Non-conventional laryngeal malignancies: a multicentre review of management and outcomes.

PURPOSE: Non-conventional laryngeal malignancies (NSCC) often have limited published data to guide management despite individual histopathological subtypes often exhibiting heterogeneous behaviour, characteristics, and treatment responses compared to laryngeal squamous cell carcinoma (SCC). This study aimed to compare oncological outcomes with SCC, specifically disease-free survival (DFS), disease-specific survival (DSS) and overall survival (OS). Secondary objectives were to compare treatment differences and perform a state of the art review. METHODS: This was a multicentre retrospective cohort study at four tertiary head and neck centres. Survival outcomes between NSCC and SCC patients were analysed with Kaplan-Meier curves and compared by log rank testing. Univariate Cox regression analysis was performed to predict survival by histopathological subgroup, T-stage, N-stage and M-stage. RESULTS: There were no significant differences in 3-year DFS (p = 0.499), DSS (p = 0.329), OS (p = 0.360) or Kaplan Meier survival curves (DSS/OS) between SCC and overall NSCC groups. However, univariate Cox regression analysis identified "rare" histopathologies (mostly small cell carcinoma) to be predictive of less favourable OS (p = 0.035) but this result was not observed for other NSCC histopathological subgroups. N-stage (p = 0.027) and M-stage (p = 0.048) also predicted OS for NSCC malignancies. Significant differences in treatment modalities were identified with treatment of NSCC typically involving surgical resection and SCC often managed non-surgically (e.g., primary radiotherapy). CONCLUSIONS: Although overall NSCC is managed differently compared to SCC, there do not appear to be differences in survival outcomes between these groups. N-stage and M-stage appear to be more predictive of OS than histopathology than many NSCC subtypes.

Hypocalcaemia following thyroidectomy among patients who have previously undergone bariatric surgery: systematic review and meta-analysis.

BACKGROUND: Hypocalcaemia is a common complication after thyroidectomy. Bariatric surgery is associated with significant changes in calcium metabolism. Some studies have identified bariatric surgery as a risk factor for hypocalcaemia after thyroidectomy. This systematic review and meta-analysis assessed whether a history of bariatric surgery was associated with an increased risk of hypocalcaemia after thyroidectomy. METHODS: This prospectively registered systematic review (PROSPERO; CRD42021295423) was performed in accordance with PRISMA guidelines. Meta-analysis was undertaken using the Mantel-Haenszel method, with outcomes reported as ORs with 95 per cent confidence intervals. RESULTS: Twenty studies were included in the qualitative synthesis. Five studies incorporating 19 547 patients met the inclusion criteria for meta-analysis, of whom 196 (1.0 per cent) had a history of bariatric surgery. Patients with a history of bariatric surgery were more likely to develop hypocalcaemia after thyroidectomy (30.6 versus 13.0 per cent; OR 3.90, 95 per cent c.i. 1.50 to 10.12; P = 0.005). Among those with a history of bariatric surgery, patients who underwent a bypass procedure were more likely to develop hypocalcaemia after thyroidectomy than those who had a restrictive procedure (38 versus 23 per cent; OR 2.12, 1.14 to 3.97; P = 0.020). CONCLUSION: Patients with a history of bariatric surgery have a significantly greater risk of hypocalcaemia after thyroidectomy, with a heightened risk among those who have had a bypass procedure. Surgeons performing thyroid surgery should be aware of the increased risk of hypocalcaemia after thyroidectomy among these patients.

Low calcium levels are a common complication after surgical removal of the thyroid gland. Patients who have had weight loss surgery (bariatric surgery) have altered calcium metabolism and are prone to low calcium levels. This study assessed whether previous weight loss surgery increased the risk of low calcium levels after thyroid surgery. A search was made of previously published studies assessing the relationship between previous weight loss surgery and low calcium levels after thyroid surgery. Studies have shown that previous weight loss surgery makes patients more than three times more likely to have low calcium levels after thyroid surgery. Management of low calcium in these patients is more challenging than in patients who have not had weight loss surgery. Surgeons performing thyroid surgery need to be aware of whether a patient has previously had weight loss surgery as they have an increased risk of low calcium after thyroid surgery.

Intra-operative nerve monitoring and recurrent laryngeal nerve injury during thyroid surgery: a network meta-analysis of prospective studies.

