Biomedical subjects

A R Shaha

Publications and source records attributed to A R Shaha.

14 recordsLinked to original sources

PubMed1992

Marginal mandibulectomy for carcinoma of the floor of the mouth.

Resection of primary tumors of the floor of the mouth mandates consideration of the management of the mandible which may be either involved by direct invasion or by close proximity. Segmental mandibulectomy can usually be performed when the tumor is either massive or directly invading the mandible. However, the cosmetic and functional results of segmental mandibulectomy are unsatisfactory. Whenever the tumor is close to the mandible or adherent to the periosteum, consideration should be given to marginal mandibulectomy. Over a period of 8 years, we have treated 65 patients with carcinoma of the floor of the mouth. Of these, 22 underwent marginal mandibulectomy. The number of patients staged T1, T2, and T3 were 4, 13, and 5, respectively. Most had oblique marginal mandibulectomy including the resection of the upper rim and medial cortex of the mandible. Vertical or horizontal mandibulectomy was rarely used. In each patient the preoperative workup included dental X-rays, panoramic films, and computerized tomography (CT) scan of the head and neck. The decision as to the extent of mandibulectomy was made primarily based on the clinical judgement. Seven patients underwent marginal mandibulectomy through the open mouth. However, in the remaining 15 patients, the cheek flap approach was utilized. The defect following marginal mandibulectomy was reconstructed either with split thickness skin graft, tongue flap, or myocutaneous flap. Small defects were left open to heal by granulation and secondary intention. Split thickness skin grafts healed very well over the surface of resected mandibles. Good local tumor control was achieved at the primary site and the functional and cosmetic results were excellent.

Adult↗

PubMed1992

Completion thyroidectomy: a critical appraisal.

BACKGROUND: Completion thyroidectomy can most accurately be described as reexploration of the neck to remove the contralateral thyroid lobe. This procedure has commonly been performed when the histopathologic condition of the ipsilateral thyroid lobe reveals papillary or follicular carcinoma of the thyroid. Because of a definitely increased risk of complications with completion thyroidectomy, avoiding its routine use is important. The purpose of this paper is to define the specific indications for completion thyroidectomy. METHODS: Over the past 9 years, we have performed 400 thyroidectomies; the patients ranged in age from 18 to 88 years. Although we have routinely used preoperative needle biopsy and intraoperative frozen section, decisions regarding the extent of thyroidectomy have been based on the gross findings at operation, taking into consideration such prognostic factors as patient age, tumor grade and size, the presence of extracapsular spread or distant metastasis, and associated risk factors. The minimal procedure for solitary thyroid nodule has been lobectomy with isthmusectomy. If the contralateral lobe is grossly normal, lobectomy with isthmusectomy has also been the maximal operation in most of patients. Very few specific indications exist for removal of the opposite lobe. RESULTS: Only three patients underwent completion thyroidectomy. All three patients had aggressive follicular carcinoma requiring radioactive iodine ablation, and all were referred after the initial surgery. We have not performed completion thyroidectomy on any of the patients on whom we initially operated. CONCLUSIONS: The most common indication considered for completion thyroidectomy is a frozen section diagnosis of a benign follicular adenoma that is subsequently changed on permanent pathologic condition to follicular carcinoma based on the presence of capsular and/or vascular invasion. However, if minimal invasion has occurred, no difference exists in survival related to the extent of the thyroidectomy. Local recurrence in the contralateral lobe occurs in less than 10% of the time. Because completion thyroidectomy carries more risks, it should be avoided in most patients when possible. The definitive decision should be made during the initial operation based on gross findings, prognostic factors, and frozen section, and this plan should only be changed to mandate completion thyroidectomy in select circumstances.

Adenocarcinoma↗

PubMed1991

Parathyroid autotransplantation during thyroid surgery.

Permanent hypoparathyroidism is one of the most distressing complications of thyroid surgery. The incidence of this iatrogenic complication varies between 3 and 25 percent among patients undergoing total thyroidectomy. Parathyroid injury may be caused by inadvertent removal of the parathyroids, ligation of the blood supply, or destruction secondary to capsular hematoma. Attention to such technical details as identification of the parathyroids, dissection close to the thyroid gland, preservation of the blood supply to the parathyroids, and avoiding manipulation of parathyroids reduces the incidence of temporary and permanent hypoparathyrodism. However, if the parathyroids are injured, the best method of preserving their function is by autotransplantation. Over the past 7 years we have performed 250 thyroidectomies. An attempt was made to identify and preserve parathyroid gland in each case. Even during lobectomy procedures, the ipsilateral parathyroids were identified and preserved. Whenever any of the parathyroids was devascularized or separated from the surrounding structures, it was autotransplanted into the sternomastoid muscle. The sternomastoid was chosen for autotransplantation rather than forearm muscles to avoid an added incision and because selective measurement of parathormone is not essential in this group of patients. Prior to autotransplantation, confirmation of the nature of the tissue was made by frozen section of a small portion of the parathyroid gland. Parathyroid autotransplantation was performed in 15 instances, even when only one parathyroid was injured. Only one member of this group of 15 patients developed temporary hypoparathyroidism, which disappeared after 4 weeks of calcium supplementation. The remaining patients had an uncomplicated recovery. Autotransplantation of the parathyroid glands should be performed whenever the parathyroid is devascularized or damaged by retraction or hematoma. It is essential for every thyroid surgeon to be familiar with the technique of parathyroid autotransplantation.

