The Functional & Quality of Life Outcomes of Total Glossectomy with Laryngeal Preservation.

BACKGROUND: The tongue is an essential organ for human interaction, communication and survival. To date, there is a paucity of objective functional, patient reported, or quality of life outcomes of patients undergoing a total glossectomy with preservation of the larynx (TGLP). OBJECTIVE: To examine prospectively collected objective, self-reported functional and quality of life (QOL) data in patients undergoing TGLP and free flap reconstruction. METHODS: Sixteen TGLP patients were identified in the prospective head and neck cancer and functional outcomes database between January of 2009 and December 2017. Data collection included patient age, sex, performance status, TNM staging, diagnosis and adjuvant treatment. Swallowing and speech functions were measured and prospectively recorded pre- and postoperatively. Patient reported outcomes were measured with the Speech Handicap Index (SHI) and the M.D. Anderson Dysphagia Inventory (MDADI). RESULTS: All patients had a significant reduction in their objective swallowing (P = 0.035), sentence (P = 0.001) and word intelligibility (P < .001) scores. There was no significant reduction in SHI or total MDADI scores. All patients maintained their QOL in the post-treatment time frame. There was no relationship between free-flap type and outcome. CONCLUSION: Total glossectomy with laryngeal sparing and free flap reconstruction results in significant reduction in objective functional measurements, but patients report stable functional and quality of life outcomes after treatment.

Late free flap failure in head and neck reconstruction: A systematic review.

Our objectives were to review all reported cases of late flap failure in head and neck surgery and describe any relevant patterns. We conducted a systematic review of all published cases of free flap failure after postoperative day 7 in head and neck surgery from January 1990 to January 2018. Data were collected with respect to flap type, site of reconstruction, reason for failure, and time to failure. A total of 45 cases of late free flap failure in the head and neck were identified. Among the 34 cases in which the necessary data were available for analysis, 50% of late failures occurred between postoperative day 7 and 14. Common reasons for failure were abscess and vascular compromise. We conclude that most late flap failures occur in the second postoperative week. In patients with risk factors for flap failure, close monitoring for up to 14 days after surgery could detect flap compromise before the flap is lost.

Serum microRNA profiling to distinguish papillary thyroid cancer from benign thyroid masses.

OBJECTIVES: Papillary thyroid cancer (PTC) is increasing in incidence. Fine needle aspiration is the gold standard for diagnosis, but results can be indeterminate. Identifying tissue and serum biomarkers, like microRNA, is therefore desirable. We sought to identify miRNA that is differentially expressed in the serum of patients with PTC. METHODS: Serum miRNA was quantified in 31 female thyroidectomy patients: 13 with benign disease and 18 with PTC. qPCR results were compared for significant fold-changes in 175 miRNAs, against a pooled control. RESULTS: 128 miRNA qualified for analysis. There were identifiable fold-changes in miRNA levels between benign and control, and between PTC and control. There were statistically significant fold changes in the level of four miRNAs between benign and PTC: hsa-miR-146a-5p and hsa-miR-199b-3p were down-regulated, while hsa-let7b-5p and hsa-miR-10a-5p were up-regulated. CONCLUSIONS: MicroRNA is differentially expressed in the serum of patients with PTC. Serum miRNA has the potential to aid in thyroid cancer diagnosis.

CO(2) laser versus cold steel margin analysis following endoscopic excision of glottic cancer.

OBJECTIVE: To compare the suitability of CO2 laser with steel instruments for margin excision in transoral laser microsurgery. METHODS: Prospective randomized blinded study. Patients with glottic cancer undergoing laser resection were randomized to margin excision by either steel instruments or CO2 laser. Margins were analyzed for size, interpretability and degree of artifact by a pathologist who was blinded to technique. RESULTS: 45 patients were enrolled in the study with 226 total margins taken. 39 margins taken by laser had marked artifact and 0 were uninterpretable. 20 margins taken by steel instruments had marked artifact, and 2 were uninterpretable. Controlling for margin size, the laser technique was associated with increasing degrees of margin artifact (p = 0.210), but there was no difference in crude rates of uninterpretability (p = 0.24). CONCLUSION: Laser margin excision is associated with a greater degree of artifact than steel instrument excision, but was not associated with higher rate of uninterpretability.