PURPOSE: Recurrent laryngeal nerve (RLN) injury is a feared complication of thyroid surgery occurring in 1-5% of cases. The present approaches to RLN preservation include RLN visualization with no nerve monitoring (No-NM), intermittent intra-operative nerve monitoring (I-IONM) and continuous intra-operative nerve monitoring (C-IONM). There is ambiguity as to which of these strategies should be the preferred method of RLN preservation. METHODS: A systematic review of the PubMed, Embase and the Cochrane Collaboration databases was undertaken with network meta-analysis (NMA) performed according to the PRISMA and Cochrane Collaboration guidelines. A Bayesian NMA was conducted using R packages netmeta with outcomes expressed as odds ratios (ORs) with 95% credible intervals (CrI). Only prospective studies were included. RESULTS: Eighteen studies met inclusion criteria, including 22,080 patients and 40,642 nerves at risk (NAR). Overall, 23,364 NARs (57.5%) underwent I-IONM, 17,176 (42.3%) No-NM and 98 (0.2%) underwent C-IONM. There were no significant differences between groups regarding the incidence of permanent RLN injury following thyroid surgery (I-IONM vs.No-NM, OR 0.84, 95% CrI 0.55-1.19; C-IONM vs. No-NM, OR 0.44, 95% CrI 0.02-5.00). Pooled analysis showed that IONM (I-IONM or C-IONM) demonstrated a protective effect versus No-NM in reducing the incidence of transient RLN injury (OR 0.75, 95% CI 0.59-0.97, p = 0.03). CONCLUSIONS: IONM strategies did not significantly reduce the incidence of permanent RLN injury following thyroid surgery. However, the small number of C-IONM NARs limits conclusions that may be drawn. Further well-designed prospective studies will be required to definitively assess the utility of C-IONM.

The role of adjuvant radiotherapy in management of recurrent pleomorphic adenoma of the parotid gland: a systematic review.

PURPOSE: Recurrent pleomorphic adenoma poses a significant treatment challenge, considering its propensity for further recurrence and potential for malignant transformation. The role of adjuvant radiotherapy in its management is widely debated. The aim of this study was to determine whether adjuvant radiotherapy is more effective than surgical resection alone in patients with recurrent pleomorphic adenoma of the parotid gland, in terms of further recurrence, malignant transformation and treatment-related complications. METHODS: Using PRISMA guidelines, a systematic review comparing adjuvant radiotherapy with surgery alone in the treatment of recurrent pleomorphic adenoma was conducted. Pubmed, OVID, EBSCO, Embase, The Cochrane Library, SCOPUS and OpenGrey databases from 1988 to 2018 were searched. Quality analysis was carried out using the Newcastle-Ottawa Scale and narrative synthesis used to summarise results. RESULTS: Of 891 records screened, eight studies were included, assessing 366 participants. Two noted a benefit of adjuvant radiotherapy in reducing further recurrence. The remainder did not show significant benefit, although four showed a trend towards lower rates. Only one case of malignant transformation was identified in a patient not irradiated. Similar rates of facial nerve dysfunction were identified between groups. CONCLUSION: The available evidence suggests that adjuvant radiotherapy reduces recurrence rates in patients with recurrent pleomorphic adenoma and certain adverse prognostic factors. While it appears not to have significant adverse effects, given the lack of prospective evidence, we recommend careful use in patients at high risk of further recurrence and further research in the form of well-designed randomised controlled trials.

Clinical decision making in paediatric otitis media: A pilot quality improvement study.

OBJECTIVES: This study aimed to improve local management of paediatric otitis media using the 2022 American-Academy of Otolaryngology Head and Neck Surgery (AAO-HNS) Clinical Practice Guideline for Tympanostomy Tubes in Children. METHODS: A SQUIRE 2.0 compliant quality improvement study was carried out within the outpatient department of our otolaryngology tertiary referral centre. Local outpatient management of paediatric otitis media was compared to the AAO-HNS guidelines, specifically focussing on the decision to offer tympanostomy tubes. Following initial audit of practice, an educational session was performed within the otolaryngology department and local practice was subsequently re-evaluated. RESULTS: Overall, 88 children were included (46 pre-intervention and 42 post-intervention) with a mean age of 7.6 years (range 1-12 years). Sixty-four (72.7%) children presented with suspected otitis media with effusion. The remainder presented with recurrent or persistent acute otitis media (24/88, 27.3%). Twenty-six children were offered tympanostomy tubes (29.5%). Initial evaluation of practice identified that the decision to offer tympanostomy tubes was guideline appropriate in 76.1% of children (35/46). This significantly improved following an educational session (40/42, 95.2%, p = 0.02). The reasons for non-guideline compliance included: otitis media with effusion <3 months, no evidence of middle ear fluid and patients meeting criteria for tympanostomy tube insertion not being offered. CONCLUSIONS: A focussed educational intervention may improve local adherence to guidelines in the management of paediatric otitis media. Continued re-evaluation of local practice is essential in order to ensure children are managed in accordance with the guidelines.

