A Retrospective Study of Lymph Node Yield in Lateral Neck Dissection for Papillary Thyroid Carcinoma.

OBJECTIVE: Lateral neck dissection (LND) is important in managing papillary thyroid carcinomas (PTCs). This study aimed to evaluate the relationship between lymph node yield (LNY) for LND and patient outcomes, specifically postoperative serum thyroglobulin levels (sTG) and radioiodine uptake on thyroid scan, and to estimate a threshold LNY to signify adequate LND. METHODS: Patients diagnosed with PTC who underwent LND from 2006 to 2015 at a single institution were included. Linear regression with restricted cubic splines was used to characterize the association of LNY with outcomes. Outcomes were log-transformed to achieve a more symmetric distribution prior to regression. For nonlinear associations, a Monte Carlo Markov Chain procedure was used to estimate a threshold LNY associated with postoperative outcome. This threshold was then used to define high LNY versus low LNY in the subsequent analyses. RESULTS: In total, 107 adult patients were included. There was a significant relationship between LNY and postoperative sTG level (P = .004), but not radioiodine uptake (P = .64). An LNY of 42.96 was identified, which was associated with the maximum change in sTG level. No association was found between LNY groups (LNY ≥ 43 vs < 43) and radioiodine uptake, risk of complication, or longer operative times (all P > .05). High LNY was associated with a decrease in log(sTG) (estimate = -1.855, P = .03), indicating that adequacy of LND is associated with an 84.4% decrease in sTG. CONCLUSION: These results suggest an association between LNY and postoperative sTG level, with an estimated threshold of 43 nodes. This has implications for adequate therapeutic LND; additional work is needed to validate thresholds for clinical practice.

Rare cases of large parapharyngeal lipomas.

Primary tumors of the parapharyngeal space are extremely rare, and lipomas are among the least common primary parapharyngeal space masses. Parapharyngeal lipomas typically present as a painless neck mass, and some may present with neurologic deficits or vascular compromise attributed to the lipomas' mass effect on nearby neurovascular structures. We report long term follow-up of two large parapharyngeal lipomas. One lesion was managed expectantly, and the other was managed with a partial transcervical excision. We demonstrate that conservative management and long term patient follow-up may be reasonable if the patient is asymptomatic and liposarcoma is ruled out. Considering the uncertainty in the need for removal, the management strategy for the individual patient is best to be tailored to their clinical presentation.

Assessment of the sensitivity and specificity of tissue-specific-based and anatomical-based optical biomarkers for rapid detection of human head and neck squamous cell carcinoma.

OBJECTIVES: We propose the use of morphological optical biomarkers for rapid detection of human head and neck squamous cell carcinoma (HNSCC) by leveraging the underlying tissue characteristics in aerodigestive tracts. MATERIALS AND METHODS: Diffuse reflectance spectra were obtained from malignant and contra-lateral normal tissues of 57 patients undergoing panendoscopy and biopsy. Oxygen saturation, total hemoglobin concentration, and the reduced scattering coefficient were extracted. Differences in malignant and normal tissues were examined based on two different groupings: anatomical site and morphological tissue type. RESULTS AND CONCLUSIONS: Measurements were acquired from 252 sites, of which 51 were pathologically classified as SCC. Optical biomarkers exhibited statistical differences between malignant and normal samples. Contrast was enhanced when parsing tissues by morphological classification rather than anatomical subtype for unpaired comparisons. Corresponding linear discriminant models using multiple optical biomarkers showed improved predictive ability when accounting for morphological classification, particularly in node-positive lesions. The false-positive rate was retrospectively found to decrease by 34.2% in morphologically- vs. anatomically-derived predictive models. In glottic tissue, the surgeon exhibited a false-positive rate of 45.7% while the device showed a lower false-positive rate of 12.4%. Additionally, comparisons of optical parameters were made to further understand the physiology of tumor staging and potential causes of high surgeon false-positive rates. Optical spectroscopy is a user-friendly, non-invasive tool capable of providing quantitative information to discriminate malignant from normal head and neck tissues. Predictive models demonstrated promising results for real-time diagnostics. Furthermore, the strategy described appears to be well suited to reduce the clinical false-positive rate.

