The Hellenic Voice Handicap Index of Different Laryngeal Mass Lesions: A Receiver-Operating Characteristic Analysis.

BACKGROUND: Voice disorders influence the quality of people's life. When the type of disorder is determined then the clinicians are capable of finding their patients' needs and address their complaints concerning their vocal problems. One of the most used tools, for assessing the patients' quality of life (in accordance with their vocal status), is the Voice Handicap Index. In this study, we determined the cut-off scores of Voice Handicap Index for population with laryngeal mass lesions such as vocal polyps and nodules. The calculated cut-off points further guide clinicians toward applying a needed interventional method/therapy even in the cases where the condition of a person could not be easily estimated. METHODS: The study involved 130 participants (aged 19-74). Specifically, 90 nondysphonic people served as the control group, while 40 participants had already been diagnosed with voice disorders due to laryngeal mass lesions. Participants who were diagnosed with a laryngeal inflammation or had undergone a surgery were excluded from the study. The cut-off scores were determined through a receiver-operating characteristic (ROC) analysis. RESULTS: The calculated cut-off points were 19.50 for the total score of VHI, 7.50 for the functional domain, and 8.50 for the physical and the emotional domain. CONCLUSIONS: The aforementioned cut-off points could be used in empowering the everyday clinical practice. Moreover, their knowledge could help the construction of an individualized therapy plan, as well as monitoring-biofeedback tool for the populations with vocal fold lesions.

Cross-cultural Adaptation and Validation of the Greek Voice Handicap Index-10 (GVHI-10) With Additional Receiver Operating Characteristic Analysis.

OBJECTIVE(S): The use of subjective evaluation tools are proven useful and of high clinical value in the case of voice disordered population. For that type of evaluation, self-assessment questionnaires about the severity of the voice like Voice Handicap Index-30 (VHI-30) have been developed. The VHI-30 is the most studied tool which includes psychometrically robustness while guiding physician's therapeutic decision making. Additionally, a valid abbreviated version of VHI-30 was developed for the first time in the Greek Language which is named as Greek Voice Handicap Index-10 (GVHI-10). Consequently, the aim of our study was to validate the proposed version of the VHI-10. METHODS: Ninety nondysphonic individuals and 90 dysphonic patients were classified by Otolaryngologists and Speech Language Pathologists. The study's subjects were evaluated with endoscopy and stroboscopy. Also, they were administrated the GVHI-30 and the translated version of the Voice Evaluation Template (VEF). The GVHI-10 was extracted by the Greek version of VHI-30. RESULTS: The group with voice disorders exhibited higher statistical significance in all GVHI-10 scores compared to those of the control group. The GVHI-10 showed a high internal consistency (Cronbach's a = 0.915 and split-half reliability coefficient equal to 0.86), good sensitivity compared to Greek VHI-30 (r = 0.764, P = 0.000) and intraclass correlation. A total cut-off point equal to 6.50 (AUC: 0.964; P < 0.001) was also calculated. CONCLUSIONS: The proposed version of GVHI-10 distinguished the perceived levels of voice between dysphonic and nondysphonic groups and between different voice disordered populations. The GVHI-10 is shown to be clinically valid and sensitive exhibiting high reliability.

Checking for voice disorders without clinical intervention: The Greek and global VHI thresholds for voice disordered patients.

Voice disorders often remain undiagnosed. Many self-perceived questionnaires exist for various medical conditions. Here, we used the Greek Voice Handicap Index (VHI) to address the aforementioned problem. Everyone can fill in the VHI questionnaire and rate their symptoms easily. The innovative feature of this research is the global cut-off score calculated for the VHI. Therefore, the VHI is now capable of helping clinicians establish a more customizable treatment plan with the cut-off point identifying patients without normal phonation. For the purpose of finding the global cut-off point, a group of 180 participants was recruited in Greece (90 non-dysphonic participants and 90 with different types of dysphonia). The voice disordered group had higher VHI scores than those of the control group. In contrast to previous studies, we provided and validated for the first time the cut-off points for all VHI domains and, finally, a global cut-off point through ROC and precision-recall analysis in a voice disordered population. In practice, a score higher than the well-estimated global score indicates (without intervention) a possible voice disorder. Nevertheless, if the score is near the threshold, then the patient should definitely follow preventive measures.

Substernal goiter: Treatment and challenges. Twenty-two years of experience in diagnosis and management of substernal goiters.

