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The article focuses on the diagnosis of esophageal lymphangioma. It describes the case of a 53-year-old man who has a three-year history of dysphagia and regurgitation, and transnasal esophagoscopy detected a soft tissue mass. It notes that the lesion has the appearance of a fibrovascular esophageal polyp. Among the most common presenting symptoms of such condition are dysphagia, heartburn, postprandial vomiting and epigastric pain.

Objectives: A series of remote access thyroidectomy techniques, some using a surgical robot, have been introduced in the last decade. Most of these approaches require awkward positioning, use unfamiliar dissection planes, and have been associated with a number of significant complications. As a result, acceptance has been limited. We describe technical details and patient selection criteria of a recently described robotic facelift thyroidectomy (RFT) approach that avoids these pitfalls., Design: Analysis of preclinical and clinical studies., Methods: Inanimate and cadaver dissection studies and clinical implementation were pursued. A 3-arm RFT technique with a 30-degree offset base location proved optimal. Supine positioning with arms tucked and the patient in slight Trendelenburg position facilitated the dissection of the optical pocket. Demographic and surgical data that have been obtained and considered include patient age, sex, body mass index, pathology, and complications., Results: A series of consecutive RFT procedures has been accomplished in a limited population of patients. All cases were completed robotically with no conversions to open surgery necessary. All but the first case was accomplished on a drainless, outpatient basis., Conclusions: A RFT technique that is gasless and uses a single access port in the postauricular crease and occipital hairline location is feasible, technically less challenging than other remote access methods, and safe. Further study in an expanded patient population and in additional high-volume thyroid centers is warranted. See the videos, Supplemental Digital Content 1, http://links.lww.com/SLE/A36andSupplementalDigitalContent2, http://links.lww.com/SLE/A37.

Objectives: Robotic thyroidectomy was introduced in the United States despite scant preclinical data. We pursued a systematic preclinical investigation of a new remote access, robotic thyroidectomy technique via a facelift incision, and sought to define differences in extent of dissection associated with this approach and a second, popular robotic thyroidectomy technique., Design: Surgical simulation and morphometric analysis in fresh human cadavers., Methods: Eleven specimens were obtained to complete four experiments designed to address two specific aims: to develop a reproducible surgical protocol for robotic removal of the thyroid through a facelift incision, and to quantify the extent of dissection required with two robotic thyroidectomy techniques., Results: The feasibility of the facelift approach was determined using an endoscopic technique, and two lobectomies were accomplished. Inanimate study of the optimal robotic positioning to facilitate resection was then completed. Three additional cadavers were used to develop a reproducible surgical protocol and define a stepwise algorithm of dissection. Seven specimens were used to simulate 28 robotic thyroidectomy dissection pockets. The mean area of dissection required for robotic facelift thyroidectomy was 39.2 ± 6.6 cm(2) compared with 63.5 ± 9.6 cm(2) for robotic axillary thyroidectomy, representing a difference of 38.3% (P < .0001)., Conclusions: We have described and refined a reproducible surgical protocol for accomplishing a new robotic facelift thyroidectomy, and then quantified the reduced dissection required when comparing it with a transaxillary technique. Cautious clinical implementation to explore safety and feasibility appears to be justified., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives: A number of remote access thyroidectomy techniques have been described in the last several years. These approaches are technically challenging, can be performed on only a limited patient population, and have been associated with significant complications. We describe a novel robotic facelift approach for thyroidectomy and report our initial clinical experience., Design: Planned analysis of a prospectively maintained database with institutional review board approval., Methods: Robotic facelift thyroidectomy (RFT) was performed on all patients. Demographic and surgical data were obtained and analyzed. Data collected included patient age, gender, body mass index (BMI), pathology, complications, and duration of surgery., Results: A total of 18 RFT procedures were undertaken in 14 patients. There were 13 females and 1 male, with a mean age of 33.7 ± 18.1 years (range: 12-70). The mean BMI was 26.9 ± 4.5. The procedures included 13 lobectomies, one bilateral thyroidectomy, and 3 completion thyroidectomies. All but the first procedure was performed on an outpatient basis without use of a drain. There were no conversions to open surgery, no permanent nerve injuries, and no cases of hypoparathyroidism. Operative times ranged from 97 to 193 minutes., Conclusions: RFT is a feasible remote access thyroidectomy approach. It appears from our initial experience that it may be performed in a safe and reproducible manner without a drain and on an outpatient basis. Additional clinical experience is warranted to further validate this technique., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives: As the prevalence of thyroid nodules and thyroid cancer increases, thyroid surgery is being performed in a growing number of pediatric patients. Minimally invasive thyroid surgery may be particularly beneficial in this patient population. Smaller incisions result in improved cosmesis in this young, predominantly female group, and minimal-access techniques better preserve tissue planes--an advantage, because of younger patients' higher lifetime likelihood of reoperation., Methods: For this case series with planned data collection, Institutional Review Board approval was obtained to analyze a prospective database and assess outcome data. The outcome measures included pathologic classification, cosmetic results, rates of complications (especially hypocalcemia), true vocal fold paralysis, and the need for admission or readmission., Results: We performed 495 thyroidectomy procedures during the study period (February 2003 to May 2008). Of these, 23 were in patients less than 21 years of age. The mean incision length was 3.3 +/- 1.0 cm (range, 1.5 to 5.0 cm), and 12 of the incisions (52.2%) were 3 cm or shorter. Nine patients (41%) had thyroid cancer, most commonly papillary carcinoma (compared with 21.9% of the adult population). There were no hematomas and no cases of permanent true vocal fold paralysis or permanent hypocalcemia. Two patients (8.7%) had temporary hypocalcemia, and both required readmission., Conclusions: Minimally invasive thyroid surgery has benefits over conventional thyroid surgery, particularly in a pediatric population. Among its many potential advantages, the social stigma of a large incision is reduced and preservation of tissue planes is improved.

