Metacarpal Stress Fractures in Athletes: A Systematic Review.

BACKGROUND: Stress fractures in general are common injuries; however, there is limited literature on metacarpal stress fractures in athletes. Our objective is to contribute the first systematic review of metacarpal stress fractures in athletes, with a particular focus on epidemiology, presentation, and outcomes. METHODS: A systematic review regarding metacarpal stress fractures in athletes was performed via PubMed, EMBASE, MedLine, Cochrane, and Web of Science. Inclusion criteria consisted of case reports and case series of metacarpal stress fractures in athletes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: A total of 11 studies (29 cases) were included. The mean patient age was 17 years, with 12 men and 15 women. The most common sports were tennis and badminton. The most common presentation was pain in the dorsal aspect of the hand related to activity. All patients underwent successful nonoperative management, with mean return to play of 9 weeks. CONCLUSIONS: Metacarpal stress fractures can present with significant pain and impact performance in athletes who perform sports involving repetitive movements of the hand and wrist. Nonoperative treatment, consisting of abstinence from sport until the patient was pain free combined with gradual return to play, was successful for all patients. The addition of proper technique and training load can result in satisfactory return to play. For patients who present with hand pain related to exercise, particularly a young racquet sport player, metacarpal stress fractures are a "can't miss" diagnosis associated with significant functional impairment.

ChatGPT Responses to Frequently Asked Questions on Ménière's Disease: A Comparison to Clinical Practice Guideline Answers.

Objective: Evaluate the quality of responses from Chat Generative Pre-Trained Transformer (ChatGPT) models compared to the answers for "Frequently Asked Questions" (FAQs) from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Clinical Practice Guidelines (CPG) for Ménière's disease (MD). Study Design: Comparative analysis. Setting: The AAO-HNS CPG for MD includes FAQs that clinicians can give to patients for MD-related questions. The ability of ChatGPT to properly educate patients regarding MD is unknown. Methods: ChatGPT-3.5 and 4.0 were each prompted with 16 questions from the MD FAQs. Each response was rated in terms of (1) comprehensiveness, (2) extensiveness, (3) presence of misleading information, and (4) quality of resources. Readability was assessed using Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease Score (FRES). Results: ChatGPT-3.5 was comprehensive in 5 responses whereas ChatGPT-4.0 was comprehensive in 9 (31.3% vs 56.3%, P = .2852). ChatGPT-3.5 and 4.0 were extensive in all responses (P = 1.0000). ChatGPT-3.5 was misleading in 5 responses whereas ChatGPT-4.0 was misleading in 3 (31.3% vs 18.75%, P = .6851). ChatGPT-3.5 had quality resources in 10 responses whereas ChatGPT-4.0 had quality resources in 16 (62.5% vs 100%, P = .0177). AAO-HNS CPG FRES (62.4 ± 16.6) demonstrated an appropriate readability score of at least 60, while both ChatGPT-3.5 (39.1 ± 7.3) and 4.0 (42.8 ± 8.5) failed to meet this standard. All platforms had FKGL means that exceeded the recommended level of 6 or lower. Conclusion: While ChatGPT-4.0 had significantly better resource reporting, both models have room for improvement in being more comprehensive, more readable, and less misleading for patients.

Sex-Stratified Predictors of Prolonged Operative Time and Hospital Admission in Outpatient Parathyroidectomy.

