Discover new updates in otolaryngology.
Made for medical students, by medical students.
2021
December 15th, 2021
December 1st, 2021
November 17th, 2021
November 3rd, 2021
October 20th, 2021
October 7th, 2021
September 15th, 2021
September 1st, 2021
August 16th, 2021
August 2nd, 2021
July 1st, 2021
December 1st, 2021
Medical Student Feature Article of the Month
Editor’s Note: The Auricle team is excited to introduce a recurring section showcasing well-designed and superbly written medical student-led projects. We love recognizing and learning from our colleagues’ hard work!
This Month's Feature: Emily L. Mace, Vanderbilt University School of Medicine, Class of 2022
Emily L Mace, Shilin Zhao, Brittany Lipscomb, Christopher T Wootten, Ryan H Belcher. Mast Cells in Pediatric Aerodigestive Disease. Otolaryngology- Head and Neck Surgery.
Beyond the allergic response: a close-up look into the role of mast cells in upper airway pathologies
Mast cells have been implicated in several inflammatory disorders ranging from migraines to rheumatoid arthritis. Despite laryngeal involvement in several aerodigestive pathologies, the role of mast cells in these specific inflammatory conditions is unknown. In this study, Mace et al. examined arytenoid mucosal biopsies obtained from 461 pediatric patients (ages 3-weeks-old to 18-years-old) who underwent airway procedures or evaluations between 2014-2019. When compared to patients without mast cells present in their biopsy specimens, patients with mast cells in their biopsies experienced a higher prevalence of asthma (p=0.006), gastroesophageal reflux disease (p=0.01), obstructive sleep apnea (p=0.008), laryngomalacia (p<0.001), and laryngeal anomalies (p<0.001). Additionally, logistic regression analyses revealed that there was a nonlinear relationship between the number of mast cells present in laryngeal biopsies and the odds of disease. This study reports a novel correlation between the presence of mast cells in the pediatric larynx and the diagnosis of specific aerodigestive pathways. Future studies may identify the exact pathophysiology of mast cells in these disease processes and also delineate how mast cell count impacts the odds of disease.
Kavya Pai’s Takeaway: This study serves as an exciting foundation for future research aiming to explore the relationship between mast cells and upper airway pathologies. As we learn more about the role of mast cells in these conditions, it would be interesting to determine if specific medications targeted against mast-cell activity may alleviate patients’ symptoms.
Head and Neck Surgery
Tooba Alwani, Jennifer N Shehan, Jessica LeClair, Taylor F Mahoney, Pratima Agarwal, Salil T Chaudhry, Judy J Wang, Jacob P Noordzij, Lauren F Tracy, Heather A Edwards, Gregory Grillone, Andrew R Salama, Scharukh M Jalisi, Anand K Devaiah. Effect of Distance from Hospital on Head and Neck Cancer Follow Up. Laryngoscope.
Want good follow up for head and neck cancer patients? Don’t let your patients stray too far!
Social determinants of health (SDOH) such as education, race, and socioeconomic status have been previously implicated in disease outcomes for head and neck cancer (HNC). HNCs represent a significant disease burden in the US, and follow up plays an important role post-treatment, although specific guidelines vary based on the primary cancer. Although there have been some previously published associations with SDOH and follow-up in HNC, the authors of this study sought to analyze long term (5 year) follow up data in this retrospective chart review of patients from 1997 to 2019 with a diagnosis of head and neck primary cancer. They found that race, insurance status, language, birth country, or income were not significantly associated with follow up. However, patients who lived further away from the primary hospital were more likely to be lost to follow up. Many SDOH have programs which attempt to ameliorate them, such as food pantries, language interpreters, or payment assistance. To help patients located farther away continue to follow up, it may be best to have increased local care options, tele-health visits, or scheduled transportation. An initial assessment pre-treatment would also be helpful in screening patients at higher risk of being lost to follow up.
Aatin Dhanda’s Takeaway: Social determinants of health and the role they play is something that we are learning more about in our medical school education. Although we often learn about the way that SDOH increases risk for diseases, this study shines light on follow up after we have already “treated” the disease. The results of this study and others regarding SDOH will present a unique challenge for the rising generation of physicians to address.
