Consistency in the Distribution of Bethesda System for Reporting Thyroid Cytology Categories Over 9 Years: A Single Institute, Retrospective Study.

BACKGROUND: The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) has evolved since it was first introduced in 2009 to become a worldwide accepted cytologic analysis reference, due to its simplicity and reproducibility. To date, the consistency of BSRTC throughout time has yet to be investigated. METHODS: Retrospective single institution case series with chart review of all patients who underwent fine-needle aspirations for a thyroid nodule in our institution between the years 2010 and 2018 with a documented BSRTC classification. Data collection included demographics, risk factors, sonographic evaluation, nodule size, and final pathology when feasible. The main outcome is the difference in the rates of BSRTC categories benign, atypia of undetermined significance (AUS), follicular neoplasm, suspicious for malignancy, and malignant (BSRTC II-VI, respectively) between the study years. RESULTS: A total of 2830 thyroid nodules were included. BSRTC II-VI distribution was 83.9% (2373), 8.2%, (232), 2.7% (75), 3.3% (93), and 2.0% (57), respectively. There was no significant change in the overall trend of each BSRTC category distribution throughout the study. There was a significant increase in the benign cytology rate (BSRTC II) in 2011 compared to 2015 and 2018 (76.4% compared to 88.7% and 87.6%, respectively. P < .005) alongside a significant decline in the AUS category rate (BSRTC III) between the same years (13.0% compared to 4.8% and 5.5%, respectively. P < .005). CONCLUSION: BSRTC showed consistency throughout the study across all observed categories. An overlap between AUS and benign may exist, possibly due to the heterogenic definition of AUS as reflected in the 2023 BSRTC subclassification for AUS.

Evaluation of the Whiteout During Fiberoptic Endoscopic Evaluation of Swallowing and Examination of Its Correlation with Pharyngeal Residue and Aspiration.

To evaluate the whiteout duration (WOd) and intensity (WOi) during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and examine their correlation with each other and age, gender, bolus consistencies, residue, and aspiration. Retrospective review of 75 videorecorded FEES. The first swallow of each of the following were scored: "Empty" swallow, semisolids, solids, and liquids (International dysphagia diet standardization initiative (IDDSI) 4, 7, 0, respectively). Data scored for each swallow included WOd, WOi, Penetration and aspiration scale (PAS), Pharyngeal residue (Yale Pharyngeal Residue Severity Rating Scale, YPR-SRS), and saliva pooling (Murray Secretion scale, MSS). The highest PAS and YPR-SRS for each consistency during the entire examination were also collected. WOd was significantly longer for stronger WOi in IDDSI4 swallows (p = 0.019). WOi was weaker for IDDSI0 swallows compared to IDDSI7, IDDSI4, and empty swallows (p < 0.05). Patients with saliva pooling had significantly shorter WOd (0.81 ± 0.3 s for MSS = 0 vs. 0.62 ± 0.24 for MSS = 3, p = 0.04). Lower WOi was associated with higher mean age for IDDSI0 (mean ages of 73 ± 12, 64 ± 14, 73 ± 7, 59 ± 16 years for intensity levels 1-4 respectively, p = 0.019). Swallows with weaker WOi and longer WOd had significantly more aspirations in IDDSI7 (28.8% of PAS ≥ 6 for intensity 2 vs 0% for intensity 4, p = 0.003 and 0.77 ± 0.4 s for PAS 1-2 vs. 1.02 ± 0.08 for PAS 6-8, p = 0.049). WOi and WOd are significantly associated with each other. WOi may vary for different bolus consistencies and decreases with age. Longer WOd and weaker WOi are associated with penetration-aspiration. Shorter WOd is associated with saliva pooling.

Outcomes of abscess tonsillectomy in patients awaiting tonsillectomy: A comparison with interval tonsillectomy.