Calcium↗

PubMed1991

An experimental model for the surgical correction of tracheomalacia.

Tracheomalacia may result from large intrathoracic goiters. Due to the chronic compression, particularly within the confines of the thoracic inlet, the tracheal wall weakens, with disintegration of some of the cartilaginous rings. Tracheomalacia can cause acute airway distress, particularly during the post-operative period, and may occasionally result in death. The other major cause of tracheomalacia is related to either prolonged endotracheal intubation or over-inflation of the tracheostomy cuff. While various techniques such as internal stenting, external support devices, tracheostomy, and tracheal resection have been used based on individual circumstances, no one method appears to be perfect. To further study this difficult problem, an experimental model of tracheomalacia was created in eight dogs. Six to seven rings of the tracheal cartilages were dissected submucosally. More than half of the circumference of the tracheal rings was resected. The tracheal walls were reconstructed with polytetrafluoroethylene (PTFE) grafts. The grafts strengthened the tracheal wall without causing luminal constriction. Tracheostomy was not performed on any of the dogs. All dogs tolerated the procedure well and were extubated at the conclusion of the experiment. The dogs were followed for 4 to 6 months and then sacrificed so that the tracheal wall could be examined histologically. There was considerable fibrosis leading to stiff neotrachea. The results of this experimental technique for prosthetic reconstruction to counteract problems simulating tracheomalacia are very encouraging.

Animals↗

PubMed1990

Extended neck dissection.

From the time Crile described radical neck dissection in 1906, this surgical procedure became popular in the management of metastatic cancer in the neck. Over the past two decades, the modified neck dissection has been effectively utilized for conservation of function and cosmesis while achieving the same oncologic goals. However, there are several instances where the above standard procedures are not adequate for resection of malignant tumors. Although there is a definite trend toward conservation procedures, extended neck dissection is often necessary especially in patients with N2 and N3 disease. Apart from the standard structures removed in radical neck dissection, the other structures removed in extended neck dissection include skin, the digastric muscle, hypoglossal nerve, vagus nerve, sympathetic chain, ramus mandibularis, carotid artery, tracheo-esophageal nodes, etc. Over the past seven years, we have performed 40 extended neck dissections. All the patients had N2 or N3 disease in the neck. Nine patients had unknown primaries. Thirteen patients had their primary tumors in the oral cavity and 11 in the laryngopharynx. Five patients had primary tumor in the salivary glands and two patients had metastatic melanoma. Patients who underwent extensive skin excision had pectoralis myocutaneous flap reconstruction. All patients received postoperative radiation therapy. One patient died of cardiac problems 4 weeks after operation. Local control was achieved in 70%. The most difficult region for local control was the disease behind the mastoid process, and the most difficult problems were patients with involvement of the subdermal lymphatics. Our data suggests that there are definite situations where extended neck dissection is indicated with satisfactory local control of the nodal disease.

Adult↗

PubMed1990

Needle aspiration biopsy in salivary gland lesions.

The value of needle aspiration biopsy in the evaluation and management of salivary gland pathology is controversial. The major reasons for this controversy are the difficulty in cytologic evaluation and the fact that the extent of surgery can be easily defined based on clinical judgement. However, a preoperative diagnosis is helpful in discussions with patients regarding the extent and type of surgery. Apart from the fact that needle biopsy can distinguish benign from malignant conditions, it is also very useful in distinguishing between salivary and other nonsalivary pathology. Over the past 7 1/2 years, we have performed 160 needle aspirations of parotid, submandibular, and submucosal lesions. Adequate specimens for cytologic evaluation were obtained in 155 patients (97%). A total of 84 parotid lesions, 70 submandibular lumps, and 6 submucosal abnormalities were detected. A cytologic diagnosis of benign pathology was made in 120 patients. Twelve patients had lymphoma and the diagnosis was suspected based on needle aspiration. There were 10 patients with tuberculosis and 30 patients with hyperplastic lymph nodes or benign lymphoepithelial disease of the parotid. There were three false-positive and two false-negative reports. No complications such as hematoma, nerve injury, or infection developed. The major difficulty was in distinguishing between malignancy and obstructive sialadenitis in the submandibular region. Needle aspiration was helpful in evaluating lesions in the tail of the parotid and submandibular area. The cytologic distinction between salivary and nonsalivary pathology was useful in planning the appropriate surgery and the extent of surgical resection. From a clinical standpoint, the distinction between benign and malignant salivary and nonsalivary pathology was very helpful. Preoperative diagnosis of Warthin's tumor, lymphoma, or benign lymphoepithelial disease was essential to the correct management of these patients.

