Can Thyroid Ultrasonography Predict Substernal Extension or Tracheal Compression in Goiters?

PURPOSE: To determine whether an ultrasonography (US)-defined thyroid volume can accurately predict substernal extension or tracheal narrowing. METHODS: After research ethics approval, we identified patients with thyroid nodules investigated with both US and computed tomography (CT). Reviewers assigned scores for both substernal extension and tracheal compression on CT using pre-established classification systems. Statistical analysis with receiver operating characteristic curve analysis was performed to find the US-determined thyroid volume thresholds that correlated with each substernal extension and tracheal compression. RESULTS: This study included 120 patients (mean age 63.4 years; SD ± 15.9; 67% female). Thirty-five patients (29%) had substernal extension. The mean US total thyroid gland volume in patients with and without substernal extension were 92.4 and 37.6 cm3, respectively (P < .001). 86% of patients with substernal extension had tracheal narrowing vs. 27% of patients without substernal extension (P < .0001). A cutoff dominant gland volume of ≥37.5 cm3 showed 83% sensitivity and 79% specificity for substernal extension (area under the curve [AUC] = 0.84). A total thyroid gland volume threshold of ≥37.8 cm3 showed 89% sensitivity and 87% specificity for any degree of tracheal narrowing (AUC = 0.90). CONCLUSIONS: This study suggests that US volumes may be used as a predictor to identify those patients with thyroid enlargement who are most at risk of substernal extension and tracheal compression and who may benefit from preoperative CT imaging for optimal surgical and anesthetic planning.

Droplet Exposure Risk to Providers From In-Office Flexible Laryngoscopy: A COVID-19 Simulation.

To provide data on risk of respiratory droplets from common otolaryngologic procedures during the COVID-19 pandemic, a novel simulation of droplet exposure from flexible laryngoscopy was performed. After completion of a nasal symptom questionnaire, topical fluorescein spray was administered into the nasal and oropharynx of 10 healthy volunteers, who then underwent flexible laryngoscopy under 2 conditions: routine without provoked response and with prompted sneeze/cough. After each, droplets on the proceduralist and participant were counted under ultraviolet A light. Droplets were observed on 1 of 10 volunteers after routine laryngoscopy and 4 of 10 during laryngoscopy with sneeze/cough. A nasal symptom score based on congestion and rhinorrhea was significantly elevated among droplet producers after sneeze/cough (P = .0164). No droplets were observed on the provider. Overall, with adequate personal protective equipment, flexible laryngoscopy poses minimal droplet risk to providers. Nasal symptoms can identify patients more likely to produce droplets after sneeze/cough.

Impact of the COVID-19 Global Pandemic on the Otolaryngology Fellowship Application Process.

On March 11, 2020, the World Health Organization declared coronavirus disease 2019 a global pandemic. In addition to massive social disruption, this pandemic affected the traditional fellowship interview season for otolaryngology subspecialties, including head and neck surgical oncology, facial plastic and reconstructive surgery, laryngology, rhinology, neurotology, and pediatric otolaryngology. The impact on the fellowship interview process, from the standpoint of the institution and the applicant, necessitated the use of alternative interview processes. This change may alter the future of how interviews and the match proceed for years to come, with nontraditional methods of interviewing becoming a mainstay. While the impact this pandemic has on the fellowship match process is not yet fully realized, this commentary aims to discuss the challenges faced on both sides of the equation and to offer solutions during these unprecedented times.

Surgical Site Infection Affects Length of Stay After Complex Head and Neck Procedures.

OBJECTIVES/HYPOTHESIS: Quality improvement (QI) initiatives emphasize a need for reduction in hospital length of stay (LOS). We sought to determine the impact of surgical site infections (SSIs) on LOS after complex head and neck surgery (HNS). STUDY DESIGN: Retrospective cohort analysis. METHODS: An analysis of the American College of Surgeons National Surgical Quality Improvement Program was undertaken. All adult patients undergoing complex HNS from 2005 to 2016 were included in the analysis. Our main outcomes were SSI incidence and increase in hospital LOS attributable to SSI. RESULTS: Of 4,014 patients identified, 16.5% developed SSI. History of smoking, diabetes, preoperative wound infection, contaminated or dirty wound classes, and prolonged operative time were found to significantly predict postoperative SSI. Adjusting for significant pre- and postoperative factors, SSI was associated with significantly increased LOS (hazard ratio = 0.486, 95% confidence interval: 0.419-0.522). CONCLUSIONS: SSI following complex HNS is associated with significantly increased hospital LOS. This result supports the need for institutional QI strategies that target SSIs after head and neck procedures in an effort to provide the highest quality care at the lowest possible cost. Our analysis identifies risk factors that can allow identification of patients at high risk of SSI and prolonged hospitalization. LEVEL OF EVIDENCE: 2b Laryngoscope, 2020.

Influence of Socioeconomic Status on Stage at Presentation of Laryngeal Cancer in the United States.

