Professor Philippe H. DeJonckere
Department of ORL, UMC Utrecht
Division of Experimental Otorhinolaryngology, Katholieke Universiteit Leuven
Federal Institute of Occupational Diseases, Brussels.

Professor Philippe H. DeJonckere

Department of ORL, UMC Utrecht
Division of Experimental Otorhinolaryngology, Katholieke Universiteit Leuven
Federal Institute of Occupational Diseases, Brussels.

Professor Jan Betka
Department of Otorhinolaryngology and Head and Neck Surgery, Charles University, Faculty Hospital Motol, Czech Republic

Thyroid surgery: surgical anatomy of the recurrent laryngeal nerve and nerve monitoring

The cornerstone of safe and effective thyroid surgery is thorough training in and understanding of anatomy and pathology of thyroid region. With appropriate techniques it can be undertaken with minimal risk of damage to the critical structures e.g. of recurrent laryngeal nerve, external branch of superior laryngeal nerve and parathyroid glands. As injury to the recurrent laryngeal nerve is one of the most frequent and important causes of morbidity in thyroidectomies it is highly suggested to identify this structure during thyroid surgery. Different techniques of identification are used. There is the only constant location of the nerve in the point of its penetration into the larynx. Its relationship to the inferior thyroid artery, paratyhroid glands, Zuckerkandl¨s tubercule, tracheoesophageal groove is variable as is variable the pattern of extralaryngeal branching of the nerve. No-recurrent laryngeal nerve represents rare developmental abnormity. Nowadays intraoperative neuromonitoring with positive identification of the recurrent laryngeal nerve and confirmation of its functional integrity at the end of the surgery is preferred technique during thyroid surgery.

Professor Jan Betka

Department of Otorhinolaryngology and Head and Neck Surgery, Charles University, Faculty Hospital Motol, Czech Republic

Professor Ashok Shaha
Chair in Head and Neck Surgery and Oncology, Memorial Sloan-Kettering Cancer Center, New York, USA

Complications of thyroid surgery: prevention and management

Thyroid surgery is a safe surgical procedure, with an overall complication rate below 5%. Understanding anatomy and knowledge of aberrations is critical to avoid to intraoperative complications.

Major complications are mainly related to postoperative wound hematoma, recurrent laryngeal nerve injury, and parathyroid problems.

Wound hematoma can lead to acute airway distress, especially if the postoperative hematoma is acute and major. The philosophy of using drains remains controversial during thyroid surgery. However, the majority of surgeons prefer not to use drains unless there is a massive substernal goiter or bleeding at the end of the surgical procedure.

Recurrent laryngeal nerve injury can be a major issue, especially in professionals requiring frequent vocal use such as lawyers, singers and teachers. Superior laryngeal nerve injury is not recognized unless the patient positively complains of inability to raise the voice. Tracheomalacia is a rare condition and is not a major issue in thyroid surgery. Wound-related problems such as seroma infection are quite rare. If a neck dissection has been performed, chyle leak can be a major issue.

Parathyroid problems can be quite difficult to handle, especially if the patient has severe hypocalcemia. Identification and preservation of parathyroid glands with their blood supply is very important. If the parathyroid gland appears to be devascularized, then it would be most appropriate to transplant parathyroid gland in the neck musculature after confirming the tissue to be parathyroid gland on frozen section. Even though the above-mentioned complications are the typical complications from thyroid surgery, if a neck dissection is added, complications related to shoulder weakness, accessory nerve injury or Horner's syndrome are also rarely seen. Chyle leak is more common in patients who have undergone a neck dissection and can extend hospitalization.

Occasionally frank disasters can be seen, especially when the tumor is stuck to the posterior wall of the trachea and during resection of the tumor a tear of the posterior wall of the trachea occurs. This can be an extremely difficult problem to manage during surgery. If the tumor is stuck to the trachea and tracheal resection is necessary, subsequent complications such as tracheal dehiscence and airway problems can be difficult to handle. Very rarely, the tumor may involve the major vasculature and injury to these vessels may lead to life threatening issues, either in the operating room or subsequently in the postoperative period.

In spite of the complications noted above, thyroid surgery continues to be a safe surgical procedure with a morbidity of less than 5% and rare mortality. The statement made by Halstead is quite appropriate for thyroid surgery – "Thyroid surgery is a supreme triumph of the surgeon's art."

