Outcome analysis of 215 patients with parotid gland tumors: a retrospective cohort analysis.

BACKGROUND: To identify prognostic factors in patients with parotid gland carcinomas who were treated at the Princess Margaret Hospital. METHODS: Clinical outcome of two hundred fifteen patients with malignancies of the parotid gland was evaluated over a 16-year period. RESULTS: Two-hundred-fifteen patients with adenoid cystic carcinoma (n = 20), adenocarcinoma (n = 19), acinic cell carcinoma (n = 62), basal cell adenocarcinoma (n = 7), carcinoma-ex-pleomorphic adenoma (n = 18), mucoepidermoid carcinoma (n = 70) and salivary duct carcinoma (n = 19) have been included. The 5- and 10-year overall and disease-free survivals were 80.62%/69.48% and 74.37%/62.42%, respectively. Multivariable analysis showed that age greater than 60 years, advanced pN classification, histopathological grade and the presence of lymphovascular invasion significantly worsened overall and disease-free survival. Univariable analysis revealed periparotid lymph node involvement was associated with decreased overall (p < 0.0001) and disease-free survival (p < 0.0001). CONCLUSIONS: In addition to age, pN classification, histopathological grade, perineural invasion, and lymphovascular involvement, periparotid lymph node metastasis appears to be an important prognosticator in parotid gland malignancy.

Assessment of phonomicrosurgical training in otolaryngology residencies: a resident survey.

OBJECTIVES/HYPOTHESIS: The primary objective of this study is to assess the adequacy of clinical and laboratory-based phonomicrosurgical training in otolaryngology residency programs using a self-report survey. The study aims to establish whether there is a need and desire for focused surgical training in phonomicrosurgery. STUDY DESIGN: Self-report Internet-based questionnaire. METHODS: An anonymous survey was sent to all current residents in otolaryngology training programs in the United States and Canada. For portions of the analysis, the residents were categorized into two groups--junior (R2 and R3) and senior (R4 and R5). RESULTS: One hundred ninety-one residents responded to the survey (USA: 166; Canada: 25), representing a 34.3% response rate. Approximately one-half of residents stated that their residency program includes a rotation during which the main emphasis is laryngology. Only 18.8% of residents were "very" satisfied with the phonomicrosurgery experience that their program offers and 21.6% of senior residents felt "very" comfortable performing a phonomicrosurgical removal of a vocal fold lesion. Whereas the vast majority of respondents found temporal bone laboratory training to be helpful, 82% had never performed laboratory training in phonomicrosurgery. The majority (87.4%) felt that their comfort level with phonomicrosurgery would increase if they had access to laboratory-based training. CONCLUSION: Our study suggests that there is a lack of emphasis on clinical and laboratory-based training in phonomicrosurgery and that there is a need and desire for focused surgical training in phonomicrosurgery.

Office-based botulinum toxin injections.

Botulinum toxin injections are an effective treatment option for several laryngeal disorders. This article reviews the indications, procedural techniques, potential complications, and outcomes of Botox injections for laryngeal disorders.

Office-based laryngeal procedures.

Awake office-based laryngeal procedures offer numerous advantages to the patient and surgeon. These procedures are well-tolerated, safe, and can be used to treat a wide variety of laryngeal pathology. This article discusses office-based laser procedures and laryngeal biopsies. Indications, procedural techniques, postprocedural care, and potential complications are reviewed in detail.

Computed tomography has low yield in the evaluation of idiopathic unilateral true vocal fold paresis.

OBJECTIVE/HYPOTHESIS: To determine the clinical yield of neck and chest computed tomography in the initial assessment of patients with idiopathic unilateral true vocal fold paresis. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review of consecutive adult patients with idiopathic unilateral true vocal fold paresis diagnosed by stroboscopy in a tertiary-care voice center from 2003 to 2010. RESULTS: There were 176 patients with unilateral vocal fold paresis of which 81 subjects had idiopathic unilateral true vocal fold paresis. Of these, 60 patients (74.1%) had a computed tomography workup. Fifty-nine patients (98.3%) had a normal computed tomography while one patient had a single mediastinal lymph node that was PET-CT negative. This demonstrates an initial 1.7% yield and ultimate 0% yield of the computed tomography workup. CONCLUSION: Our results suggest that computed tomography workup has a low yield for occult neck and mediastinal pathology in patients with idiopathic unilateral true vocal fold paresis. Chest and neck computed tomography may not be clinically beneficial provided the patient has good otolaryngologic and medical follow-up.

