Clinical diagnostic utility of ultrasound-guided fine needle aspiration biopsy in parotid masses.

BACKGROUND: Fine needle aspiration (FNA) is a common diagnostic tool used in the initial evaluation of parotid masses. In the literature, variable diagnostic accuracy of FNA is reported. Therefore, when considering clinical management of these patients, the utility of FNA is unclear. The aim of this study was to determine the capability of ultrasound-guided FNA to differentiate between benign and malignant neoplasms. Further, the way in which FNA results affect clinical decision-making was assessed. METHODS: Retrospective data were collected for all patients who underwent parotidectomy at a large Canadian tertiary care center between 2011 and 2016. Patient demographics, preoperative imaging reports, preoperative FNA results, and final pathological diagnosis were analyzed. RESULTS: Of the 199 patients who underwent parotidectomy, 184 had preoperative ultrasound-guided FNA. There were a total of 13 non-diagnostic FNAs. In diagnosing malignancy, FNA had a sensitivity and specificity of 71.4% and 98.7%, respectively. The positive predictive value (PPV) was 83.3%. The negative predictive value was 97.5%. Of the non-diagnostic FNAs, 2 out of 13 (15.4%) were deemed malignant neoplasms on final pathology. CONCLUSION: FNA is a useful adjunct in the work-up of parotid masses, but it should be used with caution. Due to limited sensitivity, it should not be relied upon as the sole determinant of a surgeon's management plan.

Should We Routinely Investigate Incidental Head and Neck Findings on 18-Fluorodeoxyglucose Positron Emission Tomography in Patients Being Staged for Non-small Cell Lung Cancer? A Retrospective Analysis.

BACKGROUND: Positron emission tomography (PET) with 18-fluorodeoxyglucose (FDG) is routinely performed for investigating suspected lung cancers. Despite the known potential for false-positive FDG uptake in the head and neck, most suspicious lesions on FDG-PET are investigated. METHODS: Between October 2002 and January 2010, FDG-PET/PET-computed tomography (CT) reports showing significant incidental uptake were retrospectively analyzed using controls to compare time to treatment for lung cancer and the rate of secondary malignancy in those with and without incidental head and neck FDG uptake. RESULTS: In this study, 48/1,846 PET/PET-CT scan reports reviewed, and demonstrated nonthyroidal head and neck abnormalities. A total of 30 patients had proven non-small cell lung cancer (1.6%); 3/30 (10%) went on to have biopsy proven malignancy. Furthermore, there was a significant increase in time to treatment in those patients with incidental head and neck findings (p = 0.002). CONCLUSION: These unexpected findings are mostly of no clinical significance and the patient should continue treatment without delay; however, aggressive work-up should be pursued if concerns for head and neck pathology are raised following clinical assessment.

Medialization thyroplasty for unilateral vocal cord paralysis secondary to advanced extralaryngeal malignant disease: review of operative morbidity and patient life expectancy.

OBJECTIVE: To review the operative morbidity and the overall length of survival following medialization thyroplasty for unilateral vocal cord paralysis (UVCP) due to advanced extralaryngeal malignancy. DESIGN: Retrospective review. SETTING: Tertiary care laryngology practice. METHOD: All cases of medialization thyroplasty over a 3-year period were reviewed. Only patients who had UVCP due to advanced extralaryngeal malignancy were included. Any cases from iatrogenic causes or for any other reason were excluded. Survival days were calculated from the date of the thyroplasty. MAIN OUTCOME MEASURE: Survival days postmedialization thyroplasty. RESULTS: Twenty-one patients met the inclusion criteria. Two distinct groups within this cohort were identified: (1) those suffering from advanced lung cancer and (2) those with metastatic cancer of another origin (ie, breast, renal cell, esophageal). There were 11 patients in the lung cancer group and 10 in the other group. Average survival was 538 days in the lung cancer group and 668 days in the other group. The procedure was well tolerated, with only one postoperative complication, which was a minor wound infection. CONCLUSION: For patients suffering from advanced malignancy, medialization thyroplasty is a safe procedure and an excellent modality for voice palliation.

Lingual thyroid in adults: management algorithm based on swallowing outcomes.

OBJECTIVE: To review the presentation, workup, and functional outcomes of adult patients diagnosed with lingual thyroid treated by transoral subtotal excision. These results were then used to formulate a management algorithm. DESIGN: Retrospective chart review (2001-2008). SETTING: Tertiary care academic hospital. PATIENTS: All patients diagnosed with a lingual thyroid as an adult were identified in the University of Alberta's head and neck mass database. Charts were reviewed for initial presentation, diagnostic methods, radiographic findings, and treatment and follow-up results. INTERVENTION: Transoral subtotal excision of lingual thyroid tissue. MAIN OUTCOME MEASURE: Postoperative swallowing function as measured by pharyngeal residue and aspiration on videofluoroscopic swallowing studies. RESULTS: Five patients with lingual thyroids meeting the study criteria were identified. All were females aged 29 to 58 years (mean 44 years). Presentations ranged from asymptomatic to acute airway obstruction. Diagnosis was made with flexible nasopharyngoscopy, thyroid scintigraphy, and computed tomography. All patients underwent transoral subtotal excision of their thyroids with either a CO2 laser or electrocautery. Two patients complained of residual symptoms and received adjunctive 131I, which led to symptom resolution. Pathologic evaluation revealed benign thyroid tissue. Swallowing function remained efficacious and safe in all patients, as shown by a lack of aspiration and low pharyngeal residue scores. These results were used to propose a management algorithm for the spectrum of adult-diagnosed lingual thyroid presentations. CONCLUSIONS: Transoral subtotal excision of lingual thyroid glands provides adequate resection of the lesion with good postoperative swallowing function. When appropriate, this is advocated as the treatment modality of choice.