Otology and Neurotology
Mirko Aldè, Federica Di Berardino, Paola Marchisio, Giovanna Cantarella, Umberto Ambrosetti, Dario Consonni, Diego Zanetti. Social Isolation and Prevalence of Otitis Media with Effusion. Otolaryngology- Head and Neck Surgery
The pandemic lockdown limits the spread of more than COVID-19
A nationwide lockdown in Italy in response to the COVID-19 outbreak took place between March 9-May 18, 2020 where all schools and day care centers were closed and people were restricted to their homes. This retrospective study investigated how social isolation during the SARS-CoV-2 pandemic may have affected the prevalence of otitis media with effusion (OME) in 932 children between 6 months and 12 years of age. These children met all 3 diagnostic criteria for OME: type B tympanogram, positive otomicroscopic findings, and ipsilateral conductive hearing loss. The prevalence of OME was reported from 3 time periods: 2 prior to social isolation due to lockdown (May 1-June 30 2019 and Jan 1-Feb 29 2020) and 1 immediately after the lockdown (May 1-June 2020). It was found that the prevalence of OME was 40.6% between May-June 2019, 52.2% between Jan-Feb 2020, and 2.3% between May-June 2020. In addition, children with chronic OME had a resolution rate of 93.3% in May-June 2020 and 20.7% in May-June 2019 (p<0.001). It was concluded that social isolation and increasingly hygienic behavior contributed to containing the development and persistence of OME. An important limitation of this study was the possibility that some patients may have postponed treatment due to parents’ reluctance to take children to the hospital during the pandemic.
Carla Baaklini’s Takeaway: This study suggests that keeping children at home for as short as 2 months could allow resolution of severe OME and that this could be considered for young children. This article will remind me to assess a child’s living and social situation when treating OME.
Rhinology and SINUS SURGERY
Jordan J Allensworth, Rodney J Schlosser, Timothy L Smith, Jess C Mace, Zachary M Soler. Utilizing a Questionnaire to Assess Dietary Quality in Patients with Olfactory Dysfunction. International Forum of Allergy and Rhinology.
Would you eat the same way if you couldn’t smell well?
Summary in my own words: Olfactory dysfunction (OD) – otherwise known as smell loss – has been shown to be associated with quality of life, social interactions, mental health, and mortality. OD has also been suspected to alter dietary behaviors. In this prospective cross-sectional study, Allensworth et al. recruited 60 subjects ≥ 18-years of age to investigate if and how OD influences nutritional intake. The Sniffin’ Sticks testing kit was used to determine odor threshold, discrimination, and identification (TDI) scores as a proxy for olfactory function, and OD was defined as a TDI score ≤ 31. Dietary intake was assessed with the Diet History Questionnaire III (DHQIII), and the Healthy Eating Index (HEI) was calculated as a measure of dietary quality and compliance. Out of the 60 subjects that met inclusion criteria, 29 (48.3%) were classified as dysosmic, with an average TDI score of 18.8 ± 8.2 (compared to normosmic controls 33.8 ± 2.6). There were significantly positive correlations between TDI score and HEI component scores for protein (r=0.256; p=0.048), dairy (r=0.285; p=0.027), and saturated fat (r=-0.262; p=0.043). Additionally, the percentage of calories obtained from saturated fats was significantly lower in dysosmic subjects compared with normosmic controls [ mean (SD): 9.5 (2.0) v. 10.8 (2.9), p=0.044].
Isaac A. Bernstein's Takeaway: Although this was an exploratory pilot study with a small sample, this paper suggests that the relationship between OD and diet quality is not as clear nor dramatic as one may suspect.
Pediatric Otolaryngology
Zahrah M Taufique, Paul J Escher, Tyler J Gathman, Amanda J Nickel, Daniel B Lee, Brianne B Roby, Sivakumar Chinnadurai. Risk of Malnutrition in Patients With Cleft Lip and Palate Based on Demographic Data. Laryngoscope.
Malnutrition in Patients With Cleft Lip and Palate: More Than a Feeding Issue
Infants with cleft lip and palate (CLP) can struggle to breast and bottle feed, leading to decreased milk transfer, low caloric intake, increased feeding time, and increased energy expenditure. As a result, many patients with CLP are malnourished, which is concerning given recent data showing that malnutrition is associated with increased risk of postoperative wound healing complications. This study sought to determine if demographic data was associated with malnutrition risk in 313 patients who underwent initial CLP repair or CLP revision surgery between 2006 to 2018. A total of 205 (65.5%) patients were white and 108 (34.5%) were black, indigenous, or people of color. For every $1000 decrease in MNI, the Z-score for acute malnutrition decreased by 0.05 (P=.047) while the Z-score for chronic malnutrition decreased by 0.9 (p=0.011). Thus, MNI should be taken into account as a risk factor for malnutrition and postoperative complications in patients with CLP.