Professor Ashok Shaha

Chair in Head and Neck Surgery and Oncology, Memorial Sloan-Kettering Cancer Center, New York, USA

Professor Lucian Sulica
Associate Professor of Otorhinolaryngology Weill Medical College of Cornell University, New York, USA

Current concepts in unilateral vocal fold palsy

Lecture Description: This lecture reviews modern concepts in the pathophysiology of vocal fold paralysis, emphasizing practical clinical implications. Traditional notions of nerve injury and recovery, contralateral compensation, significance of clinical findings, and natural history have all been challenged or invalidated by recent evidence. A review of relevant neuroanatomy is followed by a discussion of theories and realities in laryngeal nerve injury. Mechanisms of recovery are presented, as well as reasons for its failure. Available evidence regarding incidence and time course of recovery is reviewed, highlighting gaps in knowledge. Significance of office laryngoscopic findings is critically examined. Illustrative cases demonstrate how new insights influence patient counseling, clinical decision making, and rehabilitative technique.

Key Points:

1. Vocal fold paralysis represents a spectrum of nerve injury, not an all-or-none phenomenon
2. Only rarely is vocal fold paralysis a complete absence of innervation
3. Clinical laryngoscopic findings do not appear to reliably predict site of lesion, but may reveal useful information regarding the status of the vocal fold
4. Evidence regarding incidence and time frame of recovery is often confusing and contradictory because there is no accepted standard outcome measurement, BUT
1. Most laryngeal nerve injury recovers to some extent
2. Complete neurologic recovery is not necessary to have a result acceptable to the patient
5. The above information materially influences patient counseling and decisions regarding rehabilitation in most patients, both with respect to technique and timing

Educational objectives: Upon completion of this course, participants should…

1. Be familiar mechanisms of laryngeal nerve injury and recovery
2. Understand how these translate into clinical findings in vocal fold paralysis
3. Understand the natural history of vocal fold paralysis
4. Be able to critically examine the evidence for recovery of vocal fold paralysis
5. Counsel patients with vocal fold paralysis appropriately and correctly
6. Make well-informed treatment decisions for patients with vocal fold paralysis

Professor Lucian Sulica

Associate Professor of Otorhinolaryngology Weill Medical College of Cornell University, New York, USA

Professor Gerhard Friedrich
Ear, Nose and Throat University Hospital, Chairman of Department of Phoniatrics, Speech and Swallowing, Medical University of Graz, Austria

Standard therapies and limits in bilateral vocal fold palsy

Bilateral vocal fold palsy usually causes dyspnea with inspiratory stridor. Standard therapy in acute cases is tracheostomy until a reinnervation or a surgical glottic widening procedure after nine to twelve month is performed. With introduction of the temporary suture lateralization and/or weakening of adductory muscles with Botulinum Toxin tracheostomy can be avoided in the majority of cases. In permanent bilateral paralysis still a widening of the glottis by partial posterior laser chordectomy in different modifications is the gold standard. Although this method allows a good and safe restoration of the airway voice deterioration cannot be avoided to a certain extent. Today's standard therapies can only aim at finding an optimal compromise between voice and airway and do not allow a full restoration of all laryngeal functions.

Professor Gerhard Friedrich

Ear, Nose and Throat University Hospital, Chairman of Department of Phoniatrics, Speech and Swallowing, Medical University of Graz, Switzerland

Dr. László Rovó
Department of Otorhinolaryngology, Head and Neck Surgery, University of Szeged, Hungary

A new tread guide instrument for endoscopic arytenoid lateropexy and vocal cord immobility

