Thyroid US-guided FNA techniques: A prospective,randomized controlled study.

BACKGROUND: Thyroid nodules are common in the general population. Ultrasonography is the most efficient diagnostic approach to evaluate thyroid nodules. The US FNAC procedure can be performed using either the short axis (perpendicular), or a long axis (parallel) approach to visualize the needle as it is advanced toward the desired nodule. The main aim of this study was to compare the percentage of non-diagnostic results between the long and short axis approach. METHODS: A prospective study that included a randomized controlled trial and was divided into two arms-the short axis and the long axis-was conducted. A total of 245 thyroid nodules were collected through the fine needle aspiration cytology, performed with ultrasound, from march 2021 to march 2022. The patient's demographic information were collected and also nodules characteristics. RESULTS: Of 245 nodules sampled, 122 were sampled with the long axis method, while 123 with the short axis method. There is not significantly less non diagnostic approach with either method compared to the other (11.5 % vs 16.3 % respectively). DISCUSSION: Previous studies came to the conclusion that the long axis method yields fewer non diagnostic samples. This study evaluated the two FNA approaches which were proceeded by the same physician who is expert in both techniques. CONCLUSION: The US FNAC performed in the long axis approach will not produce more conclusive results and less non diagnostic results (Bethesda category 1) than the short axis approach one.

Does acute isolated sphenoidal sinusitis meet the criteria of the recent acute sinusitis guidelines, EPOS2020?

INTRODUCTION: Isolated sphenoidal sinusitis (ISS) is a rare disease with non-specific symptoms and a potential for complications. Diagnosis is made clinically, endoscopically, and with imaging like CT scans or MRIs. This study aimed to evaluate if ISS meets the EPOS 2020 criteria for diagnosing acute rhinosinusitis and if new diagnostic criteria are needed. MATERIALS AND METHODS: The study analyzed 193 charts and examination records from 2000 to 2022 in patients diagnosed with isolated sphenoidal sinusitis at the Ziv Medical Center in Safed, Israel. Of the 193, 57 patients were excluded, and the remaining 136 patients were included in the final analysis. Patients were evaluated using Ear, Nose and Throat (ENT), neurological and sinonasal video endoscopy, radiological findings, demographic data, symptoms and signs, and laboratory results. All these findings were reviewed according to the EPOS 2020 acute sinusitis diagnosis criteria and were analyzed to determine if ISS symptoms and signs fulfilled them. RESULTS: The patients included 40 men and 96 women, ranging in age from 17 to 86 years (mean ± SD, 37 ± 15.2 years). A positive endoscopy and radiography were encountered in 29.4%, and headache was present in 98%; the most common type was retro-orbital headache (31%). The results showed that there is no relationship between the symptoms of isolated sphenoidal sinusitis and the criteria for diagnosing acute sinusitis according to EPOS 2020. CONCLUSION: ISS is an uncommon entity encountered in clinical practice with non-specific symptoms and a potential for complications. Therefore, the condition must be kept in mind by clinicians, and prompt diagnosis and treatment must be initiated. This kind of sinusitis does not fulfill the standard guidelines for acute sinusitis diagnosis criteria.

Challenges in Diagnosing Dermoid Cyst in a Neurocognitive Patient.

This case report presents a unique and challenging scenario involving the diagnosis and management of a sublingual dermoid cyst in a 12-year-old male with autism disorder. Dermoid cysts within the oral cavity are exceptionally rare entities, constituting less than 0.01% of all oral cavity cysts. In addition, their co-occurrence with neurocognitive disorders further complicates the diagnostic process. The patient's clinical presentation was marked by recurrent epistaxis and behavioral changes, which were compounded by his communication limitations due to autism disorder. A thorough physical examination revealed a sublingual mass causing tongue displacement. However, due to the patient's inability to effectively communicate symptoms, parental input played a pivotal role in constructing the clinical narrative. Imaging techniques, including computed tomography (CT) and magnetic resonance imaging (MRI), provided essential insights into the cyst's size, location, and structural characteristics. The successful integration of these modalities aided in achieving a definitive diagnosis. The subsequent intraoral surgical excision of the 6.5 cm cyst yielded a positive outcome, with an uneventful recovery and a six-month follow-up demonstrating no signs of recurrence. This report underscores the significance of multidisciplinary collaboration in navigating the complexities of diagnosing and managing rare oral lesions in patients with neurocognitive disorders. The confluence of two rare conditions necessitates a tailored approach that takes into account communication barriers and the patient's overall well-being. This case offers valuable insights to healthcare practitioners, highlighting the importance of leveraging advanced imaging technologies and adapting strategies to address the unique challenges posed by such cases. By presenting this exceptional clinical scenario, this report contributes to the medical community's understanding of nuanced diagnostic processes and patient-centered management techniques.

