A novel combined transoral and transcervical surgical approach for recurrent metastatic medullary thyroid cancer to the parapharyngeal space.

Medullary thyroid cancer (MTC) represents less than 1% of all thyroid cancers. Complete surgical resection remains the mainstay of treatment for locoregional disease. Unfortunately, patients with recurrence may present with metastasis to challenging anatomic locations. We describe the first case of a recurrent MTC metastatic to the parapharyngeal space (PPS) that was managed using a combined transoral robotic surgery (TORS) and transcervical (TC) approach. We review the presentation, natural history, diagnosis and management of recurrent MTC, and describe a novel combined TORS-TC surgical approach for the treatment of PPS metastasis. A 66-year-old male with history of MTC treated with total thyroidectomy in 2000 and a liver resection in 2011 for metastatic MTC was referred to our Head and Neck Surgery Clinic in October 2016 due to increased calcitonin and CEA levels. Exam was significant for mild right tonsillar/pharyngeal bulging and induration. Imaging with PET-CT and MRI showed an enlarging ovoid mass centered within the right PPS without the presence of another systemic metastasis. FNA was consistent with MTC. The patient was taken to the operating room for a combined TORS-TC approach. Final pathology was consistent with metastatic MTC. Until recently, PPS tumors have been managed using highly morbid and cosmetically disfiguring open surgical approach. TORS provides a safe and effective alternative.

Oncologic outcomes of surgically treated early-stage oropharyngeal squamous cell carcinoma.

BACKGROUND: The purpose of this study was to characterize oncologic outcomes in early (T1-T2, N0) and intermediate (T1-T2, N1) oropharyngeal squamous cell carcinoma (SCC) after surgery. METHODS: Patients with oropharyngeal SCC treated with surgery were identified from 2 academic institutions. RESULTS: Of 188 patients, 143 met the inclusion criteria. Eighty-six (60%) had T1 to T2 N0 and 57 (40%) had T1 to T2 N1 disease. Sixty-five patients (45%) underwent a robotic-assisted resection, whereas the remaining had transoral (n = 60; 42%), mandible-splitting (n = 11; 8%), or transhyoid approaches (n = 7; 5%). Human papillomavirus (HPV) status was known for 97 patients (68%), and 54 (55%) were HPV positive. Three-year recurrence-free survival (RFS) was 82% (95% confidence interval [CI] = 0.75-0.89). Since 2008, HPV infection was protective of recurrence (log-rank p = .0334). A single node did not increase the risk of recurrence (p = .467) or chance of a second primary (p = .175). CONCLUSION: Complete surgical resection is effective therapy for early and intermediate oropharyngeal SCC. HPV-negative patients were at increased risk for locoregional recurrence or second primary disease. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1471, 2016.

Predictors of Posterior Glottic Stenosis: A Multi-Institutional Case-Control Study.

OBJECTIVE: To assess intrinsic and extrinsic risk factors in the development of posterior glottic stenosis (PGS) in intubated patients. METHODS: Patients diagnosed with PGS between September 2012 and May 2014 at 3 tertiary care university hospitals were included. Patient demographics, comorbidities, duration of intubation, endotracheal tube (ETT) size, and indication for intubation were recorded. Patients with PGS were compared to control patients represented by patients intubated in intensive care units (ICU). RESULTS: Thirty-six PGS patients were identified. After exclusion, 28 PGS patients (14 male, 14 female) and 112 (65 male, 47 female) controls were studied. Multivariate analysis demonstrated ischemia (P < .05), diabetes (P < .01), and length of intubation (P < .01) were significant risk factors for the development of PGS. Fourteen of 14 (100%) males were intubated with a size 8 or larger ETT compared to 47 of 65 (72.3%) male controls (P < .05). Posterior glottic stenosis (P < .01), length of intubation (P < .001), and obstructive sleep apnea (P < .05) were significant risk factors for tracheostomy. CONCLUSION: Duration of intubation, ischemia, diabetes mellitus, and large ETT size (8 or greater) in males were significant risk factors for the development of PGS. Reducing the use of size 8 ETTs and earlier planned tracheostomy in high-risk patients may reduce the incidence of PGS and improve ICU safety.

Voice Outcomes Following Posterior Cordotomy With Medial Arytenoidectomy in Patients With Bilateral Vocal Fold Immobility.

IMPORTANCE: Voice quality-of-life (VQOL) and perceptual voice outcomes are presumed to worsen following posterior cordotomy with medial arytenoidectomy for bilateral vocal fold immobility (BVFI); however, subjective and objective voice outcomes are not well studied in this postsurgical patient population. OBJECTIVE: To evaluate VQOL and perceptual voice outcomes following posterior cordotomy with medial arytenoidectomy for BVFI. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review of 15 patients with BVFI who underwent posterior cordotomy with medial arytenoidectomy at a tertiary care academic hospital from 2009 to 2012. INTERVENTIONS: Suspension microlaryngoscopy was performed to expose the posterior glottis. A posterior cordotomy and medial arytenoidectomy was performed anterior to the vocal process of the vocal fold in a medial to lateral fashion. MAIN OUTCOMES AND MEASURES: Data included age, sex, tracheostomy status, number of cordotomies, and voice outcomes. Voice-Related Quality of Life (VRQOL) and Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) data were collected preoperatively and postoperatively surrounding a single procedure. Comparisons within a single group were performed with a paired t test. Statistical significance was determined at P ≤ .05. RESULTS: Eight patients (53%) were male, and 7 (47%) were female. Six patients (40%) required a tracheotomy at some point during treatment, 4 were successfully decannulated. For all 15 patients, the mean VRQOL scores improved 12 points from 47.33 to 59.33 after posterior cordotomy (P = .12). Mean CAPE-V overall severity scores in 13 patients increased 26 points after posterior cordotomy with medial arytenoidectomy from 38.12 to 62.77 (P = .01), indicating further deviance from normal. CONCLUSIONS AND RELEVANCE: To our knowledge, this is the first study to compare VQOL with perceptual voice outcomes following posterior cordotomy with medial arytenoidectomy in a series of patients with BVFI. Patients who underwent posterior cordotomy in this study had significantly reduced perceptual voice outcomes with unchanged VQOL. While postcordotomy patients have a dysphonia that is noticeable to voice professionals, most patients in this study subjectively felt as though their voice improved after surgery. Surgeons should be aware of these factors when counseling patients considering cordotomy for BVFI.

Critical ENT skills and procedures in the emergency department.

Injuries and illness to the ears, nose, and throat are frequently seen in the emergency department. The emergency medicine physician must be proficient in recognizing these injuries and their associated complications and be able to provide appropriate management. This article discusses the most common otorrhinolaringologic procedures in which emergency physicians must be proficient for rapid intervention to preserve function and avoid complications. A description of each procedure is discussed, as well as the indications, contraindications, equipment, technique and potential complications.

Synovial sarcoma of the hypopharynx in pregnancy.

Synovial sarcomas of the hypopharynx are a rare form of soft tissue sarcomas. In the head and neck, they are most commonly found on the pharyngeal wall in areas that do not have synovial cells. We review a case of a 23 year-old pregnant female who presented to our hospital with acute airway obstruction due to a large hypopharynx lesion. She underwent emergency tracheotomy and tumor debulking. Pathology revealed synovial sarcoma. After the procedure the patient went into labor delivering a 29 weeks premature child. Six weeks after being discharged from the hospital the patient had a partial pharyngectomy performed to excise the remnant base of the tumor. She has had no recurrence at the 30-month post-operative period.