Methicillin-resistant and methicillin-sensitive Staphylococcus aureus laryngitis.

OBJECTIVES/HYPOTHESIS: Despite the fact that a wide variety of head and neck methicillin-resistant Staphylococcus aureus (MRSA) infections have been described, only four cases of MRSA laryngitis are reported in the literature. Our clinical experience suggests that this diagnosis is more common and can be more subtle that previously reported. The objective of this study was to identify and describe the clinical presentation, diagnosis, treatment, and outcomes of MRSA and methicillin-sensitive S aureus (MSSA) laryngitis, highlighting the in-office workup of these patients. STUDY DESIGN: Retrospective case series. METHODS: All patients with a culture-proven diagnosis of S aureus laryngitis treated within the Emory Voice Center, Department of Otolaryngology-Head and Neck Surgery at Emory University between 2007 and 2011. Demographic, diagnostic, and treatment data were retrospectively collected from the patients' hospital records. RESULTS: Three patients with culture-proven MRSA laryngitis were identified. Three further cases of MSSA were also identified. Patients ranged in age from 34 to 74 years. All three patients with MRSA were diabetics. All six patients in the study were current or past users of cigarettes. The most common presenting symptoms were vocal roughness, vocal fatigue, and decreased vocal endurance. There were no symptoms of airway or swallowing compromise. The duration of symptoms at the time of initial assessment ranged from 3 months to 5 years, and most patients had undergone numerous previous treatments. Common signs on laryngeal examination included thickened vocal fold epithelium, whitish debris or the appearance of leukoplakia, edema, and crusting. Signs and symptoms were similar in MRSA and MSSA patients. The diagnosis was made in all patients via awake in-office culture of the larynx. All patients were treated with a prolonged course of trimethoprim-sulfamethoxazole (2-4 weeks). Although repeated courses of treatment were required, most patients had an excellent response to treatment. CONCLUSIONS: This is the largest, single, case series of patients with MRSA laryngitis. Our study findings suggest that the diagnosis may be more common than previously recognized, and that the presenting signs and symptoms may be subtle and similar to MSSA. Diagnosis can be made via in-office laryngeal culture. Clinicians must have a high index of suspicion for this diagnosis.

Efficacy and safety of central compartment neck dissection for recurrent thyroid carcinoma.

OBJECTIVE: To explore the safety and efficacy of central compartment neck dissection (CCND) in the treatment of well-differentiated thyroid carcinoma (WDTC) recurrences in the central compartment of the neck. DESIGN: Retrospective medical chart review. SETTING: Tertiary-care academic hospital. PATIENTS: Eighty-two consecutively treated patients with recurrent WDTC, with a median follow-up of 28 months. MAIN OUTCOME MEASURES: Postoperative complications, disease control posttreatment, and normalization of serum thyroglobulin (Tg) level. RESULTS: Eighty-two patients underwent 86 central compartment procedures. Only CCND was performed in 36 patients (42%), while a lateral neck dissection was also required in the remainder. Postoperative hypoparathyroidism was temporary in 17 patients (20%) and permanent in 6 patients (7%). Postoperative intact serum parathyroid hormone level was greater than 15.0 pg/mL (to convert to nanograms per liter, multiply by 1.0) in 81% of patients, accurately predicting eucalcemia postoperatively. Unilateral recurrent laryngeal nerve injury was transient in 3 patients (2% of nerves at risk) and permanent in 3 patients (2%). Seventeen patients (21%) experienced subsequent recurrences after their CCND-2 patients (2%) had recurrence in the central neck, 8 (9%) in the lateral neck, 2 (2%) in the central and lateral neck, and 7 (8%) at distant sites. Twenty-seven patients underwent a CCND alone and were deemed appropriate for efficacy analysis. The Tg level was normalized in 15 patients (56%) in the group overall. Normalization occurred in 10 of the 20 patients (50%) who received sodium iodide I 131 ablation and in 5 of the 7 patients (71%) who did not. CONCLUSION: Central compartment neck dissection is a safe and efficacious procedure for the management of central neck recurrences in WDTC.

Decision making for the extent of thyroidectomy in the patient with atypical cytologic results.

