Functional Voice and Swallowing Outcome Analysis After Thyroid Lobectomy: Transoral Endoscopic Vestibular Versus Open Approach.

BACKGROUND: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless remote-access thyroidectomy technique. This study compared subjective and objective voice outcomes and swallowing outcomes of patients who underwent thyroid lobectomy using the TOETVA versus conventional open thyroidectomy (OT). METHODS: In addition to questionnaires, acoustic and aerodynamic analyses were performed to compare subjective and objective voice outcomes of the two groups. Swallowing outcome analyses were conducted using Swallowing Impairment Index-6 (SIS-6) scores. Assessments were performed preoperatively and 3 and 6 months after surgery. Propensity score matching was performed to compare the outcomes of the two groups. RESULTS: One hundred and two patients were included in this study (52 TOETVA and 50 OT). Excluding two patients who had vocal cord palsy and open conversion in the TOETVA group, 100 patients completed 3-month postoperative surveys. There were no significant differences between the groups in VAS, GRBAS, or VHI-10 scores at the preoperative and 3- and 6-month assessments. For both groups, there were no significant changes in acoustic or aerodynamic parameters during the 3-6-month postoperative period. The TOETVA group had lower SIS-6 scores at the postoperative 6-month assessment, but the SIS-6 scores after 12 months were similar between groups before and after propensity score matching. CONCLUSIONS: Following TOETVA lobectomy, there were no significant changes in voice outcomes 3 and 6 months after surgery, and the outcomes were comparable with those of OT. The TOETVA group also had swallowing outcomes that were comparable with the OT group.

Prognostic value of the posterior cricoarytenoid muscle atrophy in computerized tomography scans for unilateral vocal fold paralysis recovery.

OBJECTIVES: To evaluate the prognostic value of the posterior cricoarytenoid (PCA) muscle atrophy observed on neck computed tomography (CT) in patients with unilateral vocal fold paralysis. METHODS: CT images of 87 subjects with unilateral vocal fold paralysis (UVFP) were evaluated to analyze the PCA muscle atrophy and to measure the severity of the PCA muscle atrophy in semi-quantitative manner. The grading of the PCA muscle atrophy was compared with the recruitment pattern of laryngeal electromyography (LEMG) and restoration of vocal fold movement. RESULTS: The PCA muscle was identifiable on CT in 73 subjects. Using the PCA muscle atrophy as an indicator of UVFP, we correctly predicted the paralysis in 69 (94.5%). Grade of the PCA muscle atrophy is significantly correlated with recruitment pattern of LEMG. If the positive result is defined as the PCA muscle showed moderate to severe degree of atrophy, we could predict the persistent UVFP in 88% of patients. CONCLUSIONS: PCA muscle atrophy identified on CT scan in patients with UVFP, is associated with low rates of return of mobility in the affected vocal fold.

Role of Matrix Metalloproteinases 7 in the Pathogenesis of Laryngopharyngeal Reflux: Decreased E-cadherin in Acid exposed Primary Human Pharyngeal Epithelial Cells.

Cleavage of E-cadherin and the resultant weakness in the cell-cell links in the laryngeal epithelium lining is induced by exposure to acidic contents of the refluxate. Herein, we aimed to evaluate the role of matrix metalloproteinases (MMPs) in inducing E-cadherin level changes following acid exposure to the human pharyngeal mucosal cells. E-cadherin levels were inversely correlated with the duration of acid exposure. Treatment with actinonin, a broad MMP inhibitor, inhibited this change. Immunocytochemical staining and transepithelial permeability test revealed that the cell surface staining of E-cadherin decreased and transepithelial permeability increased after acid exposure, which was significantly inhibited by the MMP inhibitor. Among the various MMPs analyzed, the mRNA for MMP-7 in the cellular component was upregulated, and the secretion and enzymatic activity of MMP-7 in the culture media increased with the acid treatment. Consequently, MMP-7 plays a significant role in the degradation of E-cadherin after exposure to a relatively weak acidic condition that would be similar to the physiologic condition that occurs in Laryngopharyngeal reflux disease patients.

Hydrogel-laden paper scaffold system for origami-based tissue engineering.

In this study, we present a method for assembling biofunctionalized paper into a multiform structured scaffold system for reliable tissue regeneration using an origami-based approach. The surface of a paper was conformally modified with a poly(styrene-co-maleic anhydride) layer via initiated chemical vapor deposition followed by the immobilization of poly-l-lysine (PLL) and deposition of Ca(2+). This procedure ensures the formation of alginate hydrogel on the paper due to Ca(2+) diffusion. Furthermore, strong adhesion of the alginate hydrogel on the paper onto the paper substrate was achieved due to an electrostatic interaction between the alginate and PLL. The developed scaffold system was versatile and allowed area-selective cell seeding. Also, the hydrogel-laden paper could be folded freely into 3D tissue-like structures using a simple origami-based method. The cylindrically constructed paper scaffold system with chondrocytes was applied into a three-ring defect trachea in rabbits. The transplanted engineered tissues replaced the native trachea without stenosis after 4 wks. As for the custom-built scaffold system, the hydrogel-laden paper system will provide a robust and facile method for the formation of tissues mimicking native tissue constructs.

