Risk stratification of parotid neoplasms based on intraoperative frozen section and preoperative fine needle aspiration cytology.

PURPOSE: This study aims to determine the relationship of frozen section (FS) to final histology and determine how incorporating FS may change preoperative malignancy risk estimates based on preoperative fine needle aspiration cytology (FNAC). The secondary aim is to determine if FS is useful in influencing intraoperative decision-making. METHODS: Retrospective review of 426 intraoperative FS for parotidectomies performed for primary parotid lesions. RESULTS: Risk of malignancy with a benign FS was 2.5%, with indeterminate 36.1%, and with malignant 100%. Incorporating FS to fine needle aspiration for cytology helped to stratify malignancy risk especially in the Milan categories of atypia of undetermined significance, neoplasm of uncertain malignant potential and non-diagnostic categories, where a malignant FS increased malignancy risk significantly. FS was only able to identify 11% of high-risk histological subtypes for which a neck dissection would be recommended. CONCLUSIONS: FS may be used to stratify malignancy risk intraoperatively but has limited utility in clinical decision-making to perform a neck dissection and more extensive parotid resection in high-risk histological subtypes.

Percutaneous Management of Recurrent Head and Neck Cancer: Current Role and Evolving Principles in the Multidisciplinary Setting.

PURPOSE OF REVIEW: In this review, we will outline the role of percutaneous interventional radiological management of recurrent head and neck (H&N) cancer in the context of a multidisciplinary setting which consists of surgery, radiation therapy, as well as established and evolving systemic therapies that may impact current practice. RECENT FINDINGS: Management of recurrent H&N cancer is complex, with attention to the preservation of function and minimal treatment-related morbidity. The favored treatment modalities in local recurrence previously treated with radiotherapy are surgical resection, and if unresectable, for chemotherapy as definitive treatment, or as a prelude to resection if there is good tumor response. Unfortunately, some of these patients are too frail for major surgery or to withstand the toxicity of chemotherapy. There is a gap for effective local therapy without the morbidity of surgery, toxicity of re-irradiation, and systemic side effects of chemotherapy. Percutaneous interventions have the potential to bridge that gap as well as provide palliative symptomatic treatment for patients that have exhausted all treatment options. In the multidisciplinary setting involving the treatment of complex recurrent H&N cancer, percutaneous management now plays a viable and effective role with a foothold in this team-based approach.

Pearls on resecting the TMJ chondrosarcoma: how i do it.

BACKGROUND: Chondrosarcoma of the head and neck is uncommon and Chondrosarcoma of the Temporomandibular Joint is exceedingly rare. We present a 67-year-old male with a large right TMJ Chondrosarcoma. METHODS: Patient underwent right segmental mandibulectomy with excision of TMJ tumor, lateral temporal bone resection and right infratemporal fossa resection with Vastus Lateralis flap reconstruction of facial defect. Steps and technical considerations are presented in the video attached. CONCLUSION: This case and video illustration show the technical feasibility of complete resection of Chondrosarcoma of the TMJ while preserving function of critical structures most importantly the ophthalmic branch of the facial nerve.

Relationship between leisure noise exposure and otoacoustic emissions in a young Asian population.

OBJECTIVE: This study compared the otoacoustic emissions amplitudes of Asian youths at risk of leisure noise exposure through the use of portable music players with their less exposed counterparts. DESIGN: A listening habit survey was conducted. Subjects were divided into two groups for analysis. A subject was placed within the high risk group if he/she reported listening to music at near maximum volume and had a physical measurement of his/her preferred listening level recorded at > 85 dBA. DPOAE and TEOAE levels were measured and compared between the two groups. STUDY SAMPLE: A total of 1928 students from a tertiary educational institution in Singapore. RESULTS: TEOAE levels were found to be significantly lower in the high risk group at 4 kHz. DPOAE levels were also found to be significantly depressed in the high risk group at 1, 2, 3, and 4 kHz with the largest mean difference at 4 kHz. A four-way ANOVA carried out for OAE amplitudes using gender, ear laterality, risk profile, and years of usage as independent factors also showed that risk profile was a significant factor in determining the OAE amplitude at 4 kHz. CONCLUSION: We have demonstrated that both DPAOE and TEOAE values are diminished in the Asian subjects at high risk for noise exposure.

