Cigarette Smoking and Progression of Laryngeal Lesions

The association between cigarette smoking and an increased risk of laryngeal carcinoma has been demonstrated in numerous studies. The aim of the present study was to assess the prevalence of smoking habit in patients with different laryngeal pathologies. The prevalence of cigarette smoking was compared between patients with laryngeal tumors and those with nonmalignant laryngeal lesions. Data on all patients with indications for direct microlaryngoscopy at the Clinic for Otorhinolaryngology of the University Hospital Center Split, during a five-year period were analyzed. The study included 562 patients with various laryngeal pathologies, divided into three groups as follows: group 1, benign lesions; group 2, precancerous lesions; and group 3, tumors. The majority of patients (82.92%) had a long history of smoking. The proportion of smokers was lowest in benign lesion group (72.13%), higher in precancerous lesion group (81.48%) and highest in malignant lesion group (97.14%). There was a statistically significant difference in the prevalence of cigarette smoking between patients with laryngeal tumors and those with benign or precancerous lesions (p<0.001). The mean number of cigarettes per day was 20.54±14.80, and was lowest in benign lesion group (15.67±13.41) and highest in malignant lesion group (26.33±12.70). The mean length of smoking habit was 26.44±16.92 years, ranging from 19.57±16.03 years in benign lesion group to 35.20±12.12 years in malignant lesion group. Study results clearly pointed to the increased prevalence of laryngeal diseases in smokers, with a significant difference between patients with benign laryngeal lesions and those with laryngeal tumors

Veličina adenoidnih vegetacija u djece s upalom srednjeg uha s izljevom

Otitis media with effusion (OME) is amongst the most common pediatric diseases and the most common cause of hearing loss in children. It is accepted that adenoid hypertrophy (AH) is related to OME incidence. Better understanding of the correlation between the relative size of AH and the incidence of persistent OME may provide evidence to support a more standardized approach to the diagnosis and treatment of OME. A retrospective study carried out between April 2016 and April 2018 collected data on 65 children aged 2-12 years, diagnosed with chronic OME and symptoms of AH, where conservative therapy failed. Pre-diagnostic data were collected from patient history, otoscopy, rhinoscopy, and oropharyngoscopy findings. Diagnostic workup included tympanometry, audiometry, and flexible nasal fiberoptic endoscopy. Adenoid grading was performed according to Cassano method after endoscopic visualization. Of the 65 patients, 37 were male and 28 were female. There was no statistically significant difference according to gender or average age. The highest incidence of persistent OME with AH was recorded in the youngest age groups (2-5 and 6-9 years). The most frequent AH grades were grade II (35.38%) and grade III (50.77%), yielding a statistically significant result. The most common presenting symptoms were hearing impairment, snoring, and nasal obstruction (100%, 64.62% and 60%, respectively). Higher AH grades are critical for persistence of OME and may cause conservative therapy failure.Kronična upala srednjeg uha s izljevom jedna je od najučestalijih pedijatrijskih bolesti i najčešći uzrok gubitka sluha u djece. Poznato je da je adenoidna hipertrofija (AH) povezana s učestalošću upale srednjeg uha s izljevom. Bolje razumijevanje njihove povezanosti bi moglo ponuditi dokaz za novi standard u dijagnostici i liječenju kronične upale srednjeg uha s izljevom. U ovo retrospektivno istraživanje provedeno od travnja 2016. do travnja 2018. godine bilo je uključeno 65 djece u dobi od 2-12 godina s dijagnozom kronične upale srednjeg uha s izljevom i simptomima AH, kod koje je konzervativna terapija bila neuspješna. Svoj djeci je uzeta detaljna heteroanamneza i pred-dijagnostičke pretrage koje uključuju otoskopiju, rinoskopiju i orofaringoskopiju. Dijagnostičke pretrage uključuju fiberendoskopiju epifarinksa i audiološku obradu koja obuhvaća timpanometriju i tonalnu audiometriju. Gradiranje AH je napravljeno prema sustavu Cassano s endoskopskom vizualizacijom adenoidnih vegetacija. Od 65 djece, bilo je 37 dječaka i 28 djevočica, bez statistički značajne razlike u broju i spolu u svim dobnim skupinama. Rezultati rada pokazuju da je najčešća incidencija kronične upale srednjeg uha s izljevom i AH u mlađoj dobi (2-5 i 6-9 godina). Najčešći gradusi su bili AH II. (35,38%) i AH III. (50,77%) (p<0,001). Najčešći prezentirajući simptomi bili su gubitak sluha (100%), noćno hrkanje (64,62%) i otežano disanje na nos (60%). Veći gradus AH povezan je s većom učestalosti upale srednjeg uha s izljevom te može uzrokovati neuspjeh konzervativne terapije

