Guideline for the Surgical Management of Locally Invasive Differentiated Thyroid Cancer From the Korean Society of Head and Neck Surgery

The aim of this study was to develop evidence-based recommendations for determining the surgical extent in patients with locally invasive differentiated thyroid cancer (DTC). Locally invasive DTC with gross extrathyroidal extension invading surrounding anatomical structures may lead to several functional deficits and poor oncological outcomes. At present, the optimal extent of surgery in locally invasive DTC remains a matter of debate, and there are no adequate guidelines. On October 8, 2021, four experts searched the PubMed, Embase, and Cochrane Library databases; the identified papers were reviewed by 39 experts in thyroid and head and neck surgery. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of evidence, and to develop and report recommendations. The strength of a recommendation reflects the confidence of a guideline panel that the desirable effects of an intervention outweigh any undesirable effects, across all patients for whom the recommendation is applicable. After completing the draft guidelines, Delphi questionnaires were completed by members of the Korean Society of Head and Neck Surgery. Twenty-seven evidence-based recommendations were made for several factors, including the preoperative workup; surgical extent of thyroidectomy; surgery for cancer invading the strap muscles, recurrent laryngeal nerve, laryngeal framework, trachea, or esophagus; and surgery for patients with central and lateral cervical lymph node involvement. Evidence-based guidelines were devised to help clinicians make safer and more efficient clinical decisions for the optimal surgical treatment of patients with locally invasive DTC.

Comparison of the Voice Outcome After Injection Laryngoplasty: Unilateral Vocal Fold Paralysis Due to Cancer Nerve Invasion and Iatrogenic Injury

Background and Objectives@#Injection laryngoplasty is a common method for treatment of unilateral vocal fold paralysis. Unilateral vocal fold paralysis has various causes, including idiopathic, infection, stroke, neurologic condition, surgery and nerve invasion by cancer. To the knowledge of the authors, there was no study on the relationship between the causes of vocal cord paralysis and the outcome of injection laryngoplasty. Therefore, we tried to investigate the difference in the outcomes of injection laryngoplasty between vocal cord paralysis after surgery group and nerve invasion by cancer group.Materials and Method A retrospective analysis was performed for 24 patients who underwent vocal cord injection due to unilateral vocal cord paralysis caused by surgery or nerve invasion by cancer. The objective quality of the voice was assessed by acoustic voice analysis with the Multi-Dimensional Voice Program. @*Results@#Both group showed an improvement of fundamental frequemcy (F0), jitter percent, shimmer (percent), and noise to hearmonic ratio (NHR) after injection laryngoplasty. The vocal cord paralysis due to nerve invasion group showed more improvement in both the mean and median value of F0, shimmer percent and NHR than the vocal cord paralysis due to surgery group, but there was not statistically significant. @*Conclusion@#Our study did not show a statistically significant difference in outcome between vocal cord paralysis due to cancer invasion group and surgery group, but statistically tendency was suggested. The vocal cord paralysis due to nerve invasion group showed more improvement in both the mean and median value of acoustic voice analysis than surgery group.

A Case of Papillary Thyroid Cancer Coexisting with Thyroid Tuberculosis

Thyroid tuberculosis with papillary thyroid carcinoma is very rare. The current study shows the case of a 67-year-old female who was admitted to Ansan Hospital of Korea University, with her thyroid nodules showing signs of malignancy under ultrasonography. A histopathological examination proved the coexistence of papillary thyroid carcinoma (PTC) and thyroid tuberculosis (TB). A total thyroidectomy and excision of the enlarged left neck level II lymph node were performed. This report presents a rare case of coexistence of PTC and thyroid TB. Further investigation is needed to evaluate the possible role of PTC in thyroid mycobacterial infection.

A Case of Papillary Thyroid Cancer Coexisting with Thyroid Tuberculosis

Thyroid tuberculosis with papillary thyroid carcinoma is very rare. The current study shows the case of a 67-year-old female who was admitted to Ansan Hospital of Korea University, with her thyroid nodules showing signs of malignancy under ultrasonography. A histopathological examination proved the coexistence of papillary thyroid carcinoma (PTC) and thyroid tuberculosis (TB). A total thyroidectomy and excision of the enlarged left neck level II lymph node were performed. This report presents a rare case of coexistence of PTC and thyroid TB. Further investigation is needed to evaluate the possible role of PTC in thyroid mycobacterial infection.