Intrathyroidal thymic carcinoma.

A young woman in her early 30s presented with a right thyroid mass and progressive hoarseness due to a right vocal cord palsy. The preoperative fine-needle aspiration cytology was classified as Bethesda V and she underwent a total thyroidectomy and neck dissection. Intraoperatively, the thyroid mass was adherent to the oesophagus, trachea and encasing the right recurrent laryngeal nerve which was sacrificed. Final histopathology diagnosed a rare subtype of thyroid cancer known as intrathyroidal thymic carcinoma (ITC). She was then sent for adjuvant radiotherapy after a multidisciplinary tumour board discussion. This case report highlights the difficulty in preoperative diagnosis of ITC and the importance of immunohistochemical staining in clinching the diagnosis. In view of its rarity, there have been no published consensus on the treatment of ITC, hence we would like to share some learning points through a comprehensive literature review.

Performance of a multigene genomic classifier and clinical parameters in predicting malignancy in a Southeast Asian cohort of patients with cytologically indeterminate thyroid nodules.

BACKGROUND: Most thyroid nodules are benign. It is important to determine the likelihood of malignancy in such nodules to avoid unnecessary surgery. The primary objective of this study was to characterize the genetic landscape and the performance of a multigene genomic classifier in fine-needle aspiration (FNA) biopsies of cytologically indeterminate thyroid nodules in a Southeast Asian cohort. The secondary objective was to assess the predictive contribution of clinical characteristics to thyroid malignancy. METHODS: This prospective, multicenter, blinded study included 132 patients with 134 nodules. Molecular testing (MT) with ThyroSeq v3 was performed on clinical or ex-vivo FNA samples. Centralized pathology review also was performed. RESULTS: Of 134 nodules, consisting of 61% Bethesda category III, 20% category IV, and 19% category V cytology, and 56% were histologically malignant. ThyroSeq yielded negative results in 37.3% of all FNA samples and in 42% of Bethesda category III-IV cytology nodules. Most positive samples had RAS-like (41.7%), followed by BRAF-like (22.6%), and high-risk (17.9%) alterations. Compared with North American patients, the authors observed a higher proportion of RAS-like mutations, specifically NRAS, in Bethesda categories III and IV and more BRAF-like mutations in Bethesda category III. The test had sensitivity, specificity, negative predictive value, and positive predictive value of 89.6%, 73.7%, 84.0%, and 82.1%, respectively. The risk of malignancy was predicted by positive MT and high-suspicion ultrasound characteristics according to American Thyroid Association criteria. CONCLUSIONS: Even in the current Southeast Asian cohort with nodules that had a high pretest cancer probability, MT could lead to potential avoidance of diagnostic surgery in 42% of patients with Bethesda category III-IV nodules. MT positivity was a stronger predictor of malignancy than clinical parameters.

Protocol for a randomised controlled trial on impact of comprehensive geriatric and supportive assessment versus standard care in older adults with cancer undergoing curative treatment: The Geriatric Oncology SuPportive clinic for ELderly (GOSPEL) study.