PURPOSE: Peritonsillar abscesses (PTA) occasionally occur in patients who have a concurrent history of recurrent tonsillitis or prior PTA episodes. These patients sometimes meet the indications for elective tonsillectomy even prior to the current PTA event. Abscess ("Quinsy") tonsillectomy (QT) could serve as definitive treatment in this specific subgroup, though it is not performed often. The purpose of this study was to compare the perioperative outcomes between immediate QT and tonsillectomy performed several days (delayed QT) or weeks (Interval tonsillectomy, IT) after incision and drainage (I&D) of the PTA in this specific subgroup. MATERIALS AND METHODS: A retrospective perioperative outcomes analysis of patients undergoing tonsillectomy (2002-2022) compared QT to delayed QT and IT in patients with PTA meeting AAO-HNS elective tonsillectomy criteria. RESULTS: 110 patients were included: 55 underwent IT, 36 underwent delayed QT, and 19 underwent immediate QT. Postoperative hemorrhage rates were 14.5 %, 11.1 %, and 5.3 % for IT, delayed QT, and immediate QT, respectively (P = 0.08). Mean hospitalization durations were 7.98, 6.92, and 5.37 days for IT, delayed QT, and immediate QT, respectively (P < 0.01). IT had a higher readmission rate due to pain compared to QT (14.5 % vs. 1.9 %, p = 0.032). CONCLUSION: Immediate QT in PTA patients eligible for elective tonsillectomy is associated with lower postoperative hemorrhage, shorter admission time, and potentially reduced postoperative pain compared to I&D and delayed or interval tonsillectomy. These findings suggest that immediate QT should be considered as a primary treatment in this subgroup of eligible patients.

The impact of iodine deficiency exposure on thyroid nodule cytology and pathology - A single institute, case-control study.

OBJECTIVE: The association between follicular carcinoma and iodine deficiency (ID) is based on epidemiological studies and their inherent biases. The aim of the study was to assess the impact of long-term ID exposure on thyroid nodule cytology and final pathology in a distinct group of patients within a single institution. METHODS: Ethiopian origin patients were compared to an aged-matched group of non-Ethiopian patients. Demographics, risk factors, clinical presentation, cytology and pathology were collected and compared. Final outcomes were cytology and pathology distribution. RESULTS: A total of 489 (246 Ethiopian, 243 control) nodules of 461 patients (230 and 231 respectively) were included. Ethiopian patients had lower rates of thyroid cancer risk factors (p=0.05). Cytology analysis demonstrated significant group differences (p=0.03), as Ethiopian patients had higher rates of benign cytology (85% vs. 75.7%, respectively). Pathology analysis demonstrated a significantly lower malignancy rate among Ethiopian patients (39.2% (20/51) vs. 63.3% (31/49), p=0.027, respectively). The Ethiopian group had a significant higher rate of follicular carcinoma compared to the control group (25% [5/20] vs. 3.2% [1/31], p=0.034, respectively) and lower rates of papillary thyroid carcinoma (25% [5/20] vs. 61.3% [19/31], p=0.017, respectively). CONCLUSIONS: The association between ID and FC exists years following immigration and exposure to a better iodine diet, implying that differentiation may be affected in earlier stages and levels of exposure.

Zoom in: factors affecting vocal habits during online meetings, a prospective trial on 40 subjects.

PURPOSE: To identify factors that influence vocal habits during online meetings (OMs). METHODS: A prospective trial of forty participants without any known hearing or vocal cord disorders. Subjects participated in an OM divided into six randomly ordered sections, with alterations in audio/speaking equipment and language: the computer's speaker-microphone, a single earbud, two-earbuds or headphones; with/without video, native-language-speaking (Hebrew) versus second language-speaking (English). Each section included free speech, sustained phonation, and a standardized passage. Participants ranked their vocal-effort for each section. Three blinded raters independently scored the voice using the GRBAS scale, and acoustic analyses were performed. RESULTS: No significant difference in self-reported vocal effort was demonstrated between sections. Second-language speaking resulted in significantly increased intensity (p < 0.0001), frequency (p = 0.015), GRBAS (p = 0.008), and strain (p < 0.0001) scores. Using the computer's speaker/microphone resulted in significantly higher strain (p < 0.0001). Using headphones, single or two earbuds resulted in lower intensity and a lower strain score. No differences were detected between OMs with or without video. CONCLUSIONS: Using the computer's microphone/speaker or speaking in a second language during OMs, may result in vocal habits associated with vocal trauma.

Incidental Laryngeal Findings in Routine Laryngopharyngeal Reflux Diagnosis.

