Open Access Indonesian Journal of Medical Reviews

Transient Unilateral Recurrent Laryngeal Nerve Palsy Presenting as Post-extubation Stridor after Total Thyroidectomy for Non-toxic Multinodular Goiter: Anesthetic Implications and Airway Rescue

Muhammad Rezha Mansyur — 2026-06-01

Total thyroidectomy is among the most frequently performed endocrine procedures worldwide, yet it carries a defined risk of recurrent laryngeal nerve (RLN) injury that can precipitate post-extubation stridor and emergent airway compromise. Transient unilateral RLN palsy is estimated to occur in 2 to 10 percent of cases for benign disease and remains an important anesthetic consideration even in carefully planned surgery. We report the case of a 53-year-old woman with controlled hypertension and a longstanding bilateral non-toxic multinodular goiter of 8.5 by 10 centimeters who underwent intraoperative conversion from subtotal to total thyroidectomy under general anesthesia with endotracheal intubation. Intraoperative course was stable on a balanced regimen of midazolam, fentanyl, propofol, atracurium, and isoflurane. Ten minutes after a smooth extubation, she developed inspiratory stridor, suprasternal retractions, and desaturation. Awake reintubation with preserved spontaneous ventilation was performed using low-dose sedation, intravenous lidocaine, and direct laryngoscopy, which simultaneously secured the airway and demonstrated paresis of the left vocal cord while the right cord was mobile. The patient was transferred to the intensive care unit, received systemic methylprednisolone, and was extubated successfully within 24 hours with complete recovery of bilateral vocal cord mobility on follow-up laryngoscopy. In conclusion, awake reintubation with maintained spontaneous breathing is a powerful maneuver that secures the airway and confirms the laryngeal diagnosis at a single procedure. Early systemic corticosteroid, vigilant monitoring, and otolaryngology liaison support rapid neurapraxia recovery, with multidisciplinary cooperation as the cornerstone of a favorable outcome.

Medial Condyle Fracture of the Humerus Following an Arm-Wrestling Injury in an Adolescent: A Rare Kilfoyle Type II Injury with Transient Ulnar Neuropathy Managed by Open Reduction and Pinning

I Gede Mandra Adnyana — 2026-06-03

Fractures of the medial condyle of the humerus are uncommon injuries in the pediatric and adolescent population, accounting for fewer than two percent of elbow fractures, yet they are clinically important because the fracture line crosses both the articular surface and the distal humeral physis. Delayed or inadequate treatment may lead to nonunion, growth arrest, cubitus varus or valgus deformity, and elbow instability. We report a 15-year-old male who presented with one month of persistent left elbow pain after an arm-wrestling contest during which the elbow shifted and he fell onto the affected arm. He described intermittent paresthesia of the ring and little fingers and morning stiffness. Examination revealed medial elbow swelling, tenderness over the medial condyle, painfully limited motion, and paresthesia in the ulnar nerve distribution. Plain radiographs confirmed a left medial condyle fracture classified as Kilfoyle type II. Because of the intra-articular nature of the injury and the risk of displacement, open reduction and internal fixation with Kirschner-wire pinning was performed, followed by intravenous fluid support, ceftriaxone for prophylaxis, and intravenous paracetamol for analgesia. One week postoperatively the patient showed marked improvement, with resolution of stiffness, reduced pain, recovered range of motion, and improvement of the ulnar nerve symptoms, and no complications were observed. This report highlights arm wrestling as a rare mechanism of adolescent medial condyle fracture, its association with transient ulnar neuropathy, and the favorable early outcome achievable with prompt anatomical fixation and structured postoperative care.

Probiotics and Synbiotics for Glycaemic Control and Beta-Cell Function in Children with Type 1 Diabetes Mellitus: A Meta-Analysis of Randomised Controlled Trials

Michael Theodore — 2026-06-29

Gut dysbiosis has been implicated in the pathogenesis and progression of type 1 diabetes mellitus (T1DM), and microbiota-based interventions have been proposed as adjuncts to insulin. The paediatric evidence remains fragmented and the effect on residual beta-cell function has not been a focus. This meta-analysis quantified the effect of probiotic and synbiotic supplementation on glycated haemoglobin (HbA1c) and synthesised beta-cell and immune outcomes in children with T1DM. PubMed/MEDLINE was searched for randomised controlled trials (RCTs) of oral probiotics, prebiotics, or synbiotics added to insulin in T1DM, with HbA1c as the primary outcome. Standardised mean differences (SMD, Hedges’ g) were pooled with a random-effects model (DerSimonian–Laird). Subgroup, leave-one-out, an a-priori paediatric-only sensitivity, and exploratory small-study analyses were performed. Risk of bias used Cochrane RoB 2.0. Beta-cell and immune outcomes were synthesised narratively. Seven RCTs (453 participants) were included. Supplementation produced a significant, small-to-moderate reduction in HbA1c (pooled g = −0.50, 95% CI −0.71 to −0.30; z = −4.94, p < 0.0001), with low heterogeneity (I² = 11.0%, τ² = 0.008, Q = 6.74, df = 6, p = 0.345) and a prediction interval of −0.84 to −0.17, corresponding to about 0.3 to 0.5 HbA1c percentage points. The effect was consistent across disease stage (between-group p = 0.957), was preserved in the strictly paediatric analysis (g = −0.54), and was robust to leave-one-out removal. Beta-cell outcomes were inconsistent. Supplementation was safe. In conclusion, in children with T1DM, probiotics and synbiotics conferred a modest but consistent improvement in HbA1c, without convincing evidence of beta-cell preservation. The intervention appears safe but the clinical magnitude is small and does not currently justify a change to routine practice.

Laparoscopic Valve-Preserving Cecectomy for Fibrous Obliteration of the Appendix Mimicking an Appendiceal Mucocele: A Case Report

Rizky Ratria Kusumawardhani — 2026-07-08

Fibrous obliteration of the appendix is an under-recognized, benign process in which the normal appendiceal mucosa, lymphoid follicles, and submucosa are progressively replaced by fibroblastic and neurogenic tissue. When the obliterated lumen dilates and accumulates low-attenuation material, it can closely imitate an appendiceal mucocele or a low-grade appendiceal mucinous neoplasm on computed tomography (CT), creating a therapeutic dilemma: the surgeon must avoid both under-treatment, which risks a neoplastic margin or pseudomyxoma peritonei, and over-treatment with an unnecessary colectomy. We report a 59-year-old woman with six months of recurrent epigastric and right-lower-quadrant pain and a soft, non-peritonitic abdomen, in whom contrast-enhanced CT showed a well-defined, tubular, fluid-density appendiceal lesion measuring 4.5 × 2.4 × 6 cm extending toward the cecum, with a basal calcific focus and no post-contrast enhancement, interpreted as a probable mucocele. Given its size, basal location, and indeterminate nature, a laparoscopic cecectomy was performed: the mesoappendix and ligament of Treves were sealed and divided, the right colon was mobilized, and the cecum was transected with a linear stapler oriented to preserve the ileocecal valve, with intact en-bloc retrieval in an endobag. Histopathology revealed fibrous obliteration—luminal replacement by spindle cells in a loose fibromyxoid stroma with chronic inflammation and absent normal mucosa—rather than a mucinous neoplasm. Recovery was uneventful, with a one-day stay and resolution of the right-sided pain. Valve-preserving laparoscopic cecectomy is a safe, function-sparing alternative to segmental colectomy for selected benign appendiceal and cecal disease when the base is involved or the diagnosis is indeterminate.