Risk factors for postoperative hypocalcemia following total thyroidectomy: a retrospective study.

BACKGROUND: and Objectives: Hypocalcemia is a commonly reported complication after thyroid surgery. Many possible risk factors have been identified. The purpose of this study is to analyze various risk factors possibly associated with development of postoperative hypocalcemia after thyroid surgery by dividing the sample population into postoperative hypocalcemia and normal calcium groups. DESIGN: Retrospective. SETTING: Multiple centers in the Makkah region of Saudi Arabia. PATIENTS AND METHODS: Risk factors for postoperative hypocalcemia that were obtained for analysis include patient factors, perioperative blood parameters factors, disease-related factors, and surgical factors. Postoperative hypocalcemia was defined as a reduction of the total calcium level to <8.0 mg/dL. Hypocalcemic and normocalcemic patients were compared by multivariate logistic regression. MAIN OUTCOME MEASURES: Distinguish independent risk factors for postoperative hypocalcemia after thyroidectomy. SAMPLE SIZE: 215 patients. RESULTS: The incidence of hypocalcemia was 52.1% (112 of 215 patients). According to multivariate analysis, statistically significant risk factors for predicting postoperative hypocalcemia included postoperative parathyroid hormone level <10 pg/dL, inadvertent parathyroid gland resection, and neck dissection surgeries. CONCLUSION: The causes of postoperative hypocalcemia are multi-factorial. Because many of these factors are modifiable, they should be identified postoperatively to distinguish high-risk groups and implement early preventive measures. LIMITATIONS: Retrospective with a relatively small size. We encourage additional prospective studies with a larger sample size in multiple regions of the country, which might reveal further significant results.

Validity and Reliability of an Arabic Version of MD Anderson Dysphagia Inventory (MDADI).

Dysphagia is a common adverse event among head and neck (H&N) cancer patients. We aimed, for the first time, to validate the Arabic version of the MD Anderson Dysphagia Inventory (MDADI) among 82 Saudi Arabian patients with H&N cancer. We followed established validation guidelines and translated the 20-item MDADI using the forward-backward method. Our results revealed 100% feasibility. Test-retest reliability demonstrated acceptable interclass correlation coefficients (ICC) for the subscale domains (emotional = 0.973, physical = 0.971, and functional = 0.956) and composite score (ICC = 0.984). The Cronbach's alpha coefficients for the emotional, functional, and physical subscales were 0.937, 0.825, and 0.945, respectively (composite score = 0.975). We confirmed concurrent validity by demonstrating significant correlations between the domains of the Arabic MDADI and European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Head and Neck Module (QLQ-H&N35). Our study validated the Arabic version of the MDADI among H&N cancer patients from Saudi Arabia.

Tranexamic acid in head and neck procedures: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: We conducted a meta-analysis of all randomized controlled trials (RCTs) that examined the benefits of tranexamic acid (TXA) among cancer patients undergoing head and neck (H&N) procedures. METHODS: We screened five databases from inception until 20 June 2021 and evaluated the risk of bias of the eligible studies. We pooled continuous outcomes using the weighted mean difference (WMD) with 95% confidence interval (CI). RESULTS: Five studies, comprising seven RCTs, met the inclusion criteria. This meta-analysis included a total of 540 patients; 265 and 275 patients were assigned to the TXA and control group, respectively. Overall, the included RCTs revealed a low risk of bias. The volume of postoperative bleeding was significantly lower in favor of the TXA group compared with the control group (n = 7 RCTs, WMD = - 51.33 ml, 95% CI [- 101.47 to - 1.2], p = 0.04). However, no significant difference was found between both groups regarding the volume of intraoperative bleeding (n = 6 RCTs, WMD = - 3.48 ml, 95% CI [- 17.11 to 10.15], p = 0.62), postoperative hemoglobin (n = 3 RCTs, WMD = 0.42 mg/dl, 95% CI [- 0.27 to 1.11], p = 0.23), duration of drainage tube removal (n = 4 RCTs, MD = - 0.41 days, 95% CI [- 1.14 to 0.32], p = 0.27), and operation time (n = 6 RCTs, WMD = 1.59 min, 95% CI [- 10.09 to 13.27], p = 0.79). TXA was safe and did not culminate in thromboembolic events or major coagulation derangements. CONCLUSION: TXA administration is safe and significantly reduces the volume of postoperative bleeding. However, no difference is identified between TXA and control groups regarding the volume of intraoperative bleeding, postoperative hemoglobin level, duration of drainage tube removal, and operation time.