BACKGROUND: Laryngopharyngeal reflux (LPR) refers to the backflow of acidic stomach content into the larynx, pharynx, and upper aerodigestive tract. The diagnosis of LPR is based on the patient's history and findings of the laryngoscopy associated with LPR. Other possible manifestations consistent with LPR symptoms include laryngeal cancer, vocal fold granulomas, Reinke's space edema, and vocal polyps. In this study, we compared the characteristics of patients with LPR symptoms and incidental laryngeal findings (ILF) in the laryngoscopic evaluation to those without ILF (WILF). OBJECTIVES: Determine the characteristics of LPR-symptomatic patients with ILF versus WILF. METHODS: In this retrospective study, we examined 160 medical charts from patients referred to the otolaryngology clinic at Galilee Medical Center for LPR evaluation 2016-2018. The reflux symptoms index (RSI), reflux finding score (RFS), and demographics of the patient were collected. All patients with a positive RSI score for LPR (RSI > 9) were included, and the profiles of patients with versus without ILF on laryngoscopy examination were compared. RESULTS: Of the 160 patients, 20 (12.5%) had ILF during laryngoscopy. Most had vocal cord findings such as leukoplakia (20%), polyps (15%), and nodules (20%). Hoarseness, throat clearing, swallowing difficulty, breathing difficulties, and total RSI score were significantly higher in patients with ILF. CONCLUSIONS: Evaluation of LPR symptoms may provide otolaryngologists with a tool to identify patients with other findings on fiberoptic laryngoscopy. A laryngoscopic examination should be part of the examination of every patient with LPR to enable diagnosis of incidental findings.

In-office KTP laser treatment for laryngeal pathologies: 5-years outcomes.

INTRODUCTION: In the past two decades, laser systems were introduced into the office setting for laryngeal pathologies, offering the advantages of a shorter procedure and recovery. To date, long-term data on outcomes is limited. This study aims to evaluate the efficacy and safety of the office-based potassium-titanyl-phosphate (KTP) laser procedure for laryngeal pathologies. METHODS: A retrospective cohort of in-office KTP laser procedures for two main vocal folds lesions groups: (i) benign and pre-malignant; and (ii) intraepithelial lesions in a prior invasive cancer field between 2010 and 2020. Data were collected from electronic medical records, telephone interviews, and video documentation of the procedure, including treatment completion, disease control, and whether additional interventions were required. RESULTS: A total of 81 patients underwent 153 in-office KTP laser procedures for benign (36, 44.4%), pre-malignant (15, 18.5%), and lesions in a prior malignancy field (30, 37.1%) with a mean of 1.89 ± 1.81 procedures per patient. One hundred and thirty-eight (90.2%) procedures were well tolerated and completed successfully. During the 5-years of follow-up, 63% of the patients with previous malignancy were managed exclusively in the office. In the pre-malignant group, 76% required no additional type of intervention. Patients with papilloma required significantly more procedures per patient compared with other pathologies (3.6 ± 4 vs. 1.61 ± 1, p-value = 0.02). Surgery was required only in 18.2% of the papilloma patients. Three (1.9%) patients had short-term complications, all resolved within 6 months. Failure to complete the procedure was significantly associated with active smoking (p-value < 0.001) and, in most cases (90%), was related to patient intolerance. CONCLUSION: Office-based KTP laser laryngeal procedures have shown promising results for both benign and selected cases of lesions in a prior malignancy field with a high compliance and a very low complication rate, suggesting its use as an effective and safe treatment modality for selected patients.

The impact of birth weight and gestational age on acute mastoiditis in children.

