A new practical classification for spatial distribution and morphology of human hair: Ahmad's LGMA classification

Summary

Background

The human hair is a complex structure with a diversity within itself. There is a wide variation in distribution and spatial arrangement of hairs.

Methods

The current classification was developed on the basis of high-resolution photographs of adult human scalp.

Results

On the observation, the new classification consisted of 4 categories.

Conclusions

It will help the hair restoration surgeons and dermatologists to identify the various pattern and also to help in deciding the appropriate size of the punch in FUE.

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Recurrent nevus as a pitfall of melanoma diagnosis under reflectance confocal microscopy

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Neuro-Psychiatric Comorbidity among Psoriatic Adolescents

Abstract

Background

Psoriasis is a known risk factor for neuro-psychiatric diseases among adults. Less is known regarding adolescents.

Objective

Investigating the association between psoriasis and neuro-psychiatric comorbidity and social skills among adolescents.

Methods

A population based cross-sectional study between January 1^st, 1999 and January 1^st, 2014 was conducted. The study included 1746 and 1366 adolescents (aged 16 to 18) with mild and moderate to severe psoriasis, respectively. All psoriasis patients were diagnosed by a dermatologist. Neuro-psychiatric diseases were diagnosed by a neurologist and a psychiatrist, accordingly. Social skills were evaluated by a psychosocial assessment. Psoriasis patients were compared to 884653 healthy control patients by a multivariate analysis adjusted for age, sex, country of origin, socio-economic status, cognitive skills and body mass index. A subgroup evaluation was done for comorbidity which could only be evaluated for part of the recruitment years, by a univariate analysis.

Results

Overall chronic headaches (8.1% vs. 3.4%), intermediate frequency migraine (4.8% vs. 1.6%), low frequency migraine and non-migraine headaches (3.4% vs. 1.8%) were associated only with moderate to severe psoriasis compared to healthy controls [Adjusted odds ratios (adj. ORs) 1.9, 2.3, 1.5; 95% confidence intervals (CIs) 1.6-2.4, 1.8-3.0 and 1.1-2.1, respectively]. Anxiety disorders (2.1% vs. 0.7%) and impaired social adjustment skills (7.5% vs. 4.2%) were also associated only with moderate to severe psoriasis compared to healthy controls (ORs 2.9, 1.9; 95% CIs 1.6-5.5 and 1.3-2.6; Of 466 vs. 265023, respectively).

Conclusion

Psoriasis among adolescents is associated with neuro-psychiatric co-morbidities and impaired adjustment skills, depending on disease severity.

This article is protected by copyright. All rights reserved.

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The Utility of MRI in the Diagnosis of Takayasu Arteritis

Takayasu Arteritis (TA) is an inflammatory disorder involving the thoracoabdominal aorta and its branches and the pulmonary arteries, with eventual vascular stenosis, occlusion, or aneurysm formation. Conventional angiography has been the reference imaging standard for diagnosis of TA. The purpose of this case report is to demonstrate the utility of MR imaging and MR angiography in the diagnosis of Takayasu Arteritis in a pediatric patient. The patient is a 15-year-old female patient presenting with anemia, hypertension, and acute kidney injury. Initial chest CT demonstrated ectasia of the ascending and focal stenosis of the descending thoracic aorta, prompting further evaluation with MRI and MRA. MRI/MRA demonstrated mural thickening with luminal stenosis of the aorta and aortic branch vessels. These imaging findings were suggestive of a large vessel arteritis and along with the clinical presentation and laboratory abnormalities the diagnosis of Takayasu Arteritis was suggested. Several case series in adults have described the cross-sectional findings of TA. However, this case report demonstrates the utility of MRI/MRA in the evaluation of TA in children and in the course of follow-up, as it provides a noninvasive method for evaluating a child without ionizing radiation or iodinated contrast.

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Cytomegalovirus Associated Duodenal Ulcer and Duodenitis in a Malnourished Pediatric Patient

Cytomegalovirus (CMV) duodenitis is a rare occurrence, especially in pediatric patients. A thirteen-month-old female presented to the Emergency Department for a febrile seizure. She was incidentally admitted for severe malnutrition with an initial workup remarkable for only a slight elevation in her ALT at 48. The patient was found to have an oral aversion requiring nasogastric tube feeds for adequate caloric intake. She continued to fail to gain weight and underwent an EGD that demonstrated a duodenal ulcer. She was consequently started on sucralfate and omeprazole. Post-EGD lab work demonstrated a pronounced increase in AST and ALT. Pathology from the EGD biopsies later demonstrated viral inclusion bodies consistent with CMV duodenitis. Apart from malnutrition, other causes of immune deficiency were eliminated from the differential diagnosis due to negative HIV PCR and normal immunoglobulins. While on antiviral treatment, her viral load of 1080 IU/mL trended to resolution and her liver enzymes normalized. The patient was ultimately discharged home demonstrating adequate weight gain via gastrostomy tube feeds. This case advocates for pediatricians to include immunodeficiency and infectious etiologies in their differential for malnourished patients in order to lead to earlier diagnosis and management of this treatable condition.