Alyssa Reese’s Takeaway: Social determinants of health, notably income, should be taken into consideration when treating infants with CLP in order to prevent malnutrition secondary to socioeconomic status.
Laryngology
Shaghauyegh S Azar, Pranati Pillutla, Lauran K Evans, Zhaoyan Zhang, Jody Kreiman, Dinesh K Chhetri. Perceptual Evaluation of Vocal Cord Asymmetry. Laryngoscope.
Expect the unexpected – vocal cord asymmetry might sound better in some cases
Vibratory asymmetry often occurs in laryngeal paresis and can result in both dysphonic or normophonic speech. Previous articles have studied vibratory asymmetry with varying results in its relation to voice quality. This study’s goal was to utilize an in vivo canine model to analyze asymmetric vibration and its perception in speech quality as well as study cepstral peak prominence (CPP) in relation to vibration patterns. Participants ranked clips from canines with various vibratory patterns from best to worst in their own auditory perception. Participants preferred sound samples from low recurrent laryngeal nerve (RLN) levels compared to high levels. At mid-RLN stimulation levels symmetric vibration was preferred over asymmetric, while at high-RLN stimulation levels asymmetric vibration was preferred due to a perceived strain in the voice quality with symmetric vibration. Unlike previous studies, the CPP did not have a relationship with perceptual ratings limiting its use as a clinical marker for voice quality perception. There was a complicated relationship between voice quality and vibratory asymmetry, not a linear relationship as was previously expected. Since there is no quantitative assessment of vocal paresis severity, qualitative studies such as this one must provide the data needed to decipher benign asymmetries from those clinically significant.
Lauren Howser’s Takeaway: This is a very interesting article due to its unique in vivo canine study model. Overall, this model showed that vibratory asymmetries are more complex than originally hypothesized in regard to speech perception.
Facial Plastics & Reconstructive Surgery
Andrew Lee, Jonathan J Wisco, Jennifer N Shehan, Krystyne Basa, Jeffrey H Spiegel. Postoperative Effects of Chondrolaryngoplasty. Facial Plastic Surgery & Aesthetic Medicine.
Tracheal shave is effective, but is it safe in the long term?
Chondrolaryngoplasty is a component of facial feminization surgery that reduces the prominence of the thyroid cartilage. As limited data exists related to the effects this procedure may have on swallowing, this study aimed to measure postoperative swallowing symptoms among patients who underwent chondrolaryngoplasty. Using a retrospective survey study approach, the author’s conducted an evaluation on if there were significant long term postoperative swallowing difficulties. The survey was given to patients ages greater than or equal to 18 years old who underwent a chondrolaryngoplasty during the time between December 2010 and December 2020, each with the thyroid cartilage 1-2 mm above the vocal ligament removed. Patients were given a survey assessing whether they had swallowing symptoms, followed by the Eating Assessment Tool (EAT-10) questionnaire, which is a 10-item swallowing symptom survey, to further assess these symptoms. A total of 456 patients were surveyed with 88 (19.3%) completed responses. 83 of 88 patients (94.3%) did not have swallowing symptoms. Of the five patients with swallowing symptoms, two thought they were related to the chondrolaryngoplasty procedure and only one symptom was higher than mild on the severity scale. Overall, this study is the first to evaluate long-term risks of dysphagia in chondrolaryngoplasty. Although this was a single-institution, retrospective survey study, the results do point to the conclusion of very minimal risk regarding long-term swallowing problems after a chondrolaryngoplasty procedure.
Nicole Favre’s Takeaway: As a medical student, the findings of this article allowed me to recognize that in research, no associations are sometimes just as meaningful as positive/negative associations. Finding that the prevalence of dysphagia among patients after chondrolaryngoplasty were similar to those of the general population can help to make patients feel more comfortable and secure in undergoing this procedure as part of facial feminization surgery. No association between chondroplasty and swallowing problems in this case is a very meaningful, positive finding for this patient population.