OBJECTIVE: Descending goiter has been a focus of controversy in thyroid surgery until nowadays. This study aims to investigate the diagnosis and treatment options of thyroid goiters extending into the mediastinum and the thoracic cavity. METHODS AND MATERIALS: A retrospective study was conducted assessing all cases of substernal goiter managed in a tertiary care referral center within 22 years. Demographics, clinical, operative, anatomical, and pathological data of the patients were recorded and analyzed. RESULTS: Among 3.028 total thyroidectomies, 212 procedures for substernal goiters were studied. All cases underwent total thyroidectomy. The surgical approach was cervical in all but two cases. A very low rate of complications and zero mortality were noted. Incidence of malignancy on permanent histology was 16%. CONCLUSION: Descending goiter constitutes a major indication for thyroid surgery. The overwhelming majority of descending goiters may be managed surgically through a neck incision. In experienced hands good results with low morbidity should be expected. Such cases should be considered as challenging, however, and therefore management in a referral center may be necessary in order to ensure optimal results.

Postoperative day 1 levels of parathyroid as predictor of occurrence and severity of hypocalcaemia after total thyroidectomy.

BACKGROUND: Hypocalcaemia is a common and serious complication after thyroidectomy. The purpose of this study is to assess the effectiveness of first postoperative day parathyroid hormone (PTH) measurement in order to predict the presence and severity of postthyroidectomy hypocalcaemia. METHODS: One hundred consecutive cases undergoing total thyroidectomy in a tertiary referral center were prospectively assessed. Preoperative measurements of PTH were compared with postoperative levels in the first morning after surgery. All cases of hypocalcaemia were recorded and evaluated with regard to preoperative and postoperative levels of PTH. RESULTS: A decrease of 56% of PTH levels on the first postoperative day could accurately predict postoperative hypocalcaemia with a sensitivity and specificity of 80%. CONCLUSION: Serum PTH levels on the first postoperative day may be used as a reliable predictive marker for calcium supplementation need and even prolonged hospitalization in cases undergoing total thyroidectomy.

Recurrent Desmoid Tumor of the Neck: A Case Report of a Benign Disease with Aggressive Behavior.

We present a case of a desmoid tumor recurrence in a patient with a history of a resected desmoid tumor of the right neck area with free surgical margins six months earlier. The neoplasm was found to invade the parapharyngeal space, and wide excision was performed including most of the sternocleidomastoid muscle (SCM), the thrombosed internal jugular vein (IJV), and the infiltrated spinal accessory nerve (SAN). The histopathologic findings displayed free microscopic margins, with close margins at the site of the parapharyngeal space extension. After 3 months, there was no sign of tumor recurrence. After 6 months, local tumor recurrence was identified on clinical examination and imaging. The decision of the Oncology Board was further treatment with radiotherapy (RT). Response to treatment was satisfactory, and the patient was on close follow-up for twelve months. Desmoid tumors are very rare benign neoplasms of mesenchymal origin with negligible mortality but high morbidity, due to their high recurrence rates, local tissue infiltration, and unpredictable disease course and response to treatment. No universally acceptable treatment protocols have been introduced to date. Appropriate patient counseling and close follow-up are warranted in all cases.

Efficacy of inferior turbinoplasty with the use of CO(2) laser, radiofrequency, and electrocautery.

BACKGROUND: Inferior turbinate surgery is one of the most commonly performed methods for the treatment of rhinitis symptoms, especially nasal obstruction. This is a comparative study of CO2 laser, electrocautery, and radiofrequency turbinoplasty in the treatment of rhinitis symptoms. METHODS: From 1994 to 2011, 3219 patients were enrolled in the study. Two hundred eighty-three patients were lost during follow-.up. Of the remaining 2936 patients, 1066 were managed using the CO2 laser, whereas 664 and 1206 were managed with the use of radiofrequency and electrocautery, respectively. All procedures were performed under local anesthesia. Patients were asked to evaluate their symptoms with the visual analog scale (VAS) preoperatively, as well as 1 month and 1 year postoperatively. Rhinomanometry was used to objectively evaluate the effect on nasal obstruction. RESULTS: Mean VAS values preoperatively, regarding nasal obstruction, were 7.43 ± 0.96, 7.33 ± 0.87, and 7.64 ± 0.95 in the CO2 laser, radiofrequency, and electrocautery group, respectively. One month postoperatively, the score was significantly improved in all groups (CO2 laser, 3.44 ± 0.99; radiofrequency, 3.26 ± 0.76; electrocautery, 3.19 ± 0.79), which was almost stable in the 1st year of follow-up. Similar results were also observed in the evaluation of sneezing and rhinorrhea. Outcome did not statistically differ between the three methods. CONCLUSION: The CO2 laser, radiofrequency and electrocautery offer excellent postoperative results in turbinoplasty cases under local anesthesia.

Management of locally advanced laryngeal cancer.