Bilateral vocal cord immobility (BVCI) is a term used to describe vocal cords that are restricted secondary to neuropathy, muscular disorders or mechanical fixation (MF) . The moderate to severe dyspnoea generally requires surgical intervention. However, the recently suggested endoscopic treatment modalities may restore the airway patency in bilateral vocal cord paralysis (BVCP) but treatment of MF often requires external procedures. Potential reversibility of BVCP means a further therapeutical challenge which necessitates a complex assessment and gradual application of those techniques which resects the glottic structures. In contrast, long-term dependable results could be observed, if the arytenoid cartilage is directly lateralized to the normal abducted position by endoscopically inserted sutures. Benefit of this procedure is not exclusively in BVCP but even in severe cases of MF after proper mobilization of the cricoarytenoidal joint. Nevertheless, the correct creation of this location of fixating loop is a challenge for the earlier surgical techniques. For this purpose, a new procedure performed with the endolaryngeal instrument is introduced here. This thread guide device is purposely designed for safe, accurate and fast suture loop creation for the endoscopic arytenoid lateropexy. The simplicity of the intervention, the large degree of reversibility, the easily detectable laryngeal function recovery, and the good long-term results, may simplify the management of these patients with usually iatrogenic aetiology.

Dr. László Rovó

Departement of Otolaryngology, Head and Neck Surgery, University of Szeged, Hungary

Professor Paul Van de Heyning
Chairman, Dept. Otorhinolaryngology and Head and Neck Surgery, University of Antwerp, Belgium

Clinical studies for laryngeal pacing

Electrical stimulation of the vocal fold opening muscles, paced with inspiration, offers a physiologic approach to restore ventilation in case of bilateral laryngeal paralysis.This presentation demonstrates the merit of laryngeal pacing as a new treatment approach.

Professor Paul Van de Heyning

Chairman, Dept. Otorhinolaryngology and Head and Neck Surgery, University of Antwerp, Belgium

Professor Richard Nicollas
O.R.L. et Chirurgie Cervico-Faciale Pédiatrique - Phoniatrie - Surdité - Implant Cochléaire Hôpital de la Timone (Enfants), Marseille, France

Laryngeal Palsy in infants and newborns

Laryngeal palsies (LP) are quite rare in the pediatric population. In newborn and infants, their etiologies, and consequently their prognosis, management and outcome are different compared to the adults.
In this talk, we will focus on these specificities of newborns and infants.
The first case is that of a congenital LP. Their etiology can be obstetrical, cardiologic, neurologic, but more often they remain idiopathic. The mean rate of spontaneous recovery is about 80% at 1 year of follow-up. Post-operative LP can also be seen, especially after cardiac surgery (aortic coarctation +++) or after neurosurgery.
Managing a LP in a newborn is quite conceptually different than in an adult. Many factors are specific, out of which feeding and its neonatal specificities. On another hand, the high rate of spontaneous recovery leads physician to be aware of what technique he can use and when.

Professor Richard Nicollas

O.R.L. et Chirurgie Cervico-Faciale Pédiatrique - Phoniatrie - Surdité - Implant Cochléaire Hôpital de la Timone (Enfants), Marseille, France

Dr. Benjamin Lallemant
Chef de Clinique/Assistant des Hôpitaux LE CHU DE NIMES, Department of Otorhinolaryngology and Head and Neck Surgery, France

Robotic-assisted minimally invasive endoscopic thyroidectomy

Robotic-assisted endoscopic thyroidectomy is an emerging procedure based on the use of the daVinci surgical system (Intuitive Surgical, Mountain View, CA) that provides the surgeon with three dimensional, high definition, magnified visualization of the operative field, and allows control of various instruments with increased precision, tremor filtration, and more degrees of freedom. The use of this robotic system has been initially described by WY.Chung in 2009 who carried out thyroidectomies through a transaxillary approach. His technique is seducing more and more patients worldwide first, because it offers the benefit of eliminating the anterior neck incision and second because it potentially reduces the risk of post-operative laryngeal nerve palsy and/or hypocalcemia thanks to the precision of the robotic system. The publications available to date tend to prove that this innovative surgical approach is feasible, safe and provided good outcomes comparable to conventional thyroidectomy and superior to the transaxillary conventional endoscopic approaches. However, this technique remains controversial as many surgeons remain doubtful about the validity and usefulness of this technique.

Dr. Benjamin Lallemant

Chef de Clinique/Assistant des Hôpitaux LE CHU DE NIMES, Department of Otorhinolaryngology and Head and Neck Surgery, France

Workshops:

Workshop 1:
Nerve monitoring in thyroid surgery
Professor Jan Betka

Workshop 2:
How to use the new thread guide instrument for endoscopic arytenoid lateropexy
Dr. László Rovó

Workshop 3:
Injection Augmentation of the Vocal Fold
Professor Lucian Sulica