Question of the Week
A 16-year-old female presents to the ED complaining of right-sided throat pain and painful swallowing over the past 6 days. Physical exam reveals an erythematous, swollen right tonsil with left uvular deviation. Needle aspiration yields purulent fluid. Patient’s mother states that she has had three previous episodes over the past few years.
What is the next best step in management?
A. Oral penicillin, ibuprofen and observation
B. Repeat drainage over the next 8-12 hours
C. Tonsillectomy
D. Warm salt water gargling and rinsing
Quiz Answer: C (Recurrent tonsillitis)
Patients with recurrent tonsillitis (≥3 episodes in the previous 1 to 3 years) should be considered for tonsillectomy.
November 17th, 2021
Feature Article of the Month
Advancements in Sleep Surgery
Maeve Pascoe, Lu Wang, Joan Aylor, Reena Mehra, Alan Kominsky, Nancy Foldvary-Schaefer, Vaishal Shah, Tina Waters, Harneet Walia. Hypoglossal Nerve Stimulation v. Positive Air Pressure for Obstructive Sleep Apnea. Otolaryngology - Head and Neck Surgery.
Does hypoglossal nerve stimulation improve insomnia, depressive symptoms, and patient reported outcomes in those with obstructive sleep apnea?
Obstructive sleep apnea (OSA) is a condition that may produce devastating long-term cardiac and metabolic effects. OSA is also associated with other morbid conditions such as insomnia and depression due to the decreased quality and quantity of sleep that ensues. The current gold standard of treatment for OSA is positive airway pressure ventilation (PAP). However, high rates of non-compliance remain an issue with this treatment modality. Hypoglossal nerve stimulation (HNS) has emerged as a novel method in the treatment of moderate to severe OSA and has been shown to improve numerous OSA metrics. This current study attempted to assess whether HNS 1-year post-operatively beneficially improves patient reported outcomes, specifically insomnia, quality of life, and symptoms of depression when compared to PAP after 3 months of treatment in a matched cohort of patients. This was done using Apnea Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), Patient Health Questionnaire-9 (PHQ, depression), Insomnia Severity Index (ISI), and Functional Outcomes of Sleep Questionnaire (FOSQ) scales. Both HNS and PAP resulted in statistically significant, but comparable improvements in ESS, ISI, and FOSQ scores. For PHQ-9, while they both led to significant score reductions (least square means, −4.06 [95% CI, −5.34 to −2.79] for HNS vs −2.58 [95% CI, −3.35 to −1.82] for PAP, HNS was associated with a greater decrease when compared to PAP (−1.48 [95% CI, −2.78 to −0.19]). This study demonstrates thSamer’s Takeaway: The use of HNS in the treatment of OSA has been revolutionary. Not only does this method improve physiologic parameters, but also patient reported outcomes at a rate comparable to—if not better than the current recommended treatment, PAP.at sustained improvement in patient reported symptoms can be obtained from HNS in the treatment of OSA.
Samer Elsamna's Takeaway: The use of HNS in the treatment of OSA has been revolutionary. Not only does this method improve physiologic parameters, but also patient reported outcomes at a rate comparable to—if not better than the current recommended treatment, PAP.
Head and Neck Surgery
Larissa Sweeny, Erica Mayland, Brian P. Swendseid, Joseph M. Curry, Alexandra E. Kejner, Carissa M. Thomas, Joshua J. Kain, Steve B. Cannady, Kendall Tasche, Eben L. Rosenthal, Michael DiLeo, Adam J. Luginbuhl, Hailey Theeuwen, Juliana R. Sarwary, Daniel Petrisor, and Mark K. Wax. Free Flap Reconstruction for Osteonecrosis – Are Patients Happy in the Long Term? Otolaryngology-Head and Neck Surgery.
How does free flap reconstruction for osteonecrosis of the head and neck translate into quality of life and long-term outcomes?
