| Thyroid
surgery can cause temporary or permanent damage to the recurrent
laryngeal (RLN) and superior laryngeal nerve (SLN) causing hoarseness,
impaired vocal phonation, dysphonia, dysphagia and even aspiration
dyspnea. Bilateral damage to the RLN can be life-threatening leading to
airway obstruction. Damage to these nerves depends on the type of
disease (benign or malignant), extent of thyroid resection (lobectomy
vs. total thyroidectomy), type of resection (first surgery or
reoperation) and the training and experience of the surgeon. Surgical
exposure and identification of both nerves during surgery is the gold
standard in avoiding damage. For the past ten years refinement in
neuromonitoring (NM) has helped introduced electrodes in the
endotracheal tube in contact with the vocal cords to monitor the
functional viability of both nerves during thyroid surgery. Throughout
this time NM of the RLN/SNL during thyroid surgery has allowed visual
identification and exposure of both nerves, allowing recording
affording a valid legal protection in case of damage. NM localizes the
exact location in case of injury and determines if the injury is
reversible by repairing a damage nerve. NM allows young surgeons and
surgeons-in-training to approach thyroid surgery more safely. NM can
also help identify anatomic variants present in less than 5% of all
patients. NM has become and asset in difficult thyroid dissections,
substernal goiters, redo surgery and bloody thyroidectomy. Electric
nerve testing at the end of the thyroidectomy can serve for
postoperative prognostication of nerve function. Detecting nerve injury
intraoperatively aids in staging bilateral lobectomies to avoid
bilateral vocal cord paralysis and tracheotomy. It is estimated that NM
should be included as standard of care of thyroid surgery in children
and adults. NM studies are not based in class 1 evidence randomized
clinical trials, but in evidence 2 and 3 studies. NM is actually the
only way to verify the functional integrity of the RLN and SLN during
thyroid procedures. As recurrent laryngeal nerve injury is one of the
most common causes of medicolegal litigation after thyroid and
parathyroid surgery securing the nerve is an increasing demand in these
procedures. References: 1- Zheng S, Xu Z, Wei Y, Zeng M, He J: Effect of intraoperative neuromonitoring on recurrent laryngeal nerve palsy rates after thyroid surgery--a meta-analysis. J Formos Med Assoc. 112(8):463-72, 2013 2- Barczynski M, Konturek A, Pragacz K, Papier A, Stopa M, Nowak W: Intraoperative nerve monitoring can reduce prevalence of recurrent laryngeal nerve injury in thyroid reoperations: results of a retrospective cohort study. World J Surg. 38(3):599-606, 2014 3- Deniwar A, Kandil E, Randolph G: Electrophysiological neural monitoring of the laryngeal nerves in thyroid surgery: review of the current literature. Gland Surg. 4(5):368-75, 2015 4- Wong KP, Mak KL, Wong CK, Lang BH: Systematic review and meta-analysis on intra-operative neuro-monitoring in high-risk thyroidectomy. Int J Surg. 38:21-30, 2017 5- Henry BM, Graves MJ, Vikse J, et al: The current state of intermittent intraoperative neural monitoring for prevention of recurrent laryngeal nerve injury during thyroidectomy: a PRISMA-compliant systematic review of overlapping meta-analyses. Langenbecks Arch Surg. 402(4):663-673, 2017 6- Wojtczak B, Sutkowski K, Kaliszewski K, Barczynski M, Bolanowski M: Thyroid reoperation using intraoperative neuromonitoring. Endocrine. 58(3):458-466, 2017 7- Cirocchi R, Arezzo A, D'Andrea V, et al: Intraoperative neuromonitoring versus visual nerve identification for prevention of recurrent laryngeal nerve injury in adults undergoing thyroid surgery. Cochrane Database Syst Rev. 2019 Jan 19;1:CD012483. doi:10.1002/14651858.CD012483.pub2. 8- Zhang D, Pino A, Caruso E, Dionigi G, Sun H: Neural monitoring in thyroid surgery is here to stay. Gland Surg. 9(Suppl 1):S43-S46, 2020 |
| The
most common etiologies of acute pancreatitis in children consist of
hepatobiliary disorders related with mechanical obstruction such as
gallstone, drugs (steroids, cyclophosphamide), infectious (viral),
alcohol, hypercalcemia and hypertriglyceridemia. In almost 20% of
patient a cause cannot be found (idiopathic). Systemic lupus
erythematosus (SLE) can be a rare cause of pancreatitis in children.
The incidence of acute pancreatitis associated with SLE varies from 0.7
to 4%. Pathogenic features of SLE pancreatitis may include vasculitis,
interstitial edema, arteriolar microthrombus formation from immune
complex deposition, anti-pancreatic antibodies, drug toxicity,
inflammation due to T-cell infiltration and complement activation.
Cytomegalovirus have also been associated with lupus pancreatitis.
Patients with lupus associated pancreatitis are typically female with
clinically active SLE developing within the first two years of disease
onset. The diagnosis of lupus associated pancreatitis is based on
clinical symptoms, pancreatic enzyme elevation and characteristic
imaging findings (CT-Scan or US). A diagnosis of SLE pancreatitis can
be made after the exclusion of other causes of acute pancreatitis.
Clinical signs include abdominal pain, nausea and vomiting.
