Validating the 'CUT score' risk stratification tool for indeterminate thyroid nodules using the Bethesda system for reporting thyroid cytopathology.

PURPOSE: Managing intermediate thyroid nodules remains challenging. The CUT score is an Italian metanalysis-based cytologic (SIAPEC-IAP) scoring system, designed to assist clinicians. However, it was never evaluated against the Bethesda system for reporting thyroid cytopathology (BSRTC). This study aims to validate its utility for BSRTC III and IV nodules in a non-Italian population. METHODS: We collected all BSRTC III and IV thyroid nodules with a documented final pathology between 2010 and 2020. We calculated the C + U components of the CUT score using retrospective clinical (C) data collection and reevaluation of preoperative sonography (U) examination. The cytology (T) component which originally referred to the five-tiered SIAPEC-IAP cytologic classification was replaced by the corresponding BSRTC categories. Optimal test performances were calculated using receiver operating characteristic (ROC) curve analysis. Data were analyzed twice with considering of NIFTP as benign and as malignant. RESULTS: After exclusions, 62 nodules from 61 patients were included (50% BSRTC III, 50% BSRTC IV). Malignant nodules demonstrated a significantly higher C + U score compared with benign in both categories. The C + U cutoff value for BSRTC III was 5.25 (sensitivity and specificity of 69.23% and 66.67%, respectively, AUC = 0.72, p-value = 0.016), and 5.75 for BSRTC IV (sensitivity and specificity of 85.7% and 76.5%, respectively, AUC = 0.84, p-value < 0.001). CONCLUSION: Our study suggests that the CUT score is applicable for both BSRTC III and IV nodules, and highlights the need for internal validations, since the cutoffs found were higher than previously reported.

Cochlear Implantation in a Patient with Granulomatosis with Polyangiitis.

BACKGROUND: Granulomatosis with polyangiitis (GPA) otologic manifestations include conductive and sensorineural hearing loss (HL). Vasculitis is assumed to be the primary cause of otologic manifestations. Deaf patients and patients with HL who do not benefit from hearing aids can benefit from cochlear implants (CI). There are currently no specific guidelines for treatment of patients with GPA suited for CI. OBJECTIVES: To assess whether patients who are deaf due to GPA are good candidates for CI and if prior surgical or medical treatment of the inflammation are needed. METHODS: A case report is presented. RESULTS: A 71-year-old female patient with GPA and bilateral profound HL underwent CI. Prior to CI, preparation consisted of audiological evaluations by an otolaryngologist and a rheumatologist, followed by a course of prednisone and methotrexate for middle ear and nasal inflammations. CI was performed with no complications. The speech reception threshold and the monosyllabic word discrimination score after surgery were 25 dBHL and 75%, respectively. CONCLUSIONS: Inflammation due to GPA can be controlled medically with immunosuppressive medications without subtotal petrosectomy, as in chronic suppurative otitis media. Satisfactory audiological results can be expected.

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.

[IMPLANTATION OF A VIBRANT SOUNDBRIDGE IN A WOMAN WITH SENSORINEURAL HEARING LOSS AND RECURRENT OTITIS EXTERNA: A CASE STUDY].

INTRODUCTION: Rehabilitating hearing loss is highly important due to its positive impact on the ability to understand speech, and the related consequences on family, social and work communication abilities. Children with hearing loss have learning difficulties that adversely affect speech and language acquirement. Most patients with hearing loss can use conventional hearing aids that are partially or completely placed in the external ear canal. Middle ear implants are used when conventional hearing aids are not suitable due to medical reasons, mainly diseases of the external ear canal and the tympanic membrane. The external component of the middle ear implant digitally translates the acoustic information (sound waves) to the implanted part, where the digital information is back-translated to mechanical information (vibrations) which vibrates the ossicle to which it is attached. We present a patient who underwent a Vibrant Soundbridge implantation after unsuccessfully using hearing aids due to recurrent otitis externa. The patient's hearing improved significantly. We conclude that middle ear implants can be an effective treatment for patients who cannot use conventional hearing aids.

