Outcome of congenital tracheal stenosis in children over two decades in a national cardiothoracic surgical unit.

OBJECTIVE: To assess the outcomes of congenital tracheal stenosis among children. MATERIALS AND METHODS: A retrospective review of all children who underwent surgical repair of congenital tracheal stenosis reviewing charts, operative notes, echocardiograms, CT and MRI data from January 2002 to February 2019. RESULTS: Twenty-six children underwent surgical treatment for tracheal stenosis. The median age was 3 months (range 0.3-35 months) and the median weight was 4.7 kg (range 2.5-13 kg) at the time of surgical intervention. Stridor was the most common presenting symptom in 17 patients (65% of patients). Twenty-one patients (81%) had concurrent cardiac anomalies, with pulmonary arterial sling being the most common, present in nine patients (34%). Extracorporeal life support was utilised in seven patients (27%) pre-operatively. Laryngeal release was required in 16 patients. In 7 patients an end-to-end anastomosis was performed, in 18 patients slide tracheoplasty, and 1 patient had a double slide tracheoplasty. The median cardiopulmonary bypass time was 106 minutes (range 25-255 minutes). The median cross-clamp time was 30 minutes (range 5-67 minutes). The median post-operative duration of ventilation was 5 days (range 0.5-16 days). The median ICU length of stay was 12.5 days (range 2-60 days). There were three hospital mortalities with 88% survival. One patient only required reintervention with balloon dilation. Twenty-two patients (85%) remained symptom-free on median follow-up at 7.6 years (range 0.2-17 years). Two patients since 2017 had 3D printed tracheas produced from CT imaging to assist surgical planning. CONCLUSION: Congenital tracheal stenosis can be managed effectively with excellent outcomes and 3D printed models assist in planning the optimal surgical intervention.

Post-transplant lymphoproliferative disorder presenting as supraglottitis following pediatric heart transplantation treated with EBV-specific cytotoxic T-lymphocytes.

We present the case of a 4 year-old boy post heart transplantation who presented with signs and symptoms of critical airway obstruction and was initially diagnosed with infective supraglottitis. Following re-presentation and biopsy, this was confirmed as post-transplant lymphoproliferative disorder (PTLD) in an unusual site; laryngeal PTLD is rare. The patient failed standard therapy and ultimately was successfully treated with EBV-specific cytotoxic T lymphocytes (CTL). This case describes a rare presentation of PTLD which required a novel treatment approach including elective tracheostomy prior to CTL therapy. The treatment was successful and the patient was decannulated prior to discharge following 4 negative biopsies, the most recent 6 months following treatment completion. The case also highlights the importance of extra-vigilance in the post-transplant population and of a collaborative approach between multiple specialties across two separate countries including the transplant center and the referral center.

Effect of Endotracheal Tube Size on Vocal Outcomes After Thyroidectomy: A Randomized Clinical Trial.

IMPORTANCE: The optimum size of endotracheal tube (ETT) for general anesthesia remains unresolved. Choice of ETT size may be of particular relevance to thyroid surgery because of the increased risk of laryngeal trauma and concerns regarding postoperative vocal outcomes. OBJECTIVE: To test our hypothesis that intubation with a smaller ETT would lead to reduced postoperative vocal impairment and associated reduced laryngoscopic evidence of laryngeal trauma compared with intubation with a standard-size ETT. DESIGN, SETTING, AND PARTICIPANTS: This double-blind randomized clinical trial studied patients 18 years and older undergoing elective thyroidectomy at an academic teaching hospital from October 15, 2012, through June 13, 2013. INTERVENTIONS: Patients were randomized to group 1 (standard-size ETT, 8.0 mm for men and 7.5 mm for women; n = 24) or group 2 (small ETT, 7.0 mm for men and 6.5 mm for women; n = 25). Patients were assessed preoperatively and at 24 hours and 3 weeks postoperatively. MAIN OUTCOMES AND MEASURES: Fiberoptic videolaryngoscopy with modified scoring system, voice assessment using the GRBAS (grade, roughness, breathiness, asthenia, strain) rating scale, vocal self-assessment using the 30-item Voice Handicap Index, and subjective pain score. RESULTS: At 24 hours, no significant differences were found between patients in groups 1 and 2 in change in GRBAS scores, change in laryngoscopic score (1.71 vs 1.76, P = .90), or postoperative pain score (3.3 vs 3.2, P = .91). At 3 weeks, no significant differences were found in changes in the 30-item Voice Handicap Index score (-2.2 vs -1.3, P = .74), GRBAS scores, or laryngoscopic score (0.25 vs 0.16, P = .67). CONCLUSIONS AND RELEVANCE: We did not find evidence that smaller ETT size for thyroidectomy has any significant effect on postoperative vocal outcomes, incidence of laryngeal trauma as assessed by laryngoscopy, or pain scores. However, because of the small sample size, our study may have been underpowered to detect small differences. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02136459.

