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Objectives: To determine the value of preoperative Tc-sestamibi scans and the incidence of ectopic glands in tertiary hyperparathyroidism. Design: Prospective, non-randomized analysis of a consecutive cohort of surgical patients from the Medical College of Georgia Thyroid/Parathyroid Center. Materials and Methods: A consecutive series of patients with tertiary hyperparathyroidism undergoing parathyroidectomy was analyzed. Demographic data, preoperative Tc-sestamibi scintigraphy results, location of diseased glands, pre- and postoperative calcium, and parathyroid hormone levels were collected. Results: Twenty-one patients underwent parathyroidectomy for tertiary hyperparathyroidism between March 2004 and September 2006. Of these 21 patients, 3 were re-operative cases for persistent hypercalcemia and each was found to have a single diseased gland. Of the 18 patients undergoing first time surgery, 15 had four-gland hyperplasia, 2 patients had single adenomas, and 1 patient had a double adenoma. Nine of the 21 patients (43%) had ectopic glands (2 of these patients had 2 ectopic glands each). The overall sensitivity of the preoperative Tc-sestamibi scintigraphy was 76% and was not significantly different when comparing patients with ectopic glands (78%) and those without (75%). Conclusions: Tc sestamibi scintigraphy has high positive predictive value and sensitivity in patients with tertiary hyperparathyroidism. Sestamibi scanning is particularly valuable in this patient population since the incidence of ectopic glands may be higher than previously recognized. [ABSTRACT FROM AUTHOR]

Background: Conventional parathyroidectomy, as practiced only 10 years ago, has given way to considerable change, largely as a result of the evolution of technology. Several of these important technologies include radio-guided surgery, ultrasound imaging, high-resolution endoscopy, and rapid intraoperative parathyroid hormone (IOPTH) monitoring. Modern parathyroid surgeons should maintain familiarity with the appropriate role of these approaches. Study Design: Evidence-based analysis of state-of-the-art approaches to the diagnosis and management of primary hyperparathyroidism. Methods and Materials: Four distinct technologies are analyzed in detail, with particular attention to their impact on the practice of parathyroid surgery. These include radio-guided surgery, ultrasound imaging, high-resolution endoscopy, and IOPTH. Results: Each of the technologies examined has substantial value in the current practice of parathyroidectomy. Judicious implementation of these technologies will vary from practice to practice. Radio-guided surgery may obviate the need for IOPTH monitoring, therefore resulting in the fastest procedural times. Ultrasound imaging is useful as an adjunct to sestamibi scanning to localize adenomatous parathyroid glands. Endoscopic techniques facilitate visualization through small openings and may help surgeons achieve minimal access incisions. Finally, the use of IOPTH is a useful adjunct to directed explorations, and it imparts confidence that all hyperfunctioning parathyroid tissue has been removed. Conclusions: The practice of parathyroid surgery has undergone tremendous change in the past decade, and this change has largely been a technology-driven phenomenon. Acquisition of familiarity and skill with these new technologies will be necessary for the endocrine head and neck surgeon wishing to stay abreast of modern surgical techniques and provide quality care. [ABSTRACT FROM AUTHOR]

Objectives: Planned neck dissection after chemoradiation (CR) is often advocated in patients with head and neck squamous cell cancer (HNSCC) with advanced nodal disease who demonstrate a clinical complete response to CR because identification of residual occult nodal disease is difficult. We sought to investigate the utility of positron emission tomography-computed tomography (PET-CT) in identifying patients with occult nodal disease after CR. Study Design: Nonrandomized retrospective cohort analysis. Materials and Methods: The medical records of all patients treated with primary CR for advanced HNSCC with N2 or N3 disease from December 2003 to June 2005 were reviewed. Patients with a clinical complete response were eligible for inclusion if PET-CT performed at 8 to 10 weeks after CR showed no evidence of distant disease and they were treated with a planned neck dissection. Results: Seventeen patients met study criteria. PET-CT was positive for residual nodal disease in 11 (64.7%) patients, with a standardized uptake value (SUV) range of 1.7 to 3.8. Pathologic examination revealed residual viable carcinoma in five (29.4%) patients, with tumor size ranging from 2.0 to 9.5 mm. Carcinoma was present in 2 of 11 (18.2%) patients with positive PET-CT scans and 3 of 6 (50%) patients with negative PET-CT scans. The sensitivity and specificity of PET-CT in predicting occult nodal disease was 40% and 25%, respectively. There was no correlation between PET-CT findings and histologic findings (P = .26) or between SUV and size of viable tumor (P = .67). Conclusions: A significant proportion of HNSCC patients with advanced neck disease harbor residual occult metastases after CR. PET-CT is not sufficiently specific or sensitive to reliably predict the need for posttreatment neck dissection. [ABSTRACT FROM AUTHOR]