The impact of allergies and smoking status on nasal mucosa of hypertrophied turbinates - an immunohistologic analysis.

Background: Allergies and smoking are common reasons for nasal mucosa inflammations, which in turn, cause nasal obstructions. Nevertheless, the impact of coexisting allergies and smoking on nasal mucosa inflammation has not been studied.Objectives: To study the impact of smoking with relation to allergies on nasal mucosa histology and to characterize an immunologic profile using immunohistochemical (IHC) staining.Methods: A cross-sectional study. Nasal biopsies of inferior turbinates from smokers with different allergic statuses were compared. Demographics, comorbidities, histologic, and immunohistochemical (IHC) staining of CD3, CD68, CD 20, and CD138 receptors were compared and analyzed.Results: A total of 53 patients were included, of which 20 (37.7%) were smokers, and 20 (37.7%) had allergic backgrounds. Smokers, both allergic and non-allergic, demonstrated reduced edema compared to the control group (p Value = 0.034) and significantly lower eosinophil density in the stroma compared to the allergic nonsmokers' group (p Value = 0.04). Smokers had a significant negative correlation between the number of cigarettes per day and the expression of CD20 in the stroma (-0.452, p Value = 0.045) and the epithelium (-0.432, p Value = 0.057) in IHC staining. Allergic smokers had a negative correlation (-0.705, p Value = 0.023) between the number of cigarettes per day and the CD68 marked cell expression in the epithelium.Conclusion: The coexistence of an allergic background and smoking alters known immunologic responses within the nasal mucosa. Smoking may have an immunosuppressive role in the nasal mucosa in both innate and humoral immune systems.

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.

The role of endoscopic sphenopalatine artery ligation in the management of persistent epistaxis - A 15-year single-center experience.

PURPOSE: Managing persistent epistaxis poses a great challenge for the otolaryngologist. Despite continuous development in treatment methods, no universal guideline has been commonly adopted. Among the popular methods is endoscopic sphenopalatine artery ligation (ESPAL). This study aims to evaluate the impact of ESPAL integration on persistent epistaxis management over 15 years in a single academic center. METHODS: A retrospective study including all cases who were hospitalized due to persistent epistaxis and required intervention between 2000 and 2016. From 2011, ESPAL was routinely utilized in our center, hence the study population was divided based on admission year, prior to 2011 (pre-ESPAL) and from 2011 till the end of data collection (post-ESPAL). RESULTS: The pre-ESPAL group included 87 interventions and the post-ESPAL group 54 interventions. Electrocautery remained the most common intervention in both periods. However, ESPAL incorporation was accompanied by a significant decline in the use of posterior nasal packing in the post-ESPAL group. The hemoglobin recovery levels and the mortality rates were significantly improved in the post-ESPAL group compared with the pre-ESPAL group despite higher comorbidity rates among the post-ESPAL patients. CONCLUSIONS: This study demonstrates the shifting trend in managing persistent epistaxis, and suggests that ESPAL has successfully replaced posterior nasal packing. These findings may encourage clinicians to consider ESPAL as a valuable tool in the management of persistent epistaxis.

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.

[SURGEON PERFORMED THYROID AND NECK ULTRASOUND AS A TOOL FOR BETTER PATIENT CARE].

INTRODUCTION: Surgeon performed ultrasound (SUS) has become a valuable tool for the head and neck/endocrine surgeon. It allows for a complementary examination of the neck, following history and physical examination. With its reduced costs and being radiation free, US has become the modality of choice for imaging thyroid, parathyroid and lymph nodes of the neck. In thyroid cancer, the role of US has constantly grown, as reflected in the latest American Thyroid Association (ATA) guidelines: The shift from whole body iodine scans to US has allowed for surveillance in low risk patients who underwent thyroidectomy, follow-up of microcarcinomas, and has a key role in the assessment of a thyroid nodule following initial aspiration. However, US is still limited by operator dependent inherent flaws, which are reflected by a relatively moderate inter-observer agreement, even among experts. When conducted by the same surgeon, SUS allows the patients to enjoy the benefits of US while overcoming this limitation. When compared to radiologist-performed US, several studies have shown that high volume surgeons can reach non-inferior predicative values for malignant nodules, using accepted suspicious sonographic features such as solid texture, hypoechogenicity, microcalcifications, irregular margins and taller rather than wider shape. Several studies have tried to answer the most important utility of SUS - its ability to change the course of management of the cases. In all studies SUS was able to change the management of the cases in 17-45% of the patients, extending surgery in some patients while avoiding unnecessary dissections in others. In summary, SUS is an important, feasible tool for the head and neck and endocrine surgeons. Studies have shown that high volume surgeons can reach excellent rates of prediction and detection, thus saving the patients unnecessary clinic visits, tension and additional imaging, and can even directly influence the management of the patients.