Prognostic factors for metastatic cutaneous squamous cell carcinoma of the parotid.

OBJECTIVE: To explore the prognostic significance of patient and disease characteristics on the survival of patients with metastatic cutaneous squamous cell carcinoma of the parotid gland at a tertiary care center in Halifax, Nova Scotia, Canada. METHODS: A retrospective chart review for all patients diagnosed with metastatic cutaneous squamous cell carcinoma to the parotid gland from January 2000 to December 2010. Multiple variables were examined related to: patient demographics, surgical details, non-surgical procedure details, and tumor pathologic description. RESULTS: A total of 54 patients [48 men (88%) and 6 women (12%)], with a median age at surgery of 78 years (range 47-93 years) were included in the study. All patients had a minimum follow up of 12 months or until deceased, with a median duration of follow up of 24 months. Predictors that were significant for cancer recurrence were pretreatment N-stage, pathologic neck node status, total number of positive neck nodes, and perineural invasion. Predictors that were significant for cancer death were the total number of positive neck nodes and perineural invasion. The remainder of the predictors including margin status were non-significant. Only age and nodal status were significant for both cancer death and recurrence on multivariate analysis. CONCLUSION: Our results showed only two variables that remained significant on multivariate analysis were age and number of involved neck nodes, this finding suggests that re-resection of positive margins may not be necessary and that radiation therapy is the mainstay of treatment for positive margins.

Serum biomarkers of papillary thyroid cancer.

OBJECTIVE: To identify serum biomarkers of papillary thyroid cancer. METHODS: Prospective analysis was performed of banked tumor and serum specimens from 99 patients with thyroid masses. Enzyme-linked immunosorbent assay (ELISA) was employed to measure levels of five serum proteins previously demonstrated to be up-regulated in papillary thyroid cancer (PTC): angiopoietin-1 (Ang-1), cytokeratin 19 (CK-19), tissue inhibitor of metalloproteinase-1 (TIMP-1), chitinase 3 like-1 (YKL-40), and galectin-3 (GAL-3). Serum levels were compared between patients with PTC and those with benign tumors. RESULTS: A total of 99 patients were enrolled in the study (27 men, 72 women), with a median age of 54 years. Forty-three patients had PTC and 58 cases were benign tumors. There were no statistically significant differences when comparing all five different biomarkers between PTC and other benign thyroid tumors. The p-values were 0.94, 0.48, 0.72, 0.48, and 0.90 for YKL-40, Gal-3, CK19, TIMP-1, and Ang-1, respectively. CONCLUSION: Serum levels of four of the five proteins were elevated in patients with thyroid masses relative to normal values. However, the difference between benign and PTC was not significant. Two of the markers (Gal-3 & TIMP-1) displayed a greater potential difference, which may warrant further investigation. This study suggests that other serum markers should be sought. This is the first study to investigate potential serum biomarkers based on over-expressed proteins in thyroid cancer versus benign pathology.

Effects of tensor tympani muscle contraction on the middle ear and markers of a contracted muscle.

OBJECTIVES/HYPOTHESIS: Many otologic disorders have been attributed to dysfunction of the tensor tympani muscle, including tinnitus, otalgia, Meniere's disease and sensorineural hearing loss. The objective of this study was to determine adequate stimuli for tensor tympani contraction in humans and determine markers of the hypercontracted state that could be used to detect this process in otologic disease. STUDY DESIGN: Multiple types of studies. METHODS: Studies included 1) measuring middle ear impedance changes in response to orbital puffs of air, facial stroking, and self-vocalization; 2) measuring changes in stapes and eardrum vibrations and middle ear acoustic impedance in response to force loading of the tensor tympani in fresh human cadaveric temporal bones; 3) measuring changes in acoustic impedance in two subjects who could voluntarily contract their tensor tympani, and performing an audiogram with the muscle contracted in one of these subjects; and 4) developing a lumped parameter computer model of the middle ear while simulating various levels of tensor tympani contraction. RESULTS: Orbital jets of air are the most effective stimuli for eliciting tensor tympani contraction. As markers for tensor tympani contraction, all investigations indicate that tensor tympani hypercontraction should result in a low-frequency hearing loss, predominantly conductive, with a decrease in middle ear compliance. CONCLUSIONS: These markers should be searched for in otologic pathology states where the tensor tympani is suspected of being hypercontracted.