Osteonecrosis of the head and neck is a painful and debilitating condition that is most often caused by previous radiation therapy but can also be caused by prolonged bisphosphonate therapy. While milder cases can be treated conservatively, advanced osteonecrosis often requires surgical resection and subsequent reconstruction. This study is a multi-institutional retrospective review that investigated long-term outcomes and quality of life (QOL) in patients undergoing microvascular reconstruction for advanced osteonecrosis due to previous radiation (ORN) or chronic bisphosphonate use (BRONJ). QOL is assessed using the University of Washington Quality of Life (UW-QOL) questionnaire. The authors found the results of the UW-QOL to be favorable in domains that reflected stability or improvement postoperatively. Specific favorable responses included: minor or no speech difficulties (93%), normal taste function (19%), no pain (45%), minor or no change in appearance (69%), minor or no limitations in mastication (29%), generally excellent mood (44%) and no or minimal anxiety about their cancer (94%). There were no significant differences in UW-QOL domain scores when stratified by location of osteonecrosis, donor tissue used for reconstruction, or use of soft tissue only versus osteocutaneous free flap for reconstruction. Additionally, the majority of patients experienced either maintenance or advancement in their diet postoperatively. These findings suggest free flap reconstruction for advanced osteonecrosis is safe, feasible, and overall associated with improved QOL and long-term outcomes such as diet and pain.
Anastasia Jermihov’s Takeaway: After caring for patients in the hospital as they start their long road to recovery after undergoing free flap reconstruction, I have often wondered how the long hours invested in their care translate into long-term outcomes. As the largest to date study on long-term outcomes and QOL in patients requiring free flap reconstruction for osteonecrosis, this study provides reassurance that the efforts and advancements made in free flap surgery produce beneficial outcomes. This study’s findings can also help inform discussions with patients regarding expectations postoperatively.
Otology and Neurotology
Temitope G Joshua, Aysha Ayub, Printha Wijesinghe, Desmond A Nunez. Evaluation of Hyperbaric Oxygen Therapy for Patients with Sudden Sensorineural Hearing Loss. JAMA Otolaryngology-Head & Neck Surgery
Patients with Sudden Sensorineural Hearing Loss may finally breathe a sigh of relief.
Sudden sensorineural hearing loss (SSHNL) is defined as an acute, usually unilateral hearing loss of at least 30 decibels (dB) over the course of 3 days that affects 3 or more contiguous frequencies without a known cause. Typically, SSHNL is attributed to inner ear hair cell damage; however, many patients demonstrate partial or complete hearing recovery. While systemic or intratympanic corticosteroids are commonly used to treat SSHNL, hyperbaric oxygen therapy (HBOT) is another treatment that may be used in conjunction or as salvage therapy to improve outcomes in patients with SSHNL. Although it is hypothesized that decreased cochlear tissue oxygenation may cause SSHNL, HBOT is not widely offered. Therefore, the authors conducted a systematic review and meta-analysis of 3 prospective randomized controlled trials of adult (≥18 years) participants to assess the effectiveness of HBOT as a single or combination therapy for SSHNL (88 participants) compared with control treatments of steroid and/or placebo (62 participants). Outcome measures included the mean differences in absolute hearing gain recorded by pure-tone audiometric (PTA) thresholds averaged across 4 low or 3 high frequencies, as well as the odds ratio (OR) of post-treatment hearing recovery, defined as a hearing gain of ≥ 10 dB in PTA average. Ultimately, the intergroup difference in mean absolute hearing gain (mean difference, 10.3 dB; 95% CI, 6.5-14.1 dB; I2 = 0%) and the odds ratio of hearing recovery (4.3; 95% CI, 1.6-11.7; I2 = 0%) favored HBOT as part of a combination treatment over the control therapy.
David Avery Cohen's Takeaway: SSHNL may dramatically decrease someone’s quality of life. As such, the promise of HBOT is encouraging. However, given that HBOT protocols varied in the 3 studies included in this systematic review, further study is necessary to ascertain the number and duration of HBOT sessions required to definitely optimize therapeutic effects and outcomes. Moreover, although HBOT is currently recommended to all patients with SSHNL, further study may also be required to determine if the degree of SSHNL severity may impact HBOT’s therapeutic benefits.
Rhinology and SINUS SURGERY
David Zarabanda, Neelaysh Vukkadala, Katie M Phillips, Z Jason Qian, Kenji O Mfuh, Matthew J Hatter, Ivan T Lee, Vidya K Rao, Peter H Hwang, George Domb, Zara M Patel, Benjamin A Pinsky, Jayakar V Nayak. Povidone-Iodine Nasal Spray: Effective COVID-19 Treatment?. Laryngoscope.
Is Povidone-Iodine Nasal Spray tolerable in patients with COVID-19?