Thyroid cancer is a relatively common and frequently curable malignant neoplasm, accounting for nearly 2% of all new cancers diagnosed annually in the United States. The diagnostic and management options have evolved considerably in the past decade, and a current understanding of these trends in the standard of care have assumed an important consideration in the practices of head and neck surgeons and endocrinologists alike. We sought to review the epidemiology and pathology of the several types of thyroid cancer and to present our evidence-based management algorithm. Every effort was made to offer alternative treatment strategies and supporting data where available. In addition to reviewing well-established approaches to diagnosis and management, emphasis is placed on newer techniques, including minimally invasive thyroidectomy, molecular detection of disease propensity, and the use of recombinant thyrotropin prior to radioiodine ablation. [ABSTRACT FROM AUTHOR]

Objectives: This study compares the efficacy of 2 tongue-base surgical procedures in the treatment of patients with moderate to severe sleep-disordered breathing.Study Design and Setting: We conducted a prospective, randomized crossover surgical trial at a university hospital.Methods: Seventeen patients with moderate to severe sleep-disordered breathing and Fujita type II upper airway collapse for whom conservative treatment failed were enrolled into an institutional review board-approved surgical protocol. They were randomly assigned to undergo palatopharyngoplasty combined with either tongue advancement (mandibular osteotomy) or tongue suspension. Parameters assessed included severity of sleep-disordered breathing (polysomnography), sleepiness (Epworth Sleepiness Scale), and anatomic changes (upper airway endoscopy), as well as demographic factors. Patients not achieving satisfactory improvement in their condition were offered nonsurgical management or additional surgical treatment that varied based on the postoperative assessment but included crossing over to the other tongue surgical procedure.Results: Nine of the 17 patients were randomized to the tongue suspension group, and 8 to the tongue advancement group. In the 9 tongue suspension patients, Epworth Sleepiness Scale scores fell from 12.1 to 4.1 (P = 0.007). Airway collapse for all 9 patients measured on Müller maneuver improved, by a mean of 64% (P = 0.0006) at the palate and 83% (P = 0.0003) at the base of the tongue. In the 8 tongue advancement patients, Epworth Sleepiness Scale scores fell from a mean of 13.3 to 5.4 (P = 0.004). Airway collapse for 5 of 8 patients measured on Müller maneuver improved by a mean of 31% (P = 0.1) at the palate and 75% (P = 0.03) at the base of the tongue.Conclusion: Prospective, randomized trials of tongue-base surgery for sleep-disordered breathing are possible. Preliminary findings from the current protocol reveal a slight advantage of tongue suspension over tongue advancement. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Percutaneous endoscopic gastrostomy tube (PEG) placement by means of the "pull" method has been reported to result in a significantly higher complication rate when compared with "push" PEG placement. These findings have led to a renewed interest in the push, or Russell introducer, method of PEG placement at the authors' institution when PEG is required before definitive treatment of advanced head and neck cancer. The authors sought to determine whether the push method of PEG placement is associated with a lower incidence of complications in this patient population.Study Design: Nonrandomized, retrospective patient analysis.Methods: The medical records of all patients presenting to the Medical College of Georgia (Augusta, GA) who received a diagnosis of squamous cell carcinoma of the head and neck between 1999 to 2001 were retrospectively reviewed. Patients who required PEG placement as part of their treatment comprised the study population.Results: The push PEG technique was used in 29 patients, and the pull technique was used in 50 patients. There was a statistically significant difference in the complication rate between the two techniques. Patients who underwent placement by means of the pull technique had an overall complication rate of 30% (15 of 50) versus a 0% (0 of 29) complication rate in patients undergoing the push technique (P =.0006, Fisher's Exact test).Conclusion: The push PEG technique appears to have a significantly lower risk of complications compared with the pull technique in patients with advanced head and neck cancer. The authors recommend considering the use of the push method when PEG placement is required. [ABSTRACT FROM AUTHOR]