Repair of Tracheoesophageal Fistula under Laryngeal Microsurgery Approach: Case Report and Literature Review

Patients with tracheoesophageal fistula show signs of aspiration, possibly leading to pneumonia, which could be fatal to bed-ridden patients. Tracheoesophageal fistula occurs as a complication of intubation, tracheostomy tube insertion and nasogastric tube insertion. Possible etiology is pressure and ischemic necrosis given by tracheostomy tube and nasogastric tube to trachea and esophagus; or in some cases, larynx and hypopharynx. Meanwhile, for repair of tracheoesophageal fistula, transcervical approach can be considered but takes relatively long operation time and is not appropriate for patients with underlying diseases. We report a case of tracheoesophageal fistula complicated several years after tracheostomy tube and nasogastric tube insertion who came to medical attention with signs of aspiration. Authors successfully performed repair of the fistula under laryngeal microsurgery approach without skin incision and dissection, and thereby report the experience with review of literature.

A Case Report of Patient with Left Neck Mass and a History of Thyroid and Ovarian Cancer in Head and Neck / 대한두경부종양학회지

Ovarian cancer is common malignant disease with high mortality in the female. However, lymph node metastasis in the head and neck of ovarian cancer is very rare than in para-aortic, pelvic lymph node. A 49-year-old female patient came to our clinic with a left neck mass. After total thyroidectomy and left selective neck dissection for the cervical neck level II, III, IV, V, VI for ovarian cancer and thyroid cancer, she had already undergone chemotherapy (Paclitaxel+Carboplatin) 18 month ago. CT scan showed only lymph node enlargement in left neck level II. Positron emission tomography-computed tomography (PET-CT) revealed a hypermetabolic lesion in same area but no other hypermetabolic lesion, especially in the pelvic and abdominal cavity. Fine needle aspiration cytology revealed metastatic carcinoma. The serum level of CA-125 was elevated to 43.8U/mL, whereas other tumor markers (CA 19-9, CEA) were in the normal range. She underwent a revision of selective neck lymph node dissection for the cervical neck levels I, II, and III, and on the review of surgical pathology, metastatic carcinoma was suspected. Thus, we performed immunohistochemical staining for the tissue; as a result, it was finally diagnosed as metastatic ovarian cancer (positive for CK7, ER and PR, and negative for CK20). Adjuvant chemotherapy (Paclitaxel+Carboplatin) was planned on the tumor board, and the patient successfully received chemotherapy.

Repair of Tracheoesophageal Fistula under Laryngeal Microsurgery Approach: Case Report and Literature Review

Patients with tracheoesophageal fistula show signs of aspiration, possibly leading to pneumonia, which could be fatal to bed-ridden patients. Tracheoesophageal fistula occurs as a complication of intubation, tracheostomy tube insertion and nasogastric tube insertion. Possible etiology is pressure and ischemic necrosis given by tracheostomy tube and nasogastric tube to trachea and esophagus; or in some cases, larynx and hypopharynx. Meanwhile, for repair of tracheoesophageal fistula, transcervical approach can be considered but takes relatively long operation time and is not appropriate for patients with underlying diseases. We report a case of tracheoesophageal fistula complicated several years after tracheostomy tube and nasogastric tube insertion who came to medical attention with signs of aspiration. Authors successfully performed repair of the fistula under laryngeal microsurgery approach without skin incision and dissection, and thereby report the experience with review of literature.

A Case Report of Patient with Left Neck Mass and a History of Thyroid and Ovarian Cancer in Head and Neck / 대한두경부종양학회지

Ovarian cancer is common malignant disease with high mortality in the female. However, lymph node metastasis in the head and neck of ovarian cancer is very rare than in para-aortic, pelvic lymph node. A 49-year-old female patient came to our clinic with a left neck mass. After total thyroidectomy and left selective neck dissection for the cervical neck level II, III, IV, V, VI for ovarian cancer and thyroid cancer, she had already undergone chemotherapy (Paclitaxel+Carboplatin) 18 month ago. CT scan showed only lymph node enlargement in left neck level II. Positron emission tomography-computed tomography (PET-CT) revealed a hypermetabolic lesion in same area but no other hypermetabolic lesion, especially in the pelvic and abdominal cavity. Fine needle aspiration cytology revealed metastatic carcinoma. The serum level of CA-125 was elevated to 43.8U/mL, whereas other tumor markers (CA 19-9, CEA) were in the normal range. She underwent a revision of selective neck lymph node dissection for the cervical neck levels I, II, and III, and on the review of surgical pathology, metastatic carcinoma was suspected. Thus, we performed immunohistochemical staining for the tissue; as a result, it was finally diagnosed as metastatic ovarian cancer (positive for CK7, ER and PR, and negative for CK20). Adjuvant chemotherapy (Paclitaxel+Carboplatin) was planned on the tumor board, and the patient successfully received chemotherapy.

