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.

Development of the Alberta facial clinical evaluation scale: A patient-centred outcomes instrument for facial nerve paralysis.

OBJECTIVES: Facial nerve paralysis has functional, psychological and social consequences for patients. Traditionally, outcome measurements for facial nerve injuries have been clinician derived. Recent literature has shown that patient perspective is valuable and necessary in outcomes research. This study aimed to identify patient domains of concern and subsequently, develop a point-of-care questionnaire for clinical use. DESIGN: This mixed-methods prospective study was completed in three phases. In Phase I, 15 facial nerve injury patients were interviewed individually. Interviews were digitally recorded, transcribed and coded with NVivo software. Analysis led to a conceptual framework detailing the most important quality of life outcomes. During Phase II, a focus group was held with five new patients in order to prioritise the outcome themes to a top six list. A second focus group was held with Otolaryngology-Head and Neck staff surgeons to create a 25-item questionnaire based on these six themes. In Phase III, the questionnaire was administered to 10 new patients to test for comprehension. SETTING: University of Alberta Hospital, Edmonton, Alberta, Canada. PARTICIPANTS: A total of 30 patients with facial nerve injury were included in the various phases in the study. In addition, 5 staff Otolaryngology-Head and Neck surgeons participated as focus group contributors. MAIN OUTCOME MEASURES: Domains of concern and quality of life outcomes as reported by facial nerve injury patients. RESULTS: Patients identified a total of 16 themes encompassing both functional and psychological deficits related to their facial nerve injury. From these findings, a 25-item Likert-type scale, the A-FaCE scale, was developed for clinical use. CONCLUSIONS: Patients with facial nerve paralysis experience functional and psychological deficits. This study led to the creation of the first patient-reported instrument for this population that addresses functional impairment, social function, psychological well-being and self-perception of appearance.

Objective and subjective sinonasal and pulmonary outcomes in aspirin desensitization therapy: A prospective cohort study.

OBJECTIVE: Aspirin exacerbated respiratory disease (AERD) patients are challenging to manage with sinonasal and pulmonary symptoms refractory to maximal medical and surgical therapies. Our objective was to comprehensively examine objective and validated, disease-specific subjective sinonasal and pulmonary outcomes of aspirin (ASA) desensitization therapy in this patient population. METHODS: Prospective cohort study at an academic tertiary center. AERD patients with a history of chronic rhinosinusitis with nasal polyposis (CRSwNP), prior diagnosis of asthma, and a history of ASA sensitivity were eligible for inclusion. Patients underwent ASA desensitization using an established institutional protocol and continued on a 650mg twice daily maintenance dose. Baseline Sinonasal Outcome Test (SNOT-22) and Asthma Control Questionnaire (ACQ) responses, acoustic rhinometry, peak flow readings, and endoscopic scoring of nasal polyps were recorded prior to desensitization and after 6months of maintenance therapy. RESULTS: Twelve patients were recruited for participation and underwent desensitization. Eight patients continued maintenance therapy and follow up at 6months. Prior to desensitization, patients reported bothersome sinonasal symptoms with a median SNOT-22 score of 30.0±34.5 (interquartile range (IQR)). There was significant improvement after 6months of maintenance therapy to a median SNOT-22 score of 18.5±17.3 (p=0.025, Wilcoxon signed rank test). Acoustic rhinometry, endoscopic scores, ACQ and forced expiratory volume values remained stable at 6months. CONCLUSIONS: AERD patients may benefit from ASA desensitization with subjective sinonasal symptom improvement at 6months and stable asthma and objective sinonasal measures. Further discussion is needed in the otolaryngology community regarding ASA desensitization in AERD management.

Acromegaly Presenting With Bilateral Vocal Fold Immobility: Case Report and Review of the Literature.

OBJECTIVE: To present a case of bilateral vocal fold immobility (BVCI) in a patient with acromegaly and review the current literature describing this presentation. DESIGN: Case report and literature review. SETTING: Academic tertiary care center. METHODS: English language literature search of online journal databases. RESULTS: A 56-year-old man presented with 3 months of progressive stridor and shortness of breath. Transnasal flexible endoscopy revealed BVCI. A tracheostomy was performed to secure his airway. Further history was suggestive of acromegaly and imaging demonstrated a pituitary macroadenoma. The diagnosis of acromegaly was made. The patient was treated with octreotide followed by an endoscopic trans sphenoidal resection of the pituitary adenoma. Sixteen months after his initial presentation, a right laser arytenoidectomy was performed and the patient was subsequently decannulated. In the literature to date, 11 cases of BVCI in acromegaly have been reported. These patients often present with stridor and require a tracheostomy. With treatment of their acromegaly, these patients may regain vocal fold mobility and may be decannulated. CONCLUSION: Acromegaly with BVCI is a rare presentation. Acute management of the airway of patients with acromegaly presenting with BVCI typically requires a tracheostomy. A period of 15 months should be allowed for restoration of vocal fold mobility before airway opening procedures are considered.

Vocal cord paralysis secondary to spontaneous internal carotid dissection: case report and systematic review of the literature.

