The impact of thyroidectomy on obstructive sleep apnea: a systematic review and meta-analysis.

PURPOSE: Various thyroid pathologies are speculated to contribute to obstructive sleep apnea (OSA). The underlying mechanisms of the intricate relationship between OSA and thyroid structure and function, and whether thyroidectomy can alleviate OSA symptoms remain unclear. An assessment of the impact of thyroidectomy on OSA is warranted. METHODS: A systematic review of four electronic databases (PubMed (Medline), Embase, the Cochrane library, and ClinicalTrials.gov) was performed up to February 2022. The primary outcomes were preoperative and postoperative Apnea/Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), Berlin questionnaire scores, and continuous positive airway pressure (CPAP) use. A meta-analysis of continuous measures and odd ratios was conducted. Small-scale studies underwent a qualitative meta-analysis. RESULTS: Six cohort studies on 221 OSA patients who underwent thyroidectomies were included. The results showed that thyroidectomy was associated with significant reduction in postoperative AHI (Mean difference [MD], -6.39, 95% CI, -12.46 to -0.32), however, no significant association was found with CPAP withdrawal (Odd ratio [OR], 0.38, 95% CI, 0.12-1.18). Neither the Berlin questionnaire score (OR, 0.19, 95% CI, 0.03-1.17) nor the ESS improved postoperatively (MD, -1.04, 95% CI, -6.37 to 4.29). CONCLUSION: This meta-analysis provides a quantitative estimate for the effect of the thyroidectomy on OSA and suggests that thyroidectomy is associated with limited clinical improvement of polysomnographic measures. Future large-scale, well-designed prospective studies are necessary to validate these findings and to refine accordingly the preoperative assessment of both medical conditions individually and in combination.

The role of parotidectomy for advanced cutaneous squamous cell carcinoma of the head and neck.

PURPOSE: Regionally metastatic cutaneous squamous cell carcinoma of the head and neck (CSCCHN) is usually managed surgically; however, the role of parotidectomy remains controversial. Herein we elucidate the controversy and present our experience. METHODS: We retrospectively analyzed disease variables, extent of parotidectomy, and pathologic characteristics in association to outcome measures of all advanced CSCCHN patients who underwent definitive surgical resection from 2008 to 2018. RESULTS: Sixty-seven patients were enrolled, of whom 47 (70%) underwent parotidectomy; 27 superficial and 20 that included deep lobe resection. Parotidectomy had improved 5-year overall survival (OS) and disease-free survival (DFS) when neck was clinically involved (67.6% vs. 22.2%, P = 0.003 and 75.8% vs. 33.3% P = 0.002, respectively). Elective parotidectomy did not confer survival benefit for patients with no clinical involvement of the parotid gland (41.7% vs. 35%, P = 0.977). Recurrent disease was predictive for parotid metastases (P = 0.034). Thirty-nine patients received adjuvant radiotherapy, which significantly improved OS and DFS versus surgery alone (70.7% vs. 38.1%, P = 0.004 and 77.8% vs. 57.9%, P = 0.014, respectively). CONCLUSION: Parotidectomy was associated with improved survival of cervically spread CSCCHN.

4DCT in Discordant Parathyroid Adenoma Scans: Case Series and Meta-Analysis.

OBJECTIVE: To evaluate the accuracy of four-dimensional computerized-tomography (4DCT) for localizing parathyroid adenomas (PTAs) in cases with discordant or non-localizing ultrasonography (US) and Technetium-99 sestamibi (MIBI) scans. DATA SOURCES: Retrospective case series and systematic review. REVIEW METHODS: A case series and meta-analysis of patients diagnosed with primary hyperparathyroidism and discordant US and MIBI scans who underwent 4DCT prior to surgery. A comprehensive search for all relevant publications in the English literature between December 2006 and March 2022 was conducted for the meta-analysis. Patients undergoing parathyroidectomy between January 2015 and December 2021 were identified from the institutional electronic database for the case series. All studies were analyzed for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the 4DCT adenoma localization capabilities. RESULTS: Thirteen retrospective studies that included 379 patients and one case series that included 37 patients were identified and analyzed. A per-patient analysis revealed sensitivity for lateralization to the correct side (n = 181) ranging from 80% to 100% with a fixed effects model of 89% (95%confidence interval [CI]: 82%-93%) and a PPV for lateralization ranging from 63%-95% with a random effects model of 87% (95% CI: 77%-95%). Sensitivity of localization to the correct quadrant (n = 172) ranged from 53% to 100% with a random effects model of 90.4% (95% CI: 76%-99%), and the PPV for localization ranged from 52% to 100% with a random effects model of 82% (95% CI: 73%-89%). CONCLUSION: 4DCT enhances imaging capabilities of localizing PTAs in cases of discordant or non-localizing US and MIBI scans. LEVEL OF EVIDENCE: NA Laryngoscope, 134:2198-2205, 2024.

