Vallecular cyst causing sleep-disordered breathing in an older child.

Consensus-based recommendations are needed to better guide paediatric otolaryngologists in providing standardised care to children with sleep-disordered breathing (SDB). Here we present a unique case of vallecular cyst found during SDB workup in a patient in their middle childhood (6-12 years old). While the patient underwent successful cyst resection, he was noted to have a suspected recurrence 6 months later. Immediately prior to revision excision, repeat awake flexible fibre-optic laryngoscopy revealed complete resolution of the suspected recurrence. This case underscores the significance of performing a complete upper airway examination, including endoscopic examination, to identify structural and anatomical lesions in older children with SDB.

Acute Invasive Fungal Rhinosinusitis: A 15-Year Experience with 41 Patients.

OBJECTIVES: To describe a 15-year single-institution experience of 41 cases of acute invasive fungal sinusitis (AIFRS), identify clinical indicators predictive of AIFRS, and discuss our approach to these high-acuity patients. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center; The Pennsylvania State University Hershey Medical Center. SUBJECTS AND METHODS: A retrospective review was performed for AIFRS consultations between September 1999 and March 2014. Variables reviewed included underlying condition, presenting symptoms, absolute neutrophil count, disease extent on examination, radiographic findings, medical treatment, biopsy results, surgical treatment, and outcomes. Univariate analysis was performed to determine variables significantly associated with AIFRS. Outcome measures were assessed and patient assessment algorithm developed. RESULTS: Of 131 patients evaluated, 41 were diagnosed with AIFRS; 92.7% had an underlying hematologic malignancy. Disease predictive variables included absolute neutrophil count <500/µL (P < .0001; sensitivity = 78%), mucosal abnormalities of middle turbinate (P < .0001; specificity = 88%) and septum (P < .0001; specificity = 97%), and specifically, necrosis of the middle turbinate (P < .0001; specificity = 97%). Twenty-five AIFRS patients (61%) survived until discharge; 25% (n = 10) expired secondary to AIFRS infection explicitly. CONCLUSION: This series represents one of the largest single-institution experiences of AIFRS published to date. Timely diagnosis is necessary to improve patient outcomes and limit morbidity. Maintaining a high index of suspicion in at-risk patient populations, followed by prompt evaluation and management, is crucial in suspected AIFRS. The presence or absence of certain findings appear to correlate with biopsy results and may aid in appropriately gauging clinical suspicion for the presence of AIFRS.

Incidental Thyroid Nodules: Incidence, Evaluation, and Outcome.

OBJECTIVE: To examine patients with incidentally discovered thyroid nodules (IDTNs) with a focus on identification, evaluation, surgical intervention, and rates of malignancy. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care medical center. SUBJECTS AND METHODS: A total of 1408 patients were identified by cross-referencing thyroid diagnosis codes with ultrasound (US) codes between July 2008 and June 2009. Information regarding demographics, follow-up, and outcomes was extracted from the medical record. RESULTS: A total of 249 patients with IDTNs were identified. Most were discovered on computed tomography (CT) scans (59.8%); the most common indication for obtaining imaging was for evaluation of an unrelated malignancy (26.9%). Malignant IDTNs were identified on 23.8% of positron emission tomography/CT scans and 6.8% of CT scans. Initial evaluation of IDTNs was performed by US in 62.2% and by US with fine-needle aspiration (FNA) in 36.1% of patients. The most common pathology on FNA of IDTNs was benign follicular nodule (64.1%) followed by papillary thyroid cancer (PTC; 13.5%); however, 31.7% of all cytology indicated suspicion for malignancy. Fifty-five patients (22.1%) were treated surgically. On final surgical pathology, 33 malignancies were present, of which 28 were PTC. The overall malignancy rate for incidental thyroid nodules was 13.3%. CONCLUSION: We identified a malignancy of at least 13.3% in IDTNs, reaffirming that IDTNs should undergo thorough workup.

Characteristics of incidentally discovered thyroid cancer.

IMPORTANCE: The incidence of thyroid cancer has been steadily increasing; however, no clear reason for the increase in incidence has been identified. OBJECTIVES: To compare incidentally discovered (ID) thyroid cancer via non-thyroid-related imaging with nonincidentally discovered (NID) thyroid cancer, as well as determine if differences in tumor characteristics and patient presentation in ID thyroid cancer may help elucidate the increasing incidence of this disease. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review at an academic tertiary care medical center of 31 patients with ID thyroid cancer and 207 patients with NID thyroid cancer evaluated at our institution during a 12-month period. MAIN OUTCOMES AND MEASURES: Patient demographics, tumor pathology, stage, tumor size, invasion, and metastasis were recorded. RESULTS: Mean age at diagnosis was 56.4 years for the ID group and 41.8 years for the NID group (P < .001). The ID group was 54.8% male compared with 13.5% in the NID group (P < .001). The ID group had higher stage disease compared with the NID group (P = .003). There was no difference in tumor size (P = .91), invasion (P = .76), lymph node involvement, or distant metastases (P > .99). CONCLUSIONS AND RELEVANCE: Patients with ID thyroid cancer tend to be older at presentation, have higher stage disease, and are more likely to be male compared with patients with NID thyroid cancer. There does not appear to be a significant difference in the size, pathology, or behavior of the tumor at presentation between ID and NID thyroid cancers. These findings imply that improved detection may not represent the only cause of the increased incidence of thyroid cancer.