The emergence of non-infectious epiglottitis after the era of Hemophilus influenza type B universal vaccination: two case reports and literature review.

Objective: Following the global dissemination of vaccination protocols for Hemophilus influenza type B, the occurrence rate and burden of infectious epiglottitis decreased rapidly and substantially. However, this gave space to the rise of non-infectious causes, with children being more vulnerable than adults. This report aims to divert the clinician's attention to the existence of other non-infectious causes of epiglottitis, all of which require careful attention and timely management for favorable clinical outcomes. Case summary: Two cases with positive vaccination history were encountered in our practice. The first case was a 4-year-old girl, presenting with stridor drooling, and dyspnea, later complication by apnea. The fiberoptic exam revealed severe epiglottitic swelling with near-complete injury of the vocal cords with a circumferential burn. She did not respond to racemic epinephrine, and a tracheostomy was done. She was discharged after 6 days with minimal soft palate swelling. The second case was a 2-year-old boy presenting after exposure to an alkaline solution. The case exhibited similar symptoms but with white plaques and edema of the soft palate. The fiberoptic exam showed swelling and erythema of the supraglottic structures with partial obstruction. Although the blood culture was negative, he was intubated and given four intravenous boluses of dexamethasone and penicillin. On the fifth day, the patient was discharged after a normal fiberoptic examination. Discussion: These cases highlight a crucial shift in the etiology of epiglottitis post widespread Hemophilus influenza type B vaccination, underscoring the emergence of non-infectious causes, particularly in children. The two cases presented, both with vaccination histories, demonstrate diverse non-infectious triggers leading to severe epiglottitis. The first case, involving thermal injury, and the second, chemical exposure, both necessitated intensive interventions, including tracheostomy and intubation. These instances emphasize the need for heightened clinical vigilance for non-infectious epiglottitis, demanding prompt recognition and management to ensure positive outcomes. This shift in etiology calls for a reevaluation of traditional diagnostic and therapeutic approaches to pediatric epiglottitis.

Anterolateral Lingual Abscess in a Young Adult: A Comprehensive Case Study.

Lingual abscesses, characterized by infectious collections of pus within the tongue parenchyma, are rare and poorly understood clinical entities. Despite their potential for severe complications, literature on lingual abscesses remains limited, consisting mainly of sporadic case reports. This comprehensive case study examines the challenges and successful management of a severe anterolateral tongue abscess in a young adult, contributing to the emerging body of knowledge on this condition. A young adult male presented with a progressively worsening painful, swollen tongue and dyspnea over 2 days. Urgent intervention was necessary to prevent potential airway compromise despite maintaining normal oxygen saturation. The patient's medical history showed no prior oral infections, illnesses, or relevant medical conditions. Detailed clinical assessment, utilization of imaging modalities such as contrast-enhanced computed tomography scan and ultrasonography, and collaboration with a maxillofacial surgeon guided accurate diagnosis and successful treatment. This case study provides valuable insights into the diagnosis and management of anterolateral lingual abscess in a young adult. It underscores the importance of heightened clinical awareness, precise diagnostic techniques, and multidisciplinary collaboration for optimal patient outcomes. The report contributes to the limited literature and emphasizes the need for further research to establish evidence-based guidelines for lingual abscess management.

The impact of using near-infrared autofluorescence on parathyroid gland parameters and clinical outcomes during total thyroidectomy: a meta-analytic study of randomized controlled trials.