Applying the Society of Radiologists in Ultrasound recommendations for fine-needle aspiration of thyroid nodules: effect on workup and malignancy detection.

OBJECTIVE: The Society of Radiologists in Ultrasound (SRU) recommendations on thyroid nodules are intended to "diagnose thyroid cancers that have reached clinical significance, while avoiding unnecessary tests and surgery in patients with benign nodules." The aim of our study was to determine the proportion of thyroid nodules undergoing ultrasound-guided fine-needle aspiration (FNA) that do not meet SRU recommendations. MATERIALS AND METHODS: This study is a retrospective study of 400 consecutive ultrasound-guided thyroid FNA encounters from July 2010 through June 2011. An encounter was defined as presentation to the department of radiology on a given date for FNA of one or more thyroid nodules. The criteria for performing biopsy of a nodule were determined by the referring clinicians. Nodules were categorized on the basis of sonographic findings as meeting SRU recommendations for biopsy, which we refer to as "SRU-positive," or not, which we refer to as "SRU-negative." Patients without a definitive pathology diagnosis of Bethesda class benign or malignant nodules were excluded. The characteristics of malignancies were compared for SRU-positive and SRU-negative encounters. RESULTS: The final study group consisted of 360 biopsy encounters for 350 patients and 29 malignancies (8%). Of the 360 biopsy encounters, 86 (24%) were SRU-negative encounters. Malignancy rates in SRU-positive and SRU-negative encounters were 9% (24/274) and 6% (5/86), respectively, and were not significantly different (p=0.5). Eighteen malignancies (75%) in the SRU-positive group were localized, whereas the others had nodal metastases (4/24) or distant metastases (2/24). SRU-positive encounters included medullary carcinoma, anaplastic carcinoma, and melanoma metastasis in addition to papillary carcinoma. All SRU-negative malignancies were localized papillary carcinomas. CONCLUSION: One in four thyroid biopsy encounters at our institution did not meet SRU recommendations for biopsy. The application of SRU recommendations reduces the number of benign nodules that undergo workup. Potentially missed malignancies in SRU-negative nodules are less aggressive by histologic type and stage compared with SRU-positive malignancies.

Trends in incidentally identified thyroid cancers over a decade: a retrospective analysis of 2,090 surgical patients.

BACKGROUND: The aim of this study was to describe trends in the incidence of incidental thyroid cancers and compare their characteristics with clinically presenting cancers. METHODS: We performed a retrospective review of patients with thyroid cancer who underwent thyroid surgery from 2003 to 2012. Patients' initial presentation was categorized as incidental (on imaging or final surgical pathology) or clinical (palpable or symptomatic) cancer. Characteristics of incidental and clinical cancers were compared. RESULTS: Of the 2,090 patients who underwent thyroid surgery, 680 (33 %) were diagnosed with cancer. One hundred ninety (28 %) were incidental cancer, of which 101 were detected on imaging studies and 89 were detected on analysis of the surgical pathology specimens. The incidence of thyroid cancer increased by 7.6-fold from 2003 to 2012. The proportion of incidental cancers on imaging did not increase, but incidental cancers found on pathology steadily increased from 6 % in 2003 to 20 % in 2012. 84 % of the cancers were papillary cancer, and the proportion of papillary cancer was similar for both clinical and incidental cancers. Clinical cancers were larger than incidental cancers on imaging (2.2 vs. 1.8 cm, p = 0.02). Incidental cancers on imaging were less likely to have lateral compartment nodal metastases (7 vs. 13 %, p < 0.001). CONCLUSIONS: Thyroid cancer diagnoses have increased at our institution, but the proportion of incidental cancers identified on imaging relative to clinical cancers has been stable over a decade and is not the sole explanation for the observed increase in thyroid cancer diagnoses. Incidental cancers on imaging are smaller in size and less likely to have lateral compartment nodal metastases than clinical cancers.