Adolescent↗

PubMed1990

Surgery for benign thyroid disease causing tracheoesophageal compression.

Even though the incidence of multinodular goiter is decreasing in the United States, still we see a large number of neglected goiters causing pressure effects on the surrounding structures. Both tracheal and esophageal displacement cause compression symptoms. However, tracheal compression may lead to acute airway distress. Eighteen per cent of our patients presented with acute airway problems, requiring emergency admission or intubation. Surgical intervention has been our preferred approach whenever there are signs or symptoms of tracheoesophageal compression. Fifty-five per cent of patients had only tracheal compression, while 18 per cent had only esophageal compression. Twenty-seven per cent had compression of both trachea and esophagus. Eighty-five per cent of patients had some symptoms of compression, while only 15% were asymptomatic despite large goiters. Compression symptoms and acute problems were noticed more frequently in patients with substernal goiters. Our preoperative work-up regularly included complete history, physical examination, indirect laryngoscopy, and airway radiography. Barium studies were performed if patients had dysphagia. Computed tomography scans were utilized if there was mediastinal extension. Pulmonary flow volume studies were used to locate the site of compression. However, decisions relative to surgical intervention were based primarily on clinical judgment. Since the postoperative morbidity is minimal in surgery for thyroid abnormalities, we strongly recommend early surgical intervention in patients with tracheoesophageal compression caused by enlarged thyroids.

Adenoma↗

PubMed1990

Intraoperative decision making during thyroid surgery based on the results of preoperative needle biopsy and frozen section.

Prognostic factors in well-differentiated thyroid cancer are age of the patient and grade, size, distant metastasis, and extracapsular spread of the disease. However, the surgeon is often not sure about the pathologic diagnosis of thyroid nodules. The accuracy of preoperative studies, such as ultrasonography and thyroid scanning, is limited. The most cost-effective test is fine-needle aspiration, the accuracy of which exceeds 80% in most series. However, a large group of nodules exist for which aspiration cytologic studies are considered to be either suspicious or indeterminate. The decision about the extent of thyroidectomy may be difficult in these patients. Intraoperative frozen section may help the surgeon to distinguish benign from malignant lesions, but as in fine-needle aspiration, the major problem is the distinction between follicular adenoma and follicular carcinoma. The frozen section diagnosis of follicular adenoma was changed to follicular carcinoma in one third of the cases (13 of 38 cases). The decision about the extent of thyroidectomy in patients with follicular adenomas was based on other prognostic factors, such as age and sex of the patient and the size of the nodule. The accuracy of frozen section diagnosis was 95%. Our experience suggests that decisions regarding the extent of thyroidectomy can best be made by preoperative fine-needle aspiration with confirmation by frozen section diagnosis in equivocal cases.

Adenocarcinoma↗

PubMed1989

Goiters and airway problems.

Even though thyroid enlargement occurs commonly, the incidence of goiter has decreased in the United States due to the routine use of iodized salt. We continue to see a large number of patients with neglected goiters that cause airway compression. The progressive nature of this disease occasionally results in severe tracheal compression and acute airway distress. We treated 120 patients with airway compression secondary to goiters during a 7-year period. Thirty patients presented initially with acute airway distress requiring either intubation or semiemergent surgery. The decision to operate was based primarily on clinical evaluation and airway films. Ninety patients had substernal goiters. Only one patient required sternal splitting. If one lobe was enlarged causing tracheal deviation, lobectomy was performed; if both lobes were enlarged, subtotal thyroidectomy was performed. Two patients required tracheostomy. There were no operative deaths, and morbidity was limited to minor wound problems. It is important to consider early surgical decompression whenever tracheal compression is caused by goiters, especially if the patients are symptomatic or there is mediastinal extension.

Adult↗

PubMed1976

Carcinoma of the hypopharynx.

The data in this study suggest that radical surgical treatment offers the best chance for control of disease in patients with cancer of the hypopharynx. The cervical lymph nodes are at a very high risk for early involvement by metastatic disease. Elective treatment of cervical lymph nodes must be considered in initial treatment planning to obtain better control of regional disease.

Adult↗

PubMedDate not supplied

Operative treatment of substernal goiters.