Background: The lingual thyroid is uncommon, and the need for resection of this condition is even more rare. Techniques for removal have historically included wide access with associated disfiguring incisions. We sought to describe a minimally invasive and safe technique for the management of the obstructive lingual thyroid gland that achieves optimal hemostasis with the use of technology., Methods: Institutional Review Board approval was obtained to evaluate the safety and efficacy of a minimally invasive technique to remove the obstructive lingual thyroid gland. The procedure is performed in ∼1 hour; requires no splitting of the lip, tongue, or mandible, is associated with negligible blood loss, and is accomplished on an outpatient basis., Results: The procedure was undertaken in a 34-year-old woman with a longstanding lingual thyroid that began to cause dysphagia. She was found to be clinically and biochemically euthyroid, and was referred for surgical intervention. The procedural time was 90 minutes, and the estimated blood loss was 15 mL. She was discharged shortly after recovery, on an outpatient basis., Conclusions: A number of surgical approaches to the obstructive lingual thyroid have been described, including the use of a lip-split, tongue-split, mandibulotomy, and cervical pharyngotomy approach. We describe a minimally invasive transoral procedure that incorporates Harmonic technology and high-resolution endoscopy and is accomplished with no external incisions on an outpatient basis.

After nearly a century of performing thyroidectomy essentially the way it was described by Theodore Kocher in the nineteenth century, the technique has quickly evolved. Parathyroidectomy has advanced as biochemical assays and physiologic imaging have become available. Minimally invasive and endoscopic thyroidectomy and parathyroidectomy can now be performed in many patients who benefit from the reduced dissection and smaller incisions associated with these approaches. Although many of the cosmetic, quality of life, and functional improvements have been proved, a better understanding of the procedure and the appropriate indications for its application will continue to develop even as the technique itself evolves, and as new approaches emerge., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Subtotal thyroidectomy for benign thyroid disease (BTD) may lead to delayed recurrence, thus necessitating reoperative surgery. We describe our experience with reoperative thyroidectomy for BTD and recommendations for definitive primary management., Methods: Patients undergoing thyroid surgery between 2003 and 2007 by a single surgeon were prospectively assessed. Numerous clinical parameters were evaluated, including time interval between primary and reoperative surgery and complications., Results: In all, 321 thyroidectomies were identified: 45 were reoperative and 22 were related to BTD after primary surgery done elsewhere. Median interval between the primary and reoperative procedure was 8.5 years. No recurrences followed total thyroidectomy or total thyroid lobectomy. There were no cases of permanent or transient recurrent laryngeal nerve (RLN) injury related to reoperative surgery. There was 1 case of transient hypocalcemia., Conclusions: Although reoperative thyroidectomy can be performed safely in the hands of experienced surgeons, a thorough initial surgical procedure should obviate the need for exposure to this additional risk.