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Response to the letter to the editor regarding “The outcomes of overlay myringoplasty: Endoscopic versus microscopic approach”

Publication date: Available online 7 October 2017
Source:American Journal of Otolaryngology
Author(s): Yuvatiya Plodpai, Nanatphong Paje




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Small percentage of anaphylactic reactions treated with epinephrine during food challenges in Dutch children

Publication date: Available online 7 October 2017
Source:Annals of Allergy, Asthma & Immunology
Author(s): Johanna P.M. van der Valk, Irene Berends, Roy Gerth van Wijk, Nicolette. J.T. Arends, Maurits S. van Maaren, Hans de Groot, Harry J. Wichers, Joyce A.M. Emons, Anthony E.J. Dubois, Nicolette W. de Jong
BackgroundSevere allergic reactions, including anaphylaxis, occur during oral food challenges (OFCs) and the first-line treatment of anaphylaxis is epinephrine.ObjectiveTo evaluate the percentage of anaphylactic reactions treated with epinephrine during OFCs and to identify associated factors for the administration of epinephrine.MethodsChildren who underwent an OFC with peanut, hazelnut, cow's milk, hen's egg, or cashew nut from 2005 through 2015 in the Netherlands were evaluated. Children with reactions meeting the criteria for anaphylaxis according to the European Academy of Allergy and Clinical Immunology guidelines for food allergy and anaphylaxis were included. Children with an anaphylactic reaction treated with vs without epinephrine were compared. Possible factors associated with the administration of epinephrine, such as age, sex, symptoms consistent with asthma, history of an allergic reaction to the tested allergen, and symptom types during the anaphylactic reaction, were evaluated using logistic regression analysis.ResultsEighty-three children in clinical and research settings (43% boys; median age, 7 years; range, 1–17) who met the criteria for anaphylaxis were included in this study. Thirty-two of 83 children (39%) with anaphylaxis were treated with epinephrine. Respiratory symptoms during the OFC were treated significantly more often with epinephrine than gastrointestinal symptoms (P = .01).ConclusionOnly 39% of children with anaphylaxis, according to the guideline criteria, were treated with epinephrine during the OFC and most of these children had respiratory symptoms. There is need for an easy-to-use international guideline for the treatment of allergic symptoms during OFCs.



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Immediate reactions to iodinated contrast media

Publication date: Available online 7 October 2017
Source:Annals of Allergy, Asthma & Immunology
Author(s): Cristina Morales-Cabeza, Dasha Roa-Medellín, Inés Torrado, Manuel De Barrio, Carmen Fernández-Álvarez, Juan Francisco Montes-Aceñero, Inmaculada De La Riva, Alicia Prieto-García
BackgroundImmediate hypersensitivity reactions (IHRs) to iodinated contrast media (ICMs) remain a common clinical concern. Positive skin test and basophil activation test results suggest a specific IgE-mediated mechanism in some cases. Skin test and controlled challenge test (CCT) are useful to manage these patients.ObjectiveTo study clinical and allergologic features of IHRs to ICMs in a Spanish tertiary hospital during a 7-year period.MethodsDemographic and clinical data concerning the reaction were recorded. Patients treated at the Allergy Department of Hospital General Universitario Gregorio Marañón, Madrid, Spain, underwent skin tests. In those with positive results, CCTs with an alternative skin-test-negative ICM was performed. Global reaction rate was calculated and compared for each ICM.ResultsA total of 342 reactions occurred in 329 patients. Cutaneous symptoms were the most common (87.7%). A total of 196 patients underwent an allergy workup, 15 (7.6%) of whom had positive skin test results. Reactions were more severe in patients with positive vs negative skin test results (grade 1, 46.7% vs 73.6%; grade 2, 33.3% vs 20.9%; grade 3, 20% vs 5.46%; P < .05). Three patients had cross-reactivity to 3 ICMs, all including ioversol and iomeprol. Six patients allergic to iopamidol tolerated ioversol and 1 tolerated iomeprol. Four patients allergic to ioversol and 1 allergic to iomeprol tolerated iopamidol. The global reaction rate was 0.2%, differing for each ICM (iopamidol, 0.14%; ioversol, 0.2%; and iomeprol, 0.4%; P < .001). Positive skin test results were found in a low percentage of patients in whom skin test–based CCT identified an alternative non–cross-reactive ICM. Low-grade cross-reactivity was found, especially between iopamidol and ioversol. Reactions were more severe in patients with positive skin test results. The reaction rate was greater for iomeprol compared with iopamidol (reaction rate, 2.8%) and ioversol (reaction rate, 2%).ConclusionsThis study identified a possible underlying specific IgE-mediated mechanism by positive skin test result in a low percentage of patients with IHRs to ICMs. In these patients, the CCT based on skin test results was useful for identifying an alternative non–cross-reactive ICM. More studies are needed to investigate the underlying mechanism in patients with IHRs and negative skin test results.



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Successful perinatal management of hereditary angioedema with normal C1 esterase inhibitor and factor XII mutation using C1 esterase inhibitor therapy

Publication date: Available online 7 October 2017
Source:Annals of Allergy, Asthma & Immunology
Author(s): Kathleen R. Gibbons, Tina Abraham, Monica Sandhu, Brian P. Peppers, Julia F. Girzhel, Robert W. Hostoffer




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Supraglottoplasty for laryngomalacia: The experience from Concepcion, Chile

Publication date: Available online 7 October 2017
Source:International Journal of Pediatric Otorhinolaryngology
Author(s): Sahba Sedaghat, Felipe Fredes, Mario Tapia
ObjectiveTo review the clinical manifestations and outcomes of supraglottoplasty in patients with moderate to severe laryngomalacia at Guillermo Grant Benavente Hospital between January 2015 and January 2017.MethodsRetrospective study of patients with laryngomalacia who underwent CO2 laser supraglottoplasty at a tertiary referral center. A review of medical records of these patients was performed. Epidemiological data along with symptoms, comorbidities, morphological type of laryngomalacia, synchronous airway lesions, surgery outcomes and satisfaction of parents after the procedure were recorded. Surgical success was defined as the resolution of the criteria of severity of laryngomalacia.ResultsTwenty-four patients were operated, 1 was excluded due to prior tracheostomy. Twenty-three patients were included, the median age at the time of surgery was 5.5 months. All the patients had stridor, 87% presented feeding difficulties, 34.8 % had cyanosis and 21.7% had failure to thrive. Six cases had congenital anomalies and four cases had nongenetic comorbidities. Fifteen patients (65.2%) had synchronous airway lesions. 17.4% had type I laryngomalacia and 82.6% were type 2. The postoperative average hospital stay was 1.3 days. The average follow-up was 14 months and no complications were reported. The overall success rate of surgery was 95%.ConclusionsPatients with laryngomalacia and any symptom of severity should undergo a full airway evaluation, to rule out synchronous airway lesions, and supraglottoplasty if needed, as it has been shown to be a safe and effective technique for the management of these patients.