Comparison of complications in free flap reconstruction for osteoradionecrosis in patients with or without hyperbaric oxygen therapy.

BACKGROUND: Hyperbaric oxygen (HBO) therapy induces native tissue oxygenation. The hypothesis was patients with mandibular osteoradionecrosis (ORN) and a history of HBO therapy would have less free flap reconstruction complications than patients without HBO therapy. METHODS: We conducted a multisite retrospective review involving radical debridement and free flap reconstruction for ORN between January 1, 1995 and June 30, 2011. Patients were stratified based on receiving prior HBO therapy or not. RESULTS: Thirty-nine of 89 patients (43.8%) had HBO therapy whereas 50 of 89 (56.2%) did not. The HBO therapy group had significantly less patients with diabetes. There was no statistical difference in overall complication in patients between groups (p = .5478). However, there was marginal significance of increased infections in the patients with a history of HBO therapy (p = .0545). CONCLUSION: Although no significant differences in free flap reconstruction complication rates were observed between these 2 patient cohorts, there was marginal significance of increased infections in the patients with a history of HBO therapy. A prospective multi-institutional randomized study examining issues of infection would address issues inherent in this retrospective study.

Journal Club: incidental thyroid nodules detected at imaging: can diagnostic workup be reduced by use of the Society of Radiologists in Ultrasound recommendations and the three-tiered system?

OBJECTIVE: The purpose of this study was to determine the number of thyroid nodule workups that could be eliminated and the number of malignant tumors that would be missed if the Society of Radiologists in Ultrasound (SRU) recommendations and the three-tiered system were applied to incidental thyroid nodules (ITN) detected at imaging. MATERIALS AND METHODS: This retrospective study included ITN in 390 consecutively registered patients who underwent ultrasound-guided fine-needle aspiration of one or more thyroid nodules from July 2010 to June 2011. Images were reviewed, and nodules were categorized according to two workup criteria: ITN seen on ultrasound images were categorized according to SRU recommendations, and those seen on CT, MR, or PET/CT images were classified according to the three-tiered risk-categorization system. RESULTS: In this study 114 of 390 (29%) patients had nodules first detected incidentally during imaging studies, and 107 patients met the inclusion criteria. These patients had 47 ITN seen at ultrasound and 60 ITN seen at either CT, MRI, or PET/CT. If the SRU recommendations had been applied, 14 of 47 (30%) patients with ITN on ultrasound images would not have received fine-needle aspiration and one of four cases of cancer would have been missed. The missed malignant tumor was a 14-mm localized papillary carcinoma. If the three-tiered system had been applied, 21 of 60 (35%) patients with ITN on CT, MR, or PET/CT images would not have received fine-needle aspiration, but none of the three malignancies would have been missed. Overall, 35 of 107 (33%) of patients with ITN did not meet the SRU recommendations or the three-tiered criteria. CONCLUSION: Use of the SRU recommendations and three-tiered system can reduce the workup of ITN by one third compared with current practice without specific guidelines. One case of localized papillary carcinoma was missed when the SRU recommendations were used.

Surgical Training and Education in Promoting Professionalism: a comparative assessment of virtue-based leadership development in otolaryngology-head and neck surgery residents.