OBJECTIVE: Previous data correlate preterm and low birth weight (LBW) with acute otitis media, but there is a gap concerning the relations with acute mastoiditis (AM). This study investigates the effect of LBW and preterm birth on AM disease severity, neuro-otological complications, and recurrence. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary medical center. METHODS: The cohort is retrospective in nature consisting of 294 children with AM admitted between 1999 and 2020. Data collection included: patient gestational age and birth weight, signs and symptoms, physical examination, laboratory tests, imaging findings, and long-term outcomes. RESULTS: 294 cases of AM were included, 41/281 (15%) had LBW (< 2500 g), and 46/294 (15.7%) were preterm (gestational age < 37 weeks). We found no significant differences in laboratory tests, imaging studies (CT), rate of mastoidectomy performed, or late complications between LBW and normal birth weight (NBW) and between preterm and normal gestational age children. LBW children tended to develop AM at an older age compared with NBW children, 2.28 + 1.64 Vs. 1.84 + 1.4 years, respectively (p-value = 0.016). Additionally, preterm children were more prone to develop a second event of AM, with a shorter interval between these episodes. CONCLUSIONS: LBW and preterm birth are not independent risk factors for disease severity, need for intervention, or future complications in AM. Yet, LBW children present with AM at an older age, and preterm children are more prone for recurrent episodes of AM with a shorter interval between episodes suggesting a distinct disease course in these populations.

Posthemithyroidectomy Pregnancy Thyroid Function Surveillance: Frequency, Adherence, and Guideline Impact.

OBJECTIVE: Posthemithyroidectomy women are at an increased risk for gestational subclinical hypothyroidism. Therefore, the American Thyroid Association (ATA) recommends increased thyroid function surveillance for this subgroup of pregnant women. The purpose of this study was to evaluate the frequency of thyroid function surveillance during pregnancy in posthemithyroidectomy women and to evaluate the adherence to the 2017 ATA guidelines and its possible impact since being published on thyroid function surveillance rates. METHODS: A retrospective study of pregnant posthemithyroidectomy women operated at our institution between 1997 and 2020 was performed. The study cohort was subdivided by pregnancy dates before 2018 and 2018 onward to evaluate the impact of the 2017 ATA guidelines. Adherence to the guidelines was defined as at least 1 thyroid-stimulating hormone test in each trimester. RESULTS: After exclusions, a total of 120 pregnancies conceived by 66 women who underwent hemithyroidectomy surgeries were included in this study. Overall, serum thyroid-stimulating hormone examinations were performed during the first, second, and third pregnancy trimesters in 86.6%, 40%, and 16.6% of pregnancies, respectively (P <.005). The examination rate since 2018 was 88%, 40%, and 8% for the first, second, and third trimesters, respectively (P <.005). CONCLUSION: Adherence to the latest ATA guidelines is low, and its publication in 2017 did not increase the thyroid function surveillance rate in posthemithyroidectomy women. Better patient education regarding the risks of gestational hypothyroidism following hemithyroidectomy and improved communications among treating surgeons, obstetricians, and endocrinologists may improve these rates.

Sino-nasal hemangiopericytoma: a case series and systematic literature review.

BACKGROUND: Hemangiopericytoma is a rare tumor of the sino-nasal tract. Its clinical behavior is controversial. Whereas some describe an indolent course, others consider it to be an aggressive lesion with a tendency toward rapid local recurrence. Here, we describe our experience in the management of sino-nasal hemangiopericytoma (SN-HPC), comparing our experience with the current literature, and evaluating signs and tools to improve diagnosis and treatment. METHODS: All cases of SN-HPC between 2010 and 2020 were extracted and reviewed from our institutional electronic medical records. SN-HPC cases from PubMed and EMBASE between 2010 and 2020 were analyzed in a systematic literature review using the preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines. Data regarding demographics, presentation, diagnosis, treatment, and outcome were collected. RESULTS: We identified four cases of SN-HPC in the nasal cavity in our institution and an additional 53 cases in previous reports. The mean age at the time of diagnosis was 59 years, with a 1.2:1 male to female ratio. SN-HPC mostly appears unilaterally, arising in the ethmoid sinus (42.1%). The most common presenting symptoms were epistaxis (47.3) and nasal obstruction (47.3%). Both computed tomography (CT) and magnetic resonance imaging (MRI) were required for diagnosis and for tailoring the treatment plan. Endoscopic surgical excision was used in 85.9% of the patients, and in 15.7%, an additional preoperative embolization was performed, which was associated with septal necrosis in one patient (2.6%). The recurrence rate was 7%. CONCLUSION: Although previous reports attribute an aggressive tumoral behavior to SN-HPC, our experience and the literature review support a more indolent course with low recurrence rates following complete endoscopic resection. Preoperative embolization can be useful in certain cases, but due to potential complications, it should not be routinely indicated.