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Pain control following tonsillectomy in children: A survey of patients

Publication date: Available online 7 October 2017
Source:International Journal of Pediatric Otorhinolaryngology
Author(s): Philip Persino, Lena Saleh, David Walner
ObjectiveThis prospective study aimed to survey pediatric patients and their parents after tonsillectomy to assess their pain management utilization and satisfaction.IntroductionTonsillectomy is the second most common surgical procedure performed in pediatric patients. Postoperative recovery is often associated with high levels of pain and severe functional limitations. There is currently no consensus on pain control regimens. Additionally, a recent FDA Black Box Warning on narcotic use has caused more uncertainty in appropriate pain control regimens.Methods111 pediatric patients (≤18 years) included in this study underwent tonsillectomy with or without adenoidectomy between October 2013 and August 2015. Postoperatively, each patient/parent was counseled to alternate on an over-the-counter regimen of acetaminophen and ibuprofen and given an additional as-needed acetaminophen with hydrocodone prescription. A survey was administered during the patient's 2-week follow-up that included questions regarding pain levels, worst post-op pain day, pain medications taken during recovery, and patient/parental perceived satisfaction of having the acetaminophen with hydrocodone prescription.Results84 patients/parents (75.7%) felt that OTC medications were not adequate for pain control and used hydrocodone at least once. Between those who took hydrocodone versus those who did not, there was no significant difference in mean age (6.7 ± 2.9 vs. 6.0 ± 2.4 years), percentage of patients with severe pain (36.9% vs. 22.2%) and worst post-op pain day (4.3 ± 1.5 vs. 3.9 ± 1.9 days) (p > 0.05). However, regardless of pain control regimen followed, the majority of patients/parents found it valuable to have the hydrocodone prescription (p = 0.004).ConclusionPost-tonsillectomy patients and their parents find being provided with an acetaminophen-hydrocodone prescription is therapeutically valuable, and many find it necessary in their postoperative pain management. However, further studies are needed to determine patient factors that influence narcotic utilization.



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Direct tracheobronchopexy via left lateral thoracotomy for severe tracheobronchomalacia

Publication date: Available online 7 October 2017
Source:International Journal of Pediatric Otorhinolaryngology
Author(s): Evan J. Propst, Faisal Zawawi, Roxanne E. Kirsch, Osami Honjo
An infant with pulmonary atresia/ventricular septal defect/major aortopulmonary collateral arteries underwent unifocalization, ventriculoseptal defect closure and placement of a right ventricle to pulmonary artery conduit via median sternotomy. Aortopexy and pulmonary arteriopexy via redo sternotomy were insufficient to allow weaning of continuous positive airway pressure and he required direct tracheobronchopexy via left lateral thoracotomy to alleviate posterior trachealis intrusion along the length of the trachea and left main bronchus. He also underwent laryngotracheoplasty with placement of a posterior costal cartilage graft for bilateral vocal cord paralysis. The patient was weaned from positive pressure and discharged in stable condition.



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Effects of supramaximal balloon dilatation pressures on adult cricoid and tracheal cartilage: A cadaveric study

Objectives/Hypothesis

Cricoid fracture is a serious concern for balloon dilatation in airway stenosis. Furthermore, there are no studies examining tracheal rupture in balloon dilatation of stenotic segments. The aim of this study was to evaluate the effect of supramaximal pressures of balloons on the cricoid and tracheal rings.

Study Design

Prospective cadaveric study.

Methods

Seven cadaveric laryngotracheal complexes of normal adults with intact cricothyroid membranes were acquired. Noncompliant vascular angioplasty balloons (BARD-VIDA) were used for dilatation. The subglottis and trachea were subjected to supramaximal dilatation pressures graduated to nominal burst pressure (NBP) and, if necessary, rated burst pressure (RBP). Larger-diameter balloons, starting from 18 mm size to 24 mm, were used. Dilatations were maintained for 3 minutes.

Results

The cricoid ring was disrupted by larger-diameter balloons (22 mm and 24 mm) even at lower pressures (less than NBP) in six cases. Tracheal cartilages were very distensible, and external examination after supramaximal dilatation (24 mm close to RBP) revealed no obvious cartilage fractures or trachealis tears. Histopathological examination revealed sloughing of mucosa in the areas corresponding to balloon placement, but no microfractures or disruption of the perichondrium of tracheal ring cartilages.

Conclusions

These results indicate that the cricoid is vulnerable to injury from larger balloons even at lower dilatation pressures. The tracheal cartilages and the membranous wall of the trachea remained resilient to supramaximal dilatation and larger balloons.

Level of Evidence

NA Laryngoscope, 2017

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Upper esophageal sphincter augmentation reduces pharyngeal reflux in nasogastric tube–fed patients

Objectives/Hypothesis

Aspiration of gastric refluxate is one of the most commonly observed complications among long-term nasogastric tube (NGT) fed patients. The upper esophageal sphincter (UES) pressure barrier is the main defense mechanism against pharyngeal reflux of gastric contents. Our objective was to investigate the efficacy and safety of the UES assist device (UES-AD) in preventing gastric reflux through the UES in long-term NGT-fed patients.