A Case of Ectopic Thyroid Papillary Carcinoma with Incidental Papillary Thyroid Microcarcinoma

Ectopic thyroid is known to be a very rare disease. Its prevalence is 1 in 100,000-300,000, and it is the most common form of thyroid dysgenesis. In addition, it is known that primary thyroid cancer arising from ectopic thyroid tissue is rare. A 41-year-old male patient with mass in the anterior of the neck was admitted to our department of Otolaryngology. A surgical excision of the neck mass was carried out and the histopathology revealed papillary thyroid carcinoma. Total thyroidectomy and bilateral central neck dissection were then performed after 3 months from previous operation. As a result of histopathologic examination after surgery, we incidentally identified papillary microcarcinoma in the right thyroid lobe. We report a case of ectopic thyroid papillary carcinoma with incidental papillary thyroid microcarcinoma with a literature review.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient's treatment goals.

Two Cases of Papillary Carcinoma Arising from Thyroglossal Duct Cyst (TGDC)

A thyroglossal duct cyst (TGDC) is the most common congenital anomaly of the neck. However, carcinoma arising from TGDC is extremely rare. We report 2 cases of TGDC carcinoma. In the first case, a 21-year-old male patient complained of an anterior cervical mass; computed tomography (CT) and sonography revealed cystic mass that was suspected to be a TGDC. Sistrunk operation was performed. Papillary carcinoma was confirmed in pathologic examination. Additionally, he underwent total thyroidectomy and central neck dissection. After radioactive iodine ablation (RAI) was performed. In the second case, a 28-year-old male patient visited our out-patient department complaining of submental mass. He had already been diagnosed TGDC carcinoma 13 years ago and had undergone Sistrunk operation and total thyroidectomy. Malignancy was confirmed using fine-needle aspiration; thus, lateral neck dissection was performed and following this, he underwent RAI. Till date, no evidence of recurrence has been observed in these patients.

A Case of Tracheal Cancer Arising 3 Years after Radiation Therapy for Laryngeal Cancer

Tracheal cancer is rare and accounts for approximately 0.03% of all malignancies. Because of atypical symptoms, tracheal cancer can be misdiagnosed as obstructive lung disease, or tumors of thyroid or lung. Among patients of previous head and neck cancer, other primary cancer may accompany which called “second primary cancer”. We report a case of patient with tracheal cancer 3 years after definite radiation therapy of laryngeal cancer with a review of related literatures.

Clinical features of recently diagnosed papillary thyroid carcinoma in elderly patients aged 65 and older based on 10 years of sonographic experience at a single institution in Korea

PURPOSE: The aim of this study was to assess the characteristics of papillary thyroid carcinoma (PTC) in patients aged 65 and older in order to predict postoperative recurrence based on the results of ultrasonographic surveillance. METHODS: Among 1,494 patients (200 male and 1,294 female; mean age, 46.6±11.3 years) who underwent surgery for thyroid cancer at our institution between 2006 and 2015, we retrospectively enrolled 150 PTC patients (29 male and 121 female; mean age, 69.4±4.2 years). To identify the risk factors for recurrence, we analyzed age, gender, multiplicity, size, number, extrathyroidal extension (ETE) of the tumor, lymph node metastasis (LNM), type of surgery, and the dose of radioactive ablation using a Cox regression model to identify hazard ratios (HRs). RESULTS: Among the 115 asymptomatic patients with PTCs detected by screening ultrasonography (n=86), other cross-sectional imaging modalities (computed tomography or positron emission tomography-computed tomography, n=13), or incidentally through a surgical specimen (n=16), 78 patients were confirmed to have papillary thyroid microcarcinomas (PTMCs). The other 35 patients presented with palpable neck masses (n=25), vocal cord palsy (n=9) or blood-tinged sputum (n=1). During the follow-up period (mean, 43.6 months), 17 patients (12.5%) experienced recurrence in the neck. None of the patients died due to PTC-related recurrence or distant metastasis during the follow-up period. Cox regression analysis demonstrated that tumor size (HR, 2.12; P<0.001) and LNM (central LNM: HR, 9.08; P=0.004; lateral LNM: HR, 14.71; P=0.002; both central and lateral LNM: HR, 58.41; P<0.001) significantly increased the recurrence rate. ETE, LNM, and recurrence were significantly less frequent in PTMCs than in non-PTMC (all P<0.001). CONCLUSION: PTCs of small size and absent LNM showed significantly better prognoses in patients 65 years and older.