Cancer affects older adults with varying levels of frailty, but cancer treatment is extrapolated from clinical trials involving predominantly young and robust subjects. Recent geriatric oncology randomised controlled trials (RCT) report that geriatric assessment leading to frailty-guided intervention reduces treatment-related toxicity whilst maintaining survival and improving quality of life (QoL). However, these positive results have not have been consistently reported in the literature. We postulate that the impact of geriatric interventions has been underestimated in these studies with the inclusion of subjects receiving palliative-intent chemotherapy in whom dose reduction is common. Integrating supportive care with current geriatric oncology models may improve the QoL of older adults undergoing treatment. However, no studies as yet have examined such integrated geriatric and supportive models of care. The Geriatric Oncology SuPportive clinic for Elderly (GOSPEL) study is a single-centre, open-label, analyst-blinded RCT evaluating the impact of comprehensive geriatric and supportive care on QoL of older adults with cancer undergoing curative treatment. Older adults aged above 65, with a Geriatric-8 score ≤ 14, with plans for high dose radiotherapy and/or curative chemotherapy will be recruited. The primary QoL outcome is measured using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-ELD14 mobility scale at 12 weeks. Secondary outcomes include overall and disease-free survival, treatment-related adverse events, and hospital admissions. We pre-powered this study to recruit 200 subjects based on the minimally clinically important difference for EORTC QLQ-ELD14 to achieve 80% statistical power (alpha 0.05), assuming 25% attrition. Outcomes will be analysed using intention-to-treat. Intervention consists of multi-domain comprehensive geriatric and supportive care assessments from a multidisciplinary team targeting unmet needs. These include functional decline, falls, incontinence, cognitive impairment, multi-morbidity, polypharmacy, and symptom relief, as well as social and psycho-spiritual concerns. Standard care entails routine oncological management with referral to geriatrics based on the discretion of the primary oncologist. Recruitment has been ongoing since August 2020. Results from the GOSPEL study will increase understanding of the impact of integrated geriatric and supportive care programs in older adults with cancer receiving curative treatment. Trial registration: This study is registered under ClinicalTrials.gov (ID NCT04513977).

A Technical Guide to Palliative Ablation of Recurrent Cancers in the Deep Spaces of the Suprahyoid Neck.

Treatment options for patients with recurrent head and neck cancer, whether locoregional recurrence of previously treated head and neck cancer or secondary primary malignancy, are limited. Percutaneous ablation is a minimally invasive procedure that can be used with palliative intent in the head and neck to achieve symptomatic relief and local tumor control, potentially fulfilling treatment gaps of current standard of care options. Image guidance is key when navigating the deep spaces of the neck with special attention paid to critical structures within the carotid sheath. This review article provides an overview and highlights the important nuances of performing percutaneous ablations in the head and neck. It covers general principles, ablative modalities, image guidance, procedural technique, expected outcomes, and possible complications.

The efficacy and safety of high-intensity focused ultrasound in the treatment of benign thyroid nodules: A systematic review and meta-analysis from 1990 to 2021.

INTRODUCTION: To date, there have only been 2 systematic reviews, and 1 systematic review and meta-analysis on high-intensity focused ultrasound (HIFU) for benign thyroid nodules. The present systematic review and meta-analysis seeks to evaluate the efficacy and safety of HIFU in the treatment of benign thyroid nodules. METHODS: Pubmed, Embase and Cochrane databases were searched for relevant studies from 1990 to 2021. Nine studies were included in the systematic review and 6 in the meta-analysis. Pooled volume reduction rates (VRRs) at 3, 6 and 24 months after HIFU were assessed. RESULTS: This systematic review and meta-analysis showed that pooled VRRs at 3, 6, and 24 months after HIFU were 42.14 (95% confidence interval [CI] 28.66-55.62, I2=91%), 53.51 (95% CI 36.78-70.25, I2=97%) and 46.89 (95% CI 18.87-74.92, I2=99%), respectively. There was significant heterogeneity in the pooled VRRs at 3, 6 and 24 months after HIFU. No studies recorded complete disappearance of the nodules. Common side effects included pain, skin changes and oedema. There were no major complications except for transient vocal cord paralysis and voice hoarseness (0.014%) and transient Horner syndrome (0.5%). CONCLUSION: HIFU may be an effective and safe alternative treatment modality for benign thyroid nodules. Larger clinical trials with longer follow-up are needed to evaluate the effectiveness of HIFU in treating benign thyroid nodules.