BACKGROUND: Management of advanced laryngeal cancer is complex and ideal strategy is yet to be defined. This study evaluates the experience of a single head and neck oncologic centre in the management of T4 laryngeal cancer. METHODS: Retrospective assessment of cases primarily treated for T4a squamous cell carcinoma of the larynx, between 1980 and 2007, at a tertiary referral center. RESULTS: A total of 384 cases were studied. Five-year disease specific survival was 56.2% and local control 87.4%. Regional and distal control estimates were 90.3% and 88.3% respectively. Prognosis was significantly superior for cases treated with primary surgery compared to cases solely managed with non-surgical modalities. Positive surgical margins and regional disease worsened prognosis. CONCLUSION: This study suggests that primary surgery remains a key element in the treatment of advanced laryngeal cancer. The need for well-designed, prospective, randomised studies in order to further evaluate the remaining role of primary surgery in the modern management of locally advanced laryngeal lesions is emphasized.

Synchronous multifocal medullary and papillary thyroid microcarcinoma detected by elastography.

INTRODUCTION: A few cases of concomitant medullary and papillary carcinoma in the same thyroid nodule have been described in the literature. However, the presence of multiple foci of both types of malignancy in the same gland is very rare. PRESENTATION OF CASE: A 39 year-old female with multiple thyroid nodules, elevated serum calcitonin levels and elastographic findings suggestive of thyroid malignancy, underwent total thyroidectomy and central neck dissection. Histology revealed the presence of one focus of medullary and one focus of papillary carcinoma on each thyroid lobe. Subsequently, the patient underwent treatment with radioactive iodine. DISCUSSION: This is the third case of synchronous multifocal medullary and papillary thyroid carcinoma reported in the literature. Several theories for the simultaneous development of these malignant entities have been proposed. CONCLUSION: Ultrasound elastography can be a useful, noninvasive tool in the assessment of thyroid nodules.

The pathophysiology of the hygiene hypothesis.

There has been a considerable increase in the diagnosis of allergic diseases over the last decades. Prevalence of allergies in high-income countries and urban areas appears higher than in rural environments. While environmental factors like pollution or nutrition can be important, it is more likely that in the end they have a small association with allergies. Childhood infections and exposure to certain microbial antigens on the other hand seem to present a strong negative correlation with allergies, and therefore the increase of the allergic burden in the Western world has been frequently related to a decline of childhood infections giving birth to the "Hygiene Hypothesis". We address the issue with emphasis on the associated pathophysiology tightrope walking between the skepticism of the critics, which cast doubt on it, and the pilgrims' belief of having discovered allergy's Holy Grail.

Intraoperative recurrent laryngeal nerve monitoring in revision thyroidectomy.

Recurrent laryngeal nerve (RLN) palsy is one of the most important complications after thyroid and parathyroid surgery. There is controversy in the literature regarding whether or not intraoperative nerve monitoring decreases the risk of injury. We report our experience using Nerve Integrity Monitoring (NIM) system in cases of revision thyroidectomy, providing clear indications for its use. A series of 97 patients who underwent revision thyroidectomy with and without intraoperative NIM alternately was evaluated. There were 121 RLN patients at risk. Use of NIM during revision thyroidectomy was not statistically significant compared to revision operation without monitoring (p value = 0.059). Furthermore, comparison of operative times either with or without NIM showed that use of NIM led to statistically significant prolonged operation time (p value <0.001). There is no strict indication to use RLN monitoring during thyroid surgery, especially as there is no statistical evidence that the use of this technique decreases the incidence of RLN palsy, although there is a trend especially in difficult revision cases.

Atypical solitary fibrous tumor of the nose and maxillary sinus.

BACKGROUND: Solitary fibrous tumor (SFT) belongs to a group of mesenchymal tumors, also known as benign fibrous mesotheliomas or submesothelial fibromas. SFTs of the sinonasal tract are extremely rare. METHODS: We report a rare case of an atypical SFT of the sinonasal tract presenting with ipsilateral nasal obstruction and recurrent epistaxis. Endoscopy and imaging studies showed a well-circumscribed mass of the nose and the maxillary sinus. The patient underwent total endoscopic resection of the tumor. RESULTS: Permanent histology and immunohistochemical studies revealed an atypical variant of SFT of the sinonasal tract, with negative surgical margins. The patient did not receive any adjuvant treatment. Postoperative monitoring was uneventful. CONCLUSION: In general, these tumors are reported to follow an indolent course. SFTs adopt a biological behavior that cannot be determined as malignant. Total surgical resection of the tumor remains the gold-standard method of treatment.

A case of acquired tracheal diverticulum presenting with globus pharyngeus.

Acquired tracheal diverticulum is a rare pathology that has been associated with chronic cough and lung emphysema. A 72 year-old woman was referred to a tertiary Otorhinolaryngology Department for evaluation of chronic cough and globus pharyngeus. Computed tomography of the neck and chest revealed a diverticulum of the right posterolateral wall of the trachea. The patient underwent surgical excision of the diverticulum via a transcervical approach. Symptoms subsided after surgical treatment.