Pancytopenia (anemia, leukopenia and thrombocytopenia) is a
distinguishing feature of lupus associated pancreatitis. SLE articular
involvement and occurrence of generalized tonic clonic seizures are
significantly more common in patients with pancreatitis. Lupus
associated acute pancreatitis can be self-limited to severe with
fulminant progression. The mortality of acute pancreatitis in pediatric
cases of SLE is higher when several organs are involved, in particular
renal, hepatic and neurological. Within the context of SLE there are
also cases of subclinical pancreatitis in which there is an elevation
of pancreatic enzymes without clinical symptoms. Around 30% of
asymptomatic SLE patients have hyperamylasemia. The management of
SLE pancreatitis is with steroids and supportive measures. Somatostatin
therapy during the acute pancreatitis has helped a few patients. References: 1- Rodriguez EA, Sussman DA, Rodriguez VR: Systemic lupus erythematosus pancreatitis: an uncommon presentation of a common disease. Am J Case Rep. 15:501-3, 2014 2- El Qadiry R, Bourrahouat A, Aitsab I, et al: Systemic Lupus Erythematosus-Related Pancreatitis in Children: Severe and Lethal Form. Case Rep Pediatr. 2018 Dec 31;2018:4612754. doi: 10.1155/2018/4612754. eCollection 2018. 3- Wang CH, Yao TC, Huang YL, Ou LS, Yeh KW, Huang JL: Acute pancreatitis in pediatric and adult-onset systemic lupus erythematosus: a comparison and review of the literature. Lupus. 20(5):443-52, 2011 4- Goel R, Danda D, Mathew J, Chacko A: Pancreatitis in systemic lupus erythematosus - case series from a tertiary care center in South India. Open Rheumatol J. 2012;6:21-3. doi: 10.2174/1874312901206010021. Epub 2012 Apr 11. 5- Alibegovic E, Kurtcehajic A, Hasukic I, et al: Silence pancreatitis in systemic lupus erythematosus. Intractable Rare Dis Res. 6(2):141-144, 2017 6- Dwivedi P, Kumar RR, Dhooria A, et al: Corticosteroid-associated lupus pancreatitis: a case series and systematic review of the literature. Lupus. 28(6):731-739, 2019 |
| A carbuncle
is an infection of the hair follicles extending in the surrounding skin
and deep underlying subcutaneous tissue. When two or more furuncles
coalesce, a carbuncle develops. Clinically the patient present with a
tender, inflamed, erythematous (cellulitis), fluctuant nodule with
multiple draining sinus tracts or pustules in the surface of the
lesion. The child can have fever, fatigue, malaise and ipsilateral
associated lymphadenopathy. Carbuncles develop more commonly in hair
bearing areas such as the back of the neck, buttock, axilla, groin,
back and thighs. Carbuncles are usually solitary, though multiple can
be seen rarely. The most common organism associated with a carbuncle is
staphylococcus aureus, including the methicillin resistant variant.
When the skin barrier is broken or disrupted by an infected follicle,
bacteria proliferate leading to folliculitis, furuncle and then
carbuncle. When compared with adults Carbuncles are rare in the
pediatric age. They are associated with diabetes, hyperhidrosis,
alcohol use, malnutrition, immunodeficiency, obesity and overall poor
hygiene. The diagnosis is done by physical examination. There is no
need to perform imaging studies for diagnosis or treatment purposes. It
is important to culture the carbuncle before antibiotic therapy is
started. A carbuncle can cause a diabetic patient to lose control of
blood sugar or even develop sepsis. Hemogram can demonstrate
leukocytosis with a shift to the left, or it can be normal depending on
the systemic response of the patient. Carbuncles are managed with
systemic antibiotics and surgical intervention. Antibiotics should be
broad-spectrum. In children this is done in the operating room under
anesthesia. Incision and drainage of multiple loculations and
debridement of necrotic center are the surgical treatment of choice. A
drain is usually placed and removed 48 hours later. If methicillin
resistant staph aureus (MRSA) grow in culture antibiotics might need to
be changed accordingly. Recurrence is rare but may need surgical
excision in a few cases. Prognosis is
favorable. References: 1- Hee TG, Jin BJ: The surgical treatment of carbuncles: a tale of two techniques. Iran Red Crescent Med J. 15(4):367-70, 2013 2- Ngui LX, Wong LS, Shashi G, Abu Bakar MN: Facial carbuncle - a new method of conservative surgical management plus irrigation with antibiotic-containing solution. J Laryngol Otol. 131(9):830-833, 2017 3- Venkatesan R, Baskaran R, Asirvatham AR, Mahadevan S: 'Carbuncle in diabetes': a problem even today! BMJ Case Rep. 2017 Jun 19;2017 4- Hirabayashi M, Takedomi H, Ando Y, Omura K: Neck carbuncle associated with methicillin-susceptible Staphylococcus aureus bacteraemia. BMJ Case Rep. 2018 Oct 25;2018 5- Stulberg DL, Penrod MA, Blatny RA: Common bacterial skin infections. Am Fam Physician. 66(1):119-24, 2002 6- Shortt R, Thoma A: Empirical antibiotics use in soft tissue infections. Can J Plast Surg. 16(4):201-4, 2008 |
We are inviting all of you to submit contribution of your own to the newsletter. Credit will be given to the authors keeping his or her name, institution and E-mail address on their work.A list of contributors will appear in the internet homepage.All works should be send to Dr. H. Lugo-Vicente to the e-mail: titolugo@coqui.net |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|