Antibiotics or Tonsillectomy for Adult Recurrent Tonsillitis: Analyzing the Lesser of Two Evils.

OBJECTIVE: To determine the best timing for surgical intervention for adults with recurrent tonsillitis (RT). METHODS: A Markov model was constructed using variables and ranges based upon a literature review. A 1-way sensitivity analysis was performed to evaluate the number of yearly bouts at which each algorithm (antibiotics or tonsillectomy) would be favored. A Monte-Carlo probabilistic sensitivity analysis was calculated for gains and cost. Model outcomes were measured with quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICER) for tonsillectomy versus repeat antibiotic treatment. RESULTS: Patients expected to sustain a single annual tonsillitis event will have a negative QALY of 0.02 if treated with surgery and those with 2 annual events will have a QALY gain from undergoing tonsillectomy of 0.01, 3 events = 0.03, 4 events = 0.05, 5 events = 0.07, 6 events = 0.09, 7 events = 0.1, and 8 events = 0.11. These gains became meaningful only after 2 years of recurrent bouts. The average cost of tonsillectomy was 3,238 USD, and the overall average cost of RT was 7,069 USD (an incremental cost of 3,831 USD). The ICER of tonsillectomy over antibiotic treatment for 1 QALY gain was 44,741 USD. CONCLUSION: Adult patients who sustain more than 3 annual bouts of tonsillitis over a period of at least 2 years will gain QALY after tonsillectomy. These gains increase proportionally to the number of yearly events and perennial episodes. The incremental costs of tonsillectomy fail to meet the NICE guidelines but are within other acceptable reference ranges. LEVEL OF EVIDENCE: NA Laryngoscope, 134:2153-2161, 2024.

The Prognostic Value and Clinical Utility of the 40-Gene Expression Profile (40-GEP) Test in Cutaneous Squamous Cell Carcinoma: Systematic Review and Meta-Analysis.

BACKGROUND: The current tumor staging systems for cutaneous squamous cell carcinoma (cSCC) are considered inadequate and insufficient for evaluating the risk of metastasis and for identifying patients at high risk of cSCC. This meta-analysis aimed to assess the prognostic significance of a 40-gene expression profile (40-GEP) both independently and integrated with clinicopathologic risk factors and established staging systems (American Joint Committee on Cancer, eighth edition (AJCC8) and Brigham and Women's Hospital (BWH)). METHODS: Electronic databases, including PubMed (MEDLINE), Embase, the Cochrane Library, and Google Scholar, were systematically searched to identify cohort studies and randomized controlled trials on evaluations of the prediction value of 40-GEP in cSCC patients up to January 2023. The metastatic risk analysis of a given 40-GEP class combined with tumor stage and/or other clinicopathologic risk factors was based upon log hazard ratios (HRs) and their standard error (SE). Heterogeneity and subgroup analyses were performed, and data quality was assessed. RESULTS: A total of 1019 patients from three cohort studies were included in this meta-analysis. The overall three-year metastatic-free survival rates were 92.4%, 78.9%, and 45.4% for class 1 (low risk), class 2A (Intermediate risk), and class 2B (high risk) 40-GEP, respectively, indicating a significant variation in survival rates between the risk classification groups. The pooled positive predictive value was significantly higher in class 2B when compared to AJCC8 or BWH. The subgroup analyses demonstrated significant superiority of integrating 40-GEP with clinicopathologic risk factors or AJCC8/BWH, especially for class 2B patients. CONCLUSIONS: The integration of 40-GEP with staging systems can improve the identification of cSCC patients at high risk of metastasis, potentially leading to improved care and outcomes, especially in the high-risk class 2B group.

Pre-resection Intraoperative Core Biopsies in Oral Tongue Cancer-A Pilot Study.