Glutamine for prevention and alleviation of radiation-induced oral mucositis in patients with head and neck squamous cell cancer: Systematic review and meta-analysis of controlled trials.

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) that investigated glutamine efficacy in preventing and alleviating radiation-induced oral mucositis (OM) among patients with head and neck (H&N) cancer. We screened five databases from inception till February 4, 2021 and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included 11 RCTs, comprising 922 patients (458 and 464 patients were assigned to glutamine and control group, respectively). The incidence and onset of radiation-induced OM of any grade did not substantially differ between both groups. However, glutamine substantially reduced the severity of radiation-induced OM, as reflected by the reduced incidence of severe OM and reduced mean maximal OM grade score. Additionally, glutamine significantly decreased the rates of analgesic opioid use, nasogastric tube feeding, and therapy interruptions. Oral glutamine supplementation demonstrated various therapeutic benefits in preventing and ameliorating radiation-induced OM among patients with H&N cancer.

Thyroid neoplasm in Makkah region, Saudi Arabia. A retrospective epidemiological study.

OBJECTIVES: To improve our local data and demographics of thyroid neoplasm in Makkah region, Kingdom of Saudi Arabia and provide some basic statistics for future studies in our local community.  Methods: A record based retrospective epidemiological study was conducted and included 314 thyroid disease patients who were presented to our centers at Makkah region, Kingdom of Saudi Arabia between December 2009 and December 2019. Results: A descriptive statistical analysis was carried out. The average age was 42.77 years, with a female-to-male ratio of 3:1, and most of the patients were Saudi (77%). Fifty-seven percent of cases were benign, while in malignant cases, 33.4% were papillary thyroid carcinoma. The mean follow-up time was 15.44 months, with excellent compliance in 39.4% of the patients.   Conclusion: Thyroid tumors have a leading incidence in head and neck tumors in Makkah, Kingdom of Saudi Arabia, mandating further studies to determine the causes and distribution in other regions of the country.

Role of fine-needle aspiration cytology in evaluating thyroid nodules. A retrospective study from a tertiary care center of Western region, Saudi Arabia.

OBJECTIVES: To evaluate the accuracy and e cacy of ne-needle aspiration cytology (FNAC) in diagnosing thyroid nodules, correlating it with the histopathological findings. METHODS: A retrospective evaluation of 314 patients was undertaken at a tertiary referral center of King Abdullah Medical City (KAMC), Makkah, Kingdom of Saudi Arabia, between 2010-2019. Patients who presented with thyroid swellings underwent ultrasonography and FNAC. If indicated, surgery was performed. The FNAC findings were compared to the final histopathological reports. RESULTS: The findings for FNAC from our data set of 314 patients showed a sensitivity value of 79.8%, specificity of 82.1%, accuracy of 74.8%, positive predictive value of 74.8%, and negative predictive value of 85.9%. Conclusion: Our study showed that FNAC has high sensitivity and speci city in the initial evaluation of patients with thyroid nodules. When guided by ultrasonography, the accuracy can be markedly improved. Molecular markers once widely available can improve the diagnostic power of FNAC to be no less than the histopathologic evaluation of thyroid tissue.

Tongue reconstruction post partial glossectomy during the COVID-19 pandemic. A case report.