BACKGROUND: The added benefit of using near-infrared autofluorescence (NIRAF) during total thyroidectomy (TT) remains controversial. This study investigated whether or not NIRAF results in improved patient outcomes postoperatively. MATERIALS AND METHODS: We analyzed 1711 TT patients, reported in nine randomized controlled trials, following a systematic search of five databases. NIRAF was compared to the standard of care (naked eye with/without white light). Outcomes included parathyroid gland (PG) and calcium parameters and other clinical outcomes. For dichotomous outcomes, the log odds ratio (logOR) was calculated, and for continuous outcomes, the crude mean difference (MD) was measured. Sensitivity analysis was performed when heterogeneity was significant. The revised Cochrane risk of bias tool was used to assess the methodological quality. RESULTS: Compared to the standard of care, the use of NIRAF was associated with a significant reduction in postoperative hypoparathyroidism [logOR=-0.31; 95% CI: -0.57: -0.05], inadvertent PG removal [logOR=-0.93; 95% CI: -1.60: -0.26], and postoperative hypocalcemia [logOR=-0.43 mmol/l; 95% CI: -0.77: -0.09]. It was also associated with significantly higher postoperative PTH levels [MD=4.78 pg/ml; 95% CI: 2.13: 7.43], PG identification rate [logOR=1.02; 95% CI: 0.31: 1.72], postoperative serum calcium [MD=0.05; 95% CI: 0.00: 0.09], and operative time [MD=9.38 min; 95% CI: 6.68: 12.09]. No difference was seen regarding PG autotransplantation, length of hospital stay, and hospitalization due to hypocalcemia. Seven trials had low risk and the remainder had some concerns. CONCLUSION: NIRAF is superior to the naked eye in identifying all four PGs during TT. The reduced risk of postoperative hypoparathyroidism and hypocalcemia reflected this preservation value. However, it was not associated with a change in the length of hospital stay. Although rare, the readmission rate due to hypocalcemia was similar across both methods.

A meta-analysis of the prevalence and risk of mental health problems in allergic rhinitis patients.

OBJECTIVE: Allergic rhinitis (AR), a prevalent global health concern, is increasingly recognized for its impact beyond physical symptoms, affecting mental health. This research examined the extent of AR's psychological burden and sleep disturbances. METHODS: A systematic search of four databases yielded 49 studies reporting mental health problems in 18,269,265 individuals (15,151,322 AR patients and 3,117,943 controls). The primary outcomes included all mental health problems in AR patients. Subgroup analyses based on outcome and AR severity, country, AR diagnosis, recruitment setting, and age were performed. Secondary outcomes included the risk of these problems compared to controls (healthy or without AR). RESULTS: In AR, depression (25%), anxiety (25%), stress (65%), distress (57%), suicidal thoughts (14%) and attempts (4%), poor sleep quality (48%), insomnia (36%), sleep impairment (33%), and insufficient sleep duration <7 h (59%) were prevalent. The severity of these outcomes differed significantly. Patients' country, AR diagnostic method, recruitment method/setting, and age group were significant effect modifiers. Compared to controls, AR resulted in significantly higher risk of depression, anxiety, stress, suicidal attempts and thoughts, insomnia, and sleep impairment. CONCLUSION: AR patients had significantly lower sleep duration. Mental health problems are very common among AR patients, further exacerbating their sleep quality and duration and intention to suicide.

Is Piezosurgery Associated with Improved Patient Outcomes Compared to Conventional Osteotomy in Rhinoplasty? A Systematic Review and Meta-Analysis of RCTs.

Background: Rhinoplasty is a common plastic surgery procedure with evolving surgical techniques. This systematic review and meta-analysis compares the outcomes of piezosurgery versus conventional osteotomy in rhinoplasty. Methods: A comprehensive search of six databases yielded 12 randomized controlled trials (RCTs) comparing piezosurgery (292 cases) to conventional osteotomy (338 cases) in rhinoplasty patients. The examined outcomes included postoperative edema, ecchymosis, complications, pain (using the Visual Analogue Scale-VAS), and operative time. Subgroup analyses were conducted based on the assessment timepoint, surgical approach, and outcome grade. The risk of bias was evaluated using the revised Cochrane tool. Results: Piezosurgery showed a significant reduction in the degree of postoperative edema (second and seventh postoperative days) and ecchymosis (second, fourth, and seventh postoperative days). The external approach in piezosurgery demonstrated greater benefits for both outcomes. Piezosurgery was associated with a significant reduction in overall complications, especially mucosal injuries, compared to conventional osteotomy, with no significant difference regarding postoperative hemorrhage. A significant reduction in pain scores and the need for analgesia was observed with piezosurgery. No significant difference was found in operative time. Conclusions: Piezosurgery offers significant benefits in patient outcomes, with similar operative time between both techniques. However, long-term investigations are still needed.