Outcome of Subclassification of Indeterminate (Thy-3) Thyroid Cytology into Thy-3a and Thy-3f.

OBJECTIVES: The British Thy system is a widely used classification system for reporting thyroid fine-needle aspiration (FNA) cytology. The Royal College of Pathologists in 2009 recommended the subdivision of the Thy-3 (indeterminate) category into Thy-3a (atypia) and Thy-3f (follicular neoplasm). Our objective was to examine the malignancy rates of Thy-3a and Thy-3f cases at our institution and to investigate whether the risk of malignancy in Thy-3a cases is reduced by FNA on a different occasion showing benign cytology. METHODS: This is a retrospective study of 748 thyroid nodules undergoing 1,032 FNAs, with indeterminate (Thy-3) cytology subdivided into Thy-3a and Thy-3f. Cases were correlated with final histology in surgical cases. Incidental carcinomas occurring outside the biopsied nodule were discounted. RESULTS: A total of 109 nodules had a final cytological diagnosis of Thy-3a, of which 67 underwent surgery, with an incidence of malignancy of 13.4% (9/67); 90 nodules had a final cytological diagnosis of Thy-3f, of which 84 underwent surgery, with an incidence of malignancy of 17.9% (15/84). The difference in malignancy rates was not significant (p = 0.51). The incidence of malignancy in nodules with benign and Thy-3a cytology on separate occasions was not significantly different from cases with a single Thy-3a cytology. CONCLUSIONS: Thyroid nodules with Thy-3a cytology have a slightly lower risk of malignancy than Thy-3f cases. However, the difference is not significant and does not appear to be reduced by FNA on a separate occasion showing benign cytology. Management decisions for patients with Thy-3a cytology should be taken carefully to avoid missing cancers.

Pediatric epistaxis: epidemiology, management & impact on quality of life.

OBJECTIVE: Epistaxis in the pediatric population is a common problem for both primary care physicians (PCPs) and otolaryngologists. Although a frequent reason for referral to ENT clinics, data is lacking regarding causes, effects on quality of life and common treatment modalities. METHODS: Prospective, clinical and questionnaire based study, with ethical approval. We identified 50 cases of pediatric epistaxis (<16 years old) over a 6-month period. A thorough clinical history was taken, first aid measures and management outcome was recorded. The impact of recurring epistaxis on parental quality of life was assessed using the Parental Stress Index Short Form (PSISF). RESULTS: Thirty-three males and 17 females (2:1) were included. Mean age at presentation was 8.8 years. Initial management was inadequate, with only 30% of carers applying appropriate first aid measures. Quality of life was significantly affected in 10% of cases with primary parental concerns being fear of excessive blood loss and the stress of soiled bedclothes and night wear. Children were most affected by the negative impact on sporting activity. Otolaryngology consultation found the common causes to be iatrogenic trauma and rhinitis affecting "Littles" area. Of which 78% required silver nitrate cautery, and 22% just required reassurance and advice CONCLUSIONS: Recurrent minor nosebleeds in children can be troublesome and alarming for parents and children. We found the PSISF an easy and reliable method of assessing patient and parental stress in dealing with this problem. Raising awareness of simple management strategies among parents and PCPs could significantly reduce associated quality of life issues. Mucosal hydration, cautery and first aid advice are the fundamentals of management.

Thyroid tubercle of zuckerkandl is more consistently present and larger on the right: a prospective series.