Case of coronary vasospasm caused by hypocalcaemia post parathyroidectomy mimicking ST-elevation myocardial infarction.

A man in his 30s with primary hyperparathyroidism underwent an elective four-gland parathyroid exploration with intraoperative parathyroid hormone monitoring. On the fourth postoperative day (POD), the patient presented to the emergency department with severe symptomatic hypocalcaemia. ECG findings were in keeping with inferior-posterior ST-elevation myocardial infarction (STEMI); however, he was asymptomatic with no chest pain. Biochemistry revealed elevated serial troponin levels. Coronary angiogram and transthoracic echocardiogram were normal, suggesting coronary vasospasm, mimicking STEMI on ECG because of severe hypocalcaemia post parathyroidectomy. This is an uncommon and unreported complication of parathyroid surgery. The patient was successfully managed with intravenous calcium and discharged on oral calcium replacement on the tenth POD.

Use of Intraoperative Parathyroid Hormone in Minimally Invasive Parathyroidectomy for Primary Hyperparathyroidism: A Systematic Review and Meta-analysis.

Importance: Intraoperative parathyroid hormone (ioPTH) is a surgical adjunct that has been increasingly used during minimally invasive parathyroidectomy (MIP). Despite its growing popularity, to our knowledge a meta-analysis comparing MIP with ioPTH vs MIP without ioPTH has not yet been conducted. Objective: To evaluate the safety and efficacy of MIP with ioPTH for treatment of primary hyperparathyroidism. Data Sources: A systematic search of the databases PubMed, Embase, Scopus, Web of Science, and Cochrane Collaboration was performed to identify studies that compared MIP with and without ioPTH. Data were analyzed between August and September 2019. Study Selection: Inclusion criteria consisted of randomized clinical trials and observational studies with a retrospective/prospective design, comparing MIP using ioPTH vs MIP not using ioPTH for treatment of primary hyperparathyroidism. Eligible studies had to present odds ratio (OR), risk ratio, or hazard ratio estimates (with 95% CI), standard errors, or number of events necessary to calculate these for the outcome of interest rate. Studies involving patients with secondary or tertiary hyperparathyroidism or those with multiple endocrine neoplasia syndrome were excluded. Data Extraction: Two reviewers independently reviewed the literature according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Dichotomous variables were pooled as ORs while continuous variables were compared using weighted mean differences. Quality assessment was performed using the Newcastle-Ottawa Scale. Main Outcomes and Measures: The primary outcome was rate of cure. Secondary outcomes included need for reoperation, need for bilateral neck exploration, morbidity, and length of surgery. Results: A total of 12 studies, involving 2290 patients with primary hyperparathyroidism, were eligible for inclusion. The median (SD) age of participants was 60.1 (11.8) years and 77.3% of participants were women. The median Newcastle-Ottawa score was 7. Patients who underwent MIP with ioPTH had higher cure rates (OR, 3.88; 95% CI, 2.12-7.10; P < .001). There was a greater need for reoperation in the group of patients who had surgery without ioPTH (OR, 0.40; 95% CI, 0.19-0.86; P = .02). There was a trend toward longer operating times/increased duration of surgery in the ioPTH group; however, this did not reach statistical significance (weighted mean difference, 21.62 minutes; 95% CI, -0.93 to 44.17 minutes; P = .06). The use of ioPTH was associated with higher rates of bilateral neck exploration (OR, 3.55; 95% CI, 1.27-9.92; P = .02). Conclusions and Relevance: Use of ioPTH is associated with higher cure rates for patients with primary hyperparathyroidism undergoing MIP. Minimally invasive parathyroidectomy performed without ioPTH is associated with less conversion to bilateral neck exploration at initial surgery but with lower cure rates and an increased risk for reoperation. Trial Registration: PROSPERO identifier: CRD42020148588.