OBJECTIVE: To assess a novel intraoperative core biopsy technique to provide enhanced guidance in partial glossectomies. METHODS: All patients diagnosed with squamous cell carcinoma of the oral tongue were eligible for study participation. Following anesthesia, the planned resection and three points midway between the gross tumor and the intended ablation were marked. A core biopsy was performed with a needle spring on each point and sent for frozen sections. The initially planned resection was executed if the cores returned free of tumor. In case of a positive core biopsy, a new 1-1.5 cm margin was marked around that point. The main outcome measure was the closest final margin diameter, especially the deep ones. Other outcome measures were the core biopsies' sensitivity, specificity, and negative predictive value. Complications were recorded. RESULTS: The final margins of 10 patients undergoing intraoperative core biopsies and 20 matched controls were analyzed. One patient had two positive cores and final negative margins after modifying the resection accordingly. Another patient had a positive biopsy diagnosed only on final pathology, and one close final margin. Patients that were operated with the new technique had larger margins compared to the controls: median (interquartile range) closest margin 5.95 (3.97; 9.63) mm versus 4 (2.25; 5) mm (p = 0.074) and median deep margin 8.6 (6.16; 10) mm versus 5 (3;10) mm (p = 0.411), respectively. There were no complications. CONCLUSION: A novel pre-resection intraoperative biopsy technique is presented. Core biopsies taken during glossectomies have the potential to prevent inadequate margins. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:2232-2236, 2023.

Revisiting Age Criterion for Surgery in Asymptomatic Primary Hyperparathyroidism.

OBJECTIVE: To revisit the current age criterion (50 years) for surgical candidacy in patients diagnosed with asymptomatic primary hyperparathyroidism (PHPT). STUDY DESIGN: A predictive model relying on past publications using the electronic databases "PubMed," "Embase," "Medline," and "Google Scholar." SETTING: Hypothetical large cohort. METHODS: A Markov model was constructed, based on relevant literature, to compare 2 potential treatment algorithms for asymptomatic PHPT patients, parathyroidectomy (PTX), and observation. The various potential health states were characterized for the 2 treatment options and included potential surgical complications, end-organ deterioration, and death. A 1-way sensitivity analysis was performed to calculate the quality-adjusted life year (QALY) gains of both strategies. A Monte-Carlo simulation for 30,000 subjects was performed and cycled per annum. RESULTS: On the basis of the model's assumptions, the QALY value for the PTX strategy was 19.17 versus 17.82 for the observation strategy. The incremental QALY gains for various ages according to the sensitivity analyses for PTX in comparison to observation were: 2.84 QALY for 40-year-old patients, 2.2 QALY for 50-year-old patients, 1.81 QALY for 55-year-old patients, 1.35 QALY for 60-year-old patients, and 0.86 QALY for 65-year-old patients. The incremental QALY is below 0.5 after the age of 75 years. CONCLUSION: This study found PTX to be advantageous for asymptomatic PHPT patients older than the current age criterion of 50 years. The calculated QALY gains support a surgical approach for medically fit patients in their 50s. The current guidelines for the surgical treatment of young asymptomatic PHPT patients should be revisited by the next steering committee.

Functional outcome following intracapsular resection of head and neck peripheral nerve sheath tumors: a retrospective cohort.

BACKGROUND: Intracapsular resection of head and neck peripheral nerve sheath tumors (PNST) has emerged as a nerve-preserving technique compared to en bloc resection. The aim of this study was to evaluate and compare the functional outcome of both surgical techniques performed at a single tertiary referral center. METHODS: This is a retrospective cohort of patients with head and neck PNST undergoing surgical resection from 2011 to 2021 at the Tel Aviv Sourasky Medical Center. Demographic data, the nerve of origin and surgical technique, including the use of intraoperative nerve monitoring were recorded and analyzed in association with postoperative functional outcomes. RESULTS: Overall, 25 patients who had a cervical or parapharyngeal PNST resected were included. Nerve function was preserved in 11 of 18 patients (61%) who underwent intracapsular resection, while all those who underwent en bloc resections inevitably suffered from neurologic deficits (100%, N = 7). Sympathetic chain origin and an apparent neurologic deficit pre-operatively were associated with postoperative neural compromise. CONCLUSION: Improved functional outcome can be anticipated following intracapsular resection of extracranial head and neck PNST compared to complete resection, particularly in asymptomatic patients.