Značajke oporavka sluha u djece s kroničnim sekretornim otitisom nakon postavljanja aerizacijskih cjevčica

The objective was to determine the range of hearing improvement (in dB) post ventilation tube insertion in children with chronic otitis media with effusion (COME), and whether there was a difference in hearing improvement between age groups and genders. This study also investigated whether there was a difference in the mean hearing improvement between the left and right ear, how many months passed before recovery of eustachian tube function, and how long the aeration of the middle ear lasted. The children included in the study were between six and twelve years of age, diagnosed with COME by audiological processing (type B tympanometric recording and conductive hearing loss up to 40 dB on pure tone audiometry) and underwent surgical insertion of ventilation tubes in both ears. Patient data included preoperative tympanometric records, preoperative and postoperative tone audiometry findings, tubometry findings 6 and 10 months after insertion of ventilation tubes, age and gender data, and length of time during which the tubes were in place. The mean hearing improvement of the included patients was 24.2 dB on the right ear and 24.5 dB on the left ear. There was no statistically significant difference between the left and right ear or between the genders. Older age groups had a higher mean hearing improvement compared with the younger age group. Younger age groups had a longer expected period of eustachian tube function recovery, and were expected to have ventilation tubes inserted for a longer period of time. Treatment with ventilation tube insertion resulted in significant improvement in hearing in children where previous conservative therapy failed to recover eustachian tube function and improve hearing. Although children of older age groups had greater preoperative hearing impairment, the recovery of both eustachian tube function and hearing improvement was faster, and the mean length of time that the ventilation tubes had to be inserted was shorter.Cilj istraživanja bio je utvrditi koliko se prosječno poboljšao sluh (u dB) nakon postavljanja aerizacijskih cjevčica u djece s potvrđenom dijagnozom kroničnog sekretornog otitisa (KSOM) te postoji li razlika u poboljšanju sluha u dB između dobnih skupina i spolova. Također je trebalo utvrditi postoji li razlika u prosječnom poboljšanju sluha između lijevog i desnog uha i koliko je mjeseci proteklo od uspostavljanja funkcije Eustahijeve cijevi, odnosno koliko je dugo trajala aerizacija srednjeg uha. Ispitanici su bila djeca između šeste i dvanaeste godine života kojima je audiološkom obradom (timpanometrijski zapis tip B i provodni gubitak sluha do 40 dB u tonalnom audiogramu) dijagnosticiran KSOM i koja su podvrgnuta operativnom zahvatu insercije aerizacijskih cjevčica na oba uha. Materijali istraživanja su prijeoperacijski timpanometrijski zapisi, prijeoperacijski i poslijeoperacijski nalazi tonske audiometrije, nalazi tubometrije 6 i 10 mjeseci nakon insercije aerizacijskih cjevčica te podatci o dobi, spolu djeteta i vremenskom razdoblju nošenja cjevčica. Prosječno poboljšanje sluha u cijelom uzorku iznosilo je 24,2 dB za desno uho i 24,5 dB za lijevo uho. Ne postoji statistički značajna razlika u poboljšanju sluha između lijevog i desnog uha niti između dječaka i djevojčica. Starije dobne skupine imaju veće prosječno poboljšanje sluha u odnosu na mlađu dobnu skupinu. Mlađe dobne skupine imaju duže očekivano razdoblje povratka funkcije Eustahijeve tube u uredno stanje i duže očekivano razdoblje nošenja aerizacijskih cjevčica. Liječenje aerizacijskim cjevčicama dovodi do značajnog poboljšanja sluha u djece ako prethodna konzervativna terapija nije rezultirala uspostavljanjem funkcije Eustahijeve tube i oporavkom sluha. Iako su djeca starijih dobnih skupina imala veće prijeoperacijsko oštećenje sluha, oporavak funkcije Eustahijeve tube kao i poboljšanje sluha bilo je brže, a razdoblje nošenja aerizacijskih cjevčica bilo je kraće