Study Design

Self-Controlled Case series.

Methods

We studied 10 patients (mean age = 90.6 ± 3.4 years, four females) with dysphagia caused by stroke or dementia who were fed for 0.5 to 5 years (median = 3 years) by NGT. External pressures of 20 to 30 mm Hg were applied by using a handmade UES-AD, which was started 2 hours after the beginning of NGT infusion and was alternated between periods of 2 hours on and 2 hours off, for a total of 12 hours. Placement of the impedance sensors within the UES was guided by high-resolution manometry. Trans-UES and intraesophageal reflux events were recorded by using 24-hour combined pH-impedance measurements.

Results

No aspiration pneumonia events were noted in the period 1 month before or during the study in any of the cohort. Baseline UES pressure averaged 17.5 ± 9.4 mm Hg and was increased to 38.9 ± 11.9mm Hg after application of the UES-AD. Overall frequency of trans-UES reflux decreased significantly with the UES-AD compared to without (0.8 ± 0.9 vs. 3.3 ± 2.8, P < .05 for the 12-hour study period). There was no effect of the UES-AD on esophageal reflux events (7.4 ± 4.4 vs. 6.4 ± 3.0, P > .05).

Conclusions

UES-AD significantly decreases the number of trans-UES reflux events and can potentially reduce the aspiration risk associated with NGT feeding.

Level of Evidence

4. Laryngoscope, 2017

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A prospective crossover trial of botulinum toxin chemodenervation versus injection augmentation for essential voice tremor

Objectives/Hypothesis

Botulinum toxin chemodenervation (BTX) is used to treat essential voice tremor (EVT), but results are not uniformly satisfactory. This study sought to assess the comparative utility of injection augmentation (IA) for EVT.

Study Design

Prospective crossover treatment study.

Methods

Patients with EVT underwent BTX. After washout patients underwent IA. Multidimensional assessment carried out prior to and 30 days after each treatment included 1) videostroboscopy graded by the Vocal Tremor Scoring System (VTSS), 2) acoustic and aerodynamic assessment (cepstral peak prominence, cepstral spectral index of dysphonia, cepstral peak prominence fundamental frequency, airflow, peak air pressure and intensity, maximum phonation time, and amplitude/frequency of tremor), 3) audio-perceptual assessment via Consensus Audio-Perceptual Evaluation of Voice (CAPE-V), and 4) patient self-assessment via Voice Handicap Index-10 (VHI-10) and Percent of Normal Function (PNF) scale. Findings were analyzed via paired t tests and Wilcoxon rank sum tests.

Results

Seven patients (five female and two male; mean age 67 years old; range, 46–82 years old) participated. VTSS grading showed divergent outcomes for certain individual sites of tremor, but without significant differences. Airflow increased following BTX and decreased following IA, and VHI-10 scores indicated slight improvement post-BTX (26.29–23.57), and decline post-IA (25.86–29.86), although differences were not significant. Only changes in audio-perceptual ratings of loudness achieved significance, which decreased with BTX and increased with IA. Five patients chose to resume BTX; two elected long-term IA. No findings supported patient preferences.

Conclusions

IA demonstrated no advantage over BTX in the treatment of EVT.

Level of Evidence

2b Laryngoscope, 2017

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Survival of renal cell carcinoma metastatic to nonthyroid head and neck region: A systematic review

Objective

Metastasis of renal cell carcinoma to nonthyroid head and neck region is rare. Survival benefit for complete metastasectomy of more common renal cell foci has been reported in the literature. It is uncertain whether metastasectomy in nonthyroid head and neck region would provide a similar benefit.

Data Sources

We conducted a retrospective review of all renal cell metastases to the head and neck region treated in the past 15 years at an academic hospital, and a systematic review of all relevant reports with survival data in the literature between 1960 and 2016.

Review Methods

An analysis of pooled data was performed to estimate overall survival.

Results

Six cases from our institution and 260 independent cases reported in the literature were included in the survival analyses (n = 266). The median follow-up time was 12 months (range 0–180 months). The overall median survival was 36 months (95% confidence interval [CI] 23.7–48.3). The median survival for those who underwent complete metastasectomy in the head and neck was significantly higher at 60 months (95% CI 41.1–78.9) than those who had incomplete or no metastasectomy (12 months, 95% CI 9.5–14.5). Multivariable Cox proportional hazards model estimated that, after controlling for potential confounders, complete metastasectomy remained associated with reduced risk of death (hazard ratio 0.44, 95% CI 0.29–0.69).

Conclusion

Complete metastasectomy was associated with 4-year longer median overall survival than incomplete metastasectomy or no metastasectomy. Laryngoscope, 2017

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Treatment, survival, and costs of oropharyngeal cancer care in the elderly

Objectives/Hypothesis

To examine associations between treatment, survival, and costs in elderly patients with oropharyngeal squamous cell cancer (OPSCC).

Study Design

Retrospective cross-sectional analysis of Surveillance, Epidemiology, and End Results–Medicare data.

Methods

We evaluated 666 patients diagnosed with OPSCC from 2004 to 2007 using cross-tabulations, multivariate logistic and generalized linear regression modeling, and survival analysis.