Povidone-iodine (PVP-I) solution is a widely available antiseptic medication. Prior research has shown that PVP-I solutions inactivated more than 99.9% of the SARS-CoV-2 virus in vitro. There are concerns that use of PVP-I may not work in vivo due to mucociliary clearance and that adults may not tolerate high concentrations of the spray due to burning. This study included individuals with a documented positive nasopharyngeal swab for COVID-19 within 5 days. Patients were placed in 3 groups: 0.9% NaCl (placebo), 0.5% PVP-I in water, and 2% PVP-I in water. Subjects were instructed to use 2 sprays per nostril for 5 days total. On days 1, 3, and 5 the participants rated their symptoms on a Likert scale, 1 being not experiencing symptoms and 4 indicating severe symptoms. The following symptoms were assessed: fever, chills, fatigue, smell, taste, congestion, and sore throat. Eleven participants were assigned to the saline group, 11 to the 0.5% PVP-1 group, and 13 to the 2% PVP-1 group. Patients who used the 2.0% PVP-I group showed statistically significant improvement in all symptoms, while those in the 0.5% PVP-I group reported significant improvements in taste and sore throat. Patients in the saline group reported significant improvements in fever, chills, fatigue, and congestion. When asked about the overall health status, all participants reported feeling either the same or better on days 3 and 5. Those in the 2.0% PVP-I group reported significantly more nasal burning and sneezing compared to the other groups. However, no participants reported worsening of olfaction, assessed using pre and posttest UPSIT (University of Pennsylvania Smell Identification Test) smell test. Overall, patients using all of the nasal spray formulations showed a similar reduction in viral load over 3 days. The 2% PVP-I group showed the most promising improvement in symptoms; however, this group also displayed more burning symptoms than the other groups.
Lauren DiNardo’s Takeaway: PVP-I intranasal solution shows promise as a therapeutic agent for SARS-CoV-2; however, adverse effects of burning and change in olfaction need to be kept in mind when administering higher concentrations of this solution.
Pediatric Otolaryngology
Chad K Sudoko, Caryoln M Jenks, Andrew J Bauer, Amber Isaza, Sogol Mostoufi-Moab, Lea F.Surrey, Tricia R Bhatti, Aime Franco, N Scott Adzick, Ken Kazahaya. Thyroid Lobectomy for T1 Papillary Thyroid Carcinoma in Pediatric Patients. JAMA Otolaryngology- Head and Neck Surgery.
The current recommendation for pediatric patients with papillary thyroid cancer (PTC) is a total thyroidectomy but can a certain subgroup of patients benefit from a thyroid lobectomy instead?
Thyroid cancer is the most common endocrine cancer in children and its incidence has been accelerating over the past two decades. Similar to thyroid cancer in adults, approximately 90% of pediatric thyroid cancer is composed of papillary thyroid carcinoma (PTC). However, pediatric PTC patients frequently present with more advanced disease, multifocality, and higher rates of recurrence than adults. Total thyroidectomy has long been the preferred management of pediatric PTC as it has been shown in some studies to lower the risk of recurrence and persistent disease from 35% to 6% in pediatric patients. Total thyroidectomy, however, is not without considerable operative risks which are increased in children compared to adults. These include hypoparathyroidism, recurrent laryngeal nerve injury, and need for lifetime TH replacement therapy. In this study, researchers performed a retrospective cohort study of 102 patients who were surgically treated at a tertiary care medical center for T1 PTC with the goal of identifying a select group of patients who may benefit from a more conservative surgical approach. Of the 52 patients with T1a tumors unilateral multifocality was associated with bilateral disease (odds ratio [OR], 2.1; 95% CI, 1.3-3.4) and N1a disease (OR, 5.1; 95% CI, 1.5-17.6). Both N1a disease (OR, 20.0; 95% CI, 3.5-115.0) and ≥4 positive lymph nodes (OR, 8.6; 95% CI, 1.2-60.9) were associated with bilateral disease. In patients with no pathologic evidence of lymph node metastasis (N0), there was a 95% rate of unilateral PTC. The findings of this cohort study suggest that, in patients with unifocal T1a PTC without clinically evident nodal disease on preoperative ultrasonography, a thyroid lobectomy and central neck dissection may be considered as the majority of patients (approximately 80%) will have unilateral disease.
Mohammad A. Hossain's Takeaway: Despite having more advanced disease at presentation, overall survival for PTC is excellent and greater than 91% at 30 years for children. A certain subset of patients, specifically those with unifocal T1a PTC without clinically evident nodal disease and thus decreased odds of bilateral disease, may be eligible for lobectomy as an alternative to total thyroidectomy.
