Nasal tip deprojection with crural cartilage overlap: the M-arch model.

Vertical arch division is a mainstay of tip surgery, and its applications are expanding. It allows deprojection of the overprojected tip, and modifies rotation, length, and lobule definition. These parameters can be altered in a controlled, predictable fashion when the alar cartilage is preserved and overlapped, maintaining its strength. Cartilage overlay techniques aim to preserve normal anatomy and establish support for the nasal framework. We discuss the uses of vertical arch division when applied to the M-arch model, an expansion of the nasal tip tripod concept, which provides for a utilitarian approach to surgical techniques for the nasal tip.

Pediatric esthetic otoplasty.

Pediatric otoplasty is generally considered to be a "simple" procedure, but an astute surgeon recognizes the challenges of this operation and is mindful of the degree of detail involved in its planning and execution. The vast number of described otoplasty methods, which are ever evolving, is a testament to the complexity of this procedure. In this article, the authors' methodology with respect to preoperative analysis and planning, surgical technique, and postoperative care, including management of complications and potential pitfalls, are highlighted.

Global facial beauty: approaching a unified aesthetic ideal.

Recognition of facial beauty is both inborn and learned through social discourses and exposures. Demographic shifts across the globe, in addition to cross-cultural interactions that typify 21st century globalization in virtually all industries, comprise major active evolutionary forces that reshape our individual notions of facial beauty. This article highlights the changing perceptions of beauty, while defining and distinguishing natural beauty and artificial beauty.

Serum thyroglobulin improves the sensitivity of the McGill Thyroid Nodule Score for well-differentiated thyroid cancer.

BACKGROUND: The McGill Thyroid Nodule Score (MTNS) is a scoring system devised to help physicians to assess the preoperative risk that a thyroid nodule is malignant. It uses 22 different known risk factors for thyroid cancer (radiation exposure, microcalcifications on ultrasound, positive HBME-1 stain on biopsy, etc.) and attributes a percentage risk that the nodule is malignant. Recently, preoperative thyroglobulin (Tg) levels have been shown to correlate with the risk of malignancy. The aim of this study was to incorporate Tg levels into the already established MTNS. METHODS: This is a retrospective analysis of 184 thyroidectomy patients at the McGill University Thyroid Cancer Center. Patients with preoperative Tg levels were included in the study, and patients with incidental papillary microcarcinoma without extrathyroidal extent on final pathology were excluded. MTNS scores were calculated for all patients. Preoperative Tg levels of 75 ng/mL added one point to the MTNS, and levels of 187.5 ng/mL added two points. The new system is named MTNS+. RESULTS: Malignancy rates were calculated for each MTNS+ score. Patients with a score of 0-1 were <5% at risk of malignancy. The malignancy rate for scores of 2-3 was 14.29%, followed by 28.95% for scores of 4-6, 32.65% for scores of 7-8, 64.86% for scores of 9-11, 71.43% for scores of 12-14, 78.57% for scores of 15-18, and 92.31% for scores of 19-22. All patients (five of five) with an MTNS+ score of 23 or more had a malignant final pathology result. Patients with scores greater than eight had a relative risk of 2.5 [CI 1.79-3.49] of malignancy compared to patients with lower scores. MTNS+ showed good specificity at higher scores, with 89%, 96%, and 100% at scores above 11, 14, and 20 respectively. Compared to MTNS, adding Tg levels did not improve positive predictive values (PPV) or specificity, but improved sensitivity by 7.89% for scores greater than eight, and by up to 10.48% for scores greater than seven. CONCLUSION: This study shows that adding Tg to the MTNS increases the sensitivity of this scoring system. Moreover, it suggests that a combined scoring system such as the MTNS+ can accurately stratify the risk of well-differentiated malignancy in patients with thyroid nodules.

A bone to pick? Fish bones of the upper aerodigestive tract: review of the literature.

BACKGROUND: Fish bones are of particular interest to the otolaryngologist as accidental ingestion is one of the most common reasons for otolaryngology-related emergency department referrals. Furthermore, removal of fish bones deeply lodged in the oropharynx or hypopharynx can be both hazardous and technically difficult, and failure to accomplish safe removal could result in considerable morbidity and various critical complications. OBJECTIVE: We present here a literature review on the topic of fish bones in otolaryngology with a focus on selection of patients for intervention and on removal techniques. We emphasize that retained fish bones should be approached with caution as their course can at times be unpredictable, as we describe here.