Treatment of chemically induced oral ulcer using adipose-derived mesenchymal stem cell sheet.

BACKGROUND: This study investigated the effects of mesenchymal stem cell (MSC) sheet transplantation on healing of chemically induced oral ulceration in a rabbit animal model. METHODS: Oral mucosal ulcers were induced by topical application of filter paper soaked with 70% acetic acid to the anterior gingiva and buccal mucosa of 12 New Zealand white rabbits. The animals were randomly assigned to two groups: with (treatment group, n = 6) or without (control group, n = 6) cell sheets applied to ulcers. Gross findings were sequentially evaluated, and histologic examination was performed on day 7. RESULTS: Based on gross inspection, ulceration resolved before day 5 in the treatment group; however, in the control group, healing was incomplete on day 7. In the treatment group, the total area of the ulcer decreased significantly from day 2 to day 5 (P < 0.001) and from day 5 to day 7 (P = 0.020), whereas the area decreased significantly from day 5 to day 7 in the control group (P < 0.001). Histologic and immunofluorescence examination revealed full-thickness mucosa healing and complete basal cell coverage in the treatment group; in contrast, only partial healing was observed on day 7 in the control group. CONCLUSIONS: Cell sheet technology using MSC can be an alternative treatment for oral ulcerations in that it can decrease healing time without invasive properties.

Comparison of Learning Curves for Retroauricular and Transaxillary Endoscopic Hemithyroidectomy.

OBJECTIVE: This study aimed to evaluate and compare learning curves for the retroauricular (RA) and transaxillary (TA) approaches in endoscopic hemithyroidectomy. METHODS: The medical records of 290 patients who underwent hemithyroidectomy by either the RA or TA approach from November 2007 through December 2015 were retrospectively reviewed (113 patients with RA and 177 with TA). The two groups were compared with regard to patient characteristics, perioperative clinical results, and complications. Learning curves for the two approaches were compared based on the number of cases required to reach a consistent operation time and drainage amount. RESULTS: Age at diagnosis, tumor size and location, and thyroid size were not significantly different between the two approach groups. Multiplicity and extrathyroid extension were more prevalent in the RA approach (p = 0.048 and 0.020, respectively). Operation time and hospital day were significantly shorter in the RA approach (p < 0.001 and p = 0.030), while postoperative bleeding was less common in the TA approach (p = 0.021). Operation time and drainage amount stabilized after 50 cases for RA and 90 cases for TA. Additionally, operation time, amount of drainage, hospital stay, and complication rates significantly decreased after stabilization of the learning curve. When comparing the two approaches before stabilization, postoperative bleeding was more frequent in the RA approach (p = 0.044), while no difference was observed after stabilization. CONCLUSIONS: The RA approach seems to be beneficial for reducing operation time and hospital stay, and for stabilization of the learning curve. Postoperative bleeding should be considered during the period of early experience for the RA approach.

A prospective 1-year comparative study of transaxillary total thyroidectomy regarding functional outcomes: Is it really promising?

BACKGROUND: The purpose of this study was to evaluate postoperative voice outcomes and functional parameters in total thyroidectomy via a transaxillary (TA) approach. METHODS: Seventy-six patients who underwent total thyroidectomy via a TA approach (TA group) were included. A total of 204 patients who underwent conventional open total thyroidectomy (conventional group) in the same time period were analyzed as a control group. All patients underwent prospective functional evaluations before surgery and at 1 week and 1, 3, 6, and 12 months postoperatively using a comprehensive battery of functional assessments. RESULTS: There was no conversion to conventional open thyroidectomy in the TA group. Operation time and the amount of drainage were significantly higher in the TA group than in the conventional group (p < 0.001 and p = 0.033, respectively), while vocal cord paralysis, hypoparathyroidism, and hematoma were not different among two groups (p = 0.215, 0.290, and 0.385, respectively). Regarding GRBAS, the TA group showed a more aggravated tendency postoperatively, although statistical significance was attained only at postoperative 6 months (p = 0.043). The voice handicap index abruptly increased postoperatively in the TA group, showing significant differences with the conventional group at postoperative 1 week and 1 month (p < 0.001 and p = 0.001, respectively). Fundamental frequency and maximal vocal pitch did not significantly change postoperatively in either group. The conventional group showed a more rapid decline in pain than the TA group, and paresthesias on the neck and chest were more aggravated in the TA group during the early postoperative period. The dysphagia handicap index was higher in the TA group, while cosmesis was better in the TA group at all postoperative periods. CONCLUSIONS: Although cosmetic outcome was better with the TA approach, the longer operation time, aggravated subjective voice outcomes, paresthesia, and swallowing function need to be considered in selecting the operative approach.