OBJECTIVE: to identify additional preoperative factors that could reliably be used to aid in determining the appropriate extent of thyroidectomy. DESIGN: retrospective chart review. SETTING: tertiary care academic hospital. PATIENTS: two hundred consecutively treated patients who underwent thyroid surgery after having a fine-needle aspiration biopsy procedure yielding a specimen that met the criteria for atypical cytologic features. MAIN OUTCOME MEASURE: final histopathologic diagnosis of malignant vs benign disease. RESULTS: the final diagnosis was benign in 42.5% of patients and malignant in 57.5%. The presence of microcalcifications within the nodule on ultrasonography (US) was significantly associated with a higher risk of malignant disease (relative risk = 1.31, P = .04). When examined individually, age, sex, family history of thyroid malignant disease, exposure to head and neck irradiation, nodule size, rim enhancement on US, and intranodular vascularity on US were not significantly associated with an increased risk of malignant disease. Mulivariate stepwise logistic regression modeling was used to identify a model that could reliably predict a higher probability of malignant disease. The final model determined that patients with microcalcifications on US and a nodule of 2.0 cm or larger had a 74.3% risk of malignant disease vs a 47.5% risk in patients with no microcalcifications and a nodule smaller than 2.0 cm. This difference was statistically significant. When the predicted probabilities of malignant disease were compared with the observed probabilities, the goodness-of-fit test revealed no significant difference (P = .95). CONCLUSION: microcalcifications and nodule size can be used to risk-stratify patients with an atypical fine-needle aspiration biopsy result and aid in determining the appropriate extent of thyroidectomy.

Blood transfusion prediction in patients undergoing major head and neck surgery with free-flap reconstruction.

OBJECTIVE: to develop a clinically useful perioperative blood transfusion prediction model for patients undergoing a major head and neck surgical procedure requiring free-flap reconstruction. DESIGN: retrospective observational study. SETTING: tertiary care university-affiliated teaching hospital (University Health Network, Toronto, Ontario, Canada). PATIENTS: all patients with a head and neck malignant neoplasm undergoing major head and neck surgery requiring free-flap reconstruction. MAIN OUTCOME MEASURE: perioperative single-unit red blood cell transfusion. RESULTS: all the preoperative variables were tested for an association with perioperative blood transfusion using univariable and multivariable analyses. After multivariable regression analysis, the following preoperative variables were found to be significantly associated with perioperative transfusion: sex, body mass index, T stage, preoperative hemoglobin level, and type of free-flap reconstruction used (ie, osseous vs nonosseous). The regression model was used to develop a transfusion risk score. Receiver operating characteristic curve analysis confirmed adequate discrimination of risk using the transfusion risk score. CONCLUSIONS: we have developed a reliable model for predicting perioperative blood transfusion requirements in patients undergoing major head and neck surgery requiring free-flap reconstruction. This model can be used for accurate preoperative risk stratification.

Treatment of early-stage glottic cancer: meta-analysis comparison of laser excision versus radiotherapy.

OBJECTIVES: The primary objective of this study was to conduct a meta-analysis to compare the oncologic outcomes of external radiation (XRT) and transoral laser (TOL) surgical excision in the treatment of early-stage glottic cancer. The secondary outcome examined was posttreatment voice quality. DESIGN: Meta-analysis. METHOD: Systematic methods were used to identify published and unpublished data. Two reviewers screened all titles and abstracts for relevance and independently assessed all articles. All identified studies were retrospective. MAIN OUTCOME MEASURES: Local control, overall survival, laryngectomy-free survival, and posttreatment voice quality. RESULTS: For oncologic control, case series were pooled as a composite group using a random effects model. The analysis was based on over 7600 patients. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. There were no significant differences between TOL surgery and XRT for local control (OR 0.81, 95% CI 0.51-1.3) and laryngectomy-free survival (OR 0.73, 95% CI 0.39-1.35). For overall survival, the analysis favoured TOL surgery (OR 1.48, 95% CI 1.19-1.85). For voice quality, there were no objective differences; however, there was a trend toward superiority for XRT. CONCLUSIONS: This is the first study to examine the management of early glottic cancer using meta-analytic methodology. The analysis shows that although there is a trend favouring TOL surgery for overall survival, there is no clear difference in oncologic outcome between TOL surgery and XRT. However, there is a trend toward improved posttreatment voice quality with XRT. This is of questionable clinical significance as objective voice analyses often do not correlate with subjective assessments.

Risk factors for well-differentiated thyroid carcinoma in patients with thyroid nodular disease.