The aim of this paper was to explore the appropriateness and outcomes of minimally invasive thyroid surgery for the management of well-differentiated thyroid cancer. The study is a planned analysis of a prospectively maintained patient database representing a consecutive, single-surgeon experience. A systematic review was undertaken of a series of patients undergoing minimally access surgery for well-differentiated thyroid cancer. Comprehensive demographic data were considered, including age, gender, pathologic findings, complications, and oncologic outcomes. Ninety-two patients with thyroid cancer (mean age =45.6 years) underwent minimally invasive or endoscopic thyroidectomy over a five-year period. Surgical pathology revealed papillary cancer in 76 patients, follicular cancer in 10 patients, Hurthle cell cancer in 3 patients and medullary cancer in 3 patients. There have been no recurrences in any of these patients thus far (with a short median follow-up of 31 months). Excellent cosmetic results have been observed with this minimal access approach. Minimally invasive and endoscopic thyroidectomy can be safely and effectively performed in many patients with low- or intermediate-risk thyroid cancer. In addition to improved cosmesis, many patients experience decreased pain and faster recovery, and are at no increased risk for complications in the hands of high-volume thyroid surgeons.

Objectives/hypothesis: Localization and the intraoperative parathyroid hormone assay (IOPTH) have facilitated minimally invasive parathyroidectomy. The precise algorithm governing use of IOPTH has been debated. Numerous authors advocate acquisition of a so-called pre-excision (P-E) baseline level (obtained after dissection of the adenoma, but prior to excision) in addition to a preincision baseline, to guard against spurious elevation in the baseline that might confuse interpretation of postexcision levels. We sought to clarify the optimal timing of PTH level determination., Study Design: Consecutive single-surgeon case series with planned data collection from patients undergoing parathyroid surgery at a university hospital., Methods: Demographic data and intraoperative laboratory and surgical findings from patients undergoing parathyroidectomy were prospectively gathered and analyzed. Attention was paid to the value of P-E and 5-minute postexcision levels and their impact on intraoperative decision-making., Results: One hundred twelve patients underwent parathyroidectomy. Thirty were for secondary or tertiary hyperparathyroidism and were excluded. Seventy-nine (96.3%) of the 82 patients with primary hyperparathyroidism were rendered eucalcemic. In no case did the P-E value change what was otherwise destined to be a successful result. In 65.3% of cases, operative time was conserved as the procedure was correctly stopped after the 5-minute level, without the need to wait until the 10-minute postexcision level was reported., Conclusions: Pre-excision baseline IOPTH levels, although logical in their original proposal, appear to play little role in determining the completeness of an exploration. A 5-minute postexcision level adds value in nearly two thirds of cases by allowing earlier termination of the operation.

Objectives: We performed a prospective study of asymptomatic adult volunteers to establish normative values of pharyngeal pH using a novel pH probe., Methods: The Dx-pH probe is a novel pH device capable of measuring liquid and aerosolized acid levels. Twenty asymptomatic patients (Reflux Symptom Index less than 10 and Reflux Finding Score less than 6) underwent simultaneous investigation with this probe placed in the oropharynx and a dual antimony probe placed in the hypopharynx and esophagus. The reflux parameters measured from the oropharyngeal probe included the percentage of time and the number of events in which the pH was less than 5.5,5.0,4.5, and 4.0., Results: The upper limits of normal (95th percentile) for the number of events below pH of 5.5, 5.0, 4.5, and 4.0 per 24-hour period were 16.6, 10.7, 7.4, and 0.2, respectively. The upper limits of normal (95th percentile) for an acid exposure time below pH of 5.5, 5.0, 4.5, and 4.0 per 24-hour period were 820 seconds, 385 seconds, 75 seconds, and 3 seconds, respectively., Conclusions: Normative pharyngeal pH values are presented. Further studies are required to determine clinical relevance.