Lymphoepithelial carcinoma of the larynx: an extremely rare tumour in a patient of Chinese descent.

Lymphoepithelial carcinoma (LEC) of the larynx is an extremely rare tumour which, unlike its nasopharyngeal counterpart, has shown a propensity to affect elderly Caucasian men and is not commonly associated with Epstein-Barr virus. We present a 70-year-old Chinese man who complained of hoarseness and dysphagia. Nasoendoscopy revealed a left supraglottic tumour. Preoperative MRI (in particular Diffusion Weighted Imaging) showed the possibility of two distinct components within a tumour. The patient underwent total pharyngolaryngectomy and bilateral selective neck dissection. The final histology report confirmed the presence of a tumour with two distinct components: predominant LEC with a smaller conventional (keratinising) squamous cell carcinoma component. The patient recovered well after surgery and subsequently underwent adjuvant radiotherapy. Final staging was pT3 N2c M0 (AJCC stage IVA). Follow-up over 2 years revealed no tumour recurrence.

Myoclonus From Intoxication by Bismuth Iodoform Paraffin Paste (BIPP) Nasopharyngeal Packing.

Bismuth iodoform paraffin paste (BIPP) gauze is widely used as an antiseptic wound packing in otolaryngology, head, and neck surgery. Uncommonly, BIPP can cause intoxication. Our report highlights an elderly patient who developed encephalopathy and overt myoclonus after nasopharyngectomy secondary to intoxication by the components of the BIPP gauze. The patient's impaired renal function, the amount of BIPP packing and the extensive nature of his wound likely predisposed him to BIPP toxicity. The myoclonus and delirium resolved promptly after removal of the BIPP packs. Clinicians should be aware of the clinical features of BIPP intoxication because of its common usage.

Chyloma: A Manifestation of Chyle Leak Six Months After Neck Dissection.

Chyle leaks after a neck dissection usually manifest within the immediate postoperative period. However, masked chyle leaks may present as a chyloma months later. A 54-year-old male patient with squamous cell carcinoma of the tongue underwent bilateral neck dissection, subtotal glossectomy, anterolateral thigh flap reconstruction and postoperative radiotherapy. Intraoperatively, chyle leak was encountered in level IV of the left neck. We managed it by ligation of the thoracic duct, application of Tisseel™ sealant (Baxter Inc., Illinois, USA) and one week of prophylactic fat-free feeds. Six months later, an asymptomatic chyloma of the left neck was identified on surveillance MRI. Five weeks after the diagnosis, streptococcal infection developed within the chyloma. However, initiation of fat-free diet, serial aspiration, pressure dressing and antibiotic therapy allowed the chyloma to resolve within two weeks. Further surveillance MRI over three years showed no recurrence of the chyloma. Low-volume chyle leaks may manifest as an occult chyloma. Prophylactic measures cannot replace meticulous ligation of chylous channels in left level IV neck dissection.

Noninvasive follicular thyroid neoplasm with papillary-like nuclear features and the risk of malignancy in thyroid cytology: Data from Singapore.

INTRODUCTION: The impact of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) on the risk of malignancy (ROM) in fine-needle aspiration cytology (FNAC) per The Bethesda System for Reporting Thyroid Cytopathology has not been well reported in Singapore. METHODS: We retrospectively identified 821 thyroid nodules with preoperative FNAC from 788 patients out of 1,279 consecutive thyroidectomies performed between January 2010 and August 2016 in a tertiary general hospital in Singapore. Possible cases of NIFTP were reviewed for reclassification and the impact of NIFTP on ROM was analysed. RESULTS: The incidence of NIFTP was 1.2% (10 out of 821). If NIFTP is considered benign, ROM in Bethesda I through VI were 8.6%, 3.5%, 26.3%, 20.0%, 87.7%, 97.0% versus 8.6%, 4.2%, 28.1%, 26.7%, 89.2% and 100% if NIFTP is considered malignant. Eight patients with NIFTP had follow-up of 15 to 110 months. One had possible rib metastasis as evidenced by I131 uptake but remained free of structural or biochemical disease during a follow-up period of 110 months. None had lymph node metastasis at presentation, nor locoregional or distant recurrence. CONCLUSION: Classifying NIFTP as benign decreased ROM in Bethesda II through VI, but the benignity of NIFTP requires more prospective studies to ascertain. The impact of NIFTP on ROM in our institution also appears to be lower than that reported in the Western studies.