Relations between body mass index, laryngeal fat pads, and laryngeal airway configuration in adult men population.

BACKGROUND: The impact of body mass index (BMI) on pharyngeal fat pads has been well studied, yet no study has assessed its associations on laryngeal morphology. OBJECTIVES: To study the associations of BMI differences on laryngeal morphology in adult males using computed tomography angiography (CTA) scans. METHODS: All adult male patients who underwent head and neck CTAs between 2011 and 2018 were initially included and categorized according to their BMI: (1) BMI < 20; (2) 20 ≤ BMI < 25; (3) 25 ≤ BMI < 30; (4) 30 ≤ BMI < 35; and (5) BMI ≥ 35. Anatomical measurements included pre-epiglottic and paraglottic fat-pad dimensions, airway width at the epiglottis tip and base, and epiglottis angle. For statistical analysis, BMI was regarded both as a categorical and continuous variable. RESULTS: One hundred and five scans were included. BMI ranged from 15.90 to 44.40 kg/m2. Significant differences were found in pre-epiglottic and paraglottic fat measurements between BMI subgroups 1-5 (Pre-epiglottic fat depth: 17.75, 17.74, 19.04, 20.73, and 21.09 mm, respectively, P = 0.005, correlation 0.343, and P < 0.001 in continuous measurement; Paraglottic space average width: 3.5, 5.4, 5.46, 6.85, and 7.38 mm, P < 0.001, correlation 0.532, and P < 0.001 in continuous measurement). As BMI increased, the epiglottis-hard-palate angle increased (56.4°, 55.3°, 65.2°, 64°, and 68.4°, P = 0.001, correlation 0.354, and P < 0.001 in continuous measurement). No significant difference was found in airway width between subgroups at the epiglottis tip or base. Yet, in continuous variables analysis, a significant negative correlation was found between BMI scores and the airway width at the epiglottis base (-0.226, P = 0.02). CONCLUSIONS: In adult males, BMI is correlated with laryngeal fat-pad volume, affecting its morphology and airway width. Clinical implications regarding obstructive sleep apnea and voice quality should be further investigated.

Impact of age on surgical outcomes and failure rates in patients with thyroglossal duct cysts.

PURPOSE: Thyroglossal duct cyst (TGDC) may appear in all age groups. The impact of age on surgical outcome has been reported with conflicting results. The aim of the study was to evaluate different risk factors for surgical success according to stratified age groups. METHODS: A single center retrospective study. All patients who underwent a Sistrunk procedure between 2004 and 2018 were enrolled. Data included demographics, pre-operative presentation, intra\postoperative complications and surgical failures. Population groups were divided into adults (≥18 years), older children (OC, 3-18 years) and toddlers (<3 years). RESULTS: A total of 109 patients were included: 55 adults (50.5%), 36 OC (33%) and 18 toddlers (16.5%). The adult group demonstrated a significant lower rate of surgical failures when compared to the toddler (3.6%, vs. 38.9%, P < 0.001, respectively) and the OC group (3.6%, vs 16.7%, P = 0.032, respectively). A borderline significance was found when comparing surgical failure rates among toddlers and OC (38.9% vs.16.7%, P = 0.07, respectively). Post-operative complications were associated with surgical failures among toddlers (P = 0.045) and OC (P = 0.016), but not adults. Pre-operative infection and admission were significantly associated with failure in the OC group. CONCLUSIONS: Surgical failures following Sistrunk procedures and their associated risk factors vary between age groups. Familiarity with these rates and associations can contribute to better decision making in managing TGDC patients.