Determinants of clinical response to injection laryngoplasty in unilateral vocal fold paralysis: a systematic review and meta-analysis.

BACKGROUND: Unilateral vocal fold paralysis (UVFP) significantly impairs vocal function, affecting patients' quality of life. Injection laryngoplasty, a primary treatment modality for UVFP, varies in effectiveness based on the material used, injection volume, and procedural nuances. This study aims to systematically analyze how these factors influence treatment outcomes to optimize intervention strategies. MATERIALS AND METHODS: We conducted a comprehensive meta-analysis and meta-regression using data extracted from 82 studies identified through a robust literature search on databases including PubMed, Scopus, and Web of Science, up to February 13, 2024. Eligible studies were single-armed observational or experimental that reported pre- and post-operative data on UVFP patients undergoing their first injection laryngoplasty. The primary outcomes analyzed included maximum phonation time, harmonics-to-noise ratio, fundamental frequency, jitter, shimmer, and subjective voice measures such as the Voice Handicap Index and GRBAS scale components. RESULTS: The meta-analysis revealed significant improvements in maximum phonation time (MPT) and harmonics-to-noise ratio (HNR) post-injection, with variability in outcomes influenced by injection material and procedural techniques. Meta-regression identified the injection volume and the timing of the procedure as significant predictors of MPT and HNR outcomes, respectively. Materials such as polydimethylsiloxane (PDMS) and autologous fat significantly improved MPT and reduced the grade of dysphonia and roughness, respectively. The type of injection material, volume, and approach were crucial in reducing symptoms of voice handicap and enhancing the overall vocal quality. CONCLUSIONS: Injection laryngoplasty significantly improves vocal outcomes in UVFP patients. The choice of injection material, volume, and timing of the intervention plays pivotal roles in determining the effectiveness of the procedure. Tailored treatment approaches based on these factors are recommended to enhance therapeutic efficacy and patient satisfaction.

Flexible versus Rigid Bronchoscopy for Tracheobronchial Foreign Body Removal in Children: A Comparative Systematic Review and Meta-Analysis.

The removal of foreign bodies (FBs) from the airways of children is a critical procedure that can avert serious complications. While both flexible and rigid bronchoscopy techniques are employed for this purpose, their comparative efficacy and safety remain subjects of debate. Therefore, we conducted this investigation to compare between both procedures. Studies comparing flexible to rigid bronchoscopy (n = 14) were identified by searching PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar. We performed comparative meta-analyses of reported presentation characteristics and clinical outcomes, using fixed- and random-effects models. A diverse range of FB types and locations were identified. No difference was observed in the success rate of FB removal between flexible and rigid bronchoscopy (logOR = 0.27; 95%CI: -1.91:2.45). The rate of negative first bronchoscopy was higher in the flexible compared to the rigid group (logOR = 2.68; 95%CI: 1.68:3.67). Conversion rates to the alternative method were higher in the flexible bronchoscopy group. The overall complication rates were similar between both methods; however, the risk of desaturation was significantly lower with flexible bronchoscopy (logOR = -2.22; 95%CI: -3.36:-1.08). Flexible bronchoscopy was associated with a shorter length of hospital stay. The choice of bronchoscopy technique should be tailored to individual case characteristics.

Kaposi sarcoma at the base of the tongue in a renal transplant patient.

Oral Kaposi Sarcoma (OKS) commonly occurs in patients with AIDS. The incidence of Kaposi sarcoma (KS) is greatly increased in renal transplant recipients compared with the general population, with particular prevalence in certain ethnic groups where it can occur in up to 5% of transplant recipients. From them, only 2% can manifest first with OKS.A man in his early 40s, 2 years after kidney transplantation, presented with a reddish-purple hypertrophic ulcerated lesion at the base of the tongue. Cervical ultrasonography revealed enlarged lymph nodes, and pathological examination of biopsies revealed KS. The patient had HIV-negative status. Following an investigation, calcineurin inhibitor treatment was stopped, and an mTOR (mammalian target of rapamycin) inhibitor treatment was started. Fibreoptic examination 3 months after beginning mTOR inhibitor treatment revealed no traces of the disease in the base of the tongue.An isolated oral lesion should not distract clinicians from further systemic investigation for metastatic disease.OKS is a rare but serious complication in kidney transplant patients after receiving calcineurin inhibitor that could result in airway obstruction due to mass effect or bleeding and aspiration.Early diagnosis and management of OKS in a renal transplant patient who received a calcineurin inhibitor carry a good prognosis. OKS can be managed by changing the treatment regime to an mTOR inhibitor followed by radiation therapy. This contrasts with KS treatment in non-renal transplant patients without calcineurin inhibitors who may need treatment using different modalities such as surgery and chemotherapy.We emphasise the importance of this case for nephrologists responsible for patient follow-up after renal transplantation who prescribed calcineurin inhibitors. These patients must be advised that if they feel any physical mass in the tongue, they should immediately seek an examination by an ear, nose and throat specialist. Nephrologists and patients should be aware that these symptoms should not be underestimated.