Our retrospective database study investigates sex-stratified predictors of prolonged operative time (POT) and hospital admission following parathyroidectomy for primary hyperparathyroidism (PHPT). The 2016 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients with PHPT undergoing parathyroidectomy. Cases analyzed were all outpatient status, arrived from home, coded as non-emergent, and elective. POT was defined by the 75th percentile. Hospital admission was defined as LOS ≥ 1 day. Univariate and multivariable binary logistic regressions were utilized. Of 7442 cases satisfying inclusion criteria, the majority were female (78.0%) and White (78.5%). Median OT (IQR) for females and males was 77 (58-108) and 81 (61-109) minutes, respectively (P = 0.003). 1965 (33.9%) females and 529 (32.3%) males required hospital admission. Independent predictors of POT included ASA class III/IV (aOR 1.342, 95% CI 1.007-1.788) and obesity (aOR 1.427, 95% CI 1.095-1.860) for males (P < 0.05). Independent predictors of hospital admission included age (aOR 1.008, 95% CI 1.002-1.014), ASA class III/IV (aOR 1.490, 95% CI 1.301-1.706), obesity (aOR 1.309, 95% CI 1.151-1.489), dyspnea (aOR 1.394, 95% CI 1.041-1.865), chronic steroid use (aOR 1.674, 95% CI 1.193-2.351), and COPD (aOR 1.534, 95% CI 1.048-2.245) for females (P < 0.05); and ASA class III/IV (aOR 1.931, 95% CI 1.483-2.516) and bleeding disorder (aOR 2.752, 95% CI 1.443-5.247) for males (P < 0.005). In conclusion, predictors of POT and hospital admission following parathyroidectomy for PHPT differed by patient sex. Identifying patients at risk for POT and hospital admission may optimize healthcare resource utilization. Level of Evidence: IV. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04444-3.

Extranodal extension in laryngeal squamous cell carcinoma.

Objective: Although large retrospective database studies have associated extranodal extension (ENE) with worse survival in several head and neck cancers, the prognostic significance of ENE in laryngeal squamous cell carcinoma (LSCC) remains unclear. Our study examines ENE and overall survival (OS) in LSCC. Methods: The 2006-2017 National Cancer Database was queried for patients with LSCC undergoing surgical resection and neck dissection, with or without adjuvant therapy. Kaplan-Meier and multivariable Cox regression survival analyses were implemented to identify the independent impacts of pathologic nodal (pN) classification and ENE on OS. Results: Of 4208 patients satisfying inclusion criteria, 2343 (55.7%) were pN0/ENE-negative, 1059 (25.2%) were pN1-2/ENE-negative, and 806 (19.2%) were pN1-2/ENE-positive. The 5-year OS of pN0/ENE-negative, pN1-2/ENE-negative, and pN1-2/ENE-positive patients was 62.8%, 56.7%, and 32.9%, respectively (p < .001). Among pN1-2/ENE-positive patients undergoing no adjuvant therapy, adjuvant radiotherapy alone, and adjuvant chemoradiotherapy, 5-year OS was 24.1%, 30.7%, and 36.7%, respectively (p < .001). After adjusting for patient demographics, clinicopathologic features, and adjuvant therapy, ENE-positivity was associated with worse OS than ENE-negativity (adjusted hazard ratio [aHR] 1.76, 95% confidence interval [CI] 1.53-2.02, p < .001). pN1/ENE-positivity (aHR 1.82, 95% CI 1.31-2.54) and pN2/ENE-positivity (aHR 1.89, 95% CI 1.49-2.40) were associated with worse OS than pN1/ENE-negativity (p < .001). Microscopic (aHR 1.83, 95% CI 1.54-2.18) and macroscopic ENE-positivity (aHR 1.75, 95% 1.35-2.26) were associated with worse OS than ENE-negativity (p < .001). Conclusion: ENE-positivity has prognostic significance in LSCC and is associated with worse OS than ENE-negativity. pN classification did not have prognostic significance independent of ENE. ENE should be carefully considered when determining the prognosis of LSCC and selecting adjuvant therapy. Level of Evidence: 4.

Thyroid Ethanol and Radiofrequency Ablation: A Call for Patient-Friendly Online Resources.