Results

The majority of patients were nonsmokers (79%), had advanced-stage disease (59%), and received chemoradiation (38%) or radiation (28%). Surgery with postoperative radiation (hazard ratio [HR]: 0.33 [95% CI: 0.20-0.53]) and chemoradiation (HR: 0.45 [95% CI: 0.29-0.71]) were associated with improved survival, whereas stage IV disease was associated with poorer survival (HR: 1.95 [95% CI: 1.13-3.38]). Additional cancer-directed treatment after primary treatment was more likely following chemoradiation (odds ratio [OR]: 3.44 [95% CI: 1.78-6.63]). Salvage surgery was performed in 25% of patients undergoing subsequent additional cancer-directed treatment, and was associated with high-volume hospitals (OR: 2.81 [95% CI: 1.07-7.74]). Additional radiation (HR: 0.47 [95% CI: 0.31-0.72]) and salvage surgery (HR: 0.61 [95% CI: 0.38-0.99]) were associated with improved overall survival when performed >6 months following initial treatment, whereas salvage neck dissection alone was not significantly associated with survival after controlling for time to salvage (HR: 0.38 [95% CI: 0.05-2.78]). Treatment and 5-year overall costs were highest for chemoradiation, surgery with postoperative radiation, and additional cancer-directed treatment.

Conclusions

Multimodality treatment in elderly OPSCC patients was associated with improved survival and increased costs. Chemoradiation was associated with an increased likelihood of additional cancer-directed treatment. Salvage surgery was centralized at high-volume hospitals, and was associated with improved survival when performed >6 months after last initial treatment date, but was performed in <20% of patients undergoing additional treatment.

Level of Evidence

2c Laryngoscope, 2017

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Malignant fibrous histiocytoma: Database review suggests a favorable prognosis in the head and neck

Objective

The malignant fibrous histiocytoma (MFH) is the most common soft tissue sarcoma of the head and neck. Currently, most of the data on this tumor relies on small retrospective studies. The objective of this study is to use the Surveillance, Epidemiology, and End Results (SEER) database to compare characteristics of this tumor based on location to better understand its prognosis in the head and neck region. This article represents the largest study analyzing prognosis of this tumor in the head and neck to date.

Study Design

Retrospective analysis of SEER database.

Methods

Using the SEER database, 395 patients with MFH of the head and neck were compared with 3,968 patients with MFH of the trunk and extremities. Disease-specific survival was carried out comparing these two cohorts, as well as univariate and multivariate analysis to determine hazard ratios.

Results

Head and neck MFH had a significantly higher disease-specific survival compared with trunk and extremity disease. However, head and neck tumors were more frequently a smaller size (P < .0001) and lower grade (P < .0001). Larger tumors and grade III and IV tumors conferred a worse prognosis (P < .0001).

Conclusion

Head and neck malignant fibrous histiocytoma presents at a smaller size and lower grade, likely due to earlier presentation in this region. Because of this, head and neck malignant fibrous histiocytoma represents a more favorable survival prognosis compared with trunk and extremity disease.

Level of Evidence

4. Laryngoscope, 2017

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What antibiotic should be used in the management of an otherwise healthy adult with a peritonsillar abscess?

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Positive fresh frozen section margins as an adverse independent prognostic factor for local recurrence in oral cancer patients

Objectives

To access 1) the value of further surgical resection (completion surgery) in cases with a positive intraoperative margin analysis, and 2) whether cancers that undergo completion surgery following positive intraoperative margin analysis with subsequent negative margins should be considered true margin-negative (R0) resections in terms of adjuvant treatment planning.

Study Design

Retrospective analysis of patients with primary oral cancer.

Methods

One hundred and fifty-one patients underwent primary surgical resection of oral squamous cell carcinoma with intraoperative margin examination. In all cases for which frozen section margin analysis was positive, an extended resection was performed. Only patients with clear final margins were included in the study.

Results

The intraoperative analysis of surgical margins revealed that cancer-free margins were achieved in 123 cases (81.5%). In 28 specimens (18.5%), the surgical margins were positive. Local recurrence was observed in 28 (18.5%) patients, whereas regional recurrence developed in 30 (19.9%) patients. Factors significantly (P < 0.05) increased the risk of local recurrence: advanced stage of the disease (III/IV), node N-positive status, lymphovascular invasion and positive fresh frozen surgical margins. On multivariate analysis, only positive fresh frozen surgical margins remained significant independent adverse factors.

Conclusion

Our study demonstrates that positive fresh frozen margins, regardless of re-resection to R0 status, could be a powerful adverse factor that determines an aggressive nature of the tumor. This feature should be taken into consideration in adjuvant treatment planning. The greatest impact this could have is in borderline clinical situations for which the indication for adjuvant treatment may be questionable.

Level of Evidence

4. Laryngoscope, 2017

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Evidence against the mucosal traction theory in cholesteatoma

Objectives

To investigate the distribution of ciliated epithelium in the human middle ear and its potential role in the formation of cholesteatoma.

Study Design

Comparative human temporal bone study.

Methods

We selected temporal bones from 14 donors with a diagnosis of cholesteatoma, 15 with chronic otitis media without retraction pockets, 14 with chronic otitis media with retraction pockets, 14 with cystic fibrosis (CF), and 16 controls. We mapped the distribution of the ciliated cells in the mucosal lining of the middle ear and tympanic membrane using three-dimensional reconstruction analysis, and counted the number of ciliated cells in the middle ear mucosa.

Results

Ciliated cells are extremely sparse in the epithelial lining of the lateral surface of the ossicles in the epitympanum and the medial surface of the tympanic membrane. Furthermore, there is a significant decrease in the number of ciliated cells in these areas in temporal bones with cholesteatoma, chronic otitis media, chronic otitis media with retraction pockets, and CF compared to controls. Ciliated cells most commonly are located at the hypotympanum and the Eustachian tube opening but not the tympanic membrane or epitympanum.

