Is lobectomy sufficient for multifocal papillary thyroid microcarcinoma?

IMPORTANCE: Multifocal papillary thyroid microcarcinoma (PTMC) has been associated with a higher incidence of lymph node involvement, bilateral involvement, and extrathyroidal extension compared to unifocal papillary thyroid cancer (PTC). OBJECTIVE: To describe the incidence and determinants of survival for patients with multifocal PTMC using the Surveillance, Epidemiology, and End Result (SEER) database. DESIGN, SETTING, PARTICIPANTS: The SEER registry was utilized to calculate survival trends for patients with PTMC between 2010 and 2015. Patient data was then analyzed with respect to age, sex, race, multifocality, and types of surgery rendered. MAIN OUTCOMES AND MEASURES: Overall Survival (OS) and Disease Specific Survival (DSS). RESULTS: 22,283 cases of papillary thyroid microcarcinoma (T1a N0 M0) were identified. The cohort was composed of 82.6 % females, and about 82 % of patients were of white race. The mean age at diagnosis was 51.9 years. Multifocal PTMC was present in 32.2 % of the tumors (n = 7186). 73.9 % of patients underwent total thyroidectomy and 23.0 % received lobectomy. OS at 2 and 5 years was 98 % and 95 %, respectively. Multivariate analysis revealed that age, sex, and multifocality were determinants of OS. Only age was a determinant of DSS. Kaplan-Meier survival analysis revealed that multifocal PTMC had similar mean OS between lobectomy and total thyroidectomy patients (69.59 months versus 69.82 months). CONCLUSIONS AND RELEVANCE: PTMC has a good prognosis. Our analysis revealed that age was a determinant of OS and DSS; sex and multifocality were also prognosticators for OS. The type of surgery, whether lobectomy or total thyroidectomy, was not a determinant of survival in multifocal PTMC.

Contrast-Induced Sialadenitis of the Sublingual Glands.

Contrast-induced sialadenitis (CIS) is a rare, delayed pseudoallergic reaction from iodine containing contrast. Previously reported cases of CIS demonstrated that the two major salivary glands (parotid and submandibular) can be affected. The initial encounter of this entity can raise alarms to physicians as the differential diagnoses include serious infectious and inflammatory conditions such as Ludwig's angina and angioedema. Subsequently, it may lead to unnecessary testing and increased healthcare cost. Here we present a 60-year-old male who presented with bilateral sublingual gland swelling following exposure to iodinated contrast. With timely diagnosis by the otolaryngologist, the patient received conservative management that led to a full resolution within a few days. To date, this is the first case of CIS only involving the sublingual glands. We conclude that CIS can involve any of the major salivary glands.

Safety of outpatient unilateral medialization laryngoplasty across two academic institutions.

OBJECTIVES/HYPOTHESIS: Unilateral ML is a commonly performed surgery for dysphonia secondary to glottic insufficiency. The safety of this procedure performed in the outpatient setting has not been extensively examined. The purpose of the study was to assess the safety of outpatient unilateral ML in adults and determine the incidence and timing of postoperative complications across two tertiary-care academic medical centers. STUDY DESIGN: Retrospective chart review, METHODS: A review of patients undergoing unilateral ML at two tertiary-care academic centers from 2011 to 2017 was performed. Patients undergoing bilateral medialization laryngoplasty, revision surgery, or those undergoing additional laryngeal framework procedures including arytenoid adduction were excluded. Patient demographics, operative details, and perioperative and postoperative complications were recorded. Comparisons were made between those individuals who underwent inpatient versus outpatient ML. RESULTS: One hundred three total procedures met inclusion criteria. Fifty-seven were performed as outpatient procedures, and 46 individuals were observed for at least 23 hours following surgery. Silastic or Gore-Tex implants were used in all but two surgeries. There were no postoperative complications in either setting, including hematoma, dyspnea, wound infections or seromas. CONCLUSIONS: The incidence of adverse events during and immediately following unilateral ML is very low. Patients can be discharged safely the day of surgery without geographic restrictions. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1647-1649, 2019.

Microbiome and disease in the upper airway.

PURPOSE OF REVIEW: Microbiome refers to the genetic potential of resident microorganisms that inhabit a given niche. The exact role of the microbiome and its relation to chronic disease processes remains largely unknown, although various associations have been observed. We reviewed current literature investigating the microbiome of the upper airway by subsite (nasal cavity, sinus cavities, nasopharynx, and larynx) and its relation to chronic inflammatory disease processes. RECENT FINDINGS: The disruption of indigenous microbiota at a specific subsite may lead to pathogen overgrowth and increased susceptibility to infection. This has previously been demonstrated in the gastrointestinal tract and lower airways. The role of the microbiome and its relation to pathogenesis of disease in the upper airway, however, is less clearly understood. The present review discusses the recent studies that appear to link dysbiosis to upper airway chronic inflammatory diseases. SUMMARY: Despite mounting research, the role of microbiota in the upper airway remains poorly understood. Based on review of the current literature comparing healthy versus diseased patients with site-specific inflammatory conditions, a complex consortium of microbial communities inhabits the upper airway. Fluctuations in the baseline microbiome may contribute to disease pathogenesis, and improved understanding of the dynamics between shifting microbiota may be critical to guiding future medical therapy.