INTRODUCTION: The multiple treatment options available to patients with thyroid nodules can generate uncertainty and confusion. Radiofrequency ablation (RFA) and ethanol ablation (EA) are two alternative modalities to manage thyroid nodules. As patients more frequently utilize online resources to guide their decision-making, the quality of such resources must be evaluated. The goal of this study was to assess the quality of online patient materials relating to RFA and EA compared to standard thyroidectomy. METHODS: The terms "thyroidectomy," "thyroid radiofrequency ablation," and "thyroid ethanol ablation" were searched on Google. Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG), and Patient Education Materials Assessment Tool (PEMAT) understandability and actionability were calculated for each website. Statistical analysis was conducted on SPSS Statistics. Google trends were used to determine search interest for each term (May 2016 - May 2021). RESULTS: Of the 77 websites that met our inclusion criteria (30 thyroidectomy sites, 30 RFA sites, and 17 EA sites), the average FRE, FKGL, and SMOG scores of the RFA websites were significantly worse than those of the thyroidectomy websites (p < 0.05). The FKGL and SMOG scores of the EA websites were significantly worse than those of the thyroidectomy websites (p < 0.05). The average understandability and actionability scores for thyroidectomy websites were significantly higher than those of RFA and EA websites (p < 0.05). CONCLUSION: Ablation websites have lower search interest, readability, validity, understandability, and actionability scores in comparison to traditional thyroidectomy websites. Our findings emphasize the need to consider readability and PEMAT scores when developing online educational resources for ablative alternatives to thyroidectomy to allow for greater patient accessibility.

Outcomes of Supracricoid Partial Laryngectomy Performed in the United States: A Systematic Review.

OBJECTIVE: The primary objective of this study was to evaluate oncologic outcomes of all published cases of supracricoid partial laryngectomy (SCPL) performed in the United States. The secondary objective was to assess the functional outcomes associated with this procedure. REVIEW METHODS: A systematic review of PubMed, SCOPUS, and Embase for all English-language studies pertaining to SCPL performed in the United States was conducted until August 2021. Primary outcomes included disease-specific survival (DSS), overall survival, and local recurrence rate. Secondary outcomes included larynx preservation rate, gastrostromy tube dependency, days to gastrostomy tube removal, decannulation rate, and days to decannulation. RESULTS: A total of six studies were included in the analysis. A total of 113 patients (58.5%) underwent SCPL surgery as a primary treatment method whereas 80 patients (41.5%) underwent SCPL as salvage surgery. The 5-year DSS rates were 87.8% and 100% for primary and salvage procedures, respectively. Approximately 10.3% of patients undergoing a salvage SCPL procedure experienced a local recurrence whereas only 1.85% of primary SCPL procedures resulted in local recurrence. The rates of decannulation following primary and salvage SCPL were 92.7% and 88.1%, respectively. With regard to swallowing, primary and salvage SCPL procedures demonstrated comparably low postoperative gastrostomy tube dependency rates of 3.66% and 4.76%, respectively. CONCLUSIONS: SCPL performed in the United States is an effective surgical technique that produces excellent outcomes in qualifying patients, thus validating its viability as an organ-preserving surgical alternative. Laryngoscope, 134:3003-3011, 2024.

Thyroid cancer necrosis not evident on imaging: A cautionary case series on poorly differentiated thyroid carcinoma diagnosed only on final pathology.

OBJECTIVE: Poorly-differentiated thyroid cancer (PDTC) is a highly aggressive malignancy which is recently defined and understudied in the radiologic literature. Necrosis is a key histopathologic criterion for the diagnosis of PDTC. We illustrate the current difficulty in accurate identification of histopathologic necrosis on preoperative imaging. METHODS: A series of seven patients with the final diagnosis of PDTC from our institution were identified. Multimodality preoperative imaging was analyzed by two head and neck radiologists. Final pathology reports were queried confirming histopathologic evidence of necrosis. RESULTS: Patients presented with a wide range of preoperative imaging features. A consistent imaging appearance confirming necrosis was not identified. All patients were subsequently upstaged to PDTC following final pathological analysis. CONCLUSION: A lack of definitive evidence of necrosis on preoperative imaging does not exclude the possibility of PDTC. We demonstrate the need for further research to establish a clear methodology for the preoperative diagnosis of PDTC.

A novel method of hard palate reconstruction utilizing a combination of the buccal fat pad and palatal island flap.