Conclusion

The paucity of ciliated epithelial cells on the medial side of the tympanic membrane and the lateral surface of the ossicles in the epitympanum in cases with cholesteatoma and/or chronic otitis media do not support the mucosal migration theory of cholesteatoma formation.

Level of Evidence

NA. Laryngoscope, 2017

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Clinical utility of 18F-fluorodeoxyglucose/positron emission tomography in diagnosis of immunoglobulin G4–related sclerosing sialadenitis

Objectives/Hypothesis

The aim of this study was to evaluate the utility of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for accurately diagnosing immunoglobulin G4-related sclerosing sialadenitis (IgG4-SS).

Study Design

Retrospective cohort study.

Methods

We reviewed the records of 64 patients with IgG4-SS (35 male and 29 female patients) and 10 patients with clinically suspected IgG4-SS. Pathological diagnoses of patients clinically suspected with IgG4-SS included four cases of malignant lymphoma, one case of multicentric Castleman disease, one case of Sjögren's syndrome, and four cases of sialadenitis. All patients underwent submandibular gland (SMG) biopsies and baseline FDG-PET/CT evaluation. Clinical, serological, pathological, and PET/CT findings were analyzed. We also investigated maximum standardized uptake values (SUVmax) in the salivary glands of 15 patients with malignant disease of the salivary glands during the same period.

Results

Increased FDG uptake in the SMG and parotid gland was found in 63 (98%) and 23 (35%) patients with IgG4-SS, respectively. FDG uptake of the bilateral SMG and unilateral SMG was recorded in 57 patients (89%) and six patients (9%), respectively. Mean SUVmax in patients with malignant disease of the salivary glands was significantly higher than that in patients with IgG4-SS (P = .035). We defined a positive test for IgG4-SS diagnosis as high SMG FDG uptake and serum IgG4 level ≥135 mg/dL, resulting in a sensitivity, specificity, and accuracy of 96.9%, 90.0%, and 86.4%, respectively.

Conclusions

FDG-PET/CT findings in combination with serological and clinical findings may have the capacity to diagnose IgG4-SS and lead to less-invasive biopsy procedures.

Level of Evidence

4. Laryngoscope, 2017

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Outcomes and reliability of the flow coupler in postoperative monitoring of head and neck free flaps

Objectives/Hypothesis

To assess the accuracy and reliability of the flow coupler relative to the implantable arterial Doppler probe in postoperative monitoring of head and neck free flaps.

Study Design

Retrospective single-institution study, April 2015 to March 2017.

Methods

Both the venous flow coupler and arterial Doppler were employed in 120 consecutive head and neck free flap cases. When Doppler signal loss occurred, flaps were evaluated by physical exam to determine whether signal loss was a true positive necessitating operating room takeback. Sensitivity, specificity, and false positive rate (FPR) were recorded for each device. Logistic regression was conducted to identify user trends over time.

Results

Eleven of 120 patients (9.2%) required takeback, 10 from venous thrombosis and one from arterial thrombosis. Permanent signal loss (PSL) occurred in the flow coupler in all takebacks; PSL occurred in the arterial Doppler only in the case of arterial thrombosis. Salvage rate was 9/11 (81.8%). For the flow coupler, sensitivity was 100%, specificity 86.4%, and FPR 13.6%. For the arterial probe, sensitivity was 9.1%, specificity 97.1%, and FPR 2.9%. A 4.1% decrease in false positives with each additional flow coupler use was observed.

Conclusions

Monitoring the vein via flow coupler has high sensitivity in identifying vascular compromise compared to the arterial probe, especially for venous thrombosis. There is moderate FPR; this decreases with increased usage and, when supplemented with physical examination, does not result in unnecessary takebacks. The flow coupler can be a valuable tool in postoperative monitoring of head and neck free flaps.

Level of Evidence

4. Laryngoscope, 2017

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Online and call center referral for endocrine surgical pathology within institutions

Objectives/Hypothesis

We hypothesized that self-referred patients to academic centers will be equally distributed between general surgery and otolaryngology departments that perform thyroid surgery. We sought to quantify disparities in the assignment of these self-referred patients who may reach an institution through call centers or online pathways.

Study design

Cross-sectional survey.

Methods

Key words "thyroid surgery" and "thyroid cancer" were used along with the name of the Accreditation Council for Graduate Medical Education–listed otolaryngology program in both Google and Bing search engines. The top three search results for departments were reviewed, and a tally was given to general surgery (GS), otolaryngology–head and neck surgery (OLHNS), or neither. A multidisciplinary center with both GS and OLHNS was recorded as "equitable." Telephone calls were tallied if they were directed to GS or OLHNS.

Results

Out of 400 program tallies, 117 (29.25%) patients were directed to GS and 50 (12.5%) were directed to OLHNS. An additional 181 (45.25%) were directed to neither group ("neither") (P < .05). Fifty-two (13%) of the patients were referred to multidisciplinary groups ("equitable"). A telephone call survey had 62 patients (62%) assigned to a general surgeon, as opposed to 38 (38%) for OLHNS (P < .05). Five institutions offered a multidisciplinary group when searching with Bing, and 11 were found by searching with Google.

Conclusions

There is not an equal distribution of self-referred patients with thyroid surgical pathology. It may be important to increase the online presence of OLHNS surgeons who perform thyroid surgery at academic medical institutions. Multidisciplinary centers focused on thyroid and parathyroid surgical disease represents one model of assigning self-referred patients.