CO2 Laser Cordectomy Versus KTP Laser Tumor Ablation for Early Glottic Cancer: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: CO2 laser cordectomy has been the workhorse of laser surgery for early glottic squamous cell carcinoma (GSCC) since the early 1970s. During the last decades, potassium titanyl phosphate (KTP) laser surgery for early GSCC gained popularity, introducing the tumor ablation technique. Yet, there are no previous randomized controlled trials (RCT) that compare the oncologic and functional outcomes of KTP Laser ablation versus CO2 laser cordectomy for early GSCC. This study aims to compare by means of an RCT, CO2 laser cordectomy with KTP laser ablation for early GSCC, in terms of cure rates and vocal function. STUDY DESIGN/MATERIALS AND METHODS: A RCT conducted between 2013 and 2017. Patients with early GSCC were enrolled, and randomly assigned for either CO2 cordectomy or KTP-ablation surgery with curative intent. All CO2 cordectomies and most KTP-ablation procedures were performed under general anesthesia. Some KTP cases with residual disease were treated also under local anesthesia. Videostroboscopy measures, voice handicap index (VHI), GRBAS (a hoarseness scale for Grade, Roughness, Breathiness, Asthenia and Strain) score, and acoustic analyses were performed pre-operatively, 6 months and 3 years after surgery. RESULTS: Twenty-four patients, 12 in each group, were enrolled. Nine in each group had T1a carcinoma, the remaining had either carcinoma in situ or T1b. The average number of procedures was 1.67( ± 0.89) and 1.33( ± 0.89) for the KTP and CO2 groups, respectively. Although the tumor depth was comparable in both groups, patients in the KTP-ablation group underwent more superficial surgeries. Eleven (91.7%) procedures in the KTP group spared the vocal ligament, compared with 5 (41.7%) in the CO2 group, (P = 0.023). All patients were alive and disease-free after four years. On post-operative videostroboscopy, normal mucosal waves appeared in 5 (42%) of the KTP patients versus none (0%) of the CO2 (P = 0.02). The median post-operative non-vibrating portion was smaller in the KTP group (10%) compared with CO2 (50%), P = 0.043. Nevertheless, GRBAS and VHI scores improved comparably in both groups. CONCLUSIONS: KTP ablation technique offers similar curative outcome as CO2 cordectomy but may allow for better preservation of vocal fold's architecture and function. Yet, the clinical significance of these findings is unclear, since the subjective measures improved comparably for these two treatment modalities. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Usefulness of ultrasound and fine needle aspiration cytology of major salivary gland lesions.

PURPOSE: To assess the clinical value of ultrasound (US) and fine needle aspiration (FNA) of salivary gland lesions prior to surgery, for preoperative decision-making and long-term follow-up/outcome. MATERIALS & METHODS: We retrospectively analyzed the medical charts of 98 consecutive patients with major salivary gland lesions who were treated in a single medical from 2008 to 2017. Preoperative US and FNA was performed in all patients. Cytology results were compared with histopathological diagnoses. The correlation between preoperative US findings, cytology and histopathological diagnoses was assessed. RESULTS: Twenty-three specimens were histopathologically malignant, and 75 were diagnosed as benign. Three false-positive results diagnosed as malignant in cytology had a final histology of sialadenitis, pleomorphic adenoma and Warthin's tumor, respectively. In six cases, cytology yielded false-negative results. The overall accuracy of FNA in distinguishing benign from malignant lesions was 91%. Sensitivity was 70% and specificity 93%. There was no significant correlation between US features and final pathology, but larger size had some correlation with malignancy (p = 0.306). No complications were observed during or after performing FNA. CONCLUSION: FNA from salivary gland lesions is safe and in many cases can help in preoperative decision making or surgical planning. Hence, the results of FNA cytology should have an integral role in clinical decision-making and management of major salivary gland lesions. False-negative results do occur and therefore should be used only as an adjunctive measure.

Correction to: Spontaneous neck hematoma secondary to parathyroid adenoma: a case series.

In the original publication of the article, one of the author name was published incorrectly.

Spontaneous neck hematoma secondary to parathyroid adenoma: a case series.