Coblation technique as an alternative treatment modality for oral lymphangioma.

Lymphangiomas of the tongue are relatively uncommon, and traditional treatment modalities carry a high failure rate. We present here a case report of effective treatment of lymphangioma circumscriptum of the oral tongue using radiofrequency coblation, while including a review of the current literature.

Female gender as a risk factor for transient post-thyroidectomy hypocalcemia.

OBJECTIVES: Transient post-thyroidectomy hypocalcemia is a common complication following thyroid surgery. Studies have identified risk factors and possible ways to help predict post-thyroidectomy hypocalcemia with the intent of ultimately limiting its incidence. This study evaluates the role of patient gender as a potential risk factor. STUDY DESIGN: A retrospective case series with chart review of 270 consecutive total thyroidectomy patients was conducted. SETTING: Jewish General Hospital, a McGill University-affiliated hospital in Montreal, Canada. SUBJECTS AND METHODS: 219 women and 51 men were included. Postoperative hypocalcemia was defined as any 1 of the following: total serum calcium 1.90 mmol/L or less, or signs and symptoms of hypocalcemia. The following were evaluated as potential confounding factors in the study: age, menopause, preoperative calcium, parathyroid hormone, magnesium and phosphate levels, presence of carcinoma in the surgical specimen, number of parathyroid glands preserved in situ, thyroid gland volume, and nodule size. RESULTS: Female patients experienced transient postoperative hypocalcemia in 24.7% (54/219) of cases, which was significantly greater than the 11.8% (6/51) incidence detected in men (P < .05). This represents a female/male relative risk ratio of 2.1 (confidence interval, 1.0-4.6). There was no significant difference in rates of hypocalcemia between premenopausal and postmenopausal women (22.7% vs 26.6%). CONCLUSION: These findings suggest that being female is likely a risk factor for transient post-thyroidectomy hypocalcemia. Although this association is statistically significant, its magnitude and clinical relevance are uncertain and may be trivial. Additional research is needed to ascertain the physiologic mechanisms underlying this gender difference.

Preoperative parathyroid hormone levels as a predictor of postthyroidectomy hypocalcemia.

OBJECTIVES: The goal of the present study is to determine whether a decline in the 1-hour postoperative parathyroid hormone (PTH) level relative to the preoperative level is predictive of hypocalcemia. METHODS: This is a retrospective study involving 142 consecutive patients who underwent total thyroidectomy. Changes in preoperative PTH levels were then compared with the 1-hour levels. RESULTS: Thirty-four of 142 patients (23.9%) who underwent total thyroidectomy developed hypocalcemia. Thirty-one of the 34 patients who became hypocalcemic had a 1-hour postoperative PTH drop of 70% or more when compared with the preoperative value (sensitivity = 91%, specificity = 98%, positive predictive value = 94%, and negative predictive value = 97%). CONCLUSION: A decline in the preoperative PTH level of 70% or greater at 1 hour following total thyroidectomy appears to be a reliable predictor of patients at risk of developing hypocalcemia. By allowing thyroid surgeons to identify these patients in the early postoperative period, calcium supplementation can be initiated sooner.

McGill Thyroid Nodule Score (MTNS): "rating the risk," a novel predictive scheme for cancer risk determination.

OBJECTIVE: There are presently a great number of publications pertaining to the clinical risk factors associated with thyroid cancer. These studies deal mostly with a single feature from either patient demographics, physical examination, laboratory values, imaging, or cytology. We sought to create a novel scoring system that integrates the diagnostic indices of each of these clinical features for carcinoma. METHODS: A retrospective analysis of 1047 consecutive thyroidectomy patients was performed. Each patient was assigned a cancer risk score according to a newly devised 22-variable scoring scheme termed the McGill Thyroid Nodule Score (MTNS). The MTNS was developed by a multidisciplinary team of endocrinologists, thyroid surgeons, and pathologists using already established evidence-based risk factors for thyroid cancer. RESULTS: The exact incidence of malignancy was calculated for each MTNS score based on final pathology. The incidence for scores of 1 to 3 was 27%, of 4 to 7 was 32%, of 8 was 39%, of 9 to 11 was 63%, of 12 to 13 was 88%, and of 14 to 18 was 93%. All (130 of 130) patients with a score ≥ 19 had carcinoma. A score ≤ 8 correlated with a 32% (115 of 357) risk of thyroid cancer, whereas a score > 8 implied an 86% (417 of 487) risk. CONCLUSION: Our data suggest that a combined scoring system, the MTNS, can serve as an accurate predictor of the risk for thyroid cancer in a specific thyroid nodule. This will help physicians better formulate management decisions accordingly.