INTRODUCTION: Surgical Training and Education in Promoting Professionalism (STEPP) was developed in 2011 to train tomorrow's leaders during residency. It is based on virtue ethics and takes an approach similar to West Point military academy. The purpose of this research was: (i) to compare the virtue profiles of our residents with that of the military cohort using a standardized virtue assessment tool; and (ii) to assess the value of virtue education on residents. METHODS: As part of STEPP, otolaryngology residents participated in a virtue-based validated assessment tool called Virtue in Action (VIA) Inventory. This was completed at the initiation of STEPP in July 2011 as well as 1 year later in June 2012. Comparison of the VIA to a military cohort was performed. Leadership 'Basic Training' is a series of forums focused on virtues of initiative, integrity, responsibility, self-discipline, and accountability. A pre- and post-test was administered assessing resident perceptions of the value of this 'Basic Training'. RESULTS: Virtues are shared between otolaryngology residents (n=9) and military personnel (n=2,433) as there were no significant differences in strength scores between two military comparison groups and otolaryngology-head and neck surgery (OHNS) residents. There was a significant improvement (p<0.001) in the understanding of components of the leadership vision and a significant improvement in the understanding of key leadership concepts based on 'Basic Training'. All residents responded in the post-test that the STEPP program was valuable, up from 56%. CONCLUSIONS: A virtue-based approach is valued by residents as a part of leadership training during residency.

Utility of Intraoperative Frozen Sections during Thyroid Surgery.

Objective. To describe the usefulness of intraoperative frozen section in the diagnosis and treatment of thyroid nodules where fine needle aspirate biopsies have evidence of follicular neoplasm. Study Design. Retrospective case series. Methods. All patients have a fine needle aspirate biopsy, an intraoperative frozen section, and final pathology performed on a thyroid nodule after initiation of the Bethesda System for Reporting Thyroid Cytopathology in 2009 at a single tertiary referral center. Sensitivity, specificity, positive predictive value, and negative predictive value are calculated in order to determine added benefit of frozen section to original fine needle aspirate data. Results. The sensitivity and specificity of the frozen section were 76.9% and 67.9%, respectively, while for the fine needle aspirate were 53.8% and 74.1%, respectively. The positive and negative predictive values for the fine needle aspirates were 25% and 90.9%, respectively, while for the frozen sections were 27.8% and 94.8%, respectively. There were no changes in the operative course as a consequence of the frozen sections. Conclusion. Our data does not support the clinical usefulness of intraoperative frozen section when the fine needle aspirate yields a Bethesda Criteria diagnosis of follicular neoplasm, suspicious for follicular neoplasm, or suspicious for malignancy at our institution.

Prospective trial of synchronous bevacizumab, erlotinib, and concurrent chemoradiation in locally advanced head and neck cancer.

PURPOSE: We assessed the safety and efficacy of synchronous VEGF and epidermal growth factor receptor (EGFR) blockade with concurrent chemoradiation (CRT) in locally advanced head and neck cancer (HNC). EXPERIMENTAL DESIGN: Newly diagnosed patients with stage III/IV HNC received a 2-week lead-in of bevacizumab and/or erlotinib, followed by both agents with concurrent cisplatin and twice daily radiotherapy. Safety was assessed using Common Toxicity Criteria version 3.0. The primary efficacy endpoint was clinical complete response (CR) rate after CRT. RESULTS: Twenty-nine patients enrolled on study, with 27 completing therapy. Common grade III toxicities were mucositis (n = 14), dysphagia (n = 8), dehydration (n = 7), osteoradionecrosis (n = 3), and soft tissue necrosis (n = 2). Feeding tube placement was required in 79% but no patient remained dependent at 12-month posttreatment. Clinical CR after CRT was 96% [95% confidence interval (CI), 82%-100%]. Median follow-up was 46 months in survivors, with 3-year locoregional control and distant metastasis-free survival rates of 85% and 93%. Three-year estimated progression-free survival, disease-specific survival, and overall survival rates were 82%, 89%, and 86%, respectively. Dynamic contrast enhanced MRI (DCE-MRI) analysis showed that patients who had failed had lower baseline pretreatment median K(trans) values, with subsequent increases after lead-in therapy and 1 week of CRT. Patients who did not fail had higher median K(trans) values that decreased during therapy. CONCLUSIONS: Dual VEGF/EGFR inhibition can be integrated with CRT in locally advanced HNC, with efficacy that compares favorably with historical controls albeit with an increased risk of osteoradionecrosis. Pretreatment and early DCE-MRI may prospectively identify patients at high risk of failure.