PURPOSE: Spontaneous neck hematoma is a rare yet potentially fatal complication of primary hyperparathyroidism (PHPT). Here we aim to describe novel presentations of neck hematomas secondary to PHPT, discussing tools and signs that facilitate diagnosis. METHODS: Case series data were extracted by retrospective chart reviews of our institution's electronic medical records, including all neck hematoma cases from parathyroid origin between 2005 and 2020. Cases from PubMed and EMBASE between 1999 and 2020 were analyzed in a systematic literature review. RESULTS: Four patients were identified with five acute bleeding events, including a novel report of recurrent neck hemorrhage due to parathyroid adenoma. There was postmenopausal female predominance (75%), consistent with previous reports (72.7%). Common presentations included neck pain, dysphagia and hoarseness. All bleedings spread into the retropharyngeal space. Vocal cord paralysis was found in a single case and in 8.6% of the benign lesions in the reviewed cases. A single case presented with normal calcium levels (20% of bleeding episodes), in line with the reviewed cases (17.4%). A subtle CT sign of an enhancing area within the parathyroid gland, which led to the diagnosis, was identified in a single case. Conservative treatments were employed in 80% of our cases and in 51.5% of the reviewed cases, all being successful. Neck explorations performed after a 3-month waiting period from the acute event demonstrated better results compared to immediate surgery. CONCLUSION: A high suspicion index is needed, particularly in post-menopausal women, to reach a diagnosis and allow optimal management. Normal laboratory values do not exclude parathyroid etiology, yet assessment should include calcium and PTH levels along with targeted imaging. Since bleeding may recur, we suggest that PHPT complicated with neck hematoma should be an independent indication for definitive parathyroidectomy surgery. LEVEL OF EVIDENCE: 3b.

Development of the nasopharynx: A radiological study of children.

The relation between pharyngeal tonsil and the bony nasopharynx determines the nasopharyngeal airway patency. Despite its importance, an anatomical study utilizing advanced imaging has not been conducted. The aim of the study was to evaluate the pharyngeal tonsil and bony nasopharynx depth and their ratio (adenoid-nasopharyngeal ratio [ANR]) with relation to sex and age in the general pediatric population. After excluding reported history of adenoidectomy, acute upper airway illness, allergy, and poor quality, 200 randomly selected head computed tomographies (CTs) of children were evaluated. CTs were divided into five age groups (0-5, 5.1-8, 8.1-11, 11.1-14, and 14.1-17 years). For each CT scan, the pharyngeal tonsil, bony nasopharynx and ANR values were calculated. A significant difference was found in the bony nasopharynx and pharyngeal tonsil depth between the five age subgroups (P < 0.001). Both bony nasopharynx and pharyngeal tonsil depth significantly increased between the age groups of 0-5 years to 5.1-8 years (4.17 mm increase, P < 0.001 and 3.47 mm increase, P < 0.009, respectively). The pharyngeal tonsil depth gradually decreases following the age of 8 years. No difference was found between age groups beyond age of eight for both the pharyngeal tonsil tissue and the bony nasopharynx. The ANR has an upward trend in the age group of 5.1-8 years. No sexual predilection was found. The bony nasopharynx and the pharyngeal tonsil tissue both grow during childhood. Different growth rates result in the narrowest airway in the age group of 5.1-8 years (ANR peak). These growth curves should be taken under consideration when treating pediatric pharyngeal tonsil hypertrophy. Clin. Anat., 33:1019-1024, 2020. © 2019 Wiley Periodicals, Inc.

Correlation Between Pharyngeal Residue and Aspiration in Fiber-Optic Endoscopic Evaluation of Swallowing: An Observational Study.

OBJECTIVES: To examine the correlation between pharyngeal residue severity and clearance to penetration/aspiration on fiber-optic endoscopic examination of swallowing (FEES). DESIGN: Retrospective cohort. SETTING: Kaplan Medical Center dysphagia clinic. PARTICIPANTS: Patients (N=110) visiting a dysphagia clinic between 2014 and 2016 undergoing FEES. INTERVENTIONS: FEES were scored for penetration/aspiration with the Penetration Aspiration Scale (PAS), for residue severity using the Yale Pharyngeal Residue Severity Rating Scale (YPR-SRS). The numbers of swallows required to clear the pharynx were recorded. The first and the worst bolus challenges for each consistency (liquid, purée, solid) were analyzed. MAIN OUTCOME MEASURES: YPR-SRS and number of clearing swallows were correlated with the PAS of the same bolus challenge. RESULTS: The study population's mean age was 67±13.4 years; 54% were men (n=58). A significant correlation was found between the YPR-SRS and the PAS for all consistencies tested, in each anatomical site (vallecula or pyriform sinus) and for both the first and worst bolus challenges (P<.001 for all). The correlation of residue with aspiration was stronger when vallecula and pyriform sinuses scores were summated (Pearson product-moment correlation coefficient=0.573/0.631/0.446 for liquid/purée/solid for worst bolus challenge). Incorporating the number of clearing swallows to the YPR-SRS strengthened the correlation with PAS. CONCLUSIONS: Residue severity and clearance correlate with penetration/aspiration on FEES. The YPR-SRS can be applied to standardize description of residue in FEES and to aid in dysphagia evaluation.

