Andrew B. Tassler

BRONCHOGENIC CYSTS OF THE NECK IN ADULTS

Bronchogenic cysts are congenital sacs that result from maldevelopment of the primitive foregut. Although they occur predominantly in the chest, there are reports of lesions in extrathoracic locations. The majority of reported bronchogenic cysts located in the neck are found in the pediatric population; a review of the literature reveals few reports of bronchogenic cysts of the neck among adults. The diagnosis of a bronchogenic cyst relies on the histology and location of the lesion. Here, we review our experience in the diagnosis and management of 2 adult patients with pathologically proven bronchogenic cysts. Both patients presented with solitary neck masses that proved to be bronchogenic cysts on histologic examination. Our purpose is to define the histopathologic and clinical characteristics of bronchogenic cysts and discuss the features that distinguish them from other cervical cysts. In conclusion, congenital bronchogenic cysts can occur in the neck of adults and should be considered in the differential diagnosis of cystic cervical masses in adults, as well as children.

Medullary thyroid cancer with undetectable serum calcitonin.

CONTEXT Calcitonin is a sensitive biomarker that is used for diagnosis and follow-up in medullary thyroid cancer (MTC). In patients with tumors > 1 cm, it is uncommon for preoperative serum calcitonin to be in the normal laboratory reference range in patients with MTC, and even more unusual for serum calcitonin to be undetectable. THE CASE A 39-year-old woman was found to have a left thyroid nodule on magnetic resonance imaging done for neck pain. Ultrasound and fine-needle aspiration biopsy were performed, and cytopathology was positive for malignant cells. The cells also had features suggestive of a neuroendocrine tumor, and the specimen was immune-stained with calcitonin. There was positive immunoreactivity for calcitonin in isolated cells of the cytospin, highly favoring a diagnosis of MTC. Serum calcitonin was < 2 pg/mL (<6 pg/mL), and serum carcinoembryonic antigen was 3.1 ng/mL (<5.2 ng/mL). Given the low calcitonin levels, procalcitonin was also tested and was elevated at 0.21 ng/mL (< 0.1 ng/mL). The patient subsequently underwent a total thyroidectomy and central and ipsilateral lateral lymph node dissection. Histopathology confirmed a 2.6 × 2.0 × 1.2-cm MTC, with strong, diffuse immunostaining for calcitonin. Postoperatively, serum calcitonin has remained undetectable, carcinoembryonic antigen has remained within the reference range, and procalcitonin has become undetectable. CONCLUSIONS We present a rare case of a patient with MTC with undetectable preoperative serum calcitonin, whose tumor demonstrated strong, diffuse immunohistochemical staining for calcitonin. We discuss the possible pathogenesis of calcitonin-negative MTC and the challenges in following patients with this condition.

Refining the utility and role of Frozen section in head and neck squamous cell carcinoma resection.

Previous studies report high‐accuracy rates for intraoperative frozen sections, but reliability of frozen sections in predicting the ultimate final margin status is unknown. We compared frozen and permanent reads to identify risk factors for overall discrepancies between intraoperative and final margin status.

Risk Factors for Perioperative Airway Difficulty and Evaluation of Intubation Approaches Among Patients With Benign Goiter

Objective: The objective was to determine patient and gland characteristics associated with difficult intubation in patients undergoing thyroidectomy for goiter and to assess different methods of intubation in these patients. Methods: This study was an IRB-approved, retrospective chart review of 112 consecutive patients undergoing hemithyroidectomy or total thyroidectomy for thyroid goiter from 2009-2012 at an academic tertiary care facility in Bronx, New York. Patient demographics, thyroid gland characteristics (gland weight and nodule size), presence of preoperative symptoms (dyspnea, dysphagia, and hoarseness), and radiographical findings (tracheal compression, tracheal deviation, and substernal extension of the thyroid gland) were recorded. Anesthesia records were reviewed for method of intubation, as well as success or failure of intubation attempts. Results: Nineteen patients (17.0%) were men and 93 (83.0%) were women. The age of the patients included in the study ranged from 14 to 86 years with a mean ± SD age of 53.5 ± 14.7 years. Difficult intubation was noted with 13 (11.6%) patients. Only patient age was significantly associated with difficult intubation. The mean age of patients with airway difficulty was 60.7 ± 3.7 years compared to 52.1 ± 1.5 years in those who did not experience airway difficulty (P = .04). No other reviewed risk factors were found to be significantly associated with difficult intubation. Fiberoptic intubation (FOI) was used in 38 patients and difficult intubation occurred in 18.4% (7/38). Direct laryngoscopy with transoral intubation (LTOI) was used in 58 patients, in whom 3.4% (2/58) experienced a difficult intubation. FOI was aborted 6 times and LTOI was subsequently successful in each of these cases. Conclusions: Our results suggest that benign nodular goiter disease does not pose significant challenges to intubation in our patient cohort. The technique of intubation deviated from the initial plan several times in the FOI group, whereas LTOI was ultimately successful in every case. Our data suggest that the role of fiberoptic intubation for patients with large goiters should be further refined.

Minimal Margin Extracapsular Dissection: A Viable Alternative Technique for Benign Parotid Lesions?