Historical Contribution of Otorhinolaryngology in Split Region till 1923

The beginnings of the modern otorhinolaryngology in Croatia started in the second half of the 19th century. Before that, there were only rare attempts of some doctors who published medical papers touching the frame of otorhinolaryngology. Mainly those were the PhD\u27s disertations at Vienna, Budapest and Padua University. Among them there was dr Ivo Manola from Split, who in Padua in 1834 took a doctor\u27s degree dealing with otologic diseases. Dr Nikola Fertilio (Nerežišća the island of Brač, 1861 ‒ Trieste, 1928) was the first otorhinolaryngologist out of a hospital in Split and Dalmatia. He studied medicine partly in Graz and Vienna, where he graduated in 1890. During 1903 he finished severeal otorhinolaryngological courses which were held by professors Viktor Urbantschitsch and Alfred Bing and by private doctor assistant professor Markus Hajek. During the winter 1903/04 he attended the „Semestralkurs über praktische Orhenheilkunde“ at professor Adam Politzer, founder and managing director of the first Otology Clinic in Vienna and the world in 1873. He worked in Trieste, where he practiced otorhinolaryngology. Dr. Fertilio a specialist for diseases of nose, ear and throat, occasionally, usually during his holidays, came from Trieste to Dalmatia (Split, Zadar, Šibenik, Dubrovnik and Kotor) to treat and operate patients. He was comming to Split from 1904 till 1914. He published and announced his commings in the local newpapers. He used to come in summer, most often in August and stayed from several days till two weeks. He stayed and had a practice in Hotel Bellevue. As there wasn\u27t an otorhinolaryngologist in the regional hospital of Split till 1923, otorhinolaryngological operations were occasionally performed by doctors of other surgical branches. Otorhinolaryngologist dr Aleksandar Doršner came to Split hospital in 1923 and organized otorhinolaryngological service that he led till 1934

Postoji li audiovestibularni post-COVID sindrom?

The purpose of this study was to present and analyze patients with audiovestibular post COVID-19 syndrome, and highlight the most characteristic and most common findings. We analyzed 87 patients aged between 20 and 86 years who presented to the Audiology Division between February 1, 2021 and July 1, 2021 after having been isolated due to the SARS-CoV-2 infection. Study patients presented with complaints of persistent hearing loss, tinnitus, and vertigo, lasting for more than 3 months. Study results showed that there was acute sensorineural hearing loss in 4 patients during the SARS-CoV-2 infection. None of the patients experienced complete hearing recovery after 3 months. High frequency hearing loss (at 4 kHz and 6 kHz) occurred bilaterally, and was found in 52 patients. This finding of gradual hearing loss was both the most characteristic and most common in COVID patients. Extensive damage can directly occur to inner ear structures, including hair cells, the Corti organ, and the cochlear nerve because of this viral infection. A total of 73 patients had tinnitus. 68 patients had unilateral tinnitus, and only 5 patients had bilateral tinnitus. Exacerbation of tinnitus was recorded in 12 patients and new-onset tinnitus in 61 patients. Vertigo occurred in 9 patients, all of which were new-onset. A conclusion of our research is that audiovestibular post-COVID syndrome does exist. Further research with more patients and over a longer period is needed to obtain a better and longer effect on the audiovestibular system and audiovestibular complications, as well as an insight into possible recovery.Svrha ovog istraživanja bio je prikazati i analizirati bolesnike s audiovestibularnim post-COVID-19 sindromom te istaknuti karakteristične i najčešće nalaze. Analizirali smo 87 bolesnika u dobi od 20 do 86 godina koji su se od 1. veljače 2021. do 1. srpnja 2021. godine javili u Audiološki odjel nakon što su prvi put izolirani zbog infekcije SARS-CoV-2, s pritužbama na trajni gubitak sluha, tinitus i vrtoglavicu koji su trajali dulje od 3 mjeseca. Rezultati studije pokazuju da je došlo do akutnog gubitka sluha kod 4 bolesnika tijekom infekcije SARS-CoV-2. Niti jedan od bolesnika nije doživio potpun oporavak sluha nakon 3 mjeseca. Visokofrekventni gubitak sluha (na 4 kHz i 6 kHz) dogodio se obostrano, a pronađen je u 52 bolesnika. Ovaj nalaz gubitka sluha bio je i najkarakterističniji i najčešći u bolesnika s infekcijom COVID. Tinitus je imalo 73 bolesnika. Jednostrani tinitus imalo je 68 bolesnika, a bilateralni tinitus samo 5 bolesnika. Pogoršanje tinitusa zabilježeno je u 12 bolesnika, a novonastali tinitus u 61 bolesnika. Vrtoglavica se pojavila u 9 bolesnika, od kojih su svi bili novonastali. Zaključak našega istraživanja je da audiovestibularni post-COVID sindrom postoji. Potrebna su daljnja istraživanja s više bolesnikai kroz dulje vrijeme kako bi se dobio bolji i dugotrajniji učinak na audiovestibularni sustav i audiovestibularne komplikacije, kao i uvid u mogući oporavak

