Computed Tomography Measurements in Assessment of Idiopathic Vocal Fold Paralysis.

OBJECTIVE: Our study aimed to both identify the incidence and clinical presentation of patients presenting with idiopathic vocal fold paralysis (IVFP). Secondarily we aimed to assess the radiographic findings of computed tomography (CT) studies along the course of the vagus and recurrent laryngeal nerves (RLN), specifically measuring for potential areas of compression at the skull base and mediastinum. We hypothesized that a proportion of patients diagnosed with IVFP would have significant differences in measurements when compared to age-gender matched controls on CT imaging. STUDY DESIGN: Institutional review board approved retrospective cohort study METHODS: We assessed patients presenting to a tertiary voice care center between 2003 and 2019 with diagnosis of vocal fold paralysis. Data collected includes demographics, clinical exam findings, and CT measurements including dimensions at bilateral jugular foramen, aortopulmonary (AP) window and surrounding vascular structures. Statistical analysis was then performed using Pearson χ2, and Mann Whitney U tests to determine differences variables of interest. RESULTS: A total of 606 patients were reviewed. Of these patients 60 (9.9%) patients were determined to have IVFP. Left-sided VFP was seen more commonly in 78.3% (N = 47) of idiopathic patients. Our IVFP group had an overall higher incidence of cardiovascular disease [OR = 3.378, 95%CI 1.907-5.941, P < 0.001] compared to those with identified causes for paralysis. Specifically, IVFP patients showed a higher incidence of combined cardiovascular co-morbidities (P < 0.001), mitral valve stenosis (P = 0.007), pulmonary hypertension (P < 0.0001) and congestive heart failure (P < 0.001). When evaluating CT imaging, the AP window was mentioned in only 2 (3.3%) of our idiopathic patients CT reports. The IVFP cohort had a lower median AP window volume (P = 0.020) when compared to age-gender matched controls. This significantly smaller AP window volume was also seen when only left sided IVFP compared to both right-sided paralysis (P < 0.001) and age matched control patients (P < 0.001). CONCLUSION: The significance of cardiovascular comorbidities combined with findings of statistically narrowed AP window may help provide an explanation of a subset of patients diagnosed with IVFP.

Comparative Evaluation and Management of Dysphonia Between Adults <65 and ≥65 Years of Age.

OBJECTIVE: To compare presenting symptoms, etiology, and treatment outcomes among dysphonic adults <65 and ≥65 years of age. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care voice center between January 2011 and June 2016. METHODS: A total of 755 patients presenting for dysphonia were included in the study: 513 adults <65 years of age and 242 adults ≥65. Data collected included demographics, referral information, prior diagnoses, prior treatments, clinical examination findings, diagnosis, coexisting symptoms, treatments, and pre- and postintervention Voice Handicap Index scores. Statistical analysis was performed with SPSS to determine significant relationships between variables of interest. RESULTS: The most common etiologies of dysphonia were vocal cord atrophy (44.8%) in the ≥65 cohort and benign vocal cord lesions (17.8%) in the <65 cohort. When compared with adults <65 years old, patients ≥65 had a higher incidence of neurologic dysphonia (P = .006) and vocal cord atrophy (P < .001) but were less likely to have laryngopharyngeal reflux (P = .001), benign vocal cord lesions (P < .001), or muscle tension dysphonia (P < .001). Overall, 139 patients had surgery, 251 received medical therapy, and 156 underwent voice therapy. The ≥65 cohort demonstrated improvement in Voice Handicap Index scores after surgery (P = .001) and voice therapy (P = .034), as did the <65 cohort (surgery, P < .001; voice therapy, P = .015). Adult surgical patients <65 reported greater improvements than patients ≥65 (P = .021). CONCLUSIONS: There are notable differences in the pathophysiology of dysphonia between patients aged ≥65 and <65 years. Although adults <65 reported slightly better outcomes with surgery, patients ≥65 obtained significant benefit from surgery and voice therapy.

4D-CT facilitates focused parathyroidectomy in patients with primary hyperparathyroidism by maintaining a high negative-predictive value for uninvolved quadrants.

INTRODUCTION: Improved preoperative localization facilitates minimally invasive parathyroidectomy for removal of parathyroid lesions therefore preventing an invasive bilateral neck exploration. As 4D-CT has emerged, its high specificity has helped with preoperative parathyroid lesion localization. A high negative predictive value (NPV) would serve to further confirm parathyroid lesion localization and limit unnecessary surgical exploration. This study's objective was to determine the NPV of preoperative 4D-CT and its facilitation of minimally invasive parathyroidectomy. METHODS: A retrospective review was compiled for patients undergoing parathyroidectomy for primary hyperparathyroidism with a preoperative 4D-CT. Included patients were sorted into various groups for comparison: those with 4D-CT localizing to a single lesion, localizing to multiple lesions, and those with nonlocalizing findings; multiple hypercellular parathyroid gland versus single gland findings; extent of surgical exploration; lesion location; and patients with concomitant thyroid nodules. Negative predictive value was calculated and used to quantify the ability for 4D-CT to rule out biochemically significant parathyroid lesions. RESULTS: In our review of 68 patients: sensitivity was 81.3%, specificity was 95.5%, positive predictive value was 87.1%, and negative predictive value was 93.3%. 86% had a single localizing 4D-CT, 7% had a non-localizing 4D-CT, and 7% had a multiple quadrant localizing 4D-CT. NPV for single and multi-localizing 4D-CT were 96.8% and 88.9%, respectively. CONCLUSION: Preoperative 4D-CT has a high negative predictive value (93.3%), suggesting in the majority of cases, a quadrant with no 4D-CT radiographic findings suspicious for parathyroid is unlikely to harbor biochemically significant parathyroid lesions.

Neurocognitive deficits increase risk of poor retention in care among older adults with newly diagnosed HIV infection.

OBJECTIVE: To evaluate the role of neurocognitive impairment on retention in care across the lifespan in antiretroviral-naïve persons newly diagnosed with HIV. DESIGN: A prospective observational study of 138 antiretroviral-naive newly diagnosed HIV-positive participants who presented to an urban clinic between August 2010 and April 2013. METHODS: All participants underwent a baseline evaluation that included a neuromedical examination and brief neuropsychological test battery. Retention in care was operationalized as attending at least two visits separated by more than 90 days during the 12-month follow-up period. RESULTS: Fifty-five per cent of participants were retained in care over the study observation period. In a logistic regression controlling for ethnicity, there was a significant interaction between age and neurocognitive impairment in predicting retention in care (P = 0.009). Planned post-hoc analyses showed that neurocognitive impairment was associated with a significantly lower likelihood of retention in care among participants aged 50 years and older (P = .007), but not among younger participants (P > 0.05). CONCLUSION: Extending prior research on antiretroviral adherence and medication management, findings from this study indicate that neurocognitive impairment may be an especially salient risk factor for poor retention in care among older adults with newly diagnosed HIV infection.