Objectives: A public thyroid screening protocol incorporating ultrasonography was developed and implemented as a feature of the National Thyroid Cancer Awareness month. Findings and lessons learned are described., Methods: Prospective analysis of participants in a 1-day thyroid screening protocol and review of findings and referrals generated during the screening process., Results: A total of 39 patients participated in the thyroid-screening protocol. Thirty-two (82%) patients were female and 7 (18%) were male, with an overall mean age of 52.9 +/- 14.1 years (range: 20-79). Seventeen (44%) patients indicated a known history of thyroid pathology, and 5 (13%) patients reported a family history of thyroid disease. The most common complaints offered on a patient intake survey were weight gain (38%) and dysphagia (36%). Thirty patients (77%) underwent thyroid ultrasound (US). The majority of patients (69%) had an abnormal US; the most common abnormality found was multinodular goiter (21%). Eighteen participants were referred to endocrinology for further evaluation, 13 have been evaluated and 3 patients have had fine-needle aspirations performed. Two patients have undergone thyroid surgery. The majority of patients (67%) believed that the thyroid-screening increased their awareness and knowledge of thyroid and head and neck cancer., Conclusions: A public thyroid screening activity proved to be a valuable mechanism for the dual purpose of identifying individuals with thyroid pathology needing further evaluation, and increased public awareness and knowledge of thyroid and head and neck cancer. Additional value related to the provision of a community service and opportunity to increase experience with ultrasonography., (Copyright 2008 S. Karger AG, Basel.)

Background: Minimally invasive thyroid surgery has been increasingly embraced in the United States and elsewhere. The surgical standards have yet to emerge, resulting in a sometimes confusing assortment of designations for the techniques., Design: Evidence-based analysis of prospectively collected data from a consecutive, single-surgeon experience with minimally invasive and conventional thyroid surgery., Methods and Materials: Demographic parameters were obtained on patients undergoing thyroid surgery at the Medical College of Georgia from February 2003 to June 2007. Particular attention was paid to patient and tumor characteristics thought to have relevance to eligibility for minimally invasive thyroid surgery. Normally distributed variables were subjected to parametric tests, nonnormally distributed variables to nonparametric tests., Results: A total of 359 patients underwent thyroidectomy during the study period; there were 57 males and 302 females, with a mean (+/- standard deviation) age of 45.9 +/- 15.1 years. Predictably, there was a strongly positive correlation between incision length and both the size of the nodule (p = 0.0001) and the patient body mass index (p = 0.0001). A classification system was designed which established distinct and discrete levels for minimally invasive thyroidectomy (MIT I, II and III)., Conclusions: A patient- and disease-driven classification system for assigning eligibility for incremental levels of minimally invasive thyroid surgery is proposed. This system allows for both uniform reporting of outcome measures across patient populations and a logical basis for determining patient eligibility., (Copyright 2008 S. Karger AG, Basel.)

We conducted a retrospective review of 145 consecutively presenting adults treated for chronic rhinosinusitis (CRS) in a tertiary care institution. Our goals were to determine (1) the prevalence of asthma in these patients, (2) the prevalence of specific CRS symptoms in both asthmatic and nonasthmatic patients, and (3) the frequency of surgical treatmentfor CRS in patients with and without asthma. We found that asthma was present in 23.4% of CRS patients, a much higher rate than the 5% prevalence of asthma in the general adult population. Patients with asthma had a significantly higher prevalence of nasal polyps (47 vs. 22%; p = 0.004), olfactory dysfunction (26 vs. 6%; p = 0.001), and nasal congestion (85 vs. 60%; p = 0.027) than did those without asthma. Patients without asthma had a significantly higher prevalence of headache (72 vs. 53%; p = 0.037) and rhinorrhea (58 vs. 38%; p = 0.047). The prevalence ofpostnasal drip and environmental allergies in the two groups was similar Although the difference between the proportions of patients with and without asthma who required primary sinus surgery was not statistically significant (76 vs. 64%; p = 0.175), patients with asthma did require significantly more revision sinus procedures overall (mean: 2.9 vs. 1.5; p = 0.003).