Level of Evidence

NA Laryngoscope, 2017

http://ift.tt/2wFGHkF

Toolbox of assessment tools of technical skills in otolaryngology–head and neck surgery: A systematic review

Objective

To support the development of programs of assessment of technical skills in the operating room (OR), we systematically reviewed the literature to identify assessment tools specific to otolaryngology–head and neck surgery (OTL-HNS) core procedures and summarized their characteristics.

Methods

We systematically searched Embase, MEDLINE, PubMed, and Cochrane to identify and report on assessment tools that can be used to assess residents' technical surgical skills in the operating room for OTL-HNS core procedures.

Results

Of the 736 unique titles retrieved, 16 articles met inclusion criteria, covering 11 different procedures (in otology, rhinology, laryngology, head and neck, and general otolaryngology). The tools were composed of a task-specific checklist and/or global rating scale and were developed in the OR, on human cadavers, or in a simulation setting.

Conclusions

Our study reports on published tools for assessing technical skills for OTL-HNS residents during core procedures conducted in the OR. These assessment tools could facilitate the provision of timely feedback to trainees including specific goals for improvement. However, the paucity of publications suggests little agreement on how to best perform work-based direct-observation assessment for core surgical procedures in OTL-HNS. The sparsity of tools specific to OTL-HNS may become a barrier to a fluid transition to competency-based medical education. Laryngoscope, 2017

http://ift.tt/2kuQbNY

Maternal and obstetrical outcome in 35 cases of well-differentiated thyroid carcinoma during pregnancy

Objectives/Hypothesis

Thyroid cancer, with 6% to 10% of cancer diagnoses, is one of the most common malignancies during pregnancy. Its treatment poses a risk for the pregnancy, as the thyroid gland plays a crucial role in the evolution of pregnancy. The aim of this study is to evaluate treatment of primary well-differentiated thyroid carcinoma during pregnancy and fetal and maternal outcomes.

Study Design

This is an international cohort study.

Methods

Primary thyroid cancer patients were identified from the database of the International Network on Cancer, Infertility, and Pregnancy registration study. Data on histopathological characteristics, diagnostic and therapeutic interventions, outcome (obstetrical, neonatal, and maternal) and maternal follow-up were analyzed.

Results

Thirty-five patients with well-differentiated thyroid carcinoma were eligible. All 35 patients underwent surgery, 29 (83%) of which during pregnancy. Procedures during pregnancy were mainly total thyroidectomies (n = 24). The median number of days between diagnosis and surgical treatment was different between the groups with surgery during and after pregnancy (27 vs. 139 days, P < .001). Both maternal and neonatal outcomes were uncomplicated, regardless of gestational age during surgery.

Conclusions

Well-differentiated thyroid carcinoma diagnosed during pregnancy has a favorable outcome for both mother and child. Surgical management during pregnancy has no negative impact on the pregnancy regardless of the trimester at the time of surgery. However, the potential negative effects of thyroid surgery early in pregnancy demand management of these patients in an experienced multidisciplinary team to provide the best possible care for these patients and their unborn babies.

Level of Evidence

4 Laryngoscope, 2017

http://ift.tt/2wFGCgR

Evolving trends in sinus surgery: What is the impact of balloon sinus dilation?

Objectives/Hypothesis

Balloon dilation (BD) represents a minimally invasive alternative to endoscopic sinus surgery (ESS). Although BD was introduced in 2006, distinct Current Procedural Terminology (CPT) codes were not available until 2011, making prior analysis of population-based trends difficult. Our objectives were to evaluate these trends and compare any changes to the use of traditional ESS techniques. Geographic trends also were evaluated.

Methods

Medicare Part B national datasets encompassing procedures from 2011 to 2015 were obtained. ESS CPT codes (frontal sinusotomy, maxillary antrostomy with/without tissue removal, sphenoidotomy) and BD codes were searched to determine temporal trends in their use. Additionally, state carriers were individually evaluated for geographic trends.

Results

National use of BD increased greater than five-fold (39,193 from 7,496 among Medicare patients), whereas the use of ESS increased by only 5.9%. This increase in BD was observed across all sites, including the sphenoid (7.0x), maxillary (5.1x), and frontal (4.7x) sinuses. In the most recent year for which data was available (2015), a significantly greater portion of sinus procedures in these sites utilized BD in the South (42.1%) compared to the Northeast (30.6%), West (29.5%), and Midwest (25.3%) regions (P < 0.0001).

Conclusion

The performance of BD has increased markedly in recent years. Because the use of ESS codes remain stable, observed BD trends are unlikely to be due simply to greater familiarity with newer CPT coding. The reasons for the striking increase in BD popularity are speculative and beyond the scope of this analysis, but further study may be needed.

Level of Evidence

NA. Laryngoscope, 2017

http://ift.tt/2kuAAhz

Hearing loss on social media: Who is winning hearts and minds?

Objectives/Hypothesis

To analyze specific patterns of Twitter usage using common references to hearing loss, and characterize the virtual public that comprises the hearing loss community to inform hearing loss stakeholders for opportunities for engagement and outreach.

Study Design

Social media network analysis.

Methods

Twitter tweets were sampled from July 2016 to September 2016 using #hearing, #hearingloss, #deaf, #hearingimpairment, #hardofhearing, #deafness, #hearingmatters, #hearinghealth, and #hearingimpaired tags. User and Twitter social community metrics were examined including temporal trends, tweet content, user activity, tweet reach, and an analysis of the tweets' social network.

Results

We identified and analyzed 49,208 tweets from July 2016 to September 2016 with tags relevant to hearing loss. Of the 100 most active Twitter accounts, organizations owned 67% compared to 33% owned by individuals. Commercial/for profit and informational organizations were the most common organization account owners (26% and 16%, respectively). Five unique tweets were identified as each having a reach of over 100,000 Twitter users, with the greatest reach exceeding 250,000 users. Temporal analysis identified marked retweet outliers (>300 retweets per hour) that corresponded with a widely publicized event involving the dismissal of a deaf employee from a fast-food chain store.

