Objective. Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient's voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period.Purpose. The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well.Results. The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient's voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient's voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient's voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesi...

lY'leomorphic adenomas (benign mixed tumors) are the most common benign neoplasms of both the major and minor salivary glands of adults. Recurrence of disease occurs with incomplete excision of the tumor or spillage of the tumor matrix. A small subgroup of these tumors have been described that metastasize many years after multiple recurrences at the primary site. The metastasizing benign mixed tumor is distinct from the true malignant mixed tumor (i.e., carcinoma ex-pleomorphic adenoma and carcinosarcoma) because it remains histologically benign. A case of metastasizing benign mixed tumor occurring 25 years after curative parotidectomy is discussed. CASE REPORTA 75-year-old woman came to the Department of Neurosurgery with a 1-year history of urinary incontinence and severe lumbosacral and pelvic pain. The patient had undergone a right parotidectomy in 1967 at another institution. This procedure was complicated by total facial paralysis. After this complication, the patient became reclusive and did not seek medical attention for more than 20 years. The development of intractable pain and the loss ofbowel and bladder function finally prompted her to seek medical attention.Physical examination revealed a right seventh nerve paralysis, erythema of the right conjunctiva, and a right parotid scar. No palpable mass was detected in either parotid region. The remainder of the examination of the head and neck was unremarkable. Abdominal examination was significant for a large, firm mass palpable in the right lower quadrant. Neurologic examination revealed saddle anesthesia with normal Babinski reflexes. Computed tomography demonstrated a 30 x 15 x 48 cm From the Department of Otolaryngology-Head and Neck Surgery (Drs. Schreibstein and Hybels) and the Departments of Pathology and of Neurosurgery (Drs. Tronic and Tarlov), Lahey Clinic.

We do not recommend adding i.m. clonidine (2 microg x kg(-1)) to the analgesic regimen of children undergoing tonsillectomy and adenoidectomy.

S i c k l e cell disease (SCD) is an inherited hematologic disorder that may involve sensorineural hearing loss (SNHL) and that is common in those of African descent. It is an autosomal recessive hemoglobinopathy in which the carrier is said to have sickle cell trait. In African-Americans the prevalence of sickle cell trait is 7% to 9%, and that of SCD is approximately 0.25%. 1,2 Conventions of nomenclature define SCD as the family of hemoglobinopathies, including the homozygous form, sickle cell anemia (Hb SS), and multiple sickle cell variants including Hb SC. The hemoglobinopathy involves substitution of valine or lysine for glutamic acid at the sixth position on the beta chain of Hb A, resulting in Hb S or Hb C, respectively.SCD is characterized by sickling of red blood cells when exposed to low oxygen tension. When deoxygenated, the abnormal hemoglobin polymerizes, deforming the red blood cells into a rigid, sickle shape. These sickled cells occlude the capillary bed causing further local tissue hypoxia and consequent sickling, leading to a vaso-occlusive crisis. 3 All tissues are subject to acute and chronic injury from such capillary bed occlusion. In addition, the clinical course is complicated by hemolytic anemia and susceptibility to infection caused by splenic infarction. This article presents a case of sudden hearing loss (SHL) as the first manifestation of Hb SC disease in a young adult

marines, nuclear power plants, and some manufacturing plants. Organizations with extremely low failure rates have been found to have many similarities in structure and function; many of these features might be applicable to health care systems. Good surgical care can never occur in the absence of a competent, well-trained, skillful and conscientious surgeon. But even the best surgeon cannot ensure good care if he or she is practicing in a dysfunctional OR, office, or inpatient unit. Understanding the principles that underlie highly effective systems will help the otolaryngologist act effectively to help mediate change in his or her own practice environment.