Objective: Extracapsular dissection (ECD) has become an accepted, less invasive alternative for the removal of select benign parotid lesions that may reduce complications. Minimal margin extracapsular dissection (MECD) with dissection on or closer to the tumor capsule may be a reasonable alternative to ECD. The objective of this study is to review the complications and safety of the MECD technique at a single institution. Subjects and Methods: Medical records for patients who underwent MECD for suspected benign parotid lesions were reviewed. Outcome measurements included intraoperative findings, complications, and recurrences. Results: Forty patients underwent a MECD for suspected benign parotid lesions. The average tumor size was 2.2 cm. Frozen section revealed low-intermediate grade mucoepidermoid carcinoma in 2 (5%) cases, requiring completion of a superficial parotidectomy at the same setting. There was 1 case of temporary facial nerve weakness and no cases of Frey syndrome. No tumor recurrences were observed within the follow-up period (average 3.5 years.) Conclusion: In the hands of an experienced surgeon, MECD may be a viable alternative to formal superficial parotidectomy. This study reports low rates of nerve weakness and Frey syndrome. Long-term follow-up is necessary to determine the ultimate risk of recurrence.

Tumor Debulking in the Management of Laryngeal Cancer Airway Obstruction.

Patients presenting with advanced aerodigestive malignancy and respiratory compromise often undergo tracheotomy as initial airway management. Tumor debulking is a potential alternative. We present a case series with chart review to communicate our institutional experience with this technique. T3/4 glottic and supraglottic cancers treated between 2004 and 2014 underwent review, and 14 patients were identified for this study. Of these, 5 (35.7%) required subsequent tracheotomy, and 9 (64.3%) did not. Patients requiring subsequent tracheotomy had a delay in initiating definitive treatment when compared with those who did not (83.3 vs 31.3 days, P = .0025). No patient required a tracheotomy after initiation of definitive treatment. Our experience suggests that tumor debulking may be a viable option in select patients but that a delay in initiating treatment is associated with patients requiring tracheotomy subsequent to debulking. Further research is needed to better delineate patient scenarios in which tumor debulking alone is sufficient.

Randomized Controlled Trial Assessing the Feasibility of Shortened Fasts in Intubated ICU Patients Undergoing Tracheotomy.

Objective American Society of Anesthesiology guidelines recommend preoperative fasts of 6 hours after light snacks and 8 hours after large meals. These guidelines were designed for healthy patients undergoing elective procedures but are often applied to intubated intensive care unit (ICU) patients. ICU patients undergoing routine procedures may be subjected to unnecessary prolonged fasts. This study tests whether shorter fasts allow for better nutrition delivery and patient outcomes without increasing the risk. Study Design Randomized blinded controlled trial. Setting Tertiary academic medical center. Subjects ICU patients undergoing bedside tracheotomy. Methods Intubated ICU patients who were receiving enteral feeding and for whom bedside tracheotomy was indicated were enrolled prospectively and randomly allocated to 2 parallel preoperative fasting regimens: a 6-hour fast (control) and a 45-minute fast (intervention). Patients were assessed for aspiration, caloric delivery, metabolic markers, and infectious and noninfectious complications. Results Twenty-four patients were enrolled and randomized. There were no complications related to the procedure. There were no cases of intraoperative aspiration identified. There was a single postoperative pneumonia in the control group. Median (interquartile range) length of fast and caloric delivery were significantly different between the control group and the shortened fast group: 22 hours (18, 34) vs 14 hours (5, 25; P < .001) and 429 kcal (57, 1125) vs 1050 kcal (825, 1410; P = .01), respectively. Conclusions Shortening preoperative fasts in intubated ICU patients allowed for better caloric delivery in the preoperative period.

Preoperative Assessment of Risk Factors

Hemostasis is essential during endoscopic sinus and skull base surgery. Patients must be adequately assessed for bleeding risk to appropriately consent to surgery. The patient and the surgeon must be aware of the individual bleeding risk for a given procedure. A thorough history and physical examination is the best screening methodology available to determine whether a patient requires further hematologic work-up. Included in this assessment should be any medications and herbals that the patient consumes. This ensures a safe evaluation of the patient, streamlines appropriate consultation and testing when necessary, and confers accurate surgical risk assessment.

A rare case of chondroma of the parotid gland.

Patient: A 39-year-old Hispanic woman. History of Present Illness: The patient had swelling of the left side of her neck, which she had first noticed 3 to 4 months before consultation and which did not subside after 2 courses of antibiotics. She reported no tenderness, dysphagia, odynophagia, dysphonia, otalgia, fevers, chills, or weight changes. Past medical history: The patient had a past history of gastroesophageal reflux disease, arthritis (knee and cervical disease), and a prior abnormal Pap smear result (high grade squamous intraepithelial lesion). The cervical lesion was treated with a loop electrosurgical excision procedure (LEEP). Her past surgical history is remarkable for cholecystectomy and a left breast biopsy with benign results. Social history: Noncontributory. Family history: Noncontributory. Physical exam: The patient harbored a firm, nontender, fully mobile 2- to 3-cm left parotid tail mass without other abnormalities; her facial nerve function was intact in all branches. Principle Laboratory Findings: See [Image 1][1], [Image 2][2], [Image 3][3], [Image 4][4], [Image 5][5], and [Image 6][6]. * FNA : fine needle aspiration LEEP : loop electrosurgical excision procedure CT : computed tomography [1]: #F1 [2]: #F2 [3]: #F3 [4]: #F4 [5]: #F5 [6]: #F6

Tracheal invasion and perforation from advanced primary thyroid lymphoma: a case report and literature review.

OBJECTIVE We report a case of an elderly female with primary diffuse large B-cell thyroid lymphoma causing an extensive tracheal defect that was managed expectantly with good results. METHOD Case report RESULTS This is the only known reported case of a patient with tracheal invasion and perforation caused by primary thyroid lymphoma who has subsequently survived. CONCLUSION Due to the rarity of invasive primary thyroid lymphoma there is currently no standard surgical management of the airway. We propose that expectant management with temporary airway protection is an alternative to invasive procedures such as tracheotomy or tracheal stent placement, even in the scenario of serious airway defects.