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.

Does the Hebrew Eating Assessment Tool-10 Correlate with Pharyngeal Residue, Penetration and Aspiration on Fiberoptic Endoscopic Examination of Swallowing?

The Eating Assessment Tool-10 (EAT-10) is a 10-item patient-reported outcome measure (PROM) for dysphagia patients. The objective of this study was to translate and validate the EAT-10Heb and to test for a correlation between its score and residue, penetration and aspiration on Fiberoptic Endoscopic Examination of Swallowing (FEES). 136 patients visiting two specialized dysphagia clinics and undergoing FEES between April 2015 and August 2017, filled the EAT-10Heb. 23 patients refilled the EAT-10Heb during a 2-week period following their first visit. FEES were scored for residue (1 point per consistency, maximum 3 points) and penetration and aspiration (1 point for penetration, 2 points for aspiration per consistency, maximum 6 points). 51 healthy volunteers also filled the EAT-10Heb. Internal consistency and test-retest reproducibility were examined for reliability testing. Validity was established by comparing EAT-10Heb scores of dysphagia patients to healthy controls. The EAT-10Heb score was then correlated with the FEES score. Internal consistency of the EAT-10Heb was high (Cronbach's alpha = 0.925) as was the test-retest reproducibility (Spearman's correlation coefficient = 0.82, p < 0.0001). The median EAT-10Heb score was significantly higher in the dysphagia group compared to healthy controls (13, IQR 7-22 points for dysphagia patients compared to 0, IQR 0-0 points for healthy controls, p < 0.0001). A weak correlation was found between the EAT-10Heb scores and the FEES score (Pearson's correlation coefficient = 0.376, p < 0.0001). While the EAT-10Heb was found to be a reliable and valid PROM, it only weakly correlates with the pathological findings on FEES examination.

Outcome and survival following tracheostomy in patients ≥ 85 years old.

PURPOSE: To evaluate percutaneous dilatational tracheostomy in patients ≥ 85 years old: its complication rate and possible risk factors. In addition, to assess prognostic factors for short, intermediate and long term survival following the procedure. METHODS: A retrospective case-control study of 72 patients ≥ 85 years who received percutaneous dilatation tracheotomy (PTD), compared to a control group of younger patients (n = 182). Demographics, clinical and laboratory data were collected. Survival and risk for complications were analyzed. RESULTS: The study group's mean age was 89 ± 4. Twelve patients had complications, three (4.2%) were major. No significant difference was found in overall complication rates between the groups. Cerebrovascular disease with neurologic deficits and pre-procedure albumin levels were significantly associated with complications. Survival rates did not differ in 1 week and 1 month following procedure between study and control group. There was a significant difference in the 1-year survival rates between the patients ≥ 85 years and the control groups (18.1% vs. 34.4%, p = 0.01, respectively). Congestive heart failure, a frailty score > 0.27 and failure to wean from a cannula were associated with reduced 1-year survival. CONCLUSION: PTD is safe for patients ≥ 85 years. Complication risk factors and reduced survival should be discussed with patients and families before conducting tracheostomies. LEVEL OF EVIDENCE: 3b.

Local inflammatory reaction to benign, pre-malignant and malignant glottic lesions: A matched case-control study.