INTRODUCTION: The COVID-19 pandemic has necessitated temporary modifications in the current head and neck oncology treatment paradigm. Till date, no definite treatment for COVID-19 has been discovered. Considering the situation of the global COVID-19 outbreak, methods that minimize patient visits with no compromise in efficacy should be considered. The optimal method for tongue reconstruction has not been determined yet. The artificial bilayer membrane has been used as mucosal substitute in few cases of tongue reconstruction with promising results. CASE PRESENTATION: We present two cases of tongue reconstruction with acellular dermal matrix post partial glossectomy for tongue carcinoma during the COVID-19 pandemic. Both patients showed good recovery and healing, and no side effects and/or complications were reported. DISCUSSION: The acellular dermal matrix is not a standard technique for tongue reconstruction but one of the available options. The few reported cases in literature showed promising results in regard of function and healing. CONCLUSION: We believe the use of acellular dermal matrix can help in preventing the spread of COVID-19 because of the absence of donor morbidity, decreasing post-operative hospital stay and visits.

Case of childhood laryngeal papillomatosis with metastatic carcinoma esophagus in adulthood.

A young male patient was diagnosed to have laryngeal papillomas at the age of 3 years for which he underwent permanent tracheostomy and also multiple surgical and laser excision procedures. Then, later in life, the patient had progressive breathlessness and dysphagia. On examination, he had supraclavicular lymphadenopathy showing squamous carcinoma pathology. Since laryngeal papillomas have a high propensity to transform into laryngeal squamous cell carcinoma, he was first evaluated for laryngeal carcinoma which was negative. Esophagoscopy showed a growth in the esophagus, the biopsy of which was positive for squamous malignant cells. Patient was then started on palliative chemotherapy with combination of paclitaxel and carboplatin, and at progression with weekly nanoxel with stable disease. This is a rare case of childhood laryngeal papillomatosis progressing to metastatic esophageal carcinoma. This case has been presented to highlight the fact that patients with laryngeal papillomas are not only at high risk of progressing to laryngeal carcinoma but can also have other malignancies of the upper aerodigestive tract and lung. Most of them have been correlated to human papilloma virus (HPV), but in our patient HPV DNA was negative.

Can metastatic lymph node ratio (LNR) predict survival in oral cavity cancer patients?

OBJECTIVES: To evaluate the prognostic role of the lymph node ratio (LNR; ratio of total positive nodes to total dissected nodes) in oral squamous cell carcinoma (OSCC) as compared to pN staging with an aim to provide an optimal cut-off value. METHODS: 1,408 OSCC previously untreated patients who underwent treatment (surgery + neck dissection + adjuvant treatment). LNR sensitivity with respect to survival was calculated using receiver operating characteristic (ROC) curves and Cox regression method. LNR and TNM staging variables were subjected to multivariate analysis. RESULTS: LNR (0.088) showed significant association with survival outcomes. For patients with LNR ≤0.088, the OS, DFS, local control, regional control and distant metastasis rates were 64%, 70%, and 89%; for LNR >0.088 it was 22%, 19%, and 52%, respectively (P < 0.001). On multivariate analysis LNR of 0.088 was seen to be an independent prognostic factor for 5-year regional control (p, hazard ratio [95% confidence interval]; 0.044, 2.016 (1.019-3.990), DFS, 0.032, 1.858 (1.054-3.276), and OS, 0.040, 1.195 (1.033-1.144). On multivariate analysis LNR categorization showed a statistically significant [0.032, 1.858, (1.054-3.276)] advantage over pN staging [0.527, 1.208 (1.054-3.276)] in predicting survival. CONCLUSIONS: LNR is a better prognostic marker than the current N staging of TNM classification.

Intraoperative Tracheoesophageal Partywall Thickness (PWT) Measurement in Laryngectomy Patients Using Modified PROVOX Guidewire.