OBJECTIVES: To present a rare case of unilateral vocal cord paralysis (VCP) secondary to spontaneous internal carotid artery dissection and to perform a literature review. CASE REPORT: A 35-year-old male presented to the emergency department with acute onset hoarseness and dysphagia. History, physical exam and laryngoscopy revealed left sided VCP without obvious cause. Magnetic Resonance Imaging (MRI) demonstrated a left internal carotid artery dissection of unknown etiology. Neurovascular surgery was consulted and treatment with aspirin was initiated. The dysphagia and hoarseness resolved in 12 weeks with long-term neurosurgery follow-up as the management plan. METHODS: Systematic literature review was conducted by 3 independent reviewers. Since 1988 only 9 cases of VCP due to internal carotid artery dissection have been reported. These were reviewed for: demographics, diagnostic method, treatment and vocal cord function. RESULTS: 7 patients had unilateral while 2 had bilateral VCP. MRI was used for diagnosis in 7 cases and 5 cases utilized a type of angiography. All received antithrombotic treatment with 5 out of the 9 patients experiencing vocal cord recovery in an average of 7.2 weeks. CONCLUSION: MRI is crucial in the work-up of idiopathic VCP. If an ipsilateral internal carotid artery dissection is found, antithrombotic treatment is initiated with an expectation that vocal cord mobility is likely to return.

Genetic differentiation between cave and surface-dwelling populations of Garra barreimiae (Cyprinidae) in Oman.

BACKGROUND: Phenotypic similarities among cave-dwelling animals displaying troglomorphic characters (e.g. reduced eyes and lack of pigmentation) have induced a long-term discussion about the forces driving convergent evolution. Here we introduce Garra barreimiae Fowler & Steinitz, 1956, as an interesting system to study the evolution of troglomorphic characters. The only hitherto known troglomorphic population of this species lives in Al Hoota Cave (Sultanate of Oman) close to a surface population. As a first approach, we assessed the genetic differentiation between the two morphotypes of G. barreimiae to determine whether gene flow still occurs. RESULTS: We analysed the mitochondrial control region (CR). In G. barreimiae the CR starts immediately downstream of the tRNA-Thr gene, while the tRNA-Pro gene is missing at this genomic location. Interestingly, a putative tRNA-Pro sequence is found within the CR. The phylogenetic analyses of the CR sequences yielded a tree divided into three clades: Clade 1 has a high genetic distance to the other clades and contains the individuals of three populations which are separated by a watershed from all the others. Clade 2 comprises the individuals from Wadi Bani Khalid, the geographically most remote population. Clade 3 comprises all other populations investigated including that of Al Hoota Cave. The latter forms a haplogroup which also includes individuals from the adjacent surface population. CONCLUSIONS: Our data indicates that the troglomorphic cave population is of quite recent origin supporting the hypothesis that selection drives the fast evolution of troglomorphic traits. In this context pleiotropic effects might play an important role as it has been shown for Astyanax. There seems to be some gene flow from the cave population into the adjacent surface populations. One blind individual, found at a surface locality geographically distinct from Al Hoota Cave, is genetically differentiated from the other blind specimens indicating the probable existence of another cave population of G. barreimiae. The phylogeographic analyses show that while some of the surface populations are either still in contact or have been until recently, the population Wadi Bani Khalid is genetically separated. One group consisting of three populations is genetically highly differentiated questioning the conspecifity with G. barreimiae.

Results of pediatric bone-anchored hearing aid implantation.

INTRODUCTION: The bone-anchored hearing aid (BAHA) system uses an osseointegrated titanium implant to propagate sound directly to the inner ear through the bones of the skull, bypassing the impedance of the skin and subcutaneous tissues. Children as young as 18 months have had hearing rehabilitated with this device. OBJECTIVES: The goals were to evaluate the efficacy of patient selection criteria, the safety and effectiveness of the implantation procedure, and the level of patient satisfaction after BAHA implantation in children. METHODS: The records of all pediatric patients implanted in Edmonton were retrospectively reviewed. Twenty patients, who received 25 implants, with postimplantation follow-up of 6 months or greater, were included. The average follow-up was 3 years, 7 months. RESULTS: Of 20 original implants, 3 were lost owing to trauma, whereas 2 failed to osseointegrate. All were successfully reimplanted. Complications related to the implants included three instances of skin necrosis around the abutment. All patients and caregivers reported greater than 95% improvement in patient-identified listening situations. Pure-tone averages improved from a mean of 49 dB for the better hearing ear preoperatively to 16 dB with the BAHA set at normal listening levels. CONCLUSIONS: The BAHA provides a safe and effective means of rehabilitation of conductive or mixed hearing loss in the pediatric population. Our patients report a high level of satisfaction and continued use of their devices.

Combination surgical and mechanical therapy for refractory cases of obstructive sleep apnea.

OBJECTIVE: Our purpose was to investigate the effects of surgical alteration of the soft palate by laser-assisted uvulopalatoplasty (LAUP) on the effectiveness of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea. Specifically, is there any change in effective CPAP pressure after LAUP? DESIGN: Ten patients from a group of LAUP candidates who either failed LAUP treatment as measured by pre- and postpolysomnography or were unable to tolerate CPAP were prospectively evaluated. PATIENTS: Fifty patients were referred to an otolaryngologist for evaluation and treatment of obstructive sleep apnea. Forty-three had LAUP surgery. Five patients had failed LAUP therapy and another five were unable to tolerate CPAP prior to LAUP. METHODS: Polysomnography was used to evaluate patients pre- and postoperatively. Polysomnography with CPAP titration was then used to compare the effects of LAUP in combination with CPAP. RESULTS: The average, effective CPAP decreased by 4.8 cm H2O after LAUP. In patients who failed LAUP therapy, CPAP was still found to be effective.