The Impact of Thyroid Nodule Size and Fine-Needle Aspiration Biopsy Result on the Risk of Malignancy in the Patients Who Underwent Thyroidectomy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The frequency of ultrasonography and cytological examinations for thyroid nodules has increased. But the efficacy of fine needle aspiration biopsy varies according to the size of the nodules. The study aimed to identify the effect of thyroid nodule size on malignancy. SUBJECTS AND METHOD: The medical records of patients who underwent total or hemithryoidectomy in a single tertiary hospital were retrospectively analyzed. A total of 204 nodules were obtained from 193 patients who underwent fine needle aspiration biopsy before thyroid surgery. After each nodule was classified by size, the results of the fine needle aspiration test and risk of the final diagnosis were evaluated using logistic regression analysis. RESULTS: The average size of 204 Bethesda class 2 (benign) nodules was 2.99 cm, which was larger than those of other classes (p<0.05). In the final histopathologic diagnosis, there was a difference in size between benign (2.41 cm) and malignant nodules (1.23 cm) (p<0.05). In addition, a logistic regression analysis showed that the nodules below 2.0 cm in size showed an odd ratio of 7.81, compared to the nodules larger than 2.0 cm (p<0.05). CONCLUSION: According to the results of this study, malignancy was higher when the thyroid nodule was less than 2 cm. Therefore, a careful observation is needed for nodules less than 2 cm for which fine needle aspiration biopsy would be recommended. Conversely, it is necessary to reconsider the diagnostic surgery for nodules larger than 2 cm.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

The Correlation between The Size and Location of Vocal Polyp and Voice Quality, Before and After Laryngeal Microsurgery

BACKGROUND AND OBJECTIVES: Vocal polyps are caused by inflammation induced by stress or irritation. Many patients with vocal polyps complain voice discomfort. For vocal polyps, surgery such as laryngeal microsurgery has been the mainstay of management. We analyzed the clinical features of vocal polyps, and how the size and location of vocal polyps affect the outcomes of surgery. METHODS: We retrospectively reviewed 42 patients from March 2014 to December 2015, who were diagnosed as unilateral single vocal polyp. When we operated on a vocal polyp with laryngeal microscopy, we measured their size and location. The quality of voice was evaluated by GRABS scale, jitter, shimmer, NHR (noise to harmonic ratio), MPT (maximum phonation time), and VHI (voice handicap index) before operation and 4 weeks after operation. RESULTS: When we divided the patients into large-sized vocal polyp group (the longest length >3 mm) and small-sized vocal polyp group (the longest length ≤3 mm), all parameter differences tend to be greater at large sized vocal polyp. However, these differences were not statistically significant (p>0.05). When we divided into two groups depending on the volume of vocal polyp, no distinct tendency was found. When we compared the location (anterior, mid and posterior) of vocal polyp with the improvement of voice quality, more change was found at mid portion vocal polyp, except the difference of VHI. However, these differences were also not statistically significant (p>0.05). CONCLUSION: All parameter differences tend to be greater at large vocal polyp and polyp of the mid location.

Primary Intraosseous Osteolytic Meningioma of the Skull Mimicking Scalp Mass: A Case Report and Review of Literature

Primary extradural meningioma is about 1-2% of all meningiomas. Primary intraosseous meningioma is a rare form of intra-bone tumors that account for approximately 67% of extradural meningiomas. We report a primary intraosseous meningioma of a 69-year-old man who had headaches and a mass on right parietal scalp for the past few months. Remarkably, the brain tissue within the osteolytic cavity of the skull was normal in computed tomography and magnetic resonance images. Resection, duraplasty, and cranioplasty were performed. The patient's symptoms disappeared after surgery, and the histological diagnosis was an osseous meningothelial meningioma (World Health Organization grade I).