Radioiodine Remnant Ablation for Differentiated Thyroid Cancer: A Systematic Review and Meta-analysis.

Importance: Postoperative radioactive iodine (RAI) remnant ablation for differentiated thyroid cancer (DTC) facilitates the early detection of recurrence and represents an adjuvant therapy that targets persistent microscopic disease. The optimal activity of RAI in low- and intermediate-risk DTC remains controversial. Objective: To evaluate the long-term cure rate of different RAI activities in low- and intermediate-risk DTC. Secondary outcomes included successful remnant ablation, adverse effects, and hospital length of stay. Data Source: A systematic search of the databases PubMed, Cochrane Collaboration, Embase, Scopus, and Web of Science was performed to identify randomized clinical trials (RCTs) and observational studies that compared long-term outcomes (>12 months) for American Thyroid Association-classified low- and intermediate-risk DTC based on receipt of either low-activity or high-activity RAI postoperatively. Study Selection: All RCTs or observational studies evaluating patients with low- and intermediate-risk DTC who were treated initially with total/near-total thyroidectomy, followed by remnant RAI ablation with either low or high activities. Eligible studies had to present odds ratio, relative risk (RR), or hazard ratio estimates (with 95% CIs), standard errors, or the number of events necessary to calculate these for the outcome of interest rate. Data Extraction: Two investigators reviewed the literature in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Dichotomous variables were pooled as risk ratios and continuous data as weighted-mean differences. Quality assessment of the included studies was performed using the Newcastle-Ottawa and Jadad scales. Main Outcomes and Measures: Disease recurrence was the primary outcome. Secondary outcomes included successful ablation, adverse effects, and length of stay. Results: Ten studies that included 3821 patients met inclusion criteria, including 6 RCTs and 4 observational studies. There was no difference in long-term cure recurrence rates (RR, 0.88; 95% CI, 0.62-1.27, P = .50) or successful remnant ablation (RR, 0.95; 95% CI, 0.87-1.03; P = .20) between low-activity and high-activity RAI. Conclusions and Relevance: In this systematic review and meta-analysis, low-activity RAI was comparable with high-activity RAI regarding successful ablation and recurrence rates. This suggests that low-activity RAI is preferable to high-activity in low- and intermediate-risk DTC because of its similar efficacy but reduced morbidity. Trial Registration: PROSPERO Identifier: CRD42020166780.

Vocal Cord Palsy as a Complication of Epidural Anaesthesia.

Cranial nerve palsy is a rare but recognised complication of epidural anaesthesia, most commonly presenting as diplopia secondary to abducens nerve palsy. While upper cranial nerve palsies have been documented on numerous occasions, lower cranial nerve palsies, including recurrent laryngeal nerve palsy, are exceedingly rare. This case describes a 37-year-old female who, following epidural anaesthesia for spontaneous vaginal delivery of her first child, presented with dysphonia. Flexible laryngoscopy confirmed a left vocal cord palsy, and computed tomography ruled out any mass lesions along the course of the recurrent laryngeal nerve. Here, we discuss a case of vocal cord palsy secondary to epidural anaesthesia, an extremely rare complication. We also discuss the proposed etiology, treatment, and outcomes in patients with this condition. Cranial nerve palsy should be an important differential in patients presenting with dysphonia following spinal or epidural anaesthesia.

Intractable pulmonary aspiration in children: which operation?

Intractable aspiration is a life-threatening medical problem. There are many surgical procedures for the treatment of intractable aspiration. Our experience with three children was reported here. After failing initial conservative measures, the first two patients had supraglottic laryngeal closure performed through an endoscopic approach with a small hole left superiorly for phonation. However, both of them developed dehiscence of the closure postoperatively, necessitating a more definitive procedure to stop the aspiration. Their symptoms of aspiration were only relieved after they underwent laryngotracheal separation. In the third child, laryngotracheal separation was performed as the initial procedure and the symptoms of recurrent aspiration were relieved. In conclusion, the treatment of intractable aspiration requires a definitive procedure from the outset and we would suggest, based on literature review and on our experience, that laryngotracheal separation is the most effective and reliable option, albeit lack of phonation is inevitable. A comprehensive review of all procedures used for treatment of this condition was also undertaken.