Post laryngectomy voice rehabilitation using primary tracheoesophageal puncture (TEP) and voice prosthesis insertion is considered the "gold standard" method. No special effort is taken to measure the tracheoesophageal partywall thickness before inserting voice prosthesis. TE puncture related problems (peri-prosthetic leakage) are commonly seen in our population as compared to device failures (central leak). An accurate prosthesis inserted primarily may prevent the development of peri-prosthetic leakage. We surmise that tracheoesophageal party wall thickness (PWT) to be an important factor determining this phenomenon. There is still no consensus on the size of the prosthesis to be inserted during a primary TEP. To cater this, we propose a simple, quick and accurate method of measuring tracheoesophageal PWT intraoperatively. This method will guide us to determine an accurate prosthesis size which can be inserted during primary TEP. We also propose that this method will prevent future TE puncture related problems.

Ultrasound-guided botulinum toxin injection: A simple in-office technique to improve tracheoesophageal speech in postlaryngectomy patients.

BACKGROUND: Pharyngoesophageal spasm is a known entity to cause hypertonic/failed tracheoesophageal speech and is successfully treated by botulinum toxin A injection. However, success of botulinum toxin treatment is based on the accurate localization of the pharyngoesophageal segment. METHODS: A 65-year-old man who had a laryngectomy using voice prosthesis with hypertonic speech underwent ultrasonographic localization of the hypertonic pharyngoesophageal segment. The ultrasound findings were confirmed using videofluoroscopy. Under ultrasound guidance, botulinum toxin was injected into the hypertonic pharyngoesophageal segment and subsequently voice outcomes were evaluated by a speech language pathologist and the pharyngoesophageal segment was assessed by using an ultrasound scan. RESULTS: The patient had improvement in his postinjection tracheoesophageal puncture speech. Ultrasound scan assessment of the pharyngoesophageal segment showed adequate dilation as compared to the pre-botulinum toxin injection treatment. CONCLUSION: Ultrasonographic localization of the hypertonic pharyngoesophageal segment and ultrasound-guided botulinum toxin injection is a simple, quick, and relatively cheap method to be used in routine practice.

Microbial colonization of Blom-Singer indwelling voice prostheses in laryngectomized patients: a perspective from India.

We analyzed a series of adults with an implanted voice prosthesis that had malfunctioned and required removal as a result of the attachment and growth of microorganisms. Our goal was to determine the characteristics of these colonizing microbes. We swabbed the esophageal side of each prosthesis to obtain microbial flora for analysis with standard culture media. In all, we studied 22 prostheses in 18 patients (3 patients had received multiple prostheses). We found mixed contamination (both yeast and bacteria) in 19 of the 22 cultures (86.4%); the other 3 cultures yielded bacteria only, and there was no instance of yeast only. The most common yeast isolated was Candida albicans (68.2% of cultures), and the most common bacterium was Pseudomonas aeruginosa (63.6%). The average lifetime of the prostheses was 201 days (∼6 mo, 3 wk). This study, which was the first of its kind in India, revealed that the microbial picture here was different from that found in previously reported studies of European populations. We presume the differences are attributable to different lifestyles and dietary habits.

Clinical health research in India: is there a way forward?

A vibrant health research industry is an indispensible asset for societal development. Health research focus and output in India is sadly not at par with the magnitude and distribution of the prevalent disease burden. In the current scenario of the ever evolving Indian public health sector, the balancing of research efforts between different competing fields, especially when resources are meagre, is a delicate one and quite typical of the problems anticipated in developing countries. To progress, the nation's clinical health research needs good quality, authentic and relevant research in the varied aspect of public health. Rhetoric or theoretical concepts alone cannot move the health status and research forward in this country. Evidence and evidence based medicine have revitalised the academic aspects of the public health sector. But, its up to the Indian policy makers, administrators and medical professionals to assure that the vast research opportunity this country offers is exploited to its maximum potential.

Current concepts of surveillance and its significance in head and neck cancer.

Follow-up in head and neck cancer (hNC) is essential to detect and manage locoregional recurrence or metastases, or second primary tumours at the earliest opportunity. A variety of guidelines and investigations have been published in the literature. This has led to oncologists using different guidelines across the globe. The follow-up protocols may have unnecessary investigations that may cause morbidity or discomfort to the patient and may have significant cost implications. In this evidence-based review we have tried to evaluate and address important issues like the frequency of follow-up visits, clinical and imaging strategies adopted, and biochemical methods used for the purpose. This review summarises strategies for follow-up, imaging modalities and key investigations in the literature published between 1980 and 2009. A set of recommendations is also presented for cost-effective, simple yet efficient surveillance in patients with head and neck cancer.