Laryngology
Tiffany V. Wang, Nat Adamian, Phillip C. Song, Ramon A. Franco, Molly N. Huston, Nate Jowett, Matthew R. Naunheim. Machine Learning Analysis of Vocal Fold Paralysis. Otolaryngology - Head and Neck Surgery.
Artificial intelligence driven approach to quantitatively assess unilateral vocal fold paralysis.
The Massachusetts Eye and Ear Infirmary developed a machine learning program for objectively analyzing vocal fold dynamics called Automated Glottic Action Tracking by artificial Intelligence (AGATI), capable of automatically measuring anterior glottic angle (AGA), angular velocity and angular acceleration from videoendoscopy. This study was conducted to demonstrate AGATI’s clinical applications for differentiating between patients with and without unilateral vocal fold paralysis (UVFP) and determining relationships between AGATI-measured AGA and patient outcomes following vocal fold procedure. 70 individuals with UVFP and 72 healthy individuals without UVFP were included and video of their vocal fold movements were analyzed using AGATI. Moreover, 26 UVFP patients received procedural intervention, and their AGATI-measured AGA and VHI-10, EAT-10, and DI scores were compared before and after intervention. There were significant differences in average 3rd percentile, 97th percentile, and maximum AGA between UVFP and healthy patients (p<0.001). Difference between 97th percentile and 3rd percentile AGA was found to be the best predictor of UVFP with an AUC of 0.869, sensitivity of 77%, and specificity of 92% (p<0.0001). There were no significant associations between AGA and VHI-10, EAT-10, and DI scores before and after procedural intervention. While AGATI demonstrated utility in detecting UVFP, the authors conclude that further study will be necessary to validate this software’s application towards the automatic diagnosis of UVFP and identifying correlations with other measurements of patient clinical characteristics and outcomes.
Christopher Tseng's Takeaway: With the further advancement of artificial intelligence technology, great strides have been taken to investigate applications of machine learning to medical image analysis, especially in Otolaryngology. Programs like AGATI hold significant potential for developing diagnostic tools which can enhance our understanding of vocal fold movement disorders and the applications of these technologies to clinical practice.
Facial Plastics & Reconstructive Surgery
Laryngoscope
Optimal Management of the Vascular Pedicle: Maneuvers, Flap Survival, and Complications in Upper and Midfacial Free Flap Reconstruction
Brian Swendseid, Matthew Stewart, Eric Mastolonardo, Elanor McCreary, Ryan Heffelfinger, Adam Luginbuhl, Larissa Sweeny, Mark K. Wax, Joseph Curry
How can we apply the goldilocks principle to reconstructive surgery?
Reconstruction of the upper and midface is a challenging procedure due to many anatomic concerns such as orbital support, nasal patency, midfacial projection, dietary and dental rehabilitation, and facial buttress restoration. This procedure is usually performed using soft tissue or osteocutaneous free flaps which further complicate things, given the considerable distance from the flap to the recipient vessels for anastomosis. There are several vessel-related and pedicle-related solutions to this surgical challenge which are what the present authors sought to investigate using a prospective database collecting multicenter data between 2004 and 2019 on patients who underwent partial/total maxillectomy or periorbital tumor resection and received free flap reconstruction for the resulting defect. The resulting 295 patient cases meeting inclusion criteria were subsequently analyzed to characterize frequency of vascular pedicle-related maneuvers, flap survival, and complications. 86% of vascular pedicles were able to reach the ipsilateral neck for anastomosis with the most common recipients being facial artery (78%) and facial vein (63%). Cases which required alternative techniques to accommodate anastomosis were vascular grafting (7% of cases) using the saphenous, external jugular, or anterior jugular veins; additionally, revision cases were more likely to require venous grafting (17% versus 5%, OR 3.8, 95% CI 1.5-9.6, p=.004). Venous grafting featured an increased risk of complications, overall, and flap failure (42% versus 19%, OR 3.6, 95% CI 1.4–9.1, p=.006) and flap failure (19% versus 3%, OR 6.9, 95% CI 1.9–24.8, p=.003).
Pavan S. Krishnan's Takeaway: Management of the vascular pedicle is a crucial aspect of flap reconstruction, which is made more difficult by the multitude of variability in these cases based on anatomical and pathological differences, surgeon preference, and resident training. Further studies with similar methods in a larger population would help increase the generalizability of these findings.