Contents ：

ü Patients with suspected primary hyperparathyroidism (1°HPTH) are frequently referred to endocrinologists to confirm a diagnosis and recommend treatment.

ü Once a diagnosis of 1°HPTH is confirmed, imaging studies are often obtained both to assist in determining disease etiology and to direct operative planning.

ü Early efforts at parathyroid localization were of limited utility.

ü The superior glands are derived from the fourth branchial pouch and are less variable in location owing to their shorter descent during embryological development.

n 80% located posterior to the midportion of the thyroid at the level of the cricoid cartilage.

ü The inferior glands, derived from the third branchial pouch along with the thymus.

n Typically located posterior to the inferior pole of the thyroid.

n More inconsistent in location due to their lengthier migration.

ü Ectopic superior glands are most commonly found within the thyroid gland or capsule(parafollicular cells of the thyroid are also derived from the fourth branchial pouch).

ü Ectopic inferior glands can be located anywhere along their shared descent with the thymus from the third pouch.

n Thyrothymic ligament or within the thymus.

n Less common : neck or carotid sheath, retroesophageal locations, and within the mediastinum.

ü The principle of sestamibi parathyroid scanning is that

n MIBI tracer is taken up by both the thyroid and parathyroid adenoma.

n Washes out of the thyroid faster than the parathyroid.

n Early images at 20 minutes after injection are obtained, followed by delayed images typically at 2 hours.

ü Recently, a new CT-based parathyroid imaging modality termed 4-dimensional (4D)-CT has emerged, with the extra dimension referencing time.

ü Overall 4D-CT sensitivity is approximately 90% and can correctly localize the quadrant of a single adenoma in 85% of cases.

ü Parathyroidectomy

n The principles of 4-gland exploration, which is essential for treatment of hyperplasia, 2 o HPT, and tertiary hyperparathyroidism.

n With the ability to preopeatively localize an adenoma with imaging - unilateral exploration became acceptable.

n Limitation : a second adenoma {double adenoma) on the contralateral side can be missed.

n Radioguided parathyroidectomy, in which technetium sestamibi is injected prior to surgery and a gamma probe is then used to compare the radioactive level before and after excision adenoma.

Discussion ：

Dr.Houng ： ntraoperative PTH can be used as an adjunct in focused explorations to assure biochemical success.

Conclusion ：

Dr.Ho ： MIRP, not only reduces the cost to both the hospital and the patient, but importantly, also decreases the time under anesthesia.

Contents ：

ü Vidian nerve : union of postsynaptic parasympathetic fibers and presynaptic sympathetic fibers.

ü Vidian neurectomy - inhibits excessive activity of the parasympathetic system by interrupting cholinergic innervation to the nasal mucosa.

ü Possible surgical complications, including permanent dry eyes, were explained to patients prior to surgery.

ü EVN was performed under general anesthesia, with patients lying in reverse Trendelenburg position.

ü Preoperative packing : Cottonoid swabs soaked in a 3-mL solution consisting of 1 mL of 10% cocaine, 1 mL of 1:1000 adrenaline, and 1 mL of saline, 10 minutes prior to surgery.

ü A continuous esmolol infusion was used during the surgery to improve surgical fields.

ü The esmolol (100 mg/10 mL) infusion was started 2 minutes prior to initiation of surgery

ü loading dose : 0.5 mg/kg: maintenance infusion : 50 µg/kg/minute.

ü Inhaled anesthetic was titrated to achieve a mean arterial blood pressure of 50-75 mmHg.

ü OP Method :

n The lateral nasal wall over the region of the posterior fontanelle was infiltrated with 2% xylocaine with 1:80,000 adrenaline.

n A U-shaped mucosal incision was made with the base centered over the sphenopalatine foramen.

n A lateral wall periosteal mucosal flap was elevated by suction freer dissector to expose the ethmoid process of the palatine bone.

n The sphenopalatine artery was identified and cauterized by suction bipolar.

n The mucosal flap was then elevated toward the sphenoid until the posterior nasal artery was identified and then cauterized.

n The flap was then advanced posteriorly and inferiorly to the level of choana, to expose the perpendicular plate and sphenoid process of the palatine bone, which were then drilled to allow better exposure of the PPF.

n A coblator was then used to defat the fully exposed PPF, allowing the vidian nerve to be transected without bleeding.

n The navigation system was also utilized to confirm the precise location of vidian nerve or canal.

n The flap was then repositioned and no packing was required.

Discussion ：

Dr. Xiao : The vidian neurectomy was often done incorrectly in conjunction with a pharyngeal neurectomy prior to the clear identification of the vidian canal.

Conclusion ：

Dr. Ho : The coblator device is the ability of the wand to be used to retract the lesion while simultaneously dissecting, coagulating, irrigating, and suctioning.

Contents ：

ü Recurrent head and neck squamous cell carcinoma (HNSCC) is an extraordinarily challenging disease process.

ü Depending on site, recurrence rates range from 25% to 50%.

ü Many authors have advocated surgical salvage as the primary option for recurrent HNSCC.

ü A significant factor in determining patient prognosis in the recurrent setting is performance status.

ü The recurrent stage appears to be of substantial importance in predicting prognosis.

n Goodwin 2000 : 2-year disease-free survival (DFS) based on recurrent stage (67% for rStage II vs 33% for rStage III and 22% for rStage IV).

ü A short disease-free interval (DFI) has been shown to have significant negative prognostic impact.

n Stell 1991 : a 20% difference in 5-year overall survival (OS) using an interval of 9 months.

ü Recurrent stage had significant prognostic impact: 5-year OS for rStage I–II was 83% compared with 48% for all recurrent stages.

ü Survival outcomes after surgical salvage for recurrent oropharyngeal cancer are generally poorer than for laryngeal or oral cavity, with quoted 5-year OS rates of 13% to 28%.

Discussion ：

Dr.Lee ： Systemic agents and radiation are important means of locoregional control, and their efficacy should balanced with high and very real toxicity.

Conclusion ：

Dr.Ho ： Surgical salvage remains the primary option for resectable disease, although proper patient selection is essential.