Implications of understanding cancer stem cell (CSC) biology in head and neck squamous cell cancer.

Head and neck squamous cell cancer (HNSCC) is the sixth most common cancer in the world. Effective therapeutic modalities such as surgery, radiation, chemotherapy and combinations of each are used in the management of this disease. Efforts are ongoing throughout the world to improve early detection and prevention of HNSCCs. Often, treatment fails to obtain total cancer cure and this is more likely with advanced stage disease. In recent years it appears that one of the key determinants of treatment failure may be the presence of cancer stem cells (CSC) that 'escape' currently available therapies. CSCs form a minute portion of the total tumour burden but may play a disproportionately important role in determining outcomes. Molecular mechanisms which underlie the genesis of CSCs are yet not fully understood and their detection within the total tumour bulk remains a challenge. Specific markers like Aldehyde dehydrogenase 1 (ALDH1), CD44 and Bmi-1 have shown early promising results both in CSC detection and in guiding treatment protocols. CSCs have been shown to be relatively resistant to standard treatment modalities. It is hoped that developing robust in vitro and in vivo experimental models of CSCs might provide a means of devising more effective therapeutic strategies.

Robotic surgery in head and neck cancer: a review.

The invasion of robotic technology in surgical fields cannot be ignored. Its success in various surgical disciplines especially in urology, cardiology, and gynaecology has set its own benchmarks. Extrapolation of similar results in head and neck is still in experimental stages and long term results are still eagerly awaited to truly establish its efficacy beyond awe and reality. Nonetheless, its future role in this area is inevitable given the encouraging results obtained so far. This article covers the inception to current application to speculation of robotic technology in complex area of head and neck surgery.

Primary tracheoesophageal puncture using carbon dioxide laser.

Primary tracheoesophageal puncture (TEP) is now considered to be the preferred method for voice rehabilitation after laryngectomy . The traditional method of creating a puncture with a no. 11 stab knife often leads to an eccentric puncture with irregular ragged margin, leading to scarring in the future. In this report we describe the innovative way of creating a TEP using a carbon dioxide (CO(2)) laser. This novel method of using a laser for the creation of a precise TEP could, perhaps, influence peri-prosthetic leakage and lead to better voice rehabilitation for patients that have undergone laryngectomy.

Tracheo-oesophageal party wall thickness in laryngectomised patients in India: implications for surgical voice restoration.

OBJECTIVE: To document accurately the tracheo-oesophageal party wall thickness (PWT) intra-operatively in patients undergoing total laryngectomy and to correlate it with constitutional parameters like height, weight, body mass index (BMI), age, and gender. Also, to correlate PWT with the length of tract (LOT), that is prosthesis size, as measured using the standard valve length measuring device provided by the manufacturers. METHODS: Twenty-eight patients of carcinoma larynx, following removal of the diseased larynx had their tracheo-oesophageal PWT measured using a special custom-designed and calibrated external (or outside) calliper and a primary trachea-oesophageal puncture (TOP) was made and inserted 10-14 days postoperative with an appropriately sized Blom-Singer(R) indwelling voice prosthesis. RESULTS: The mean PWT was 3.1 mm. PWT showed significant correlation with the weight of the patients (P = 0.006). There was no significant correlation between PWT and height, BMI, age or gender of the study group. The average LOT was found to be 4.8 mm (SD 1.5). There was a significant correlation (P = 0.009) between PWT and initial LOT, with the most commonly used prosthesis sizes being 4-6 mm. CONCLUSIONS: The study shows that Indian patients with a thin party wall require a smaller prosthesis size and it is advisable to measure the PWT intra-operatively. Tracheo-oesophageal PWT in laryngectomised patients in India: implications for surgical voice restoration.