Treatment-induced changes in vocal cord mobility and subsequent local recurrence after organ preservation therapy for laryngeal carcinoma.

BACKGROUND: As multidisciplinary cancer treatment evolves, strategies to identify patients needing early resection/salvage are necessary. Some have suggested that vocal cord function after organ-preservation treatment may be an indicator. METHODS: A retrospective review was performed of patients presenting with fixed or impaired vocal cord function at a tertiary center. Local recurrence rates were examined in patients with and without improved/normal mobilization after treatment. RESULTS: Sixty-nine patients met the inclusion criteria, with 35 patients having vocal cord fixation and 34 patients with impaired mobility. After treatment, 44 patients had normalization of vocal cord function, while 25 patients did not, with 2-year local control rates of 70% and 77%, p = .23, respectively. No difference in local control was found between patients with normalized/improved cord function (n = 53) and those who remained the same/worsened (n = 16; p = .81). CONCLUSION: Therapy-induced changes in vocal cord mobility did not correlate with local recurrence. Other criteria are needed to identify patients most likely to benefit from early surgical resection/salvage after organ preservation.

Extent of neck dissection required after concurrent chemoradiation for stage IV head and neck squamous cell carcinoma.

BACKGROUND: The management of initially bulky nodal disease after primary nonsurgical treatment for stage IV head and neck squamous cell carcinoma (HNSCC) continues to be a subject of debate. METHODS: A retrospective chart review of neck management in patients after chemoradiation was performed. RESULTS: Of the initially positive necks analyzed, 210/329 (65%) had a complete clinical response to treatment and 161 necks underwent neck surgery. Patients were pathologically positive 13.8% and 39.6% of the time after clinical complete or partial response, respectively. Regional recurrence was more frequent in necks with partial clinical (p = .04) or pathologic responses (p < .01) and with primary site recurrences (p < .01). CONCLUSIONS: It is still safest at our institution to perform selective neck dissection on patients with > or = N2 neck disease when initially observed to prevent unsalvageable regional recurrence until more accurate interval assessment tools are confirmed.

Impact of preepiglottic space tumor involvement on concurrent chemoradiation therapy.

PURPOSE: The aim of the study was to determine the prognostic impact of preepiglottic space (PES) involvement on local failure after concurrent chemoradiation therapy for squamous cell carcinoma. MATERIALS AND METHODS: Retrospective chart review of patients who underwent concurrent chemoradiation therapy for T3 or T4 laryngeal, T4 hypopharyngeal, and T3 or T4 oropharyngeal squamous cell carcinoma were eligible for inclusion. Patients were then stratified by the presence or absence of PES tumor involvement. A multivariate analysis was performed on the presence of recurrence using the following pretreatment variables: PES involvement, tumor extent, pathologic cell differentiation, lymph node involvement, age, and sex. RESULTS: A total of 102 patients were included in the study. Twenty-seven (28%) patients had documented PES involvement. Mean follow-up for all patients was 46 months. Involvement of the PES was not significantly associated with local tumor persistence or recurrence (P = .69). No other variables significantly impacted tumor recurrence. CONCLUSION: Preepiglottic space involvement does not negatively impact local tumor control after concurrent chemoradiation therapy.

Organ and function preservation: the role of surgery as the optimal primary modality or as salvage after chemoradiation failure.

The treatment for squamous cell carcinoma (SCC) of the head and neck has advanced considerably with the use of multimodality therapy including radiation, chemotherapy, and surgery. Efforts to achieve greater rates of disease control and survival have been coupled with attempts to reduce acute and chronic toxicity and preserve function. In the setting of advanced-stage disease, these goals have typically been achieved via the use of combined radiation and chemotherapy. Although very effective, (chemo)radiation does not always succeed and may not offer benefits to the patient equal to those achieved with surgical resection and reconstruction. This article discusses the issues involved in the selection of surgical therapy both for the primary treatment of SCC of the head and neck and for salvage of disease persistence or recurrence after chemoradiation.