Voice risk factors in kindergarten teachers in Greece.

OBJECTIVE: The purpose of this study was to identify voice risk factors for female kindergarten teachers and nurses in Heraklion, Crete. PATIENTS AND METHODS: A questionnaire consisting of voice use and lifestyle activities was given to 200 kindergarten teachers in Heraklion, Crete, of which 151 were returned (75.5%). A group of 89 nurses served as the control group. Both groups also completed the Greek version of the Voice Handicap Index (VHI-G). RESULTS: Kindergarten teachers sing more often, speak loudly more often when they are at work and present with more infections of the upper respiratory tract compared to nurses. They talk less than 30 min per day on the phone, drink less alcohol and water and smoke less in comparison with nurses. The median VHI-G score for the kindergarten teachers was significantly higher than that for the nurses. CONCLUSION: The results suggest that there is a difference in the factors that may be responsible for the appearance of voice problems in kindergarten teachers and in nurses. For kindergarten teachers, the risk factors for voice disorders are primarily related to vocal load factors and for nurses appear to be lifestyle-related more than voice use alone.

Nasal packing aspiration in a patient with Alzheimer's disease: a rare complication.

Nasal bleeding is a frequent problem for patients receiving anticoagulant agents. Most cases are successfully managed with anterior or posterior nasal packing. However, the complications of nasal packing should be always considered. We report the case of a 78-year-old man with Alzheimer's disease who was treated for anterior epistaxis with anterior nasal packing using three pieces of antibiotic-soaked gauze. Two days later, the patient was admitted to the emergency department in respiratory distress. A chest x-ray demonstrated atelectasis of the right lung. During an examination of the nasal cavities, the nasal packing was removed, and one of the gauze pieces was missing. The patient underwent rigid bronchoscopy, and the missing gauze was found to be obstructing the right main bronchus. The patient's respiratory function improved considerably after removal of the foreign body. It is assumed that gauze packs should be used with caution in patients with an impaired level of consciousness and neurodegenerative diseases.

Rare presentation of occult medullary carcinoma of the thyroid as a mediastinal mass.

OBJECTIVE: To describe a rare case of occult (<1 cm in diameter) medullary thyroid carcinoma (MTC) in a 45-year-old woman, presenting as an asymptomatic mediastinal mass. DESIGN: The diagnostic methodology included laboratory measurements of relevant biochemical and hormonal parameters including calcitonin (CT), carcinoembryonic antigen (CEA) and chromogranin A, and imaging techniques including ultrasound (U/S), computed tomography (C/T), magnetic resonance imaging (MRI) and radio labeled somatostatin analog ((111)In-DTPA-octreotide). RESULTS: Chest CT revealed a mediastinal mass measuring 5 cm in diameter abutting the right thyroid lobe. CEA was elevated and an association with thyroid malignancies was considered. CT was found to be markedly elevated, pointing to the diagnosis of MTC metastatic to the mediastinum. The patient underwent total thyroidectomy, lymph node dissection and removal of the mediastinal mass. Histological examination revealed MTC of the right thyroid lobe measuring 0.5 cm, metastatic to regional and superior mediastinal lymph nodes. CONCLUSIONS: Occult MTC can infrequently present as an asymptomatic mediastinal mass. Elevated serum CT and CEA along with imaging techniques leads to the correct diagnosis and surgical management of the disease.

Management of advanced carcinoma of the base of tongue.

BACKGROUND AND OBJECTIVE: Base-of-tongue carcinoma is a relatively rare disease with aggressive behavior and poor prognosis. Up to date no consensus exists regarding the ideal management strategy for each stage of the disease. This study aims to evaluate the experience of a single head and neck oncology center in the management of advanced stage base-of-tongue cancer. METHODS: A retrospective evaluation of cases primarily treated for stage III/IV(A-B) base-of-tongue carcinoma, between 1980 and 2007, at a tertiary referral center. RESULTS: A total of 366 cases were studied. Five-year disease specific survival (DSS) was 42% and local control (LC) 80%. Regional and distal control estimates were 91.3 and 84%, respectively. Prognosis was significantly superior for cases receiving surgery plus adjuvant treatment compared to cases solely managed with non-surgical modalities. Positive surgical margins and regional disease significantly worsened prognosis. Satisfactory retention of pharyngeal function and no fatal complications were noted in surgical cases. CONCLUSION: Although no consensus exists regarding ideal therapy for advanced base-of-tongue carcinoma, combined strategies with the use of surgery and adjuvant chemoradiotherapy (CRT) seem to offer the best possibility for a positive outcome.