Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Parathyroidectomy for Primary Hyperparathyroidism and Nonlocalizing Hyperparathyroidism

Introduction The parathyroid glands are usually found adjacent to the thyroid gland and produce parathyroid hormone (PTH), which increases serum calcium levels by enhancing bone resorption, increasing calcium reabsorption in the distal tubules of the kidneys, and converting calcidiol to the active calcitriol form of vitamin D, which stimulates intestinal calcium absorption. About 85% of the population have two superior (4th pouch) and two inferior (3rd…

Intraoperative Parathyroid Hormone Monitoring

Introduction Parathyroid hormone (PTH) is secreted from the parathyroid glands and is primarily responsible for calcium homeostasis. The mechanism by which this occurs is through renal tubular reabsorption, bone resorption, and formation of calcitriol from calcidiol in the renal tubular cells. The hormone is synthesized as an inactive polypeptide chain, which is then cleaved at the N-terminal in the parathyroid glands to an active form. The…

Invasive Thyroid Cancer

Introduction Thyroid cancer is a curable disease with increasing incidence and treatment strategies. This corresponds with the widespread use of screening modalities and improved health care availability. With more cases being detected in early stages, the incidence of invasive thyroid cancer is relatively low, ranging from 5% to 25%. Despite the low incidence, invasive thyroid cancer has significant prognostic implications, with nearly half of deaths from…

Massive and Substernal Goiter

Introduction Prior to the 20th century, thyroid surgery was associated with a high operative mortality rate. The meticulous surgical technique advanced by Kocher in the late 1890s transformed thyroidectomy into a safe operative procedure associated with a 1% mortality rate. Although generally safe and effective, surgery for massive and substernal goiter remains subject to potentially significant surgical complications. Approximately 5% of the population in the United…

Robotic-Assisted Thyroidectomy

Introduction Open thyroidectomy incorporated a midline skin crease was first popularized by Kocher in 1906; since that time it has remained the standard surgical technique for thyroidectomy. This approach provides the most direct route to the thyroid bed and offers complete visualization of the surgical field. Therefore it results in excellent, predictable, and reproducible clinical outcomes with consistent preservation of the parathyroid glands and recurrent laryngeal…

Minimally Invasive Video-Assisted Thyroidectomy

Introduction Thyroid nodules are a common clinical problem, diagnosed by palpation on clinical examination in approximately 5% of women and 1% of men in Western society. Their presence requires evaluation to exclude thyroid cancer, the incidence of which is 15% in at-risk groups. In recent decades, the incidence of thyroid cancer has nearly tripled from 4.9 per 100,000 in 1975 to 14.3 per 100,000 in 2009.…

Open Thyroidectomy

Introduction Although thyroid disease has been recognized for centuries, consistently accepted techniques of thyroid surgery date back approximately 100 years. With a combined mortality of 40% from hemorrhage and sepsis, thyroidectomy was banned by the French Academy of Medicine in 1850. However, with the advent of antiseptic technique, vascular ligation, and precise capsular dissection, Theodor Kocher reduced the perioperative mortality rate to less than 1% in…

Anterior Transcervical Approach to the Cervical Spine

Introduction The otolaryngologist is often involved in surgery to provide access to the cervical spine. This is usually for the treatment of cervical spondylosis by the orthopedic or neurologic surgeon. Rarely the head and neck surgeon will be involved in the treatment of pathology involving the spine, such as infection or primary and metastatic neoplasms. Potential benefits for the primary surgeon of the participation of the…

Deep Neck Abscesses

Introduction The potential for a seemingly benign entity like an infected tooth, tonsil, or skin lesion to cause life-threatening illness is due to the complex relationship between the spaces of the neck. Deep neck infection (DNI) may result from any of the above and can extend into the mediastinum and beyond when these spaces are involved. Aggressive bacterial species, inadequate host defenses, and access to medical…

Management of Traumatic Soft Tissue and Vascular Injuries to the Neck

Introduction Patients with evidence of vascular or soft tissue trauma must be approached in a similar fashion as all trauma patients. Primary and secondary surveys initially screen for any imminently life-threatening injuries and guide the acute workup. Occasionally, that survey reveals a vascular injury to the neck requiring immediate surgical exploration, but in most cases, soft tissue injuries are addressed following initial evaluation and stabilization. Fractures…