Reversal of laryngotracheal separation in paediatric patients.

OBJECTIVE: Laryngotracheal separation (LTS) is an effective and reliable definitive treatment for intractable aspiration. A major advantage of this treatment for intractable aspiration is its' potential reversibility. Should the underlying disorder improve, a reversal of the procedure may be attempted. This has been successfully achieved in the adult population. To our knowledge, no previous cases have been reported of successful reversal of LTS in children. METHODS: A retrospective review from 2003 to 2010 identified four cases of intractable aspiration treated with LTS in our department. Two of these patients displayed objective evidence of sufficient recovery of their underlying aspiration to consider reversal. Patient selection for reversal was dependent upon successful oral intake for 9 months along with videofluoroscopic evidence of normal or minimally impaired swallow. RESULTS: Two children who were successfully treated for intractable aspiration with LTS demonstrated objective evidence of recovery sufficient to attempt reversal. Both children underwent successful surgical reversal of LTS using a cricotracheal resection with end-to-end anastamosis, similar to that used in treatment of subglottic stenosis. Both children can now tolerate oral diet and their speech and language development is in line with their overall developmental level. CONCLUSIONS: Laryngotracheal separation is an effective and reliable definitive treatment for intractable aspiration facilitating protection of the airway and allowing safe swallowing with unimpeded respiration, but with the major drawback of loss of phonation. To our knowledge, we document the first two cases of successful LTS reversal in children.

Levels of oxidative damage and lipid peroxidation in thyroid neoplasia.

BACKGROUND: This study assessed the presence of oxidative damage and lipid peroxidation in thyroid neoplasia. METHODS: Using tissue microarrays and immunohistochemistry, we assessed levels of DNA damage (8-oxo-dG) and lipid peroxidation (4-HNE) in 71 follicular thyroid adenoma (FTA), 45 papillary thyroid carcinoma (PTC), and 17 follicular thyroid carcinoma (FTC) and matched normal thyroid tissue. RESULTS: Cytoplasmic 8-oxo-dG and 4-HNE expression was significantly higher in FTA, FTC, and PTC tissue compared to matched normal tissue (all p values < .001). Similarly, elevated nuclear levels of 8-oxo-dG were seen in all in FTA, FTC, and PTC tissue compared to matched normal (p values < .07, < .001, < .001, respectively). In contrast, a higher level of 4-HNE expression was detected in normal thyroid tissue compared with matched tumor tissue (p < .001 for all groups). Comparing all 3 groups, 4-HNE levels were higher than 8-oxo-dG levels (p < .001 for all groups) except that cytoplasmic levels of 8-oxo-dG were higher than 4-HNE in all (p < .001). These results were independent of proliferation status. CONCLUSION: High levels of DNA damage and lipid peroxidation in benign and malignant thyroid neoplasia indicates this damage is an early event that may influence disease progression.

Suture lateralization of vocal cord treating paradoxical vocal cord movement: a case report.

Paradoxical vocal cord movement (PVCM) causes inspiratory stridor and extra-thoracic airway obstruction through inappropriate adduction of the vocal cords during the respiratory cycle. We report on a patient with severe PVCM necessitating tracheostomy insertion. Using the technique of endoscopic suture lateralization of a vocal cord, we succeeded in decannulation 22 years after tracheostomy. PVCM of this severity is rare and its management remains unclear. Successful treatment in this manner has not been documented previously. A brief review of current management options for this condition is included.

KTP laser and nitinol alloy stents: are they compatible?

BACKGROUND/OBJECTIVE: Nitinol alloy stents are in frequent use in recanalizing malignant airway stenoses. Potassium titanyl phosphate (KTP) is one of the lasers of choice in removal of obstructing airway lesions. There is a paucity of research regarding the safety of these advances working together. STUDY DESIGN/MATERIALS AND METHODS: In vitro study involving direct contact application of KTP laser with nitinol alloy stents under microscope guidance in varying gaseous environments. RESULTS: Stent damage can occur once power settings exceed one watt. Complete stent destruction occurs regardless of gaseous environment at a mere three watts of power. CONCLUSIONS: Our results suggest that KTP laser is unsafe to use in the presence of a nitinol alloy stent, regardless of the gaseous environment.