Benign lymphoid hyperplasia of the tongue base causing upper airway obstruction.

Severe benign lymphoid hyperplasia (LH) is unusual in the head and neck region, but the diagnosis of LH is of clinical importance as it may be confused with malignant lymphoma, both on clinical examination and pathologically. While the etiology is poorly understood, a number of previous theories exist, which are included here in the context of a literature review. In this paper we present a case of severe pharyngeal lymphoid hyperplasia causing airway obstruction and requiring tracheotomy and subsequent surgical debulking.

Value of thyroid incidentalomas on positron emission tomographic scans among thyroidectomy patients.

OBJECTIVES: To evaluate the preoperative predictive value of a positive positron emission tomographic (PET) scan with respect to malignancy in future thyroidectomy candidates, particularly when the fine-needle aspiration biopsy (FNAB) results in indeterminate findings, and to establish the efficiency with which this can be incorporated as a preoperative marker and potentially contribute to a standardized scoring system for thyroid nodule patients. METHODS: This retrospective study examined 1048 thyroidectomy patients, of whom 45 underwent PET with computed tomography for unrelated reasons, among which 13 results were focally positive. The final pathology was evaluated and compared to this result to determine the correlation. RESULTS: All patients with positive PET results were shown postthyroidectomy to have a thyroid malignancy (13 of 13), corresponding to a positive predictive value of 100%. There was no correlation between a negative PET scan and malignancy, however. When integrating the PET scan criteria in the McGill Scoring System, 4 of these 13 were shifted into a high chance of malignancy group, allowing a more accurate assessment of their risk than they might have previously received. CONCLUSION: In comparison with previous data, our results indicate a strong relationship between a positive PET scan and malignancy. If available and used in conjunction with the other preoperative diagnostic tools (outlined by the McGill Thyroid Nodule Scoring System), this test can hold significant merit in determining a therapeutic strategy, particularly in the face of an indeterminate FNAB.

Hepatoid adenocarcinoma of the anterior skull base: a case report.

We report the first case of hepatoid adenocarcinoma of the skull base, as well as the first reported case in the head and neck region. Hepatoid adenocarcinoma is a rare, aggressive, extrahepatic malignancy with a distinct morphological similarity to hepatocellular carcinoma, in the absence of primary hepatic disease. A 45-year-old man presented with sinus headaches and retro-orbital pain and was found to have a nasopharyngeal mass on endoscopy and a large, destructive sinonasal mass extending intracranially on imaging. Histo- and cytopathological features were similar to hepatocellular carcinoma, and the cells were immunoreactive for α-fetoprotein, epithelial membrane antigen, periodic acid-Schiff, cytokeratin (CK)8/18, CK19, and S100.

Preoperative serum calcium levels as an indicator of postthyroidectomy hypocalcemia.