LigaSure versus conventional hemostasis in thyroid surgery: prospective randomized controlled trial.

BACKGROUND: Meticulous hemostasis is a critical and often time-consuming step of safe thyroid surgery. The LigaSure system (Valleylab, Boulder, CO) is a diathermy hemostasis method that fuses vessel walls to form a collagen seal. Previous studies have shown reduced operative times in thyroidectomy using the LS system. The primary objective of the study was to compare operative times using the LS system to conventional titanium clips and surgical ties (CLTs). Secondary outcomes included vocal cord dysfunction, scores on the Voice Handicap Index (VHI), postoperative hypocalcemia, and operative costs between the two groups. METHODS: Twenty-eight patients were block randomized to thyroidectomy with either the LS system or CLTs. Patient demographics, operative times, pre- and postoperative VHI scores, vocal cord endoscopy, and operative costs were collected on all patients. Patients were also monitored for clinically significant hypocalcemia postoperatively. RESULTS: The mean operative time for CLTs was 68.6 minutes (SD 14.56) versus 68.5 minutes (SD 27.47) for the LS system, which was not statistically significant. VHI scores differed between CLTs and the LS system for the postoperative score only: CLT 19.83 (SD 19.81) versus LS 6.57 (SD 10.83). This was statistically significant, with p = .041. No difference was detected for hypocalcemia rates or endoscopic vocal cord dysfunction. The operative cost for the LS system was $387.15 (SD $11.93) and for the CLTs was $73.60 (SD $27.72), which was statistically significant (p < .001). CONCLUSION: The use of the LS system in thyroidectomy did not reduce overall operative time by a clinically significant level, indicating limited utility in terms of cost reduction contradictory to current literature.

Lansoprazole in globus pharyngeus: double-blind, randomized, placebo-controlled trial.

OBJECTIVE: To evaluate the effectiveness of once-daily lansoprazole in the typical globus pharyngeus patient, who presents with a normal head and neck examination and without other sinister otolaryngologic complaints. STUDY DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: Outpatient otolaryngology office practice. METHODS: After meeting the inclusion criteria, patients were randomized to a 3-month course of either treatment (30 mg lansoprazole daily) or placebo (lactose). All patients were given a medication diary and instructed to take the medication daily on waking. During the office visit, counseling regarding lifestyle modifications for gastroesophageal reflux disease was provided to all patients. MAIN OUTCOME MEASURE: The Glasgow-Edinburgh Throat Scale questionnaire was given prior to treatment and at 1- and 3-month intervals during treatment. RESULTS: Forty patients were enrolled between June 2005 and December 2006. Nineteen patients were randomized to the lansoprazole treatment arm, whereas 21 were enrolled in the placebo arm. Both groups were similar with regard to age, sex, and smoking history. The globus symptom score improved an average of 6.7 of 70 points in the treatment group and 2.9 points in the placebo group. There was no clinically or statistically significant difference between the two groups at any time point. CONCLUSION: The globus pharyngeus patient who presents with a normal head and neck examination and without sinister otolaryngologic complaints does not benefit from once-daily lansoprazole therapy.

Epiglottic histoplasmosis presenting in a nonendemic region: a clinical mimic of laryngeal carcinoma.

Histoplasma capsulatum is a dimorphic fungus endemic to North America. Histoplasmosis is primarily an inhalation-acquired mycosis that is encountered rarely outside of endemic regions. In nonendemic regions, histoplasmosis may present a diagnostic challenge and both clinical and laboratory vigilance are required to accurately identify infection. Unusual clinical presentations with limited physical findings may compound the difficulty in diagnosis. We describe a 78-year-old retired soil science professor who presented with an eroded epiglottic mass secondary to disseminated histoplasmosis in a nonendemic region (Alberta). Clinically, this mass was thought to represent a primary laryngeal carcinoma, as no other buccal or oropharyngeal ulcers were identified. Histoplasmosis was confirmed by tissue biopsy and a positive immunodiffusion test for immunoglobulin G. Disseminated histoplasmosis is often associated with laryngeal and oropharyngeal disease; however, isolated epiglottic histoplasmosis is rare. Histoplasmosis should be included in the differential diagnosis of neoplasms and chronic ulcers of the upper aerodigestive tract.

Selective denervation: reinnervation for the control of adductor spasmodic dysphonia.

OBJECTIVES: The objective of this study was to evaluate the efficacy of a new surgical procedure for adductor spasmodic dysphonia (AddSD). This surgery involves the bilateral selective division of the adductor branches of the recurrent laryngeal nerves with immediate reinnervation of the distal nerve trunks with branches of the ansa cervicalis (selective denervation-reinnervation). METHODS: Our first six patients to undergo this procedure were enrolled in the study. All patients suffered from AddSD and had previously received botulinum toxin A (Botox, Allergen, Markham, ON) therapy. Patients were recorded preoperatively and all underwent the same surgical procedure performed by the same lead surgeon. All patients were surveyed postoperatively and then re-recorded. Expert and untrained judges undertook perceptual evaluation of voice quality. Voice samples were also objectively evaluated for aphonic voice breaks. RESULTS: No major surgical complications were noted. Patient satisfaction was excellent, and five of the six patients no longer require botulinum toxin therapy. In five of the six patients, the majority of untrained and expert listeners perceived the postoperative voice to be superior. Objectively, the rate of aphonic voice breaks was also reduced in five of the six patients.