Dyspnea as a prognostic factor in anaplastic thyroid carcinoma.

Anaplastic thyroid cancer (ATC) is a rare but aggressive form of thyroid cancer. In this study, we review a single institution's experience with ATC over past 34 years. Through retrospective review, we attempted to identify the prognostic factors affecting the survival at our institution. We reviewed the records of 33 patients diagnosed with ATC by pathology over the last three decades. At our institution, median age at diagnosis was 68 years, the male to female ratio was 1.1:1, mean survival was 10 months and median survival was 4.7 months. Thirty-nine percentage of patients were treated with chemotherapy and 52% received radiation treatment. Thirty-six percentage received both chemotherapy and radiation and 58% of patients were treated with surgical intervention. Four of the patients received surgical intervention with curative intent. Tracheotomy was performed in 40% of patients. Eight patients survived more than 10 months. Univariate analysis showed that age greater than 60 and dyspnea at presentation were associated with decreased survival and that surgical intervention was associated with increased survival. Multivariate analysis identified only dyspnea at the time of presentation to be a significant independent prognostic factor affecting the mortality. While long-term survival is possible in some patients, ATC has a poor prognosis despite the attempts at aggressive treatment. In this study, we report that dyspnea was the only independent factor found to negatively affect the survival. This finding is unique in our study and supports the role of using signs at the time of presentation as potential prognostic factors for those patients with this aggressive disease.

Multilevel esophageal biopsy in children with airway manifestations of extraesophageal reflux disease.

OBJECTIVES: Extraesophageal reflux disease (EERD) is a recognized cause of upper airway symptoms in children. Direct microlaryngoscopy and bronchoscopy (MLB) is performed for diagnostic information as to the extent and severity of the inflammation caused by gastric refluxate. Esophagoscopy with multilevel biopsy performed at the time of MLB may provide the clinician with additional information to assist in the management of EERD. We undertook to determine the role of multilevel esophageal biopsy in children who have airway manifestations secondary to EERD. METHODS: We performed a retrospective chart review of 139 esophagoscopies with multilevel biopsy done at the time of MLB by a single provider for evaluation of symptoms highly associated with EERD at a tertiary care children's hospital. The histopathologic presence of esophagitis was analyzed by site and compared to the presence and location of tracheolaryngeal abnormalities. RESULTS: Tracheolaryngeal abnormalities associated with EERD were found in 97% of patients when evaluated by MLB. Concomitant esophagitis was found in 59% of these patients. Of patients who had 0, 1, 2, 3, 4, or 5 positive findings on MLB, 75% (3 of 4), 58% (7 of 12), 57% (20 of 35), 62% (32 of 51), 56% (18 of 32), and 80% (4 of 5), respectively, had at least 1 positive biopsy. CONCLUSIONS: We found that EERD that affects the pediatric upper airway was associated with esophagitis in more than half of the patients. The usefulness of 4-level biopsies during esophagoscopy and concomitant airway endoscopy will be discussed.

The relationship of plasma glucose and HbA1c Levels among emergency department patients with no prior history of diabetes mellitus.

OBJECTIVES: Patients without a history of diabetes mellitus may be incidentally found to be hyperglycemic in the emergency department (ED). If the hyperglycemia is due to undiagnosed diabetes, then an opportunity for detection exists. Hemoglobin A1c (HbA1c) provides a weighted average of blood glucose levels over the past several months; high HbA1c levels could indicate diabetes. The objective of this study was to determine whether hyperglycemia in ED patients without a history of diabetes was associated with higher HbA1c levels. METHODS: This was a prospective nonconsecutive case series of adults aged 18 years or older presenting to the ED with acute illness for whom a plasma glucose sample was drawn for clinical management. A history of diabetes/hyperglycemia or current symptoms of diabetes excluded patients. HbA1c levels were analyzed for a glucose cutoff of 110 mg/dL; the data were further analyzed using additional glucose cutoffs. Based on the Third National Health and Nutrition Examination Survey outpatient screening data, an HbA1c level > or =6.2% was considered elevated (sensitivity of 63% and specificity of 97% for identifying diabetes). RESULTS: There were 541 patients enrolled; the glucose level correlated with the HbA1c level (r = 0.60, p < 0.001). Among the 331 patients with a glucose level > or =110 mg/dL, 22.4% had an elevated HbA(1c) level; among the 210 patients with a glucose level < 110 mg/dL, 7.6% had an elevated HbA1c level. There were few patients (n = 13) with a glucose level > or =200 mg/dL, but most (85%) had an elevated HbA1c level. Among the 140 patients with a mildly elevated glucose level (110-125 mg/dL), 16.4% had an elevated HbA(1c) level. CONCLUSIONS: Elevated HbA1c levels are found in ED patients with elevated random plasma glucose values. ED patients with hyperglycemia may warrant referral for diabetes testing.