Aleix Rovira

Objective: To evaluate voice outcomes following thermal ablation techniques for the management of benign and malignant thyroid nodules. Data Sources: A systematic literature review of PubMed and Embase databases was performed up to March 2025. Review Methods: This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) guidelines. Inclusion criteria were studies with adult patients undergoing thermal ablation for thyroid nodules with reported objective voice outcomes. Data extracted included study characteristics, patient demographics, ablation modality, and objective and subjective voice outcomes. Results: Eighteen studies comprising 5168 patients were included. Ablation modalities were radiofrequency ablation, microwave ablation, laser ablation, and high‐intensity focused ultrasound. Objective pre‐procedural assessment of vocal cord function using fibreoptic nasoendoscopy or sonographic evaluation was reported in 2054 patients (39.7%). Post‐procedural objective vocal cord assessment was most commonly performed in symptomatic cases, while assessment was routinely performed irrespective of symptoms in 2110 patients (40.8%). The pooled post‐procedural vocal cord palsy rate was 1.4%, with most cases being transient. Permanent vocal cord palsy was rare (n = 2, 0.05%). Subjective voice symptoms without objective vocal cord dysfunction were generally mild and self‐limiting. Conclusion: Thermal ablation of thyroid nodules is associated with a low risk of clinically significant voice complications. Most voice changes are transient, although the lack of standardized voice assessment likely underestimates true complication rates. Routine objective laryngeal evaluation and standardized reporting are essential to ensure accurate detection of voice complications, optimize patient counseling, and enhance the safety of thyroid ablation practice.

Importance: Significant international variations exist for prevention methods, diagnostic, and management criteria for pharyngocutaneous fistula. Objective: To formulate best practice management guidelines for pharyngocutaneous fistula after total laryngectomy. Design: Modified Delphi consensus study conducted between January 2024 and November 2025 using two rounds of a structured survey. Levels of consensus were evaluated through a 9‐point Likert scale and predefined cutoffs: strong consensus (≥ 80% in 7–9 range, median ≥ 9), consensus (≥ 80% in 7–9 range, median 8–9), near‐consensus (≥ 70% in 7–9 range), or no‐consensus (< 70% agreement). Setting: International multicenter study. Participation of experts from 18 countries of America, Europe, Asia, South America, and Oceania, under the guidance of the International Federation of Oto‐rhino‐laryngological Societies (IFOS). Participants: A multidisciplinary international panel of 36 experts in head and neck surgery, otolaryngology, radiation oncology, radiology, and plastic surgery. The panelists were chosen for their clinical expertise in the area of total laryngectomy and pharyngocutaneous fistula management; published work in the form of peer‐reviewed publications, as well as geographical representation. Main Outcomes and Measures: The level of consensus in 59 statements regarding fistula definition and classification, preoperative risk factors, prevention strategies, diagnostic modalities, conservative management protocols, surgical intervention criteria, nutritional support, and patient outcomes. Results: A consensus or strong consensus was reached on 30 of 59 statements (50.8%). Strong consensus levels were reached for preoperative nutrition optimization (median 9.0), postoperative enteral feeding support (median 9.0), standardized surveillance protocols (median 9.0), and revision surgery for persisting fistulae (median 9.0). Consensus was also achieved for the use of vascularized tissue reinforcement in selected high‐risk settings, although the preferred reconstructive strategy varied according to flap type and clinical scenario. Of the 29 statements, 5 (8.5%) were excluded at Round 1 as a result of conceptual repetition as highlighted by panel feedback, and 24 (40.7%) did not reach consensus after both rounds, including fistula classification systems, prophylactic salivary bypass tubes, time to resume oral feeding postoperatively and negative pressure wound therapy. Conclusions and Relevance: This Delphi study from an international panel provides areas of agreement and ongoing equipoise across the prevention, diagnosis, and management of PCF, while demonstrating significant practice variability in terms of their classification, the use of prophylactic interventions, and conservative therapies.

The anatomical relationship of the inferior thyroid artery (ITA) and the recurrent laryngeal nerve (RLN) is highly variable. This study aims to evaluate bilateral RLN branching patterns and their relationship to the ITA within the same patient, predicting contralateral anatomical variations and ultimately reducing intraoperative risk of RLN injury. A retrospective review of prospectively collected intraoperative data was performed on adults undergoing total or completion thyroidectomy at a tertiary center between February 2022 and June 2025, with standardized documentation and intermittent nerve monitoring in all cases. RLN–ITA relation was classified as posterior, anterior, or between branches, and RLN morphology as single, bifurcated, or plexiform. Bilateral agreement, conditional probabilities, and predictors were evaluated using Cohen's κ and McNemar's test. Seventy‐five patients (150 RLNs) were included. Overall RLN–ITA relations were posterior 72.7%, anterior 24.7%, and between branches 2.7%. Extra‐laryngeal branching was observed in 24.7% of nerves (18% bifurcated, 6.7% plexiform). High bilateral agreement was demonstrated (κ = 0.83, p < 0.001), with 93.3% concordance between sides. When variation was present on one side, the probability of contralateral variation was 94.7% (left) and 81.8% (right). Variant RLN‐ITA relations were associated with larger median lobe volumes (21.7 vs. 12.3 mL), thought this trend did not reach statistical significance. Our study reveals a high degree of intra‐patient symmetry in both recurrent laryngeal nerve (RLN) branching patterns and the RLN‐ITA relationship, highlighting that anatomical variations are often mirrored contralaterally. While further larger‐scale studies are necessary to confirm the reproducibility of these findings, the identification of an RLN variation on one side should prompt greater caution during contralateral dissection.

