Andrea Castellucci

Long-term outcomes of central neck dissection for cN0 papillary thyroid carcinoma ☆

OBJECTIVE The risk-benefit ratio of central neck dissection (CND) in patients affected by papillary thyroid carcinoma (PTC) without clinical or ultrasonographic (US) evidence of neck lymph node metastasis (cN0) is currently debated. The aim of this study was to evaluate long-term outcome of CND on locoregional recurrence, distant metastasis, survival, and postoperative complications in a large series of patients with cN0-PTC. STUDY DESIGN Observational retrospective controlled study. METHODS Clinical records of patients (n=610) surgically treated for cN0-PTC at the Otolaryngology Unit of the Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy, from January 1984 to December 2008, were retrospectively reviewed. Study population was divided into three groups according to surgical treatment: Group A, total thyroidectomy (n=205); Group B, total thyroidectomy and elective ipsilateral CND (n=281); Group C, total thyroidectomy and bilateral CND (n=124). RESULTS Of a total of 610 patients, 305 (50%) were classified as low-risk, 278 (45.57%) as intermediate-risk, and 27 (4.43%) as high-risk. Response to initial therapy was excellent in 567 patients (92.95%), acceptable in 21 (3.44%), and incomplete in 22 (3.61%), with no significant differences among groups. Locoregional recurrence was detected in 32 (5.2%) out of 610 patients. Distant metastasis was found in 15 patients (2.5%). Statistical analysis showed no significant differences in the rates of locoregional recurrence (p=0.890) or distant metastasis (p=0.538) among groups. Disease-specific mortality and overall survival did not significantly differ among groups (p=0.248 and 0.223, respectively). Rate of permanent hypoparathyroidism was significantly higher in Group C patients compared to those in Groups A and B. CONCLUSION CND does not confer any clear advantage in the treatment of low-risk patients, regardless of surgical procedure. Instead, bilateral CND may be effective in limiting disease relapse and/or progression in patients at higher prognostic risk. Our data indicate that elective CND does not confer any clear advantage in terms of locoregional recurrence and long-term survival, as demonstrated by outcomes of the study Groups, regardless of their different prognostic risk. Elective CND allows a more accurate pathologic staging of central neck lymph nodes, despite its increasing the risk of permanent hypoparathyroidism. Intraoperative pathologic staging is a valuable tool to assess the risk of controlateral lymph node metastasis in the central neck compartment and to limit more aggressive surgery only to cases, otherwise understaged, with lymph node metastasis.

Waldenström's macroglobulinemia presenting with bilateral vestibular loss: a case report

Waldenstrom’s macroglobulinemia (WM) is a low-grade lymphoma originally described in 1944. It is a malignant lymphoproliferative disease characterized by the clonal expansion of B cells with lymphoplasmacytic differentiation that secrete monoclonal immunoglobulin M (IgM). Diagnostic criteria are based on specific clinical, morphological, and immunophenotypic parameters, besides the evidence of pathologic plasmacytoid cells in the bone marrow. Symptoms can be related either to tumor infiltration or to the amount and properties of the circulating monoclonal protein: cardiac and renal failure, mucosal bleeding, headache, visual disturbances, ataxia, and eventually coma have been described as part of the clinical spectrum of WM. Peripheral neuropathy occurs in nearly half of the patients and is mostly related to the reactivity of the IgM protein with different neural antigens. Frequently, it represents the initial presentation of the disease; sometimes it could precede the diagnosis of macroglobulinemia by several years.

The treatment of superior semicircular canal dehiscence: A review of the literature about a not completely clarified problem

Abstract Objective: This paper reviews the principal surgical strategies proposed in the literature in approaching the Superior Semicircular Canal Dehiscence (SSCD) syndrome. It examines the controversies regarding each treatment modality including surgical indications, procedures and the main outcomes. Design: A systematic literature research was conducted using a number of resources including electronic databases, books and websites. Relevant citations from current publications were also followed up. Results: Two principal types of surgical procedure for the treatment of superior canal dehiscence were identified: canal plugging and resurfacing. Each can be performed by both a middle cranial fossa (MCF) and transmastoid (TM) approach. An alternative and less invasive option to treat this pathological condition, without repairing the underlying lesion, has recently emerged from the literature: the round window (RW) niche reinforcement through a transmeatal approach. Conclusions: All the reported techniques represent reliable and effective solutions in cases of intolerable symptoms; nevertheless, the controversies still present about the pathophysiological changes linked to dehiscence reflect the difficulties in proposing a universal method of treatment. It is, therefore, probable that a more prolonged knowledge of this affection is necessary to fully understand all its implications.

Superior canal dehiscence with tegmen defect revealed by otoscopy: Video clip demonstration of pulsatile tympanic membrane

Superior canal dehiscence is a pathologic condition of the otic capsule acting as aberrant window of the inner ear. It results in reduction of inner ear impedance and in abnormal exposure of the labyrinthine neuroepithelium to the action of the surrounding structures. The sum of these phenomena leads to the onset of typical cochleo-vestibular symptoms and signs. Among them, pulsatile tinnitus has been attributed to a direct transmission of intracranial vascular activities to labyrinthine fluids. We present the first video-otoscopic documentation of spontaneous pulse-synchronous movements of the tympanic membrane in two patients with superior canal dehiscence. Pulsating eardrum may represent an additional sign of third-mobile window lesion.