Eran E. Alon

Idiopathic subglottic stenosis: an evolving therapeutic algorithm.

Idiopathic subglottic stenosis (ISS) is a rare type of airway stenosis of unclear etiology. Open resection, while effective, remains a complex surgery and requires a hospital stay. Endoscopic management is often preferred but has historically been associated with a high recurrence rate. We aimed to analyze our experience, consisting of a standardized endoscopic approach combined with an empiric medical treatment.

ACTIVE SURVEILLANCE FOR PAPILLARY THYROID MICROCARCINOMA: NEW CHALLENGES AND OPPORTUNITIES FOR THE HEALTH CARE SYSTEM.

OBJECTIVE The dramatic increase in papillary thyroid carcinoma (PTC) is primarily a result of early diagnosis of small cancers. Active surveillance is a promising management strategy for papillary thyroid microcarcinomas (PTMCs). However, as this management strategy gains traction in the U.S., it is imperative that patients and clinicians be properly educated, patients be followed for life, and appropriate tools be identified to implement the strategy. METHODS We review previous active surveillance studies and the parameters used to identify patients who are good candidates for active surveillance. We also review some of the challenges to implementing active surveillance protocols in the U.S. and discuss how these might be addressed. RESULTS Trials of active surveillance support nonsurgical management as a viable and safe management strategy. However, numerous challenges exist, including the need for adherence to protocols, education of patients and physicians, and awareness of the impact of this strategy on patient psychology and quality of life. The Thyroid Cancer Care Collaborative (TCCC) is a portable record keeping system that can manage a mobile patient population undergoing active surveillance. CONCLUSION With proper patient selection, organization, and patient support, active surveillance has the potential to be a long-term management strategy for select patients with PTMC. In order to address the challenges and opportunities for this approach to be successfully implemented in the U.S., it will be necessary to consider psychological and quality of life, cultural differences, and the patients clinical status.

Database and registry research in thyroid cancer: Striving for a new and improved national thyroid cancer database

BACKGROUND Health registries have become extremely powerful tools for cancer research. Unfortunately, certain details and the ability to adapt to new information are necessarily limited in current registries, and they cannot address many controversial issues in cancer management. This is of particular concern in differentiated thyroid cancer, which is rapidly increasing in incidence and has many unknowns related to optimal treatment and surveillance recommendations. SUMMARY In this study, we review different types of health registries used in cancer research in the United States, with a focus on their advantages and disadvantages as related to the study of thyroid cancer. This analysis includes population-based cancer registries, health systems-based cancer registries, and patient-based disease registries. It is important that clinicians understand the way data are collected in, as well as the composition of, these different registries in order to more critically interpret the clinical research that is conducted using that data. In an attempt to address shortcoming of current databases for thyroid cancer, we present the potential of an innovative web-based disease management tool for thyroid cancer called the Thyroid Cancer Care Collaborative (TCCC) to become a patient-based registry that can be used to evaluate and improve the quality of care delivered to patients with thyroid cancer as well as to answer questions that we have not been able to address with current databases and registries. CONCLUSION A cancer registry that follows a specific patient, is integrated into physician workflow, and collects data across different treatment sites and different payers does not exist in the current fragmented system of healthcare in the United States. The TCCC offers physicians who treat thyroid cancer numerous time-saving and quality improvement services, and could significantly improve patient care. With rapid adoption across the nation, the TCCC could become a new paradigm for database research in thyroid cancer to improve our understanding of thyroid cancer management.

Delayed Sino-nasal Complications of Radiotherapy for Nasopharyngeal Carcinoma

Objective There are only sporadic reports of delayed sino-nasal complications associated with nasopharyngeal carcinoma (NPC) treated with radiotherapy. These include choanal stenosis, osteoradionecrosis, chronic sinusitis, and intranasal synechiae. Most likely, these complications are underestimated as in many institutions nasal endoscopies in NPC patients are not performed routinely. The aim of this study was to identify the onset and incidence of delayed sino-nasal complications in NPC patients and their effect on quality of life (QOL). Study Design Case series with chart review. Setting Tertiary medical center. Subjects and Methods A retrospective chart review was performed on all patients treated for NPC in our institution between 1988 through 2009. The inclusion criteria required at least a 3-year follow-up without recurrence. Included patients were contacted prospectively and asked to fill a SNOT-16 questionnaire. Results Sixty-two patients were included in our review. There were 42 males and 20 females. The average age at onset was 42 years. The AJCC staging for T1, T2, T3, and T4 tumors was 22 (35%), 11 (18%), 18 (29%), and 11 (18%), respectively. Eleven patients (18%) suffered from chronic sinusitis. Nine patients (15%) developed choanal stenosis. Five patients (8%) developed osteoradionecrosis. Two patients suffered from nasal synechiae. Forty-eight patients completed the SNOT-16 questionnaire. Patients with choanal stenosis had the lowest QOL scores out of the cohort. Conclusion The incidence of delayed sino-nasal complications after radiation treatment for NPC is not negligible and should be kept in mind when addressing the quality of life of NPC survivors.