Mutated TP53 in Circulating Tumor DNA as a Risk Level Biomarker in Head and Neck Squamous Cell Carcinoma Patients.

Circulating tumor DNA (ctDNA) has been suggested as a surrogate biomarker for early detection of cancer recurrence. We aimed to explore the utility of ctDNA as a noninvasive prognostic biomarker in newly diagnosed head and neck squamous cell carcinoma (HNSCC) patients. Seventy HNSCC specimens were analysed for the detection of TP53 genetic alterations utilizing next-generation sequencing (NGS). TP53 mutations were revealed in 55 (79%). Upon detection of a significant TP53 mutation, circulating cell-free DNA was scrutinized for the presence of the tumor-specific mutation. ctDNA was identified at a minimal allele frequency of 0.08% in 21 out of 30 processed plasma samples. Detectable ctDNA correlated with regional spread (N stage ≥ 1, p = 0.011) and poorer 5-year progression-free survival (20%, 95% CI 10.9 to 28.9, p = 0.034). The high-risk worst pattern of invasion (WPOI grade 4-5) and deep invasion were frequently found in patients whose ctDNA was detected (p = 0.087 and p = 0.072, respectively). Detecting mutated TP53 ctDNA was associated with poor progression-free survival and regional metastases, indicating its potential role as a prognostic biomarker. However, ctDNA detectability in early-stage disease and the mechanisms modulating its release into the bloodstream must be further elucidated.

CD24 in Head and Neck Malignancies-An Uprising Biomarker?

INTRODUCTION: CD24 is often overexpressed in human tumors as a regulator of cell migration, invasion and proliferation. It has been associated with poor prognosis and chemoresistance in laryngeal cancer. In oral cavity tumors, it was correlated with better overall survival. In this study, we aimed to evaluate the role of CD24 in peripheral blood leukocytes (PBLs) as a potential marker for head and neck malignancies. MATERIALS AND METHODS: CD24/CD11b expression in peripheral blood leukocytes (PBLs) of head and neck cancer patients and matched healthy controls was analyzed via flow cytometry. Tumors and healthy tissues were immune-stained for CD24 expression and the intensity of stain was ranked. Clinical data including tumor site, size, locoregional or metastatic spread, histopathological characteristics and recurrence events were analyzed. RESULTS: CD24 expression in PBLs was significantly higher in a cohort of 101 head and neck cancer patients compared with 101 matched healthy controls (26.9 ± 12.9 vs. 22.4 ± 13.8; p = 0.02). No significant differences in CD24 levels in PBLs were found between different head and neck subsites involved with malignancy. Higher CD24 levels did not correlate with any adverse feature, i.e., perineural invasion or lymphovascular invasion, advanced T stage or regional spread. Immunohistochemistry analysis demonstrated that CD24 was highly expressed in tumor tissue in comparison to healthy surrounding tissue. CONCLUSIONS: CD24 is a possible uprising marker for tumor identification, overexpressed in PBLs and is intensely stained in tumor tissue and pre-malignant lesions. Tumor-PBLs should be further studied.

Diagnostic efficacy of positron emission computerized tomography scans in suspicious laryngeal findings postorgan preservation treatment.

BACKGROUND: Larynx preservation protocols (LPP) for glottic primary squamous cell carcinoma has gained popularity worldwide. Direct laryngoscopy (DL) with biopsy is mandated when recurrence is suspected. The efficacy of 18Fluoro-deoxy-glucose positron emission computerized tomography (PET-CT) as alternative first-line diagnostic investigation in suspected recurrence was evaluated. METHODS: A retrospective study of patients with suspicious fiber-optic findings at more than 12 weeks after LPP. Sensitivity, specificity, and the negative predictive value (NPV) of DL and PET-CT were compared. RESULTS: Seventy-two patients presenting 105 cases of suspicious events were included in this study. Fifty-two events were initially investigated by DL and 53 events by PET-CT. The sensitivity of DL and PET-CT was 56.25% and 100%, respectively. The NPV was 84% for DL and 100% for PET-CT (p = 0.015). CONCLUSION: Negative PET scans after LPP are highly accurate in ruling out recurrent/persistent disease and may spare the patient from negative biopsies.

Nasal foreign bodies incidentally detected on dental radiography.