The palatal island flap is reliable for single-staged reconstruction of select oral defects. However, fistula formation is a disruptive potential complication. The authors employed this technique in five patients and present a representative case of a 65-year-old female with a left-sided palatal salivary neoplasm. The patient underwent resection and was reconstructed utilizing a combination of the buccal fat pad and palatal island flap. Four of the five patients healed uneventfully. One patient experienced partial loss of the marginal zone of the palatal island flap which successfully granulated and did not lead to an oroantral fistula. The representative patient recovered uneventfully. At 2 weeks, she felt well, with no evidence of fistula. The anterior palate demonstrated early mucosalization. We present the novel, combined use of the palatal island flap and buccal fat pad flap to create a two-layer closure and describe its advantages for posterior palate reconstruction.

The anatomical basis for preserving the blood supply to the parathyroids during thyroid surgery, and a review of current technologic advances.

BACKGROUND: Devascularization of the parathyroid glands is generally accepted as the most common mechanism for iatrogenic hypocalcemia, a frequently seen complication of both total and completion thyroidectomy procedures. Much has been written about iatrogenic hypoparathyroidism, but few papers have precisely delineated the arterial supply of the parathyroid glands and the common anatomical variations that may impact parathyroid preservation during thyroid surgery. METHODS: We offer an illustrated review and discussion of the only two anatomic studies published in the medical literature focusing on parathyroid vasculature. In addition, we examine current techniques of parathyroid identification, preservation, and classification. FINDINGS: A surgical technique that preserves the parathyroid arteries is vital to preserving the viability of the parathyroid gland(s) during thyroid surgery. In 1907, Halsted and Evans described a technique of ligating the distal branches of the thyroid arteries beyond the origin of the parathyroid arteries, a technique termed ultra-ligation. In 1982, Flament et al.. reported three distinct anatomical variations of the parathyroid arteries which place the parathyroid blood supply at risk for devascularization during thyroid surgery. Our review also highlights novel techniques that aid surgeons in identification and assessment of the parathyroid glands. CONCLUSIONS: Recognition of the variations of parathyroid anatomy and their potential to lead to devascularization aids thyroid surgeons in their pursuit of parathyroid preservation. An awareness of the variety of novel parathyroid identification and preservation techniques can assist surgeons to achieve this goal.

Rare case of anaplastic plasmacytoma in the sinonasal tract.

BACKGROUND: Extramedullary plasmacytomas are tumors that develop from plasma cells and rarely express anaplastic features. To our knowledge, there have only been three reported cases of anaplastic plasmacytomas of the sinonasal tract in the English literature. We detail the fourth case. METHODS: A 70-year-old male was seen with a 4-month history of nasal congestion, bloody mucous, and left sided nasal obstruction. On positron emission tomography/computed tomography, the lesion was FDG-avid with an SUVmax of 25.1. A biopsy of the lesion and subsequent immunohistochemical staining confirmed the diagnosis of an anaplastic plasmacytoma. RESULTS: The patient is undergoing a 5-week course of curative-intent radiation therapy. CONCLUSION: Extramedullary plasmacytomas with anaplastic features are very rare. We highlight the value of thorough histopathological review and detailed immunostains to arrive at a diagnosis of anaplastic extramedullary plasmacytoma.

Reconstruction of the external auditory canal: The tragal flap revisited and review of contemporary reconstructive techniques.

BACKGROUND: Primary malignancies arising in the external auditory canal (EAC) are rare and usually are treated surgically. We review techniques to reconstruct the EAC following ablative surgery, and introduce a rarely utilized tragal skin flap which has particular advantages for reconstruction of limited anterior EAC defects. METHODS: The terms "tragal flap", "external auditory canal", "preauricular tragal flap", "reconstructive techniques" were searched on PubMed and Google Scholar. RESULTS: Our review identified one description of a tragal flap to reconstruct the EAC following resection of a malignancy. We add an additional case of a preauricular tragal flap to reconstruct the anterior EAC following resection of a recurrent basal cell carcinoma located in the EAC that led to a circumferential defect. CONCLUSION: There are several surgical techniques that can be utilized to reconstruct the EAC. We describe a novel tragal flap used to reconstruct the anterior EAC following resection of a recurrent tumor.