Audiovestibularni post-COVID sindrom

Cilj ovoga istraživanja bio je prikazati i analizirati bolesnike s audiovestibularnim post-COVID-19 sindromom, te istaknuti karakteristične i najčešće nalaze u tonskoj audiometriji i vestibulometriji. Analizirali smo 87 bolesnika u dobi od 20 do 86 godina koji su se od 1. veljače 2021. do 1. srpnja 2021. godine javili u Zavod za audiologiju pri Klinici za bolesti uha, nosa i grla s kirurgijom glave i vrata u KBC Split, a nakon što su prvi put izolirani zbog infekcije SARS-CoV-2, s pritužbama na trajni gubitak sluha, tinitus i vrtoglavicu koji su trajali dulje od tri mjeseca. Svi simptomi pojavili su se za vrijeme aktivne faze bolesti. Bolesnici su selektirani prema gubitku sluha na one s iznenadnim, postupnim, te jednostranim ili obostranim senzoneuralnim gubitkom sluha, novonastalim tinitusom ili egzacerbacijom postojećeg tinitusa, te vrtoglavicom. Tonska audiometrija i timpanometrija urađena je svim ispitanicima, a vestibulometrijska ispitivanja samo onima s vrtoglavicom. Vizualno analogna skala (VAS) od 1 do 10 (od najblažih do najtežih simptoma) korištena je da bismo utvrdili težinu tinitusa. Rezultati studije pokazuju da je došlo do akutnog gubitka sluha kod 4 bolesnika tijekom infekcije SARS-CoV-2. Niti jedan od bolesnika nije doživio potpun oporavak sluha nakon tri mjeseca. U bolesnika s postupnim gubitkom sluha došlo je do obostranog visokofrekventnog gubitak sluha (na 4 kHz i 6 kHz) , a pronađen je u 52 bolesnika. Ovaj nalaz gubitka sluha bio je i najkarakterističniji i najčešći u bolesnika s infekcijom COVID. Tinitus je imalo 73 bolesnika. Jednostrani tinitus imalo je 68 bolesnika, a bilateralni tinitus samo pet bolesnika. Pogoršanje tinitusa zabilježeno je u 12 bolesnika, a novonastali tinitus u 61 bolesnika. Vrtoglavica se pojavila u devet bolesnika, od kojih su svi bili novonastali. Zaključak našega istraživanja je da audiovestibularni post-COVID sindrom postoji. Potrebna su daljnja istraživanja s više bolesnika kroz dulje vrijeme, kako bi se dobio bolji i dugotrajniji učinak na audiovestibularni sustav i audiovestibularne komplikacije, kao i uvid u mogući oporavak

A Battery in the Stenotic Esophagus of a Child with a Congenital Tracheoesophageal Fistula

A case of a three-year-old male child who was admitted to our hospital with the suspicion that he had swallowed a battery approximately one hour before admittance. The parents believed that it was a button-shaped lithium battery approximately 12 mm in diameter. A chest X-ray was taken immediately, and a battery was identified in the esophagus at the fifth thoracic vertebra. By reviewing the child’s medical history, we found that the child had had surgery the day after birth due to congenital atresia of the esophagus and a tracheoesophageal fistula type III b. An esophagoscopy was performed one hour after admittance, and the battery was found to be partially past the scar from the first surgery. Because of that, the battery was pushed further toward the stomach, out of fear that retrieving the battery through the scarred section of the child’s esophagus could damage the stenotic wall. Upon the next X-ray of the abdomen, the battery was observed in the stomach. The child was monitored, and X-rays were taken over the next several days. The battery was evacuated in stool eight days after it had been ingested

