International neuromonitoring study group guidelines 2018: Part II: Optimal recurrent laryngeal nerve management for invasive thyroid cancer-incorporation of surgical, laryngeal, and neural electrophysiologic data.

The purpose of this publication was to inform surgeons as to the modern state-of-the-art evidence-based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real-time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision-making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal. Level of Evidence: 5 Laryngoscope, 128:S18-S27, 2018.

Surgical management of the recurrent laryngeal nerve in thyroidectomy: American Head and Neck Society Consensus Statement.

"I have noticed in operations of this kind, which I have seen performed by others upon the living, and in a number of excisions, which I have myself performed on the dead body, that most of the difficulty in the separation of the tumor has occurred in the region of these ligaments…. This difficulty, I believe, to be a very frequent source of that accident, which so commonly occurs in removal of goiter, I mean division of the recurrent laryngeal nerve." Sir James Berry (1887).

Antibiotic resistance and otomycosis in the draining ear: culture results by diagnosis.

OBJECTIVE: The objective of the study was to better define changes in the bacteriology of suppurative otitis in recent years and the role of cultures in the management of these patients. STUDY DESIGN: A retrospective review was performed. METHODS: Outpatient records from 170 patients collected over 3 years with information regarding the bacteria cultured, antibiotic resistance, and clinical diagnosis were analyzed. RESULTS: A large variety of organisms were seen, with Staphylococcus aureus, Corynebacterium sp, and Pseudomonas aeruginosa being the most common. Forty percent of cultures showed bacteria with moderate antibiotic resistance, whereas 5% were sensitive to only intravenous antibiotics. Resistant bacteria were found in all diagnosis categories and were significantly higher in cases of chronic mastoiditis. The rate of methicillin-resistant S aureus infections was 7.8% and was significantly higher in cases of chronic myringitis. Fungus was often cultured in patients without clinical signs of otomycosis. CONCLUSIONS: Community-acquired ear infections may be caused by antibiotic-resistant bacteria in a substantial number of patients. In our opinion, outpatient cultures play an important role in the management of suppurative otitis.

Necrotizing fasciitis secondary to bisphosphonate-induced osteonecrosis of the jaw.

Osteonecrosis of the jaw is an uncommon consequence of biphosphonate therapy. This has most commonly been a bone complication with little if any soft tissue involvement. An unusual case of necrotizing fasciitis with extensive soft tissue infection stemming from a prolonged case of osteonecrosis of the jaw presented. The management of this patient (aggressive surgical debridement and prolonged wound care) is reviewed as well as the review of the underlying processes.

Is there a role for fluorodeoxyglucose positron emission tomography/computed tomography in cytologically indeterminate thyroid nodules?

OBJECTIVE: The aim of this study was to determine the accuracy of the fluorine 18 ((18)F)-labeled fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scan in the evaluation of thyroid nodules in which the cytopathology of fine-needle aspiration (FNA) biopsies are classified as "indeterminate," ie, either follicular or Hürthle cell lesion. METHODS: At an academic medical center, we conducted a prospective pilot study of 15 patients with thyroid nodules in whom adequate FNA was diagnosed as indeterminate. All patients underwent a whole-body FDG-PET/CT scan followed by thyroidectomy. Preoperative FDG-PET/CT results and the histopathology of the surgical specimen were compared and statistically analyzed. RESULTS: The FNA demonstrated follicular cells in 11 (73%) patients, Hürthle cells in 3 (20%) patients, and both types of cells in 1 (7%) patient. The histopathology of the surgical specimen revealed thyroid cancer in 7 (47%) patients. The FDG-PET/CT scan was positive in 8 patients; 4 (50%) patients were found to have cancer. The FDG-PET/CT scan was negative in 7 patients. Four of these patients had benign lesions and 3 had thyroid carcinoma. Thus, 4 (27%) patients had false-positive FDG-PET/CT scans and 3 (20%) patients had false-negative studies. The sensitivity of FDG-PET/CT to detect a malignant focus was 57% with a specificity of 50%. The positive predictive value was 50% and the negative predictive value was 57%. CONCLUSIONS: In this pilot study of patients with cytologically indeterminate thyroid nodules, FDG-PET/CT was not a predictable indicator of benign or malignant disease. Although a larger series may elucidate a role for FDG-PET/CT, the relatively low predictability shown in this study should caution clinicians about using FDG-PET/CT to consider foregoing thyroidectomy for cytologically indeterminate nodules.