Association Between Laryngeal Sensation, Pre-swallow Secretions and Pharyngeal Residue on Fiberoptic Endoscopic Examination of Swallowing.

Reduced laryngeal sensation and accumulated pharyngeal secretions are known predictors of aspiration. Yet, their association with residue has not been fully explored. One Hundred and ten fiberoptic endoscopic examination of swallowing (FEES) examinations were retrospectively analyzed. Murray's secretion scale (MSS) for secretion stasis and laryngeal sensation were tested for association with residue severity (Yale pharyngeal residue severity rating scale, YPR-SRS) and the number of swallows required to clear the bolus. The bolus challenges of each consistency (liquid, purée and solid) with the highest PAS and YPR-SRS scores were analyzed. Impaired laryngeal sensation (ILS) and MSS were both independently significantly associated with higher YPR-SRS for all consistencies examined. Mean YPR-SRS for patients with both ILS and secretion stasis was respectively 2.4 ± 1.1, 2.5 ± 1.2, 2.4 ± 1.2 for liquid, purée and solids in the vallecula, and 2.9 ± 1.3, 2.3 ± 1.1, 2 ± 1 for pyriform sinuses residue compared to 1.8 ± 0.7, 1.6 ± 1, 1.6 ± 1 for vallecular residue and 1.8 ± 0.8, 1.4 ± 0.8, 1.3 ± 0.7 for pyriform sinus residue of patients with normal laryngeal sensation and no stasis (p < 0.05 for all except liquids in vallecula). The combined findings of both ILS and MSS ≥ 1 had a sensitivity of 25.9%, specificity of 94.2%, positive predictive value (PPV) of 83.3% and negative predictive value (NPV) of 53.3% for prediction of pharyngeal residue and a sensitivity of 58.3%, specificity of 88.8%, PPV of 39.9% and a NPV of 94.6% for prediction of aspiration. Both ILS and MSS were significantly associated with increased number of swallows required to clear a bolus. Abnormal laryngeal sensation and secretion stasis are associated with pharyngeal residue severity and reduced residue clearing on FEES.

Translation and Validation of the Dysphagia Handicap Index in Hebrew-Speaking Patients.

The Dysphagia Handicap Index (DHI) is a 25-item questionnaire assessing the physical, functional, and emotional aspects of dysphagia patients' quality of life (QoL). The study goal was to translate and validate the Hebrew-DHI. 148 patients undergoing fiberoptic endoscopic examination of swallowing (FEES) in two specialized dysphagia clinics between February and August 2017 filled the Hebrew-DHI and self-reported their dysphagia severity on a scale of 1-7. 21 patients refilled the DHI during a 2-week period following their first visit. FEES were scored for residue (1 point per consistency), penetration and aspiration (1 point for penetration, 2 points for aspiration, per consistency). 51 healthy volunteers also filled the DHI. Internal consistency and test-retest reproducibility were used for reliability testing. Validity was established by comparing DHI scores of dysphagia patients and healthy controls. Concurrent validity was established by correlating the DHI score with the FEES score. Internal consistency of the Hebrew-DHI was high (Cronbach's alpha = 0.96), as was the test-retest reproducibility (Spearman's correlation coefficient = 0.82, p < 0.001). The Hebrew-DHI's total score, and its three subscales (physical/functional/emotional) were significantly higher in dysphagia patients compared to those in healthy controls (median 38 pts, IQR 18-56 for dysphagia patients compared to 0, IQR 0-2 for healthy controls, p < 0.0001). A strong correlation was observed between the DHI score and the self-reported dysphagia severity measure (Spearman's correlation coefficient = 0.88, p < 0.0001). A moderate correlation was found between the DHI score and the FEES score (Pearson's correlation coefficient = 0.245, p = 0.003). The Hebrew-DHI is a reliable and valid questionnaire assessing dysphagia patients' QoL.