We reviewed a 7-year experience at a tertiary-care, academic medical center with balanced, minimally invasive decompression for Graves' ophthalmopathy, in an effort to define the goals, risks, and outcomes of surgical intervention. Endoscopic medial decompression was performed in 26 patients; 23 underwent lateral decompression as well, and 13 also had inferior decompression. Septoplasty, turbinate reduction, and orbital rim augmentation were performed as needed. The indications for surgery were threat to vision (n = 10) and proptosis with a desire to return to the predisease state (rehabilitative, n = 16). The exophthalmos improved by a mean of 4.4 mm (p < .001). All patients who had surgery for threatened vision had improved vision after the operation. There were 3 patients with new-onset postoperative diplopia, 2 of whom underwent strabismus surgery. There was 1 case of postoperative sinusitis, which resolved with oral antibiotics and nasal decongestion, and 1 case of transient ulnar neuropathy. There were no other intraoperative or postoperative complications. Modern methods of orbital decompression provide a minimally invasive, effective, and relatively safe approach to the treatment of Graves' ophthalmopathy. [ABSTRACT FROM AUTHOR]

Objective: Numerous authors have reported the potential usefulness of positron emission tomography (PET). These studies have had conflicting results, at least partly owing to limited sample sizes. The objective of this study is to define not only the uses, but also the limitations of PET in patients with head and neck cancer.Study Design: Nonrandomized, retrospective analysis of PET at an academic institution.Methods: The authors performed 146 PET scans on 133 patients with head and neck cancer. Eighteen patients (19 PET scans) with thyroid disorders were excluded. A minimum 1 year of follow-up was available in 84 patients, who were separated into groups based on whether the PET was used to detect unknown primary cancers (n = 20), stage neck nodal and distant metastases (n = 8), monitor response to nonsurgical therapy (n = 22), or detect recurrent or residual cancers (n = 34). The results of PET were compared with results from computed tomography (CT) and magnetic resonance imaging (MRI) performed in the same patients.Results: Of the unknown primary cancers, PET correctly identified 7 of 20 primary sites, giving a sensitivity of 35%. When combined with CT or MRI, the sensitivity increased to 40%. When used for detection of metastatic disease, PET demonstrated five of five nodal metastases (100%) and two of four distant metastases (50%). In evaluating the response to nonsurgical therapy, PET had a sensitivity of 50% and a specificity of 83% for detecting tumor at the primary site and a sensitivity of 86% and a specificity of 73% for detecting nodal disease. When used for evaluation of recurrent/residual disease, PET identified seven of seven cases of local recurrences/residual disease and had a specificity of 85%. PET also detected seven of seven cases of nodal disease and had a specificity of 89%.Conclusions: For staging purposes, PET is limited by its lack of anatomic detail. However, PET compares favorably with CT and MRI in detecting recurrent/residual cancers. PET imaging complements the more traditional imaging modalities (CT or MRI), especially for an unknown primary cancer. [ABSTRACT FROM AUTHOR]