Audiovestibularni post-COVID sindrom

Cilj ovoga istraživanja bio je prikazati i analizirati bolesnike s audiovestibularnim post-COVID-19 sindromom, te istaknuti karakteristične i najčešće nalaze u tonskoj audiometriji i vestibulometriji. Analizirali smo 87 bolesnika u dobi od 20 do 86 godina koji su se od 1. veljače 2021. do 1. srpnja 2021. godine javili u Zavod za audiologiju pri Klinici za bolesti uha, nosa i grla s kirurgijom glave i vrata u KBC Split, a nakon što su prvi put izolirani zbog infekcije SARS-CoV-2, s pritužbama na trajni gubitak sluha, tinitus i vrtoglavicu koji su trajali dulje od tri mjeseca. Svi simptomi pojavili su se za vrijeme aktivne faze bolesti. Bolesnici su selektirani prema gubitku sluha na one s iznenadnim, postupnim, te jednostranim ili obostranim senzoneuralnim gubitkom sluha, novonastalim tinitusom ili egzacerbacijom postojećeg tinitusa, te vrtoglavicom. Tonska audiometrija i timpanometrija urađena je svim ispitanicima, a vestibulometrijska ispitivanja samo onima s vrtoglavicom. Vizualno analogna skala (VAS) od 1 do 10 (od najblažih do najtežih simptoma) korištena je da bismo utvrdili težinu tinitusa. Rezultati studije pokazuju da je došlo do akutnog gubitka sluha kod 4 bolesnika tijekom infekcije SARS-CoV-2. Niti jedan od bolesnika nije doživio potpun oporavak sluha nakon tri mjeseca. U bolesnika s postupnim gubitkom sluha došlo je do obostranog visokofrekventnog gubitak sluha (na 4 kHz i 6 kHz) , a pronađen je u 52 bolesnika. Ovaj nalaz gubitka sluha bio je i najkarakterističniji i najčešći u bolesnika s infekcijom COVID. Tinitus je imalo 73 bolesnika. Jednostrani tinitus imalo je 68 bolesnika, a bilateralni tinitus samo pet bolesnika. Pogoršanje tinitusa zabilježeno je u 12 bolesnika, a novonastali tinitus u 61 bolesnika. Vrtoglavica se pojavila u devet bolesnika, od kojih su svi bili novonastali. Zaključak našega istraživanja je da audiovestibularni post-COVID sindrom postoji. Potrebna su daljnja istraživanja s više bolesnika kroz dulje vrijeme, kako bi se dobio bolji i dugotrajniji učinak na audiovestibularni sustav i audiovestibularne komplikacije, kao i uvid u mogući oporavak