Two nasal foreign bodies were discovered by a dental practitioner on a routine radiographic examination of a 15-year-old autistic patient. Going over past radiographs, one of the nasal foreign bodies was detected in a radiograph performed 2 years previously. No nasal complaints or other clues to the problem were apparent. The patient was referred to the emergency room, and the foreign bodies were removed by an Ear Nose and Throat specialist, under general anesthesia. This paper reviews the diagnosis and treatment of nasal foreign bodies, and highlights the important role of the dental practitioner in the proper detection and diagnosis, prompt referral for management, and reduction in related complications.

Neoadjuvant PD-1/PD-L1 Inhibitors for Resectable Head and Neck Cancer: A Systematic Review and Meta-analysis.

Importance: The emerging approach of neoadjuvant immunotherapy for solid cancers has set the ground for the integration of programmed cell death 1 (PD-1)/PD-1 ligand 1 (PD-L1) inhibitors into the neoadjuvant setting of head and neck squamous cell carcinoma (HNSCC) treatment. Objective: To assess the reported efficacy and safety of neoadjuvant immunotherapy for resectable HNSCC. Data Sources and Study Selection: Electronic databases, including PubMed (MEDLINE), Embase, the Cochrane Library, and ClinicalTrials.gov were systematically searched for published and ongoing cohort studies and randomized clinical trials that evaluate neoadjuvant immunotherapy for resectable HNSCC. The search results generated studies from 2015 to July 2021. Data Extraction and Synthesis: Two investigators (R.M. and L.K.) independently identified and extracted articles for potential inclusion. Random and fixed models were used to achieve pooled odds ratios. All results are presented with 95% CIs. Data quality was assessed by means of the Cochrane Collaboration's risk of bias tool. Main Outcomes and Measures: The primary outcomes were reported efficacy, evaluated by major pathological response and pathological complete response in the primary tumors and lymph nodes separately, and safety, assessed by preoperative grade 3 to 4 treatment-related adverse events and surgical delay rate. Results: A total of 344 patients from 10 studies were included. In 8 studies, neoadjuvant immunotherapy only was administered, and the other 2 studies combined immunotherapy with neoadjuvant chemotherapy and/or radiotherapy. The overall major pathological response rate in the primary tumor sites from studies reporting on neoadjuvant immunotherapy only was 9.7% (95% CI, 3.1%-18.9%) and the pathological complete response rate was 2.9% (95% CI, 0%-9.5%). Preoperative grade 3 to 4 treatment-related adverse events were reported at a rate of 8.4% (95% CI, 0.2%-23.2%) and surgical delay at a rate of 0% (95% CI, 0%-0.9%). There was a favorable association of neoadjuvant immunotherapy with all outcome measures. The subgroup analyses did not find one specific anti-PD-1/PD-L1 agent to be superior to another, and the favorable association was demonstrated by either immunotherapy alone or in combination with anti-CTLA-4. Conclusions and Relevance: In this systematic review and meta-analysis, neoadjuvant anti-PD-1/PD-L1 immunotherapy for resectable HNSCC was well tolerated and may confer therapeutic advantages implied by histopathological response. Long-term outcomes are awaited.

Surgically Treated Advanced Cutaneous Squamous Cell Carcinoma of the Head and Neck: Outcome Predictors and the Role of Adjuvant Radiation Therapy.

OBJECTIVES: Advanced cutaneous squamous cell carcinoma of the head and neck (CSCCHN) is associated with poor outcome despite multimodality therapy. Comprehensive risk stratification may pinpoint the most suitable adjuvant treatment. This study aimed to evaluate the outcomes of surgically treated locoregional CSCCHN and to identify prognostic indicators of treatment outcomes. METHODS: We retrospectively analyzed disease variables, pathologic characteristics, and management in association with treatment outcomes of all consecutive advanced CSCCHN patients who underwent surgical resection at Tel Aviv Sourasky Medical Center. RESULTS: From 2008 to 2018, 74 patients met the inclusion criteria. Only perineural invasion (PNI) was significantly associated with worse overall survival (OS) (P = .001). Location within the facial "mask areas" was significantly associated with pathologically negative cervical disease (P = .001). Forty-seven patients underwent adjuvant radiation therapy (RT) which significantly improved OS and disease-free survival versus surgery alone (P = .025 and P = 0.035, respectively). CONCLUSION: PNI was associated with worse OS in surgically treated advanced CSCCHN. Adjuvant RT conferred better outcomes despite high risk features.