Pembrolizumab as a first line therapy in a patient with extensive mucoepidermoid salivary gland carcinoma. A complete clinical, radiological and pathological response. A very specific case.

BACKGROUND: Patients with advanced salivary gland malignancies (SGCs) have few therapy options. Although results from newly published trials suggest that checkpoint inhibition may be useful in a subgroup of patients, there are no clear criteria for PD-L1 score in SGCs. Chemotherapy benefits were observed to be limited, with a dismal prognosis in unresectable and high-grade SGC. Immunotherapies have demonstrated extraordinary efficacy in a variety of cancers, including non-small cell lung cancer and malignant melanoma. Anti-PD-1 antibody pembrolizumab has been shown to have potent anti-tumor action in a number of clinical trials. CASE PRESENTATION: We report a unique case of advanced high grade mucoepidermoid carcinoma of the parotid salivary gland after Pembrolizumab treatment as a first line therapy. The tumor was downstaged as a result of the pembrolizumab treatment, allowing for a successful surgical excision with no facial nerve sacrifice and no major neoadjuvant treatment adverse effects, and the final specimen pathology was tumor-free. In these types of malignancies, a similar technique resulted in a complete response (CR) radiologically and pathologically has never been discussed before. CONCLUSIONS: In pretreated patients with high-grade salivary gland mucoepidermoid carcinoma, pembrolizumab showed good anticancer activity and provided a clinically, radiologically, and pathological response with a viable treatment choice. More research is needed to bring Pembrolizumab to the front-line of treatment. The time and duration of medication should be compared to the time required for surgery in these investigations.

Ultrasound-Guided Fine Needle Aspiration of Deep Thyroid Nodule: Is There a Correlation between the Nodule's Depth and Nondiagnostic Results?

Objective: To evaluate whether thyroid nodule depth correlates with nondiagnostic results in ultrasound-guided fine needle aspiration cytopathology. Background: Many factors correlate with nondiagnostic ultrasound-guided fine needle aspiration cytology (FNAC) results, including older age, macrocalcification, small-sized nodules, aspirin medication, and cystic portion in more than 50% of the thyroid nodules. However, there are few studies which have examined whether there is a relationship between the depth of nodules and the percentage of nondiagnostic results in cytology (Bethesda category I). We conducted this study in order to investigate if such a correlation exists. Materials and Methods: FNAC was performed on 283 thyroid nodules between January 2019 and December 2020. Cytological analyses of the nodules were reviewed and sorted as nondiagnostic and diagnostic according to the Bethesda score. Patient files and ultra sound (US) scans were reviewed for clinical information (such as age, sex, and ethnic group) and sonographic features of nodules (such as depth, size, cystic portion, type of calcification, and echogenicity) and were compared between the nondiagnostic and diagnostic nodule results. The depth of a nodule was calculated as the shortest distance from the skin to the most superficial border of the nodule in the axial plane, using our medical center's computer program, which allows reviewing all saved shots of the US scan. Results: Age, sex, and ethnicity were not significantly different between the nondiagnostic group and the diagnostic group (p > 0.05). Nodule diameter, cystic portion, calcification, and echogenicity were also not associated with the frequency of nondiagnostic results. The depth of nodules ≥9 mm was correlated with nondiagnostic US-guided FNA cytological results (OR = 2.55, p=0.018). Conclusions: Deep thyroid nodules correlated with nondiagnostic US-guided FNA cytological results. Further studies are needed for optimizing the approach to deep thyroid nodules in order to improve the efficacy of FNA in deep thyroid nodules.