BACKGROUND: our group has previously demonstrated that serum calcium levels measured in conjunction with parathyroid hormone (PTH) levels early in the postoperative period can help identify and prophylactically treat patients at significant risk for postthyroidectomy hypocalcemia. This study evaluated whether preoperative serum calcium levels can similarly be used as a reliable indicator of a patient's risk for developing postoperative hypocalcemia. MATERIALS AND METHODS: this was a retrospective review of 1000 consecutive total thyroidectomy patients (2004-2008), with multiple exclusion criteria considered. Postoperative hypocalcemia was defined as total serum calcium of ≤ 1.90 mmol/L up to 1 month following surgery, a PTH ≤ 8 ng/L, or signs and symptoms of hypocalcemia. Laboratory values were drawn at various intervals according to our institution's protocol. RESULTS: the pertinent data were analyzed for 247 of 1000 patients and indicated that patients with a preoperative corrected calcium level below 2.27 mmol/L had a postthyroidectomy hypocalcemia rate of 63%, whereas those with a calcium level above 2.27 mmol/L experienced hypocalcemia 24% of the time (p < .0001*). This threshold calcium value yielded a specificity of 93% and a likelihood ratio of 4.2. CONCLUSION: our data suggest that preoperative serum calcium levels may correlate with the development of postoperative hypocalcemia. A serum calcium level of 2.27 mmol/L is an important threshold separating patients with an elevated risk of hypocalcemia from those who will likely remain normocalcemic. These data are relevant and useful clinically in identifying patients at risk for hypocalcemia. Current studies are investigating whether patients below our critical threshold of 2.27 mmol/L would benefit from early prophylactic supplementation.

Preoperative serum thyroglobulin as an adjunct to fine-needle aspiration in predicting well-differentiated thyroid cancer.

BACKGROUND/PURPOSE: when fine-needle aspiration biopsy (FNAB) of a thyroid nodule yields indeterminate pathology, management decisions become complex, and other preoperative predictors of thyroid cancer must be employed to assess the risk of malignancy. Although thyroglobulin (Tg) is currently accepted as the serum marker of choice in the detection of well-differentiated thyroid cancer (WDTC) recurrence, its preoperative role in the workup of a thyroid nodule remains controversial. The purpose of this study was to evaluate the potential role for Tg as a preoperative indicator of primary WDTC, specifically in patients with indeterminate FNAB. METHODS: this was a retrospective review of 861 consecutive thyroidectomy patients; 297 patients had indeterminate FNAB, of which 68 had serum levels of Tg measured prior to surgery. The predictive value of various threshold levels of preoperative Tg for WDTC was evaluated. Patients with nonindeterminate FNAB or final pathology containing medullary carcinoma, anaplastic carcinoma, or lymphoma were excluded. RESULTS: eighty-one percent (25 of 31) of patients with both indeterminate FNAB and preoperative Tg ≥ 75 microg/L had well-differentiated cancer on final pathology compared to 58% (172 of 297) of patients with indeterminate cytology alone (p = .014, RR = 1.4). In addition, mean preoperative Tg levels were found to be significantly higher in patients with WDTC compared to those with benign pathology (223 vs 53 microg/L, p = .007). DISCUSSION/CONCLUSION: our results imply that elevated preoperative serum Tg levels may be predictive of WDTC. This marker may be useful as an aid when making management decisions in patients with indeterminate cytology.

Thyroidectomy: exactly how painful is it?

BACKGROUND: The level of pain post-conventional thyroidectomy has been studied from two aspects: the short-term effect of different perioperative analgesics on the pain level and in comparison with endoscopic thyroidectomy. OBJECTIVE: The level of pain experienced post-open thyroidectomy and postoperative long-term analgesia requirements have not been prospectively studied. We have undertaken this study to have a clearer understanding of this issue. We also compared the implication of two different surgical approaches toward the sternothyroid muscle: retraction versus incision on the level of postoperative pain. METHODS: Prospective screening of 53 patients undergoing total thyroidectomy was conducted. Patients received a form containing information as to analgesic drugs taken postoperatively and a self-estimated pain severity scale. RESULTS: The pain level decreased steadily from the first postoperative evening, and the average pain level at the peak was moderate. Most of the patients chose not to use narcotics. In our study population, males, as a trend, reported higher pain levels compared with females and for a longer duration. Sternothyroid muscle division did not increase pain level, the duration of pain, or the pattern of postoperative analgesic requirements. CONCLUSIONS: We recommend that only patients with severe pain, on the first postoperative day, be prescribed mild narcotics in small quantities. All others can be prescribed with a nonnarcotic analgesia. We did not find evidence that sternothyroid muscle splitting causes more pain; hence it should be used at the surgeon's discretion.

Series of congenital vallecular cysts: a rare yet potentially fatal cause of upper airway obstruction and failure to thrive in the newborn.