Objective: Considerable evidence exists to suggest that tumor hypoxia results in radioresistance. Historically, it has been difficult to assess tumor oxygen tension levels reliably. These levels can now be assessed in head and neck malignancies using the Eppendorf pO2 histograph, which uses a fine-needle electrode and a computerized micromanipulator. This technology was used to compare the pretreatment tumor oxygen tension level in lymph node metastases of patients with head and neck cancer to measurements taken during nonsurgical treatment after a partial response had been achieved.Study Design: Prospective study.Methods: Oxygen tension levels were measured in the cervical lymph nodes of 10 patients with biopsy-proven head and neck squamous cell carcinoma and cervical metastases who were being treated with nonsurgical management. These levels were obtained using the Eppendorf pO2 histograph system. Measurements were taken before the start of treatment and were repeated when the size of the cervical metastatic node had decreased by 50%. Normal subcutaneous tissue was measured during the same session. The mean and median pO2 levels, as well as the percentage of measurements with pO2 less than 5 mm Hg were determined.Results: A mean of 72.6 measurements per session was taken from each lymph node. The median tumor pO2 measurement fell from a mean (+/-SD) of 13.9+/-8.0 mm Hg to 7.3+/-9.9 mm Hg. Even more dramatic, however, was the substantial increase in the percentage of values less than 5 mm Hg, a rise from 29% to 52%.Conclusions: While there is variability both in the pretreatment oxygenation of head and neck cervical metastases and in the change in tumor oxygen tension during treatment, there appears to be a decrease in the overall oxygenation of the tumors. The dramatic increase in very low oxygen measurements may reflect selective survival of radioresistant or chemoresistant hypoxic tumor cells. Cells at the very low level would be expected to be radiobiologically hypoxic (resistant to radiation-induced cell kill). [ABSTRACT FROM AUTHOR]

Although significant complications can result after upper airway surgery for obstructive sleep apnea (OSA), there is a lack of consensus regarding the most appropriate level of monitoring in the perioperative period. A retrospective analysis was performed on the operative records of 109 adult patients who underwent 125 surgical procedures from January 1, 1991, to May 31, 1996, with particular emphasis on complications that would have mandated intensive care monitoring and management. Airway complications occurred in one patient (0.8%), who became obstructed immediately after surgery; he responded to naloxone and suctioning. Five other patients (4%) suffered oxygen desaturation to levels below 90% (none fell below 80%, and in only one case was it below the lowest preoperative oxygen saturation level). Cardiac complications, primarily significant hypertension, were the most common adverse events. Four (3.2%) bleeding complications were encountered; all occurred after discharge from the hospital. Routine postoperative intensive care monitoring for all adult patients undergoing upper airway surgery for OSA is unnecessary. Although high-risk patients cannot always be identified preoperatively, significant complications generally emerge within 2 hours after surgery. Therefore a decision regarding the level of postoperative monitoring needed may be made with confidence during the period of time that the patient is in the recovery room. [ABSTRACT FROM AUTHOR]

Cephalometric studies have shown narrowing in the upper airway at multiple levels in patients with obstructive sleep apnea. Uvulopalatopharyngoplasty (UPPP), mandibular osteotomy with genioglossus advancement, and hyoid myotomy with advancement address narrowing in the retropalatal and retrolingual regions. In an effort to relate postoperative clinical changes to anatomic changes, cephalometric studies were performed on 44 patients who underwent multilevel pharyngeal surgery (UPPP, genioglossus advancement, hyoid myotomy with advancement). Both pre- and postoperative radiographs were available for 23 of these patients. The posterior airway space (P = .09), minimal posterior airway space (P = .04), posterior uvular space (P = .06), mandibular plane-to-hyoid distance (MP-H) (P = .06) and central incisor-to-tongue base distance (P = .02) all improved after surgery. None of the measurements of the posterior airway were significantly different between responders and nonresponders. The degree of collapse of the palate on modified Müller maneuver was highly correlated with the severity of sleep apnea as measured by the respiratory disturbance index; the collapse of the lateral pharyngeal walls was moderately correlated; and collapse of the base of tongue was not correlated. Cephalometric radiographs may reflect the anatomic changes that result from upper airway surgery for sleep apnea, but these changes are not useful for assessing surgical efficacy. The modified Müller maneuver, however, may represent a more predictive evaluation. [ABSTRACT FROM AUTHOR]