Cochlear implant rehabilitation for patients with vestibular schwannoma: report of two cases.

OBJECTIVE AND IMPORTANCE: The objective of this paper is to highlight two main points. The primary aim is to demonstrate that cochlear implants can function in the presence of retrocochlear pathology, even after stereotactic radiosurgery (SRS), and hence to introduce this as a management option in selected patients with retrocochlear pathology, such as Neurofibromatosis type II (NFII) patients. A secondary aim is to act as a caveat that computed tomography (CT) scanning alone may not be sufficient imaging in subjects undergoing cochlear implantation (CI). CLINICAL PRESENTATION: In this paper we report two patients who underwent cochlear implant despite the presence of a vestibular schwannoma (VS) on the same side. The first case is a 59-year-old male, diagnosed with VS after 9 months of good hearing with a cochlear implant. The second case is 26-year-old female known case of NFII, received a cochlear implant after controlling the tumor growth with a SRS. CONCLUSION: We show the consequences of missing important pre-implant pathology prior to CI in one case. In both cases, we add to the literature showing that cochlear implants can work well in the presence of VS, even in the presence of previous SRS. This adds significantly to the management options available to NFII patients, and the results seem to be better than those expected for auditory brainstem implant (ABI), and with a much simpler and safer intervention.

Anatomic analysis of the mastoid tegmen: slopes and tegmen shape variances.

OBJECTIVES: To examine the dural slope shapes and slope depths in different axes in the mastoid. These are important for surgical guidance. STUDY DESIGN: Setting-Tertiary care otologic center. Patients/materials-105 temporal bone CT scans were used from subjects who had undergone High Resolution Temporal Bone CT scanning for CSOM, using the non-diseased ear scans. In addition, 21 "diseased side" temporal bones were included. INTERVENTIONS: Scans were reconstructed in 3D using Amira software to examine tegmen shapes. The highest and lowest points on the tegmen were measured along 4 axes, 2 in the coronal plane (latero-medial axes posteriorly and anteriorly [L-M ant and L-M post]), and 2 in the sagittal plane (posterio-anterior axes medially and laterally [P-A med and P-A lat]). MAIN OUTCOME MEASURES: The highest and lowest point difference was labeled ΔH. We also measured the height from the superior external canal to the tegmen. RESULTS: There was a unimodal distribution in the ΔH variable for all axes measured. Means and (SD) in mm for ΔH are as follows: L-M post 4.1 (2), L-M ant 2.9 (2.2), P-A med 6.5 (1.9), P-A lat 5.4 (2.2). Tegmen-EAC lat and med height means were 8.4 and 9.7 mm respectively. Representative 3D shapes are presented. CONCLUSION: There appears to be a unimodal distribution of mastoid tegmen shapes and sizes, without clustering into subpopulations. The tegmen slopes have real implications for surgical exploration and disease eradication. A Tegmen classification scheme is presented.

Transmastoid resurfacing of superior semicircular canal dehiscence.

OBJECTIVES/HYPOTHESIS: To describe a new and fast surgical technique in treating superior semicircular canal dehiscence syndrome by resurfacing the canal defect via the transmastoid approach without retraction of the whole temporal lobe and to demonstrate the clinical and audiologic results of the superior canal dehiscence repair. Superior semicircular canal dehiscence syndrome is a well-described pathology. Surgical procedures through the middle fossa approach to resurface the superior canal and transmastoid plugging are considered the main surgical therapeutic options for patients with debilitating symptoms. Both have drawbacks; plugging is invasive to the inner ear, and resurfacing requires a middle fossa approach. STUDY DESIGN: Retrospective review. METHODS: Four patients presented with classic symptomatic semicircular canal dehiscence syndrome with radiographic confirmation of their dehiscence. The patients underwent the resurfacing procedure with a transmastoid approach. RESULTS: All four patients reported resolution of their symptoms. Audiograms documented some improvement in three subjects. CONCLUSIONS: The transmastoid approach for resurfacing superior semicircular canal dehiscence is a safe and less-invasive technique than the standard middle fossa approach, which has many potential complications and requires much longer hospitalization. In our study, the surgeries were completed within 90 minutes, and patients stayed in the hospital only overnight.