OBJECTIVES: Stridor is a relatively common symptom during the neonatal period. The most probable cause of inspiratory stridor and supralaryngeal airway obstruction in infancy is laryngomalacia. Laryngeal cysts are known to be found in association with supraglottic prolapse and are a rare yet potentially lethal cause of respiratory distress in the newborn. In the absence of more alarming presenting signs, the vallecular cyst, a form of laryngeal cyst, frequently defies diagnosis. We present a series of illustrative cases to raise awareness of vallecular cyst to help reduce the therapeutic delays that are currently encountered clinically. METHODS: A retrospective case series of four patients was reviewed. Each patient presented initially with stridor and additional signs of upper airway obstruction shortly after birth and was later diagnosed with vallecular cyst. RESULTS: The predominant presenting signs were stridor (four cases), signs of respiratory distress (three cases), failure to thrive (three cases), poor feeding (two cases), and cyanotic spells (one case). Age at presentation ranged from 16 days to 8 months. A definitive diagnosis was achieved by flexible laryngoscopy in all four cases. Coexistent laryngomalacia was found in three of the four cases. Primary outcomes at 1 month following marsupialization were complete remission in all four cases. CONCLUSIONS: The challenge in making an early diagnosis of vallecular cyst, especially when laryngomalacia is comorbid, has been reaffirmed in our case series. Diagnosis requires a high index of clinical suspicion in combination with careful inspection of the tongue base with direct examination and/or appropriate imaging modalities.

Cost savings associated with post-thyroidectomy parathyroid hormone levels.

OBJECTIVES: A 1-hour post-thyroidectomy parathyroid hormone (PTH) level of < or =8 ng/L is predictive of patients who will develop hypocalcemia and guides early supplementation with calcium and vitamin D. However, most hypocalcemic patients fail to meet this criterion. The goal of this study was to determine whether PTH < or = 15 ng/L could be used as a better predictor of hypocalcemia. STUDY DESIGN, SUBJECTS, AND METHODS: This retrospective study involved 270 thyroidectomy patients (2004-2006). PTH and calcium levels, length of admission, supplementation, and rates of hypocalcemia were recorded. RESULTS: Forty-three percent (26/60) of patients developing hypocalcemia met the PTH < or = 8 ng/L cut-off. In contrast, 80% (48/60) of patients developing hypocalcemia had a PTH < or = 15 ng/L. Two point two percent of patients had a 1-hour PTH < or = 15 ng/L and failed to develop hypocalcemia, for a specificity of 97%. CONCLUSIONS: A 1-hour PTH cut-off of < or =15 ng/L for prophylactic supplementation should allow the prevention of the majority of cases of hypocalcemia, leading to significant cost savings by shortening hospital stays.

Extranodal T-cell lymphoma of the sinonasal tract presenting as severe rhinitis: case series.

OBJECTIVES: Systemic diseases such as Wegener granulomatosis, Churg-Strauss syndrome, and sarcoidosis can present initially as severe rhinitis alone. One clinical entity that mimics severe rhinitis and thus poses a particular challenge in this regard is extranodal T-cell lymphoma of the sinonasal tract. Sinonasal lymphoma has a vague initial presentation that masquerades as more common, benign causes of rhinitis but progresses as a "midfacial progressive destructive lesion" and is uniformly fatal if untreated. In the absence of systemic involvement, the precise etiology frequently defies diagnosis. We present a series of illustrative cases to raise awareness of this rare yet lethal disease to help reduce the therapeutic delays that are currently encountered clinically. METHODS: A retrospective case series of four patients was reviewed. Each patient presented initially with severe rhinitis but was later diagnosed with extranodal natural killer/T-cell non-Hodgkin lymphoma of the sinonasal tract. RESULTS: The predominant presenting symptoms were unilateral nasal obstruction (four patients), rhinitis (three patients), and facial pain (two patients). Only one patient reported systemic B symptoms. Initial management of all four patients included repeated biopsies revealing nonspecific inflammation, which resulted in extensive therapeutic delays (mean time until diagnosis 21.5 months). The primary outcomes were two deaths and two complete remissions. CONCLUSION: The challenge in making an early diagnosis of T-cell lymphoma of the sinonasal tract has been reaffirmed in our case series. We emphasize that diagnosis requires a high index of clinical suspicion in combination with multiple deep and appropriately processed biopsies that are submitted for immunohistochemistry and molecular studies.