This report describes the operative experience in 72 patients with substernal goiters treated over the past 5.5 years. Even though the incidence of multinodular goiter has decreased in the United States due to the routine use of iodized salt, we continue to see a large number of patients with massive goiters, predominantly from Caribbean Islands. The diagnosis of substernal goiter was made on clinical examination augmented by such radiologic studies, as chest x-ray, barium esophagograms, airway films, and CT scans. Computed tomographic (CT) scanning was particularly helpful in evaluating the extent of substernal extension. Confirmation of the extent of disease was made at the time of operation. Ninety percent of the patients had tracheal deviation and 85% were symptomatic from airway compression. Esophageal compression was noted in 60% of the patients. All patients had a long history of goiter with recent onset of pressure symptoms. Flow-volume-loop studies were performed in 44% of the patients and were useful in the evaluation of pressure symptoms. However, the decision for operation was made primarily based on clinical evaluation of signs and symptoms. Sixteen patients in this group were admitted with acute airway distress requiring airway intubation or semi-emergency decompression. Only 1 patient required mediastinal splitting, while all others were operated by the cervical approach. The decision as to the extent of thyroidectomy was made at the time of operation. Drains were routinely used because of the large dead space. One patient developed a hematoma in the recovery room and required re-exploration.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMedDate not supplied

Preoperative evaluation of the mandible in patients with carcinoma of the floor of mouth.

Preoperative evaluation of the mandible for invasion by tumor has always been a difficult problem. Various methods have been used, including clinical evaluation, panoramic x-rays, dental films, routine mandible films, bone scans, computed tomographic (CT) scans, and magnetic resonance imaging (MRI) scans. The diagnostic accuracy of these methods has not been totally satisfactory from the clinical standpoint. We compared the diagnostic effectiveness of clinical evaluation, panorex films, and CT scans in 60 patients with carcinoma of the floor of mouth. The relative value of these tests was studied in relation to marginal or segmental mandibulectomy. Our data showed that CT scanning was not very helpful, mainly because of the presence of irregular dental sockets and artifacts. Clinical evaluation was the most accurate, both to determine bone invasion and to decide the type of mandibular resection necessary in association with the primary tumor. Panoramic films were helpful in evaluating the gross extent of mandibular invasion. However, they were not of any help in determining minimal bony invasion or cortical invasion. Even though CT scanning has made a tremendous impact in other areas of head and neck surgery, it is not of much help in making the critical decisions in the type of mandible resection, marginal or segmental, in patients with carcinoma of the floor of mouth. Our experience demonstrates that clinical evaluation is superior in preoperative evaluation of the mandible, and especially in deciding the type of mandible resection.

False Negative Reactions↗

PubMedDate not supplied

Synchronicity, multicentricity, and metachronicity of head and neck cancer.

Two hundred patients with squamous carcinoma of the head and neck were evaluated prospectively for synchronous second primary tumors. Complete head and neck examination, chest x-ray, and barium study (when indicated) revealed synchronous tumors of the upper aerodigestive tract in 24 patients (12%). Eleven patients had a second primary in the head and neck area. Nine patients had carcinoma of the lung, while four had carcinoma of the esophagus. Seven patients had a second primary outside the upper aerodigestive tract either in large bowel or prostate. During the period of this study, an additional 13 patients were seen with metachronous tumors 1-12 years after initial treatment of their index tumor. Most of these metachronous tumors were in the lung and esophagus and were noted within 1-3 years of treatment of the primary head and neck cancer. Detection of synchronous second primary is very important for prognosis and management of the index tumor, while early diagnosis of metachronous lesion is crucial in the follow-up of these patients.

Carcinoma, Squamous Cell↗

PubMedDate not supplied

Mandibulotomy and mandibulectomy in difficult tumors of the base of the tongue and oropharynx.

Wide exposure of the tumors of the base of the tongue and oropharynx can be easily obtained via mandibulotomy, which provides equally good exposure for tumors of the posterior oral cavity and oropharynx. Segmental mandibulectomy can be avoided in patients where the tumor does not invade the mandible or is not in close proximity of the mandible. Preoperative work-up may include evaluation by means of the fiberoptic telescope to determine the extent of the tumor, examination under anesthesia, panoramic X-ray of the mandible, CT scan and MRI, as well as dental evaluation. Tracheostomy provides airway during the operation and tracheobronchial access for clearance of pulmonary secretions postoperatively. The technique for median labiomandibuloglossotomy is described, as well as the mandibular swing approach and mandibulectomy. Cosmetic deformity after segmental mandibulectomy is minimal but mandible reconstruction should nonetheless be considered based on the extent of the tumor, tumor control, and the need for postoperative radiation therapy.

Humans↗