Therapeutic inhibitory RNA in head and neck cancer via functional targeted lipid nanoparticles.

Currently there are no specific therapies addressing the distinctive biology of human papillomavirus (HPV)-induced cancer approved for clinical use. Short interfering RNA (siRNA) has much potential for therapeutic manipulation of HPV E6/E7 oncoproteins. Lipid-based nanoparticles (LNPs) can be utilized for systemic transportation and delivery of siRNA at target site. We recently developed a recombinant protein linker that enables uniform conjugation of targeting antibodies to the LNPs. Herein, we demonstrate the therapeutic efficacy of anti-E6/E7 siRNA delivered via targeted LNPs (tLNPs) in a xenograft HPV-positive tumor model. We show that anti-epidermal growth factor receptor (EGFR) antibodies, anchored to the LNPs as targeting moieties, facilitate cargo delivery but also mediate anti-tumor activity. Treatment with siE6 via tLNPs resulted in 50% greater reduction of tumor volume compared to treatment with siControl encapsulated in isoLNPs (coated with isotype control antibodies). We demonstrate superior suppression of HPV oncogenes and higher induction of apoptosis by the tLNPs both in vitro and in vivo. Altogether, the coupling of inhibitory siE6 with anti-EGFR antibodies, that further elicited anti-tumor effects, successfully restricted tumor progression. This system that combines potent siRNA and therapeutically functional tLNPs can be modulated against various cancer models.

The Effect of Diathermy Power Settings on Oral Cavity Mucosal Contraction: A Rat Model.

OBJECTIVES/HYPOTHESIS: The effects of different electrocautery power settings on mucosal contraction and margin status in the oral cavity have not been well established. The aim of this study was to examine how different levels of electrocautery energy outputs affect oral mucosal tissue margins. STUDY DESIGN: Animal model. METHODS: A model of 23 adult rats was used (two specimens per rat). After anesthetizing the animals, a 6-mm biopsy punch marked the resection margin on the buccal mucosa (one per cheek). The specimens were excised by means of three energy levels, a cold knife, and monopolar diathermy that was set on either 20 W or 30 W cut modes. The specimens were evaluated for extent of contraction. RESULTS: A total of 45 samples were obtained and measured, including 15 specimens in the cold-knife group, 15 specimens in the 20 W group, and 15 specimens in the 30 W group. The median diameters of the specimens after resection were 4.5 mm for the cold-knife group (interquartile range [IQR] = 4.0-5.0), 3.5 mm for the 20 W group (IQR = 3.5-4.0), and 2.8 mm for the 30 W group (IQR = 2.5-3.0). Specimen contraction was 25.0%, 41.7%, and 53.3%, respectively. The difference in shrinkage between each pair was statistically significant: cold knife versus 20 W, P = .001; cold knife versus 30 W, P < .0001; and 20 W versus 30 W, P < .001. CONCLUSIONS: Diathermy power settings result in a significant difference of mucosal tissue contraction, with higher outputs resulting in a narrower mucosal margin. It is imperative that the surgical team take into consideration the diathermy settings during initial resection planning. Laryngoscope, 131:E1514-E1518, 2021.

Scrotal Hematoma Precipitated by Centrifuge Training in a Fighter Pilot with an Asymptomatic Varicocele.

BACKGROUND: Varicocele is quite common in the general population, affecting up to 15% of men. It is not considered disqualifying for the pilot's training program of the Israeli Air Force as long as there are no related symptoms or associated pathologies. During combat flight, increased venous pressure due to acceleration forces and anti-G straining maneuvers, used to counteract high gravitational G forces, can theoretically aggravate the venous blood pooling in varicocele, leading to rupture. CASE REPORT: We describe a case of a young fighter-jet pilot presenting with a painful inguinal hematoma extending to the scrotum a day after participating in centrifuge training. Sonographic examination demonstrated dilated spermatic veins and intratesticular varicocele along with subcutaneous thickening of the scrotal wall consistent with hematoma. DISCUSSION: The effects of high G loads on blood flow in spermatic veins, and especially in varicocele, still need to be determined. Varicocele rupture has been described in relation to increased intra-abdominal pressure and could theoretically occur during anti-G straining maneuvers. Such an acute adverse event during combat flight can be detrimental to flight safety and the pilot's well-being.