Targeting HIF1α peri-operatively increased post-surgery survival in a tongue cancer animal model.

BACKGROUND: The purpose of the present study was to evaluate the relationship between hypoxia-inducible factor 1 alpha subunit (HIF1α) and tumor initiation in squamous cell carcinoma cell lines and whether targeting HIF1α perioperatively might exert positive effects on survival or recurrence in an animal model. METHODS: The expression of HIF1α and tumorigenic potential in nude mice was compared using human head and neck squamous cell carcinoma cell lines (SNU1041, SNU1066, SNU1076, PCI01, PCI13, PCI50). A recurrent tongue cancer model was established by first injecting tumor cells in the lateral tongue and then excising the tongue masses for replanting in the neck. The effect of HIF1α inhibitors was assessed using this animal model. RESULTS: We observed good correlation between tumorigenic potential and HIF1α nuclear expression in the cell lines tested. Furthermore, knockdown of HIF1α inhibited tumor growth in the animal model. After in vitro testing of five HIF1α inhibitors, echinomycin and LAQ824 were selected for the animal study. Pre- and postoperative treatment with echinomycin showed significant improvement in postsurgery survival and recurrence. CONCLUSIONS: Our results suggested that adjuvant targeting of HIF1α before and after surgery could be a new targeted therapy strategy for squamous cell carcinoma.

Prediction of thyroid hormone supplementation after thyroid lobectomy.

BACKGROUND: Thyroid function, as assessed by thyroid-stimulating hormone (TSH) levels, was evaluated in patients after thyroid lobectomy. These assessments were analyzed against perioperative measurements to determine if any of these preoperative values were predictive of postoperative hypothyroidism and the need for postoperative levothyroxine treatment. METHODS: In a retrospective study, data from 276 thyroid lobectomy patients were examined. These surgeries occurred over the period from January 2003-December 2012. Age, sex, volume of resected thyroid, thyroiditis, preoperative free T4, TSH, and microsomal antibody levels were analyzed for correlation with postoperative levothyroxine supplementation. RESULTS: The overall percentage of the patients taking postoperative levothyroxine was 23.6%. The preoperative TSH level showed strong correlation with TSH levels measured 1-mo postoperatively (P < 0.001). Preoperative TSH levels >2.5 mIU/L and positive microsomal antibody showed significant correlation with postoperative levothyroxine supplementation (P < 0.001; relative risk, 8.933, and 3.438, respectively). By stratifying the patients based on preoperative TSH levels and presence of microsomal antibodies, in the low-risk group with TSH <2.5 mIU/L and negative microsomal antibody, 7% of patients received postoperative levothyroxine replacement but in the high-risk group with TSH >2.5 mIU/L and positive microsomal antibody, 77.8% required levothyroxine replacement (P < 0.001). CONCLUSIONS: The most significant preoperative predictors for levothyroxine supplementation are preoperative TSH level and presence of microsomal antibodies. Patients with preoperative TSH <2.5 mIU/L showed a low risk of requiring postoperative levothyroxine supplementation.

Neck computed tomography in pediatric neck mass as initial evaluation in ED: is it malpractice?

BACKGROUND: Although ultrasound is regarded as the first choice imaging modality for evaluating a pediatric neck mass, neck computed tomography (CT) is necessary for urgent surgical conditions such as deep neck infections. Our aim was to evaluate the diagnostic effectiveness of and proper patient selection for neck CT as a method for the initial evaluation of pediatric neck masses in the emergency department. METHODS: We analyzed the medical records of 105 pediatric patients who visited the emergency department with neck mass whose initial imaging work-up was a neck CT and who visited the emergency department with a neck mass. The parameters investigated included the patient's age, sex, symptom duration, clinical impression, CT interpretation, final diagnosis, and treatment. The positive predictive value (PPV) for CT was calculated, and the parameters that correlated with an urgent surgical condition post-CT were evaluated. RESULTS: The median age was 6.5 years (1 month to 12 years), and the male-to-female ratio was 2:1. The most common initial impression was acute cervical lymphadenopathy. A comparison of the final diagnosis and CT scan demonstrated that the overall PPV was 96.2%. If the initial impression was a deep neck infection, a salivary gland infection, or tonsillitis, the PPV for CT was 100%. Fever (>38.0°C) and severe tenderness were significant between patients with and without urgent surgical conditions on CT. CONCLUSIONS: Computed tomography could be considered as the first diagnostic modality when an urgent surgical condition such as a deep neck infection is highly suspected.