Clinical predictors of larynx preservation after multiagent concurrent chemoradiotherapy.

BACKGROUND: Determining which patients benefit from larynx preservation strategies remains problematic. We reviewed our experience using multiagent concurrent chemoradiotherapy to identify clinical predictors for success. METHODS: Cisplatin and fluorouracil were given during weeks 1 and 4 of radiation to 115 patients with locoregionally advanced larynx or hypopharynx squamous cell cancer without cartilage invasion or laryngeal destruction. Laryngectomy was reserved for local failure. RESULTS: The 5-year Kaplan-Meier projected overall survival was 58%, survival with larynx preservation 52%, local control without surgery 82%, local control (including surgical salvage) 94%, and survival with functional larynx 49%. Local control without surgery was superior in patients with T1-2 versus T3-4 tumors (97% vs 77%, p = .032). No other clinical parameters proved predictive of local control. CONCLUSION: Larynx preservation was successful in all subsets of appropriately selected patients. Although local failure was more likely in patients with T3-4 tumors, it was infrequent and surgical salvage was effective.

Ansa cervicalis-to-recurrent laryngeal nerve anastomosis for unilateral vocal fold paralysis: experience of a single institution.

OBJECTIVES: One treatment option for unilateral vocal fold paralysis (UVFP) is ansa cervicalis-to-recurrent laryngeal nerve (ansa-RLN) anastomosis to provide reinnervation to the affected vocal fold. The advantages of this treatment approach are that it 1) provides vocal fold tone, bulk, and tension, 2) is technically simple, and 3) does not preclude other medialization procedures. We present all patients who have undergone ansa-RLN anastomosis for UVFP at our institution. METHODS: An Institutional Review Board-approved retrospective chart review was performed to include all patients who had undergone an ansa-RLN anastomosis procedure for UVFP at our institution. Data from clinical and endoscopic laryngoscopy with stroboscopy were recorded. Statistical analysis was performed on visual and perceptual vocal data. RESULTS: A total of 46 patients were included in the study. Stroboscopic analysis and perceptual vocal evaluation was performed in a blinded fashion on the 21 patients who had preoperative and postoperative stroboscopy. Severity, roughness, breathiness, and strain all improved significantly over time. Glottic closure, vocal fold edge, and supraglottic effort all significantly improved after operation. Of the 38 patients with at least 3 months of follow-up, all except 1 demonstrated evidence of reinnervation. CONCLUSIONS: This technique for treating UVFP results in significant improvements in patients' voice and on visual examination.

Swallowing outcomes after microvascular head and neck reconstruction: a prospective review of 191 cases.

BACKGROUND: The use of microvascular free tissue flaps tailored specifically to the ablative surgical defects has allowed precise anatomic reconstructions to be performed and, in turn, has improved patient outcomes. We report here the postoperative swallowing outcomes of patients undergoing microvascular reconstructions for a range of head and neck defects at the Cleveland Clinic. METHODS: The study includes 191 consecutive reconstructions for varied defects. All patients were reconstructed with four specific microvascular flaps based on their surgical defect, and postoperative swallowing outcomes were evaluated and recorded on a prospectively maintained database. Pre- and postoperative swallowing was graded on an ordinal scale. Data were simultaneously collected on the precise anatomic ablative defect in each patient, subdividing the head and neck into 16 subsites. The data were analyzed using a multivariate analysis accounting for comorbid factors, type of flap used, and subsite of defect. RESULTS: The findings are summarized as follows. There were no flap failures. The percent of patients who were able to swallow and maintain an exclusively oral diet postoperatively was 78.5%. Only 16.8% were unable to have an oral diet (NPO) and dependent on a gastric tube (G-tube) for feeding. The factors that predicted an inability to swallow include tongue resection, preoperative radiation therapy, and hypopharyngeal defects. In contrast, floor of mouth, mandibular, and pharyngeal defects, regardless of size, had excellent long-term swallowing outcomes. Most patients with these defects were able to tolerate at least a soft solid diet. CONCLUSIONS: In summary, we report excellent postoperative swallowing outcomes after microvascular reconstructions at our institution that compare favorably with outcomes with pedicled flaps and historic controls. The type of flap used and the size of defect had minimal effects on swallowing outcomes. The most difficult subsites to reconstruct were tongue defects, which strongly correlated with poor swallowing outcomes. The other factor that strongly impacted outcomes was preoperative radiation treatment. We believe these results highlight the utility of free flaps in recreating the precise anatomy required to maintain swallowing function. These data will hopefully support numerous previous studies that have established the use of microvascular reconstruction as standard of care for ablative surgical defects in the head and neck.