Conclusions

Twitter accounts owned by organizations outnumbered individual accounts, and commercial/for profit user accounts were the most frequently active organization account type. Tweets pertaining to hearing loss may have a broad reach to a large community base. Analyses of social media use can be helpful in discovering issues of interest to the hearing loss community, as well as determining which users and organizations are dominating social network conversations.

Level of Evidence

NA Laryngoscope, 2017

http://ift.tt/2wFGuxT

Safety of outpatient thyroidectomy: Review of the American College of Surgeons National Surgical Quality Improvement Program

Objectives/Hypothesis

To investigate national trends in admission status after thyroidectomy in the United States and to evaluate the factors associated with 30-day unplanned readmission and reoperation.

Study Design

Retrospective review of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP)

Methods

The ACS-NSQIP database was queried for patients who underwent a partial or total thyroidectomy between 2005 and 2014. Outpatient surgery was defined as discharge on the day of surgery. Patient demographic information, unplanned hospital readmission, and reoperation were reviewed. Risk factors were identified using logistic regression modeling.

Results

A total of 76,604 cases met inclusion criteria as described above. There were 1,473 (1.9%) patients who underwent reoperation and 477 unplanned 30-day readmissions (1.4%) for procedures performed since 2012. There was a significant positive trend in the percentage of thyroidectomy (partial and total) patients who underwent outpatient procedures by year of operation (P < .001). Outpatient procedures were not more likely to have unplanned readmissions or reoperations. Independent patient risk factors for unplanned readmission and reoperation included current dialysis, chronic steroid use, unintentional weight loss, American Society of Anesthesiologists class 3 to 4, and active bleeding disorders.

Conclusions

Over the past decade there has been a clear trend toward increasing outpatient thyroid surgery. Thyroidectomy performed as an outpatient was not found to be an independent risk factor for readmission or reoperation. Patients with serious medical comorbidities and active bleeding disorders are at increased risk of unplanned readmission or reoperation and should have their surgery performed on an inpatient basis.

Level of Evidence

2c. Laryngoscope, 2017

http://ift.tt/2kwSK27

Risk factors for salvage surgery failure in oral cavity squamous cell carcinoma

Objectives/Hypothesis

Locoregional recurrences of oral cavity squamous cell carcinoma (SCC) may be diagnosed during follow-up of surgically treated patients. Nevertheless, few studies have investigated factors that impact salvage surgery failure and the mortality rates of these patients. The objectives were to identify predictive factors of salvage surgery failure and mortality in patients who undergo surgical treatment for recurrent oral cavity SCC and to compare the overall survival rates of these patients with those of patients who undergo only one surgical treatment.

Study Design

Retrospective cohort study.

Methods

Forty-six patients submitted to salvage surgery for local or locoregional recurrence.

Results

The presence of lymph node metastasis and positive surgical margins at the salvage surgery time were the only independent factors associated with both recurrence rates (hazard ratio [HR]: 5.04 and 2.82, respectively) and mortality (HR: 3.51 and 3.24, respectively). When the overall survival rates of the 199 patients who only underwent one surgical treatment were compared to those of the 46 patients subjected to salvage surgery, a similarity was evident when patients who underwent salvage surgery did not have a new disease recurrence (70.7% vs. 54.7%, respectively; P = .158). Likewise, patients with new recurrences after salvage surgery and patients who received palliative treatment for relapsed disease had similar overall survival rates (0.6% vs. 0.0%, respectively; P = .475).

Conclusions

The presence of lymph node metastasis at the time of recurrence and positive surgical margins after the salvage surgery were associated with a worse overall survival rate in patients with oral cavity SCC relapse.

Level of Evidence

2b. Laryngoscope, 2017

http://ift.tt/2wEKizD

How reliably can computed tomography predict thyroid invasion prior to laryngectomy?

Objectives/Hypothesis

There is little evidence to support the removal of thyroid tissue during total laryngectomy. Although oncological control of the tumor is the priority, thyroidectomy can lead to hypothyroidism and hypoparathyroidism. This study aimed to test the usefulness of preoperative computed tomography in predicting histological invasion of the thyroid.

Study Design

Ambispective cohort study.

Methods

All patients undergoing total laryngectomy for squamous cell carcinoma at one center from 2006 to 2016 were included. Data were recorded prospectively as part of the patients' standard care, but were collated retrospectively, giving this study an ambispective design. The histology report for thyroid invasion was taken as the gold standard. The computed tomography report was categorized by invasion of tumor into intralaryngeal, laryngeal cartilage involvement, and extralaryngeal tissues.

Results

Seventy-nine patients were included. Nine patients had thyroid involvement on histology, translating to an incidence of 11.29% in this population. The positive predictive value for cartilage involvement on computed tomography for thyroid invasion was 52.9% (95% confidence interval [CI]: 28.5%-76.1%) and the negative predictive value was 100% (95% CI: 92.7%-100%).The positive predictive value for extralaryngeal spread on computed tomography for thyroid involvement was 100% (95% CI: 62.9%-100%), and the negative predictive value was also 100% (95% CI: 93.5%-100%).

Conclusions

This study has shown that preoperative computed tomography is an effective method of ruling out thyroid gland invasion. The absence of extralaryngeal spread on computed tomography has been shown to be the most useful finding, with a high negative predictive value and a narrow 95% CI.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2wFIM06

Does a single dose of pregabalin help with postoperative pain after septoplasty?

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