Protective Role of Trimetazidine Against Neomycin-induced Hair Cell Damage in Zebrafish

OBJECTIVES: Trimetazidine (TMZ) is known to reduce the generation of oxygen-derived free radicals. The objective of the present study was to evaluate the effects of TMZ on neomycin-induced ototoxicity in transgenic zebrafish (Brn3C: EGFP). METHODS: Five-day, postfertilization zebrafish larvae were exposed to 125 microM neomycin and one of the following TMZ concentrations for 1 hour: 10 microM, 100 microM, 500 microM, 1,000 microM, 1,500 microM, or 2,000 microM. Hair cells within the neuromasts of the supraorbital (SO1 and SO2), otic (O1), and occipital (OC1) lateral lines were analyzed using fluorescence microscopy and confocal microscopy (n=10). Hair cell survival was calculated as a percentage of hair cells in the control group that were not exposed to neomycin. Ultrastructural changes were evaluated using scanning electron microscopy. RESULTS: TMZ protected against neomycin-induced hair cell loss in the neuromasts (TMZ 1,000 microM, 11.2+/-0.4 cells; 125 microM neomycin only, 4.2+/-0.5 cells; n=10; P<0.05) and decreased the terminal deoxynucleotidyl transferase (TdT)-mediated dUTP-biotin nick end labeling (TUNEL) reaction. In the ultrastructural analysis, structures of mitochondria and hair cells within the neuromasts were preserved in zebrafish exposed to 125 microM neomycin and 1,000 microM TMZ. CONCLUSION: TMZ attenuated neomycin-induced hair cell loss in zebrafish. The results of this study suggest that neomycin induces apoptosis, and that apoptotic cell death can be prevented by treatment with tremetazidine.

Effect of Isolated Uvulopalatopharyngoplasty on Subjective Obstructive Sleep Apnea Symptoms

OBJECTIVES: The aims of this study were 1) to evaluate the effect of isolated uvulopalatopharyngoplasty (UPPP) on subjective obstructive sleep apnea (OSA) symptoms in adult patients regardless of the response to surgery, and ultimately 2) to investigate the differences in changes in subjective OSA symptoms between successful and unsuccessful surgery groups. METHODS: Twenty consecutive adult patients who underwent isolated UPPP were enrolled. Pre- and postoperative subjective OSA symptoms (snoring, witnessed apnea, daytime sleepiness, morning headache, daytime fatigue, restless sleep, difficulty with morning arousal) and polysomnographic data were evaluated in all subjects. Changes in subjective OSA symptoms before and after surgery were investigated in the successful (n=11) and unsuccessful (n=9) groups. Surgical success was defined as a reduction of at least 50% in the preoperative apnea-hypopnea index (AHI) and a postoperative AHI less than 20 per hour. RESULTS: After isolated UPPP, all subjective OSA symptoms changed significantly in the patients, especially in the successful group. In the unsuccessful group, snoring, witnessed apnea and daytime fatigue changed significantly, while other symptoms did not change significantly after surgery. CONCLUSION: Isolated UPPP may improve subjective OSA symptoms in adult patients whom surgery was successful or unsuccessful. However, after isolated UPPP, the improvements in subjective OSA symptoms in the unsuccessful group may be different from those in the successful group.

The Usefulness of CO2 Laser-Assisted Phonomicrosurgery Using a Computer-Guided Scanner in Broad-Based Vocal Polyp / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: New computer-guided scanner (CGS) recently applied to CO2 laser micromanipulator allows the beam to sweep a given surface with extreme rapidity. Our aim in this study is to evaluate the efficacy and usefulness of CO2 laser-assisted phonomicrosurgery using a CGS in broad-based vocal polyp. SUBJECTS AND METHOD: The current study enrolled 41 patients who underwent phonomicrosurgery for broad base polyp of vocal fold. Twenty patients underwent CO2 laser-assisted phonomicrosurgery using CGS (Group 1), and 21 patients underwent conventional phonomicrosurgery using cold instruments (Group 2). RESULTS: All voice analysis parameters showed significant improvement after surgical treatment, except fundamental frequency and noise-to-harmonic ratio. Differences between preoperative and postoperative parameters of each voice analysis data did not differ significantly between the two groups. CONCLUSION: Although no significant difference was observed between the two groups, CO2 laser-assisted phonomicrosurgery using CGS allow for performance of more accurate and delicate incision with a controllable depth of beam penetration.