Ability of positron emission tomography to detect residual neck node disease in patients with head and neck squamous cell carcinoma after definitive chemoradiotherapy.

OBJECTIVE: To report our experience using the neck examination, computed tomography (CT), and positron emission tomography (PET) to clinically evaluate node-positive patients with head and neck squamous cell cancer for residual neck node disease after definitive chemoradiotherapy. DESIGN: Retrospective review of all Cleveland Clinic patients with head and neck squamous cell cancer and N2 or N3 neck node involvement at presentation who were treated with definitive concurrent chemoradiotherapy and who underwent clinical restaging after treatment using the neck examination, CT, and PET. SETTING: Tertiary care referral institution. PATIENTS: Forty-eight patients with 72 positive necks at diagnosis were followed up for a median of 20 months. MAIN OUTCOME MEASURES: Palpable nodes on examination, nodes larger than 1 cm, nodes with central necrosis on CT, or any hypermetabolic lymph nodes on PET were considered clinical evidence of residual nodal disease. The true rate of pathologic involvement was determined by histologic examination after planned neck dissection or if regional recurrence developed. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for all 3 clinical assessment tools. RESULTS: Planned neck dissection was performed in 33 necks and was positive for residual neck node disease in 5 necks. A delayed neck dissection was performed in 5 necks and was positive in 3 necks. The positive predictive value was low for all 3 clinical assessment tools. The addition of PET did not significantly improve the negative predictive value or positive predictive value of CT and the clinical examination. CONCLUSIONS: Residual neck node disease after definitive chemoradiotherapy was infrequent and was not well predicted by PET. A positive PET finding in this setting is of little utility. Although a negative PET finding was highly predictive for control of neck disease after chemoradiotherapy, it added little to the clinical neck examination and CT.

Results of ansa to recurrent laryngeal nerve reinnervation.

OBJECTIVE: We sought to describe the results of ansa cervicalis to recurrent laryngeal nerve (ansa-RLN) reinnervation for unilateral vocal fold paralysis. STUDY DESIGN: A chart review was performed on patients undergoing ansa-RLN reinnervation for unilateral vocal cord paralysis at a tertiary care center. Patient perceptions of preoperative and postoperative voice quality was surveyed. Acoustic and visual parameters were assessed from videostroboscopy. RESULTS: From a total of 25 study patients, 15 patients underwent both preoperative and postoperativ video stroboscopies. In stroboscopies within 6 months, the average improvement in overall severity, roughness, and breathiness was 69, 79, and 100 percent, respectively. In stroboscopies after 6 months, the average improvement in overall severity, roughness, and breathiness was 63, 66, and 100 percent, respectively. Postoperatively, all patients had reinnervation of the vocal fold. CONCLUSIONS: Voice outcomes were improved in patients with preoperative and postoperative stroboscopies. SIGNIFICANCE: Ansa-RLN reinnervation should be considered as a treatment for unilateral vocal fold paralysis.