OBJECTIVES: To study the inflammatory infiltrates associated with the different stages of laryngeal carcinogenesis. DESIGN: Observational, matched case-control study of histopathologic specimens. SETTING: An academic referral centre. PARTICIPANTS: A total of 45 patients who underwent removal of glottic lesions between 2008 and 2015. Patients were enrolled and categorised into three matched groups according to lesions' histopathologic diagnoses, 15 patients in each group: benign, pre-malignant and squamous cell carcinoma (SCC). Matching was based on age, gender and pack-years. MAIN OUTCOME MEASURES: Immunohistochemistry staining using monoclonal antibodies against CD4, CD8, CD68, CD20 and S100 representing T-helper cells, cytotoxic T cells, macrophages, B cells and dendritic cells, respectively. Cell counts and distributions were measured and compared between groups. Correlations between the different cells were examined. RESULTS: The predominant cell type was CD8+, followed by CD68+ and CD4+. All inflammatory cells increased significantly in number in SCC (P-value < 0.001), with no significant difference between benign and pre-malignant groups. Strong correlations between the different cells were demonstrated only in the malignant group. S100+ cells correlated with both T-cell subsets, CD4+ (rho = 0.769, P-value = 0.001) and CD8+ (rho = 0.697, P-value = 0.0004). Infiltrates exhibited more extensive distribution in SCC compared to pre-malignant and benign; CD8+ and CD68+ cells were demonstrated in both intraepithelial and stromal regions in 93% of SCC lesions (P-value = 0.0001). CONCLUSIONS: Laryngeal carcinoma demonstrates a unique pattern of inflammatory infiltrates, with significant changes in cell counts and distribution. Leucocyte infiltrates increased significantly in the transition from laryngeal pre-malignant lesion to malignancy while no significant differences were seen between benign and pre-malignant lesions.

Evaluation and Predictors for Nasogastric Tube Associated Pressure Ulcers in Critically Ill Patients.

BACKGROUND: Nasal device-related pressure ulcers are scarcely addressed in the literature. OBJECTIVES: To assess the prevalence and severity of cutaneous and mucosal nasogastric tube (NGT)-associated pressure ulcers (PU) in critically ill patients and to define predictors for their formation. METHODS: A single center observational study of intensive care unit patients with a NGT for more than 48 hours was conducted. Nasal skin was evaluated for PU. Ulcers were graded according to their depth. Consenting patients underwent a nasoendoscopic examination to evaluate intranasal mucosal injury. RESULTS: The study comprised 50 patients, 17 of whom underwent nasoendoscopic examination. Mean time of NGT presence in the nose was 11.3 ± 6.17 days. All patients had some degree of extranasal PU, 46% were low grade and 54% were high grade. Predictors for high grade extranasal PU compared to low grade PU were higher peak Sepsis-related Organ Failure Assessment (SOFA) scores (11.52 vs. 8.87, P = 0.009), higher peak C-reactive protein (CRP) levels (265.3 mg/L vs. 207.58, P = 0.008), and bacteremia (33.3% vs. 8.7%, P = 0.037). The columella was the anatomical site most commonly involved and the most severely affected. The number of intranasal findings and their severity were significantly higher in the nasal cavity containing the NGT compared to its contralateral counterpart (P = 0.039 for both). CONCLUSIONS: NGTs cause injury to nasal skin and mucosa in critically ill patients. Patients with bacteremia, high CRP, and high SOFA scores are at risk for severe ulcers, warranting special monitoring and preventive measures.

[THE RATIONALE OF MINIMALLY INVASIVE SINUS TECHNIQUE (MIST)].

INTRODUCTION: Chronic rhinosinusitis is one of the most common diseases in the world. Mucosal contact in narrow draining pathways of the sinuses (called transition spaces) may lead to chronic sinusitis by disruption of mucociliary clearance, stasis and blockage of mucous flow. Minimal invasive sinus technique (MIST) is a targeted procedure designed to address the transition spaces surrounding the natural sinus ostia. Surgical clearing disease in a transition space, allows the dependent sinus to recover function. Compared to other conventional endoscopic procedures, MIST can accomplish good and reproducible results in treating patients for chronic rhinosinusitis over long term follow-up.