OBJECTIVE: Identify socioeconomic predictors of stage at diagnosis of laryngeal cancer in the United States. STUDY DESIGN: Retrospective analysis of the North American Association of Central Cancer Registries' Incidence Data-Cancers in North America Deluxe Analytic File for expanded races. SETTING: All centers reporting to the US Centers for Disease Control and Prevention's National Program of Cancer Registries. SUBJECTS AND METHODS: All cases of laryngeal cancer in adult patients from 2005 to 2013 were reviewed. Ordinal logistic regression models were used to evaluate odd ratios (ORs) for socioeconomic indicators potentially predictive of advancing American Joint Committee on Cancer stage at diagnosis. RESULTS: A total of 72,472 patients were identified and included. Analysis revealed significant correlation between advanced stage at diagnosis and: Medicaid insurance, lack of insurance, female sex, older age, black race, and certain states of residence. The strongest predictor of advanced stage was lack of insurance (OR, 2.212; P < .001; 95% CI, 2.035-2.406). The strongest protective factor was residing in the state of Utah (OR, 0.571; P < .001; 95% CI, 0.536-0.609). Once adjusted for regional price and wage disparities, relative income was not a significant predictor of stage at presentation across multiple analyses. CONCLUSION: Multiple socioeconomic factors were predictive of severity of disease at presentation of laryngeal cancer in the United States. This study demonstrated that insurance type was strongly predictive, whereas relative income had surprisingly little influence.

Effect of statin use on oncologic outcomes in head and neck squamous cell carcinoma.

BACKGROUND: Preclinical and early-phase clinical studies have suggested an oncoprotective role of statins in head and neck squamous cell carcinoma (HNSCC). The purpose of this study was to determine whether incidental statin use in patients with human papillomavirus (HPV)-negative HNSCC is predictive of improved oncologic outcomes. METHODS: A retrospective cohort study of 1194 patients from the Ontario Cancer Registry diagnosed with HNSCC from 2007 to 2012 was performed using linked databases from the Institute for Clinical Evaluative Sciences. Overall survival (OS) and disease-specific survival (DSS) were compared between patients taking statins and controls. RESULTS: Patients with statin exposure demonstrated improved OS (hazard ratio [HR] 0.758; P = .0011; 95% confidence interval [CI] 0.642-0.896), and DSS (HR 0.693; P = .0040; 95% CI 0.539-0.889) compared with those not on statins at the time of diagnosis. CONCLUSION: Incidental statin use at the time of diagnosis of HPV-negative squamous cell carcinoma (SCC) of the larynx, hypopharynx, and nasopharynx demonstrated improved OS and DSS.

Does metformin usage improve survival in head and neck squamous cell carcinoma? A population-based study.

BACKGROUND: We sought to expand upon preliminary data suggesting that metformin confers a survival benefit to patients with head and neck squamous cell carcinoma (HNSCC). METHODS: A large-scale retrospective cohort study of all patients in Ontario diagnosed with squamous cancer of the larynx, hypopharynx, and nasopharynx between Dec 1st 2007 to Dec 1st 2012 was undertaken. The Institute for Clinical and Evaluative Sciences was accessed to obtain patient demographic, treatment and outcome information. We included patients on metformin at the time of diagnosis. Kaplan Meier methods and Cox Regression models were used. RESULTS: Patients taking metformin at the time of diagnosis had a higher comorbid status but were otherwise similar to patients without metformin usage. Using multivariate analysis, neither overall survival nor disease specific survival was improved in patients on metformin (OS: HR 1.123, p = .338; DSS: HR 1.048, p = .792). CONCLUSIONS: No survival advantage was observed in patients with HNSCC taking metformin at the time of diagnosis.

Peri-operative factors predisposing to pharyngocutaneous fistula after total laryngectomy: analysis of a large multi-institutional patient cohort.

BACKGROUND: Pharyngocutaneous fistula (PCF) is a problematic complication following total laryngectomy. Disagreement remains regarding predisposing factors. This study examines perioperative factors predicting PCF following total laryngectomy using a large multicenter data registry. METHODS: Retrospective cohort analysis was performed using patients undergoing total laryngectomy in the ACS-NSQIP database for 2006-2014. Sub-analysis was performed based on reconstruction type. Outcome of interest was PCF development within 30 days. RESULTS: Multivariate analysis of 971 patients was performed. Three variables showed statistical significance in predicting PCF: wound classification of 3 and 4 vs. 1-2 (OR 6.42 P < 0.0004 and OR 8.87, P < 0.0042), pre-operative transfusion of > 4 units of packed red blood cells (OR 6.28, P = 0.043), and free flap versus no flap reconstruction (OR 2.81, P = 0.008). CONCLUSIONS: This study identifies important risk factors for development of PCF following total laryngectomy in a large, multi-institutional cohort of patients, thereby identifying a subset of patients at increased risk.

Selectively false-positive radionuclide scan in a patient with sarcoidosis and papillary thyroid cancer: a case report and review of the literature.

BACKGROUND: Radioiodine and Tc-99 m pertechnetate scans are routinely relied upon to detect metastasis in papillary thyroid cancer; false-positive scans are relatively rare. To our knowledge, no published reports exist of sarcoidosis causing such selectively false-positive scans. METHODS: We present a case of a 41-year-old woman with known metastatic papillary thyroid cancer (T1bN1aMx) in whom sarcoidosis-affected cervical and mediastinal lymph nodes demonstrated uptake of thyroid-targeting radionuclides. Only the minority of these nodes demonstrated radionuclide uptake, raising the suspicion of adjacent or coexisting sarcoid and metastatic involvement. Selective uptake of thyroid-targeted radionuclides by isolated sarcoidosis is, to our knowledge, a previously undocumented occurrence. RESULTS: Biopsies of uptake-negative mediastinal nodes revealed sarcoidosis. Pathology from a subsequent neck dissection excising uptake-positive cervical nodes also showed sarcoidosis, with no coinciding malignancy. CONCLUSIONS: We document a case of sarcoidosis causing a selectively false-positive thyroid scintigraphy scan. It is useful for clinicians to be aware of potential false-positives and deceptive patterns on radionuclide scans when managing patients with both well-differentiated thyroid cancer and a co-existing disease affecting the nodal basins draining the thyroid gland.