Endoscopic and Robotic Applications to Neck Surgery

Introduction Traditional approaches for surgery of the neck involve a relatively long incision that is usually through a transverse skin crease. The length of the incision varies and depends on the procedure to be performed, but it must be of sufficient length to provide adequate exposure and removal of the desired tissue. For neck dissections, several eponymous incisions have been described such as the Crile, MacFee,…

Excision of Carotid Body Tumors

Introduction Most of the tumors that originate in the poststyloid parapharyngeal space (PPS) are tumors of neural origin. Most of these are paragangliomas (PGLs), the most common of which is the carotid body tumor (CBT). It is usually possible to tell preoperatively, by imaging studies, whether these tumors are in fact CBT, glomus vagale tumors, or schwannomas. The computed tomography (CT) scan with contrast is very…

Excision of Neural Tumors of the Parapharyngeal Space

Introduction To safely resect neural tumors of the parapharyngeal space (PPS) and to counsel patients about potential consequences and complications of surgery requires that the surgeon has a detailed knowledge of the surgical anatomy of the PPS, requests appropriate radiological studies from which the likely pathology can be predicted (80% benign), and understands the possibilities and limitations of the various surgical approaches. Neural tumors in the…

Posterolateral Neck Dissection

Introduction The posterolateral neck dissection is an operation that is typically used in the management of cutaneous cancers of the posterior scalp, auricle, or upper neck. It is done either electively, to stage the clinically node-negative neck, or therapeutically, to treat the node-positive neck. In contemporary practice, this operation is most often used to treat a clinically node-negative neck that has been found to have microscopically…

Transoral Approach to the Parapharyngeal Space

Introduction The management of patients with tumors of the parapharyngeal space (PPS) is a challenge for head and neck surgeons. The diverse anatomic structures in the PPS give rise to many different tumors, and the relationship of such lesions to critical neurovascular contents provides a technical challenge during surgery. Various operative techniques have been described to safely approach this deep neck space. However, while considering that…

Management of Tumors in the Prestyloid Parapharyngeal Space

Introduction The management of a patient with a tumor of the parapharyngeal space (PPS) is a challenging task. The complex nature of the anatomy of the PPS and the diversity of its contents gives rise to a wide variety of tumors. This presents an opportunity for technically challenging surgery. Current imaging modalities, including computed tomography (CT) and magnetic resonance imaging (MRI), have characterized the intricate anatomy…

Retropharyngeal Neck Dissection

Introduction The retropharyngeal lymph nodes (RPLNs) are a small chain of lymph nodes located in the retropharyngeal space (RP) where they are divided into the medial and lateral groups. The boundaries of the RP are the carotid sheath laterally, skull base superiorly, prevertebral fascia posteriorly, and the pharynx anteriorly, and inferiorly, the RP is in continuity with the posterior mediastinum. The medial group of nodes are…

Central Compartment Neck Dissection

Introduction The central compartment contains the first nodal basin for cancer originating in the thyroid and parathyroid and can be involved in cancers of the laryngotracheal complex. This space encompasses the prelaryngeal, pretracheal, and paratracheal lymph nodes, also known as the level VI lymph nodes, although superior mediastinal nodes and retro-esophageal nodes are often included and represent level VII. In cases of squamous cell cancer involving…

Radical Neck Dissection

Introduction The cervical lymphatics remain an important area of consideration in the evaluation of advanced cancer of the head and neck. Metastasis to cervical nodes carries negative prognostic implications, and therefore management of the neck is a critical topic of discussion. Although operative management of the neck has become more selective over time, radical neck dissection (RND) still plays an important role in the management of…

Modified Radical Neck Dissection

Introduction In the early 1900s, George Crile recognized that cancer of the head and neck was primarily a locoregional disease and felt that patients could be cured if the cancer was completely excised. The cervical lymph nodes were recognized as the initial area of spread and so the best chance for cure was excision of the primary cancer sites in concert with the ipsilateral cervical soft…