Objectives: Minimally invasive thyroid surgery is rapidly becoming a common approach in busy endocrine surgery practices. The surgical concepts necessarily include a number of principles found within the realm of plastic surgery., Design: The study was a prospective, nonrandomized analysis of a consecutive series of thyroid surgical patients., Methods and Materials: All patients who underwent thyroid surgery at the Medical College of Georgia in the Department of Otolaryngology were prospectively evaluated. Recommendations for endoscopic thyroidectomy, minimally invasive nonendoscopic thyroidectomy (MINET), or conventional thyroid surgery were based on patient and disease parameters as previously described. Specific factors contributing to improved cosmetic outcomes were sought., Results: Two hundred forty-eight patients underwent thyroidectomy between September 2003 and June 2006. There were 50 males and 198 females, with a mean age of 44.9 +/- 14.6 years. Seventy-seven (31.0%) patients underwent conventional thyroidectomy (group A), 120 (48.4%) patients had MINET (group B), and the remaining 51 (20.6%) patients underwent thyroidectomy with an endoscopic technique (Group C). Incision lengths were 92.4 +/- 22.3 mm in Group A, 46.4 +/- 9.9 mm in Group B, and 24.3 +/- 5.9 mm in Group C. The factors that contributed most to an optimal cosmetic result were marking the patient while he or she was sitting up prior to surgery, resecting skin edges during closure, avoidance of subplatysmal flap elevation and drains, and use of Dermabond., Conclusions: Achieving an optimal cosmetic result when performing thyroid surgery is easiest when oneapplies a number of principles, including elements normally associated with plastic surgery.

Objectives: We previously introduced the concept of the collaborative percutaneous tracheostomy (PercTrach) performed in conjunction with pulmonary medicine/critical care (PCC), and now present a robust experience that validates our original concept of exploiting subspecialty expertise., Methods: One hundred consecutive PercTrachs were performed. The PCC team performed bronchoscopic guidance, while the otolaryngology team performed the PercTrach using the Blue Rhino introducer set. Demographic data were gathered., Results: One hundred PercTrachs were performed between May 2003 and December 2005. The mean +/- SD patient age was 54.3 +/- 15.9 years. Procedural times ranged from 5 to 37 minutes, with a mean of 12.9 +/- 5.7 minutes. Surgical complications included one patient with bleeding who required surgical intervention., Conclusions and Significance: There are numerous benefits to capitalizing on the respective expertise represented by otolaryngology and PCC including conservation of operating room time, rapid and safe establishment of the tracheostomy, and educational benefits for both programs.

Background: Thyroid surgery has traditionally been done on an inpatient basis. With the advent of minimal access techniques, drains are frequently not required and ambulatory thyroidectomy is possible., Design: Prospective, nonrandomized analysis of consecutive series of patients., Methods and Materials: Patients undergoing thyroid surgery between 12/1/04 and 10/31/05 were stratified based on admission status. Demographic data were collected and outcome measures were considered., Results: Ninety-one patients underwent thyroid surgery. Fifty-two were done on an outpatient basis, 26 patients were observed under a 23-hour status, and 13 were admitted. There were two complications in the outpatient group and one in the inpatient group (P = 1.0). Costs were significantly lower for outpatients ($7,814) than for inpatients ($10,288; P < 0.0001)., Significance: In carefully selected patients who prefer convalescence at home, outpatient thyroidectomy can be performed safely and cost-effectively, particularly when prophylactic calcium supplementation is utilized after total thyroidectomy to prevent transient postoperative hypocalcemia.

Objectives: The introduction of percutaneous tracheostomy (PercTrach) has resulted in tension over the scope of practice between otolaryngologists and pulmonary/critical care (PCC) specialists. We sought to determine the value of a collaborative approach to the performance of PercTrach at the bedside in the intensive care unit setting., Study Design and Methods: A retrospective study of consecutive patients who underwent bedside PercTrach at the Medical College of Georgia between May of 2003 and November of 2003. All cases were performed in conjunction with the PCC team, which typically provided bronchoscopic guidance during the performance of the procedure, whereas the PercTrach was performed by the otolaryngology team, although these roles were occasionally reversed. In all cases, the PercTrach was performed using the Ciaglia Blue Rhino introducer set., Results: Twenty-three patients (12 males, 11 females) with a mean age of 47.6 +/- 14.3 (range 23-65) years underwent PercTrach. The procedural times ranged from 7 to 21 minutes, with a mean of 13.9 +/- 4.4 minutes; this represented 9.6 minutes on average to insert the tracheostomy tube and an additional 4.3 minutes to completely secure the tracheostomy tube. The time interval from consultation to PercTrach was less than 24 hours in 16 of 23 cases (overall mean time to PercTrach = 41.7 +/- 37.1 hours), with delays beyond 24 hours related in most instances to patient stability., Conclusion: A multidisciplinary approach to PercTrach results in a number of clinical and educational benefits. Chief among these benefits is a rapid, cost-effective response to requests for elective tracheostomy. Practicing otolaryngologists with a prior bias against this approach (as we had) should reconsider adopting this revised procedure.