Impact of COVID-19 on a Tertiary Otolaryngology Practice in Singapore.

The COVID-19 pandemic has had a major impact in healthcare systems across the world, with many hospitals having to come up with protocols and measures to contain the spread of the virus. This affects various specialties' clinical practices in many ways. Since early 2020 in Singapore, the Department of Otorhinolaryngology at Tan Tock Seng Hospital had to rapidly adapt to this pandemic as we provided services to the main healthcare facility combating the virus in our country. We had to design new workflows and also remain flexible in view of the ever-changing situation. There are 6 important domains for an otolaryngology department or any clinical department in general to consider when making adjustments to their practices in an outbreak: (1) clinical work, (2) education, (3) research, (4) safety of patients and staff, (5) morale of medical staff and (6) pandemic frontline work. We hope that the sharing of our experiences and the lessons learnt will be useful for both our local and international colleagues.

Progressive Cheek Swelling in an Older Woman.

An 87-year-old woman presents with sudden-onset worsening right facial swelling and pain and generalized maxillary alveolar hyperplasia. What is your diagnosis?

Laryngeal gout mimicking chondrosarcoma with concurrent longus colli tendinitis.

A 42-year-old man with multiple comorbidities, including gout, presented to the emergency department with severe odynophagia for 4 days with intermittent dysphagia for 1-2 months. A CT scan of the neck showed right longus colli tendinitis and partially calcified excrescences from the right thyroid cartilage which raised suspicion of a cartilaginous tumour. He underwent an MRI scan of the neck to better evaluate the thyroid cartilage findings, which showed a heterogeneous mass suspicious for a chondroid tumour. He then underwent a positron-emission tomography-CT scan which showed a fluorodeoxyglucose-avid mass containing foci of calcification involving the right thyroid cartilage and adjacent strap muscle, with high standardised uptake value of 7.7. He subsequently underwent a CT-guided biopsy and an open biopsy of the right thyroid cartilage, and the results revealed gouty tophi. To our knowledge, this is the first reported case of laryngeal gout with longus coli tendinitis, both of which are rare conditions.

Risk stratification of fine-needle aspiration cytology of parotid neoplasms based on the Milan system-Experience from a tertiary center in Asia.

BACKGROUND: The recently described Milan system provides a unified way of categorizing salivary gland fine-needle aspiration (FNA) cytology. We aim to use this system to stratify risk of malignancy in parotid FNAs. METHODS: In this retrospective case series, 376 FNAs were preoperatively performed for 573 parotidectomies over 14 years. RESULTS: Risk of malignancy on FNA is as follows: nondiagnostic 14.5%, non-neoplastic 26.7%, atypia of undetermined significance 29.3%, benign neoplasm 2.7%, neoplasm of uncertain malignant potential 19.1%, suspicious for malignancy 87.5%, and malignant 100%. The specific diagnoses of pleomorphic adenoma and Warthin tumor on FNA have high positive predictive value of 97.5% and 96.6%, respectively. Multivariate regression associates smaller size of lesion with a nondiagnostic or indeterminate result. Seniority of operator is associated with a lower likelihood of a nondiagnostic result. CONCLUSIONS: This large Asian series validates the Milan system as a valuable tool in stratifying malignancy risk of parotid FNAs.