Current practice patterns in the management of glottic cancer in Canada: results of a national survey.

OBJECTIVE: In this study, we sought to determine current trends in the management of glottic cancer in Canada. We further sought to determine the approach to margin status following treatment of glottic cancer. METHODS: An online survey was distributed to all head and neck (H&N) surgeons and all radiation oncologists (ROs) in Canada. Respondents were asked to choose management recommendations for a series of tumour descriptions and to offer their opinion of margin evaluation. The results were compiled and analyzed using descriptive statistics for frequencies and chi-square analysis for comparison between H&N surgeons and ROs. RESULTS: The survey attained a response rate of 60% among H&N surgeons and 20% among ROs. There was a significant difference in choice of management for T1a, T1b, T2a, and T2b tumours, with ROs heavily favouring radiation therapy and H&N surgeons' opinions divided between radiation therapy and transoral laser microsurgery (TLM). There was no significant difference of opinion in the treatment of T3 and T4a tumours. The size of an adequate margin was significantly different between ROs and H&N surgeons, as was the management of a positive margin. CONCLUSION: Compared to previous surveys, this study reflects a move toward TLM as the preferred treatment for T1a glottic cancer among H&N surgeons, whereas ROs continue to favour radiation therapy. The results also show a split in opinions among H&N surgeons with respect to TLM versus radiation therapy for early-stage glottic tumours. The study underscores a difference of opinion between specialties regarding the management of glottic cancer and the need for a definitive comparison study to guide recommendations.

Audiometric thresholds measured with single and dual BAHA transducers: The effect of phase inversion.

The bone-anchored-hearing-aid (BAHA) transduces airborne sound into skull vibration. Current bilateral BAHA configurations, for sounds directly facing listeners, will apply forces that are in-phase with each other and directed roughly towards the center of the head. Below approximately 1000 Hz the two cochleae respond in approximately the same direction and with approximately the same phase to each BAHA, thus it may be preferable to drive bilateral BAHAs such that when one pushes, the other pulls. This can be achieved by adjusting the relative phase offset of the BAHAs, and doing so results in greater vibration and improved hearing threshold. In this paper we compare performance of bilateral BAHAs driven in this configuration to the standard configuration. In twelve normal participants we show significant improvements in low-frequency (≤750 Hz) hearing thresholds using out-of-phase BAHAs. The threshold measurements are further supported by velocimetric measurements taken at the cochlear promontory in a cadaveric head. Comparing vibration arising from each configuration confirms that out-of-phase driving results in greater vibration. Neither dataset shows either improved or reduced threshold at high frequencies.

Surgical emergencies in pediatric otolaryngology.

OBJECTIVE: To obtain baseline data on the most common surgical emergencies in pediatric otolaryngology in Saudi Arabia. METHODS: This report is a retrospective study of all children presenting to the pediatric otolaryngology emergency service at King Abdulaziz University Hospital in Riyadh, Kingdom of Saudi Arabia. Between January 2001 to January 2006 data were carefully collected and then analyzed for patients requiring emergent surgical intervention by the pediatric otolaryngology service. RESULTS: A total of 15,850 children presented to our pediatric otolaryngology emergency service. Surgical intervention was indicated in 183 children (1.2%). The larynx/head & neck was the most common site involved. Foreign body related emergencies were the most common presentation requiring surgical interventions (42%). The aero-digestive tract was the most common site for foreign body retrieval (54%). CONCLUSION: Pediatric patients have always constituted a significant portion of the general otolaryngology service. Most pediatric otolaryngology emergencies are relatively benign. Aero-digestive tract foreign bodies are the most common indication for surgical intervention in ped iatric otolaryngology.

Nasopharyngeal teratoma associated with cleft palate in a newborn.

Teratomas of the head and neck are rare congenital lesions comprising less than 10% of reported cases. Nasopharyngeal teratomas (NPT) are even rare. A case presented of a newborn with NPT associated with cleft palate. The most common presenting symptom of NPT is respiratory distress. The management of choice for NPT is surgical excision. Overall, the prognosis for NPT is excellent. Recurrences are rare, and are felt to be due to incomplete surgical resection.