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.

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.

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.

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.

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.

Dysphagia in head and neck cancer.

Dysphagia is an important symptom of head and neck cancer (HNC), as well as representing a significant complication of its treatment. The treatment of HNC can result in neuromuscular and sensory damage affecting any stage of the swallow. The protective mechanisms during swallowing afforded by the structures in the pharynx are also affected in HNC. This article reviews the effect of the various treatment modalities in HNC on the swallowing mechanism. Various interventions which may play in role in relieving this dysphagia are also discussed. Due stress has been laid on the need for a multi-disciplinary approach for an optimal outcome in rehabilitating a patient's swallow after treatment for HNC.

Challenges for the future modifications of the TNM staging system for head and neck cancer: case for a new computational model?

The TNM system of staging cancers is a simple and effective method to map the extent of tumours. It had traditionally strived to maintain a balance between being simple and user-friendly on one hand and comprehensive on the other. A number of revisions have taken place over the years with the goal of improving utility. However, numerous controversies surround the TNM system. There is a school of thought that contends that patient co-morbidity and specific tumour-related factors should be incorporated to add further prognostic capabilities in the TNM system, but this raises concerns that such an approach may unnecessarily complicate the system. This review highlights some controversies that surround the TNM system and suggests prognostic indicators that may be added to make it more useful in guiding treatment decisions and predicting outcomes.

Is electroglottography-based videostroboscopic assessment of post-laryngectomy prosthetic speech useful?

OBJECTIVES: To use an electroglottography (EGG)-based videostroboscopy tool to assess the anatomical and morphologic characteristics of the pharyngoesophageal (PE) segment in tracheoesophageal (TO) speakers. STUDY DESIGN: Cross-sectional cohort study. SUBJECTS: Fifty-two post-laryngectomy patients with no recurrence and using prosthetic (Blom-Singer) speech. INTERVENTION: An electroglottography (EGG)-based videostroboscopy tool EGG-based rigid videostroboscopy as well as perceptual evaluation. OUTCOME MEASURES: Stroboscopic protocol included nine subjective/visual parameters to evaluate the neoglottis and study correlation of the G (GRBAS scale) and the overall voice quality (OVQ) with the treatment variables. RESULTS: Of the 52 laryngectomees, videostroboscopic recordings were possible in 46 patients (36 males and 10 females) with a mean age of 63.4 +/-10.5 (SD) an electroglottography (EGG)-based videostroboscopy tool years. All used the Blom-Singer valve and the median time since Total Laryngectomy was 2 years. The neoglottis was assessable in 26 patients. We were able to strobe only 9 patients. There was excellent correlation between G and OVQ (Spearman rho > 0.9). Statistically significant correlation was found between G1 and saliva (P = 0.03) and between good OVQ and saliva (P = 0.02); similarly, there was significant correlation between G1 and LVV (P = 0.05) and between good OVQ and LVV (P = 0.03). CONCLUSIONS: This study is the first to examine the use of an EGG-based stroboscopy instrument to evaluate TO speech. Our observations suggest that from the standpoint of functional voice, saliva and the LVV had statistically significant effect in determining voice quality.

Quality of life and outcomes research in head and neck cancer: a review of the state of the discipline and likely future directions.

Quality of life (QOL) is by definition a multi-dimensional global construct that has become an increasingly important outcome measure in cancer treatment. The impact of a head and neck cancer (HNC) diagnosis on the person and the consequences of its treatment cross multiple functional domains that have a clear and direct influence on one's post-treatment well-being and associated QOL. The evaluation of QOL and performance outcome in cancer is critical to optimal patient care, comprehensive evaluation of treatment alternatives, and the development of informed rehabilitation and patient education services. Despite the difficulties of going from concept to quantification of patient perceptions, the number of instruments available to measure QOL psychometrically has increased rapidly. Assessments can now be made in a variety of distinctive ways using both specific and generic measures. There is no gold-standard questionnaire and the choice is based on psychometric properties, research objectives and study design. QOL assessment has evolved over the years into an organised scientific discipline, such that useful insights can be obtained by a review of the current literature. However, more work needs to be done to improve the applicability and clinical utility of QOL assessment. Most importantly, QOL studies should be reported in such a way as to provide clinically meaningful data to physicians and surgeons, in order to link research to clinical practice. Further attention should be paid to the development of newer theoretical models, minimalist approaches, development of more sensitive and specific instruments and the effective use of modern technology to achieve this objective.

Current status and future prospects in prosthetic voice rehabilitation following laryngectomy.

Total laryngectomy or laryngopharyngectomy remains the procedure of choice for advanced-stage (UICC T3 and T4) laryngeal carcinoma around the world despite advances in conservative laryngeal surgery and radiotherapy. However, it has profound effects on respiration and deglutition, in addition to the most disabling effect-the loss of verbal communication. Successful voice restoration can be attained with any of three speech options, namely esophageal speech, electrolarynx, and tracheoesophageal (TO) speech using an artificial valve. Although, no single method is considered the best for every patient, the tracheoesophageal puncture has become the preferred method in the past decade. Several types of voice prostheses have been produced since the first prosthesis was introduced in 1980 by Blom and Singer. However, eventually all prostheses are confronted by the same problem, i.e., the development of a biofilm, leading to deterioration and ultimately to dysfunction of the prostheses, necessitating replacement. This article attempts to sum up the historical background as well as the current state of surgical voice rehabilitation following laryngectomy; we review the recent major advances as well as the future prospects. Data was collected by conducting a computer-aided search of the MEDLINE and PubMed databases, supplemented by hand searches of key journals. Over 50 articles published in the last three decades on the topic have been reviewed, out of which about 20 were found to be of relevance for this article.