OBJECTIVE: The tubercle of Zuckerkandl (TZ) is a lateral projection from the thyroid lobe in the vicinity of the extralaryngeal termination of the recurrent laryngeal nerve (RLN), which is a very useful landmark for identification of the RLN during thyroidectomy. The purpose of the present study was to test our hypothesis that the TZ is more consistently found and is larger on the right than on the left side, and to investigate the frequency of anatomic variations of the TZ. STUDY DESIGN: Prospective cohort study of 156 consecutive patients undergoing primary total thyroidectomy at an academic teaching hospital. Thyroidectomy was performed using a capsular dissection technique, with identification of the RLN only at its entry point into the larynx, using the TZ as a landmark. In vivo recording of size of right and left TZ was performed. The size of the right and left TZ was compared. RESULTS: Identification of the TZ was 72.6% right side and 53.9% left side (p = 0.003). The mean size of the TZ, when present, was 11.2 mm on the right and 7.5 mm on the left (p = 0.0002). In matched-pair analysis, the right TZ was significantly larger than the left TZ (p < 1 × 10(-7)). The TZ overlay the RLN in nearly all cases; however, there were 2 cases (0.8%) of a TZ extending medial to the RLN. In 12 cases (4.7%), the TZ appeared as a bilobed structure. CONCLUSION: The right TZ is consistently larger and more often identified than the left.

Is systematic identification of all four parathyroid glands necessary during total thyroidectomy?: a prospective study.

OBJECTIVES/HYPOTHESIS: Routine identification of all four parathyroid glands has been advocated as a means of reducing rates of postoperative hypocalcemia and inadvertent parathyroidectomy. The object of the present study was to investigate whether identification of more parathyroid glands during thyroidectomy performed by capsular dissection technique had any impact on incidence of postoperative hypocalcemia and unintentional parathyroid resection. STUDY DESIGN: Prospective cohort study of consecutive patients undergoing total thyroidectomy by capsular dissection technique over a 3-year period. Exclusion criteria included performance of concomitant central neck dissection, hyperparathyroidism, revision surgery, and invasive cancer. METHODS: The number of parathyroid glands identified intraoperatively was recorded. No effort was made to find glands that were not obviously apparent during the course of dissection. Patients were not placed on routine calcium supplementation. RESULTS: The final study population consisted of 126 patients. The mean number of parathyroid glands identified was 2.3. The incidence of biochemical (any postoperative calcium <2 mmol/L) and clinical hypocalcemia was 22.2% and 10.3%, respectively. Patients in group A (0-2 parathyroids identified) had a significantly lower incidence of clinical hypocalcemia than patients in group B (3-4 parathyroids identified) (3.2% vs. 17.1%, P = .02). The differences in biochemical hypocalcemia were not significant (16.1% vs. 28.1%, P = .13). The incidence of inadvertent parathyroidectomy was 9.5%. There was no difference between the groups in incidence of inadvertent parathyroidectomy (9.7% vs. 9.4%, P = 1.0). CONCLUSIONS: Routine identification of all four parathyroid glands is not necessary in thyroidectomy performed using capsular dissection technique.

False negatives in thyroid cytology: impact of large nodule size and follicular variant of papillary carcinoma.

OBJECTIVES/HYPOTHESIS: Fine-needle aspiration (FNA) cytology is well established in the diagnosis of thyroid nodules. However, false-negative rates for malignancy of 3% to 10% are reported. The purpose of the present study was to investigate the impact of nodule size and follicular variant of papillary carcinoma (FVPTC) on false-negative FNA rates in thyroid nodules and on malignancy rates in nodules with indeterminate cytology. STUDY DESIGN: Retrospective study. METHODS: A total of 765 consecutive ultrasound-guided FNAs were reviewed. Histological correlation was available in 262 cases. RESULTS: The overall sensitivity of FNA for malignancy was 84%, and the false-negative rate 9.1%. Nodules ≥ 3 cm were significantly more likely to ultimately be diagnosed as cancer by histology than nodules <3 cm (14% vs. 6.8%, P = .006); however, they were also significantly more likely to undergo surgery than smaller nodules (P < .0001). Among the surgical series, the false-negative rate was 10.9% in nodules ≥ 3 cm and 6.1% in nodules <3 cm (P = .71). Most false negatives were due to FVPTC. FVPTC was significantly more likely to be missed by preoperative cytology than conventional or other variants of papillary carcinoma (P < .001). Among cases with indeterminate cytology, nodule size and Thy-3f versus Thy-3a subclassification did not have any significant impact on likelihood of malignancy. CONCLUSIONS: The sensitivity of FNA for detection of FVPTC is reduced compared to conventional papillary carcinoma. The impact of nodule size is not significant. LEVEL OF EVIDENCE: 4.