Titanium middle ear prostheses in staged ossiculoplasty: does mass really matter?

OBJECTIVES: Several articles have demonstrated the efficacy of titanium middle ear prostheses. Our study compares the results of 2 brands of titanium implants that differ in design and weight to assess potential benefit of one over the other. The purpose of this study was to investigate the relationship of prostheses mass based on the stiffness vs mass curve of acoustic transfer between 2 different brands of titanium implants. STUDY DESIGN: A retrospective study was done for this article. METHODS: A chart review was conducted including the postoperative results, complications, and audiometric data for 34 patients with titanium middle ear implants (21 Tuebingen VARIO prostheses [Kurz Co, DuBlingen, Germany] and 13 Micron Monolithic prostheses [Gyrus ENT, Bartlett, TN]) with an average follow-up of 19 months. Both total and partial prostheses were included. Average postoperative air-bone gap (ABG) and average improvement in ABG was compared between the groups. RESULTS: There was a considerable variability in the postoperative results with both implants. Both the Kurz prostheses (group A) and the Gyrus prostheses (group B) demonstrated an average postoperative ABG of less than 25 dB (23.2 and 21.3 dB). There was no significant difference between the groups. Both groups also demonstrated an improvement in average ABG (preoperative minus postoperative ABG), 9.6 and 11.2 dB. There was no significant difference between the 2 prosthesis types in the frequency-specific ABG (500, 1000, 2000, and 4000 Hz). Both groups demonstrated maximal resonant frequency at 2000 Hz. The extrusion rates (5% and 8%) were comparable between the groups. CONCLUSION: Factors other than the prosthesis design (eg, surgical technique, fibrosis, retraction, and cholesteatoma) primarily determine hearing results after staged ossiculoplasty. The differences we noted in frequency-specific hearing improvement do not demonstrate that the mass of the prostheses plays a significant role in outcome.

Long-term results of inferior turbinate hypertrophy with radiofrequency treatment: a new standard of care?

OBJECTIVE: The objective of this study was to report the long-term efficacy of radiofrequency volumetric tissue reduction (RFVTR) and to compare this with other accepted surgical treatments of inferior turbinate hypertrophy. STUDY DESIGN AND SETTING: Prospective, 2-year follow-up of 19 patients originally enrolled in a prospective, randomized, single blinded, placebo controlled trial for treatment of inferior turbinate hypertrophy with RFVTR. Patients evaluated their severity of obstruction, frequency of obstruction, and overall ability to breathe by way of a 10 cm visual analogue scale. RESULTS: RFVTR for inferior turbinate hypertrophy showed continued benefit at 2 years posttreatment, with no indication of increasing symptomatology. The benefit demonstrated in frequency of obstruction, severity of obstruction, and overall ability to breathe (P < .05) was maintained at 2 years. No complications occurred. Review of the literature shows lower short- and long-term complications for RFVTR compared with other surgical methods CONCLUSION: RFVTR is effective in treating inferior turbinate hypertrophy with sustained benefit at 2 years follow-up while resulting in fewer complications than other surgical methods. SIGNIFICANCE: RFVTR is a relatively new procedure, and therefore there are few long-term evaluations of its effectiveness; this is the first prospective study to document successful outcomes at 2 years follow-up.

Dietary nucleotides prevent decrease in cellular immunity in ground-based microgravity analog.

Microgravity and stress of spaceflights result in immune dysfunction. The role of nutrition, especially nucleotide supplementation, has become an area of intensive research and significant interest in immunomodulation for maintenance of cellular immune responses. The studies presented here evaluate the plausibility of administering nucleotides to obviate immune dysfunction in an Earth-based in vivo analog of microgravity as studied in anti-orthostatic tail suspension (AOS) of mice. Mice were divided into three housing groups: group, isolation, and AOS. Mice were fed either control chow diet (CD), or RNA-, adenine-, or uracil-supplemented CD for the 1-wk duration of the experiments. In AOS mice, supplemental nucleotides significantly increased in vivo lymph node proliferation and ex vivo lymphoproliferation response to alloantigen and mitogens, respectively, and interleukin-2 and interferon-gamma production. A lower corticosterone level was observed in uracil-supplemented CD compared with CD. These results suggest that exogenous nucleotide supplementation, especially uracil, of normal diet is beneficial in the maintenance and restoration of the immune response during the microgravity analog conditions.