Laryngeal Pilar Cyst Masquerading as an Internal/External Laryngocele.

OBJECTIVES: This study aimed to document and describe a case of a laryngeal pilar cyst and to review the literature. METHODS: We describe the case of a 65-year-old woman with a laryngeal pilar cyst presenting with occasional ear pain and positional dyspnea, with imaging studies suggesting external/internal laryngocele. We also review the existing clinical literature. RESULTS: Pilar cysts are adnexal skin lesions most commonly found in the scalp of elderly women. They generally have a benign course, but in rare instances single or multiple foci of proliferating cells can lead to the neoplastic formation of proliferating trichilemmal cysts, which carry malignant potential. Depending on the location of the cyst, pilar cysts may also present functional challenges for the patient. CONCLUSIONS: Herein, we describe a pilar cyst in and around the larynx appearing initially as a laryngocele. Pilar cysts may present surrounding the larynx and may be mistaken for a vast array of pathologies. It is important to keep the differential broad when evaluating laryngeal masses.

A comparative study between adenoids and nasal mucosa for ciliated epithelium in children with recurrent or chronic rhinosinusitis.

OBJECTIVE: To determine whether adenoid epithelium is superior to nasal mucosa for biopsy of ciliated epithelium for electron microscopy (EM) to evaluate pediatric patients with rhinosinusitis for primary ciliary dyskinesia (PCD). METHODS: A retrospective review compared electron microscopic results in children with chronic or recurrent rhinosinusitis who underwent both adenoidectomy or nasopharyngeal biopsy and nasal mucosa biopsy in the course of evaluation for PCD at a tertiary care institution. RESULTS: Forty pediatric patients met inclusion criteria for this study. Nine of these patients had a prior adenoidectomy and therefore underwent nasopharyngeal biopsy for collection of adenoid tissue. All nine of the nasopharyngeal biopsies and 25 of the 31 (80.6%) adenoid biopsies had sufficient cilia for EM evaluation of the ultrastructure. Of the 40 patients who also had a nasal biopsy, only 12 (30.0%) had sufficient cilia for EM analysis. The distribution of sufficient versus insufficient cilia for analysis between adenoid and nasal mucosa was statistically significant (P < 0.05). Abnormal cilia were found in only 2.5% of our patients. CONCLUSIONS: In current practice, the nasal cavity is a common location for obtaining ciliated epithelium for EM analysis, as it is easily accessible for biopsy and the procedure itself causes relatively low patient morbidity. Chronic rhinosinusitis, however, has been associated with decreased cilia density on nasal respiratory epithelium. Given that adenoidectomies are often performed in children with chronic rhinosinusitis, our data suggest that adenoid tissue is a better source of ciliated tissue for analysis compared to turbinate epithelium.

Individualizing Prevention for Older Adults.

Prevention can help older adults avoid illness by identifying and addressing conditions before they cause symptoms, but prevention can also harm older adults if conditions that are unlikely to cause symptoms in the individual's lifetime are identified and treated. To identify older adults who preventive interventions are most likely to benefit (and most likely to harm), we propose a framework that compares an individual's life expectancy (LE) with the time to benefit (TTB) for an intervention. If LE is less than the TTB, the individual is unlikely to benefit but is exposed to the risks of the intervention, and the intervention should generally NOT be recommended. If LE is longer than the TTB, the individual could benefit, and the intervention should generally be recommended. If LE is similar to the TTB, the individual's values and preferences should be the major determinant of the decision. To facilitate the use of this framework in routine clinical care, we explored ways to estimate LE, identified the TTB for common preventive interventions, and developed strategies for communicating with individuals. We have synthesized these strategies and demonstrate how they can be used to individualize prevention for a hypothetical beneficiary in the setting of a Medicare annual wellness visit. Finally, we place prevention in the context of curative and symptom-oriented care and outline how prevention should be focused on healthier older adults, whereas symptom-oriented care should predominate in sicker older adults.

Models for joint ophthalmology-optometry patient management.

PURPOSE OF REVIEW: American Academy of Ophthalmology (AAO) and American Society of Cataract and Refractive Surgery (ASCRS) presented a joint position paper in February 2000 declaring that they do not support routine comanagement of patients with the optometrists. American Optometric Association and American Academy of Optometry quickly responded in support of AAO and ASCRS. All four entities did not preclude legitimate and proper comanagement arrangements. RECENT FINDINGS: Since that time, the pattern of practice has changed, requiring us to rethink our positions. SUMMARY: This paper is written to provide a possible model for the ophthalmology-optometry practice management in ophthalmic surgeries including refractive surgery. Since the publication of the Joint Position Paper, the concept of comanagement has faded and a new model of integrated management has evolved. This has occurred as the changes in the employment pattern of the ophthalmic practice have incorporated optometrists into its fold. This evolution allowed ophthalmic and optometric community to co-exist and thrive to provide better patient care.