OBJECTIVES: Evaluate current accepted risk factors for well-differentiated thyroid carcinoma, and develop a predictive model to determine one's risk of malignancy given a thyroid nodule. STUDY DESIGN: Retrospective analysis of 600 patients. SUBJECTS AND METHODS: Patients with benign thyroid nodular disease and with well-differentiated thyroid cancer were randomly selected. Patient, clinical, and investigational data were compared by means of univariate and multivariate regression analyses. RESULTS: Age, regional lymphadenopathy, ipsilateral vocal cord palsy, solid and/or calcified nodules, and an aspiration biopsy being malignant or suspicious predicted for cancer (P < 0.05). Regional lymphadenopathy and vocal cord palsy are perfect predictors of malignancy. Multivariate analysis indicated age, solid and/or calcified nodules, and all fine-needle aspiration biopsy results to be significant in assessing risk (P < 0.05). CONCLUSION: Taking individual risk factors in isolation is not always reliable. Using a predictive model, one can anticipate a patient's risk of malignancy when the diagnosis is unclear.

Piloting a novel porcine model for endolaryngeal injury following prolonged intubation.

OBJECTIVES: (1) To develop a practical animal model of endolaryngeal damage secondary to prolonged endotracheal intubation. (2) To demonstrate the contribution of chronic hypoxia to laryngeal injury in the context of this model. METHODS: Four Sus scrofa piglets were anaesthetized and intubated for 24h. Two animals were maintained in a state of constant hypoxia (pO(2)<60 mmHg) while two others were ventilated with 100% oxygen. Prior to sacrifice, fluorescein dye was infused intravenously to highlight areas of hypoperfusion. The larynx and trachea were then harvested for gross and histological examination. RESULTS: All four specimens demonstrated areas of edema, erythema, and ulceration on gross examination. Areas of significant histological inflammation, ulceration, and necrosis involved tube-mucosa contact, in particular, the arytenoids, the interarytenoid area, and the subglottis. CONCLUSIONS: This animal model represents a practical and novel means for the investigation and treatment of laryngeal injury secondary to prolonged endotracheal intubation. Significant injury to the endolarynx was evident after only 24h of intubation and the injury involved similar areas within the larynx as described in human studies. Although clinical experience suggests that chronic hypoxia is a risk factor for endolaryngeal injury, this model did not provide experimental evidence to support this observation, most likely due to the small study size.

Quality of life in patients undergoing thyroid surgery.

OBJECTIVE: The extent of thyroidectomy in the management of low-risk, well-differentiated thyroid carcinoma (WDTC) has been debated extensively. Our objective was to determine if hemithyroidectomy has a less detrimental effect on quality of life (QOL) than total thyroidectomy. DESIGN: Prospective, nonblinded, nonrandomized, cohort study. SETTING: Tertiary care academic otolaryngology-head and neck surgery practice. METHODS: Using both disease-specific and global QOL instruments, patients treated with either hemi- or total thyroidectomy were prospectively followed. QOL was assessed preoperatively and for 12 months postoperatively. MAIN OUTCOME MEASURES: Scores on the two QOL instruments throughout a 12-month postoperative period. RESULTS: Patients with cancer experienced a greater drop in QOL during the first 6 months following surgery when compared with patients with benign disease (p < .03). Additionally, patients treated with total thyroidectomy did not have a significantly different QOL than patients treated with hemithyroidectomy (p > .2). CONCLUSION: These results suggest that QOL is not significantly impacted by the extent of surgery and that QOL should not be a factor in the decision-making process for the treatment of low-risk WDTC.

Clinical course of thyroid carcinoma after neck dissection.

OBJECTIVES/HYPOTHESIS: The objective was to compare the rate and site of recurrences in patients with well-differentiated thyroid carcinoma who underwent a central compartment dissection, a posterolateral neck dissection, or a combination of both procedures. STUDY DESIGN: Retrospective chart review. METHODS: The charts of 522 consecutive patients with well-differentiated thyroid carcinoma were reviewed, and 74 patients who had undergone a neck dissection were identified. The rates of recurrence in three sites were noted: the central compartment nodes (levels VI, superior mediastinum), posterolateral compartment neck nodes (levels II-V), and distant sites. These rates were compared in patients who underwent a central compartment dissection (level VI, superior mediastinum) and in patients who underwent a posterolateral neck dissection (levels II-V). RESULTS: Six patients underwent only a central compartment dissection, 47 patients had only a posterolateral neck dissection, and 21 patients had both a central compartment and a posterolateral neck dissection. In these three groups there were zero, two, and two central compartment node recurrences; two, nine, and seven posterolateral neck recurrences; and zero, two, and three distant recurrences, respectively. There were no significant differences in the rate of recurrence in any of the three sites examined between any of the three treatment groups (Fisher's Exact test, all P values >.20). CONCLUSION: In patients with well-differentiated thyroid carcinoma, dissection of only the central or posterolateral compartments of the neck with clinical or radiographic evidence of disease is advocated.