The association of allergy and otitis media with eff usion in children

Upala srednjeg uha s izljevom (OME) česta je bolest u djece s prevalencijom koja doseže do 20% i s utjecajem na provodni gubitak sluha, zakašnjeli razvoj govora i oštećenje sluznice srednjeg uha. Cilj ove studije je utvrditi povezanost alergija i perzistirajućih upala srednjeg uha s izljevom (OME) u djece. U istraživanje je uključeno sedamdeset šestero (76) djece između 2 i 14 godina s dijagnozom perzistirajuće upale srednjeg uha s izljevom, koja su podvrgnuta operativnom zahvatu postavljanja aerizacijskih cjevčica. Sedamdeset šestero (76) zdrave djece slične dobi koja su podvrgnuta različitim neotorinolaringološkim operativnim zahvatima uključena su u kontrolnu skupinu. Pozitivna anamneza alergijskog rinitisa, rezultati intradermalnih kožnih testova i vrijednosti ukupnog i specifi čnog IgE-a su dokumentirani.U skupini s dijagnozom upale srednjeg uha s izljevom 58-ero djece (76,3%) imalo je pozitivnu anamnezu alergijskog rinitisa, a njih 45-ero (59,2%) imalo je pozitivne nalaze intradermalnog kožnog testiranja. Vrijednosti ukupnog IgE-a bile su povišene u 46-ero djece (60.5%), a vrijednosti specifi čnog IgE-a bile su povišene u njih 39-ero (51,3%) u OME skupini. U kontrolnoj skupini 12-ero djece (15,8%) imalo je pozitivnu anamnezu alergijskog rinitisa, njih 10-ero (13,2%) imalo je pozitivne nalaze intradermalnog kožnog testiranja, vrijednosti ukupnog IgE-a bile su povišene u 17-ero djece (22,4%) iz kontrolne skupine, a njih 9-ero (11,8%) imalo je povišene vrijednosti specifi čnog IgE-a. Rad pokazuje značajno veću prevalenciju alergija u skupini djece s upalom srednjeg uha s izljevom u usporedbi s kontrolnom skupinom. Značajno veći broj pozitivnih nalaza alergoloških testiranja nalazimo u skupini djece s upalom srednjeg uha s izljevom u odnosu na kontrolnu skupinu.Otitis media with eff usion (OME) is a common disease in children with a prevalence of up to 20% and great impact on conductive hearing loss, delayed speech development and destruction of middle ear mucosa lining. The aim of the study was to evaluate the association of allergy and persistent OME in children. Seventy-six children aged 2 to 14 years diagnosed with OME were included in the study. Control group included 76 age-matched healthy children attending pediatric surgical unit for diff erent pediatric surgical procedures other than ENT surgery. Fifty-eight (76.3%) OME children had positive history of allergic rhinitis and 45 (59.2%) had positive results of intradermal skin tests. Total IgE levels were elevated in 46 (60.5%) children and specifi c IgE levels were elevated in 39 (51.3%) children in OME group. In control group, 12 (15.8) children had positive history of allergic rhinitis and only 10 (13.2%) had positive results of intradermal skin tests. Total IgE levels were elevated in 17 (22.4%) children and specifi c IgE levels were elevated in 9 (11.8%) control group children. This study showed the prevalence of allergic history to be higher in children with OME as compared with control group. The prevalence of positive results of diff erent allergy tests was also higher in the OME group as compared with control group

A study of surgical efficiency of ultrasonic shear (harmonic scalpel) thyroidectomy compared with conventional thyroidectomy

Uvod: Cilj rada je evaluirati uspješnost ultrazvučnog rezača u kirurgiji štitnjače u odnosu na konvencionalnu metodu. Radi se o prospektivnoj case-control studiji. Metoda rada: 69 bolesnika podvrgnuto je operaciji štitnjače u razdoblju od 24 mjeseca. Bolesnici su podijeljeni u dvije grupe ispitanika u odnosu na operativnu tehniku - tehnika ultrazvučnog rezača i konvencionalna tehnika (skalpel i bipolarna dijatermija). Da bi izmjerili kiruršku efikasnost koristili smo omjer operativnog vremena i težine ektomirane štitnjače (min/g). Rezultati: Srednje operativno vrijeme po jedinici težine uzorka je 2,49 min/g kod kirurgije štitnjače s ultrazvučnim rezačem, dok je kod konvencionalne metode 5,78 min/g. Razlika je bila statistički značajna (p = 0,037), dok je značajnija bila kod zahvata na manjim štitnjačama. Zaključak: Naša studija pokazuje da upotreba ultrazvučnog rezača u kirurgiji štitnjače skraćuje vrijeme kirurškog zahvata u odnosu na konvencionalnu metodu, naročito kada se radi o manjim štitnjačama.Introduction: The aim of our study is to evaluate the efficiency of ultrasonic shear (harmonic scalpel) thyroidectomy, compared with conventional thyroidectomy. Study design: Prospective, case control comparison. Methods: sixty- nine consecutive patients were recruited over a twenty-four month period. Patients were divided into two groups according to their thyroidectomy technique, i.e. ultrasonic shear technique (harmonic scalpel) vs conventional technique (scalpel and bipolar diathermy). The ratio of surgical time to specimen weight, in minutes per gram, was used to measure surgical efficiency. The unpaired Student`s test was used for statistical analysis. Results: The mean surgical time per specimen unit weight was 2.49 min/g for harmonic scalpel thyroidectomy and 5.78 min/g for conventional thyroidectomy. This difference was statistically significant (p = 0.037). The difference was most evident for procedures involving smaller thyroid glands. Conclusion: Our study suggests that thyroidectomy using a harmonic scalpel is more time-efficient than conventional thyroidectomy, especially when operating on smaller thyroid glands