Objective: Therapeutic lateral neck dissection is recommended for papillary thyroid cancer with metastatic lymph nodes detected on palpation or on preoperative imaging. Current guidelines recommend systematic dissection of levels IIA, III, IV and VB in these patients. Despite this recommendation, management of level V remains controversial due to a varying degree of clinical and occult lymph node involvement reported in published retrospective studies, but also due to the functional risk involved in level V dissection in which the spinal accessory nerve may be temporarily or permanently injured. The aim of this review was to address the issues involved in level VB dissection and to provide our view of surgical management of level VB. Method: Narrrative review. Result: We propose a new concept of a partial or “super-superselective” level VB dissection in patients with clinical disease in levels IIA, III and IV.

Introperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) is a well-established technique to aid in thyroid/parathyroid surgery. However, there is little evidence to support its use in non-thyroid or non-parathyroid surgery. The aim of this paper was to review the current evidence regarding the use of IONM in non-thyroid/non-parathyroid surgery in the head and neck and thorax. A literature search was performed from their inception up to January 2024, including the term “recurrent laryngeal nerve monitoring”. IONM in non-thyroid/non-parathyroid surgery has mainly been previously described in oesophageal surgery and in tracheal resections. However, there is little published evidence on the role of IONM with other resections in the vicinity of the RLN. Current evidence is low-level for the use of RLN IONM in non-thyroid/non-parathyroid surgery. However, clinicians should consider its use in surgery for pathologies where the RLN is exposed and could be injured.

Head-and-neck cancer (HNC) can present with life.threatening symptoms in the emergency department. Patients can sometimes be misdiagnosed with pulmonary disease due to similar signs and symptoms, ultimately leading to delayed diagnosis and potentially devastating consequences. Reasons for this include lack of awareness of patient risk factors and knowledge of the myriad of presenting complaints in the disease process among physicians working in primary care and in the emergency department. This article explores the contemporary risk factors and common presenting symptoms and discusses initial management for a patient with potential head-and-neck malignancy. Emergency presentations of HNC are wide ranging and can overlap with common respiratory pathologies. Clinician awareness of this can assist the team in deciding what appropriate examination and investigations are required to reduce the risk of delaying diagnosis and further treatment.

Purpose: This study aims to evaluate the association between 2 weeks wait referral and survival in the head and neck cancer. Methods: Retrospective cohort study of consecutively discussed new head and neck cancer patients at large United Kingdom Cancer Alliance including two tertiary referral hospitals and two district general hospital. Results: A total of 276 cancer patients were included for analysis. Patients referred under the 2 weeks wait had were seen and diagnosed sooner from referral (p < 0.0001 and p < 0.0001 respectively). However, this did not translate into better survival outcomes. No survival differences were seen between those patients that were managed within the proposed cancer targets and those that were not. Conclusions: The 2 weeks wait head and neck cancer pathway did not offer a survival advantage. Targeting the delay in referral as well as delay in treatment to prevent late-stage cancer presentation is paramount. Fulfilment of cancer time targets do not translate into better outcomes and should not be prioritised to clinical judgement.

Objective: Numerous factors are considered to impact on the rate of complications during salvage total laryngectomy procedures. Neck dissection could be one of these factors. This study analysed the pattern of lymph node metastasis and rate of occult neck disease during salvage total laryngectomy as well as the impact of neck dissection on survival and complication rates.Method: This was a retrospective analysis of a prospectively maintained laryngectomy database in two large tertiary teaching hospitals.Results: The rate of occult neck disease was 11.1 per cent. Most cases with occult neck disease had rT₄ disease. Patients with complications, advanced tumour stage and positive margins had a significant decrease in overall survival. Patients receiving elective neck dissection did not have any survival benefit. Positron emission tomography-computed tomography showed a very high specificity and negative predictive value.Conclusion: According to the low risk of occult neck disease when using contemporary imaging techniques as well as the lack of impact on survival, conservative management of the neck should be considered for crT₁-T₃ recurrence.