The past decade has seen several innovations in the surgical techniques available for treatment of patients with sleep-disordered breathing. Outpatient techniques such as laser-assisted uvulopalatoplasty (LAUP) and more aggressive procedures designed to address hypopharyngeal and base of tongue obstruction (genioglossus advancement and hyoid myotomy) have been developed and proven successful. We describe the efficacy of LAUP for snoring (72.7%), upper airway resistance syndrome (81.8%), and mild (mean [+/-SD] respiratory disturbance index [RDI] = 12 +/- 8.1) obstructive sleep apnea (41.7%) in 56 patients who underwent 132 LAUP procedures in a 26-month period. Thirty-two patients with more significant obstructive sleep apnea (mean RDI = 41.8 +/- 23.1) underwent multilevel pharyngeal surgery consisting of genioglossus advancement and hyoid myotomy combined with uvulopalatopharyngoplasty. The surgical success rate in this group of patients was 85.7% when commonly accepted criteria were applied. We recommend a stratified surgical approach to patients with sleep-disordered breathing. Progressively worse airway obstruction marked by multilevel pharyngeal collapse and more severe sleep-disordered breathing is treated with incrementally more aggressive surgery addressing multiple areas of the upper airway. [ABSTRACT FROM AUTHOR]

Laser-assisted uvulopalatoplasty (LAUP) has been introduced as an alternative to uvuloplatopharyngoplasty for the treatment of snoring. Despite limited study, the use of this procedure has been expanded to include patients with obstructive sleep apnea syndrome. Although the potential cost-savings of performing sleep apnea surgery on an outpatient basis are self-evident, concern exists regarding the safety of this practice. In an effort to characterize the risk of performing LAUP on an outpatient basis, eight patients with mild or no sleep apnea were identified and intensively studied before and after the first stage of LAUP to cure snoring. Assessment included preoperative magnetic resonance imaging (MRI) scans, polysomnography, and videoendoscopy. Each of these diagnostic studies was then repeated between 48 and 72 hours after LAUP. Complete polysomnographic data were available for seven of the eight patients. The mean ( +/- SD) preoperative respiratory disturbance index (RDI) was 11.3 +/- 10.9, and the mean oxygen saturation nadir (LSAT) was 87.7 +/- 6.2% (n = 7). The mean airway cross-sectional area at the palate (by MRI) was 49.8 +/- 22.8 mm2 (n = 8). After LAUP, the mean RDI nearly doubled to 21.7 +/- 9.9 (P > .1). The apnea index increased fourfold from 3.3 +/- 3.5 to 14.8 +/- 10.9 (P < .03). The mean LSAT remained stable at 87.4 +/- 4.1% (P > .5). The cross-sectional area of the airway decreased to a mean of 47.9 +/- 22.4 mm2 (P > .5). These data suggest that LAUP may temporarily worsen obstructive sleep apnea. Although the clinical significance of this degree of worsening is uncertain, it would be prudent to consider perioperative use of nasal continuous positive airway pressure in patients with more than mild obstructive sleep apnea who undergo ambulatory LAUP. [ABSTRACT FROM AUTHOR]

Objective: To define critical elements that contribute to successful parathyroidectomy based on a high-volume single-surgeon experience and explore learning curve characteristics., Study Design: Systematic analysis of prospectively maintained quality assurance database., Setting: Academic tertiary care endocrine surgery practice., Subjects and Methods: In total, 4737 consecutive patients who underwent thyroid or parathyroid surgery from 2004 to 2020 were identified. Demographic data acquisition was undertaken on a subset of these patients who had initial surgery for primary hyperparathyroidism during the academic years 2005 to 2018. Patients with renal or syndromic hyperparathyroidism and those undergoing reoperative surgery were excluded., Results: From 1710 patients who underwent parathyroid surgery, 1082 met inclusion criteria in order to focus on a homogeneous data set. These patients had a mean age of 60.1 ± 12.5 years and 76.4% were female. The overall cure rate was 98.3%, reflecting a success rate that increased from 95.5% during the first 200 cases to 99.7% over the final 300 cases. The complication rate was 1.7%. Over 2 decades, the patient phenotype evolved toward milder disease and smaller adenomas. A learning curve of 200 cases was required to become a proficient parathyroid surgeon; to achieve exceptional results required several hundred additional cases. Parathyroid surgery represents a higher proportion of an endocrine surgery practice than previously (54.0% in 2019 compared with 25.5% in 2004)., Conclusion: A focused practice dedicated to endocrine surgery yields surgical volumes exceeding 500 cases annually. There has been a steady shift toward parathyroid surgery. A lengthy learning curve can be shortened by pursuit of several specific strategies that are outlined in detail.