon Lee, MD
article

Paranasal sinus mucoceles are epithelial-lined cystic lesions containing mucus or mucopurulent fluid. Symptoms vary depending on the location of the mucocele.

Use of the chorda tympani nerve in reconstruction of the ossicular chain

April 27, 2015     Yi Qiao, MD; Wen-Wen Chen, MD; Ya-Xin Deng, MD; Jun Tong, MD
article

Abstract

We conducted a study to assess the use of the chorda tympani nerve in reconstruction of the ossicular chain. We retrospectively examined the medical records of 141 patients (154 ears) who had undergone middle ear surgery with 12 months of follow-up. The study population was made up of 58 males and 83 females, aged 9 to 83 years (mean: 45). These patients were divided into three groups based on the specific type of surgery they had undergone: in 35 patients, the chorda tympani nerve was used to spring and press the auricular bone prosthesis (CTN group); in 67 patients, the tympanic membrane was used to spring and press the auricular bone prosthesis (TM group); and in 39 patients, a gelatin sponge was used to support the auricular bone prosthesis (GS group). We compared pre- and postoperative air-bone gaps (ABGs) in each group, as well as the differences between these gaps among the three groups. We found significant differences between the pre- and postoperative ABGs in all three groups (all p < 0.01). These differences were also compared between the CTN and TM groups (t = 0.41; p > 0.05), between the CTN and GS groups (t = 2.07; p < 0.05), and between the TM and GS groups (t = 2.51; p < 0.05). In the CTN group, 1 patient experienced temporary postoperative hypogeusia, and another developed a mild case of delayed facial paralysis; both patients recovered within 2 weeks. We conclude that the chorda tympani nerve can be used to repair the ossicular chain to improve hearing without causing taste and facial nerve dysfunction and without the need for a second operation.

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.

Streamlined bilateral otologic surgery: How I do it

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

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.

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.

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.

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.

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.

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