Neurosarcoidosis Affecting the Vagus Nerve

Objectives Our objective was to review patients who presented to our medical center with a diagnosis of neurosarcoidosis affecting the vagus nerve and to present symptoms, progression, treatments, and outcome. Methods We performed a chart review of patients who presented to our medical center in the past 10 years with a diagnosis of neurosarcoidosis specifically affecting cranial nerve X. Results A chart review of 53 patients revealed only 4 with findings suggestive of vagal neurosarcoidosis. All were male and had a mean age of 50 years (range, 42 to 57 years) at presentation of symptoms. Two of the 4 patients presented initially with cough, 1 had recurrent syncope, and another presented with left facial pain. Vagus nerve involvement included vocal fold paresis or paralysis in all 4 patients, 2 of whom reported coughing with exposure to various odors and 2 of whom were found to have a unilateral palatal weakness. All but 1 had positive findings on magnetic resonance imaging of the head. Conclusions Neurosarcoidosis involving the vagus nerve is a rare finding, but should be considered in the differential diagnosis of vocal fold paresis or paralysis.

Improving the adoption of thyroid cancer clinical practice guidelines

To present an overview of the barriers to the implementation of clinical practice guidelines (CPGs) in thyroid cancer management and to introduce a computer‐based clinical support system.

Relation between preoperative computed tomographic criteria of injury to the nasofrontal outflow tract and operative findings in fractures of the frontal sinus

Injury to the nasofrontal outflow tract is important in the treatment of fractures of the frontal sinus. In 2008 preoperative computed tomographic (CT) criteria or signs of such injuries were proposed and stated to be reliable. The aim of this study was to evaluate the validity of these criteria by comparing the radiological evidence with the operative findings. Thirty-nine patients for whom the data from preoperative CT could be compared with operative findings were eligible for the study, all but 4 of whom had at least one indicator of injury to the outflow tract. Patients whose tracts were found to be obstructed at operation had at least 2 preoperative CT signs of obstruction of the tract. If the outflow tract was obstructed all 3 criteria were significantly more likely to be present than if it was intact (p=0.02). Two criteria or fewer did not correlate significantly with obstruction. Fractures were managed by reconstruction (n=18), obliteration (n=11), or cranialisation (n=10). This study is the first to our knowledge to examine the correlation between preoperative CT criteria and operative findings, and there was a significant difference in the number of criteria present depending on whether the outflow tract was intact or injured. Our findings allow for more accurate planning of management of fractures of the frontal sinus.

Rare Tracheal Tumors and Lesions Initially Diagnosed as Isolated Differentiated Thyroid Cancers

BACKGROUND Thyroid carcinoma with tracheal invasion is uncommon; however, this is significantly more prevalent than primary tracheal tumors. Rare tracheal tumors at the level of the thyroid can be misinterpreted as invasive thyroid cancer upon initial diagnosis. We present a series of tumors within the tracheal wall that were initially misdiagnosed as isolated, but aggressive, thyroid cancer, and later diagnosed to be different histopathologic entities. METHODS The series consisted of four women and five men, all but two age 60 or older, who were initially diagnosed with tracheal invasion from differentiated thyroid carcinoma (DTC). Eight had obstructive airway symptoms and one experienced gagging and choking sensations. Preoperatively, the patients underwent fine-needle aspiration (FNA) and imaging studies. A complete resection of the involved airway in combination with the thyroid gland was performed in all patients. RESULTS In this series of patients, the final diagnosis was tracheal stenosis, recurrent laryngeal nerve schwannoma, papillary thyroid carcinoma (PTC) with benign intratracheal thyroid tissue, adenoid cystic carcinoma, and squamous cell carcinoma, each in one patient. Two patients had a tracheal chondrosarcoma, and two patients had collision tumors (PTC with laryngeal squamous cell carcinoma). All patients were misunderstood preoperatively as having isolated DTC with aggressive involvement of the trachea. An accurate diagnosis in these cases was difficult due to misleading FNA readings, thought due to the FNA needle passing through the thyroid before reaching the trachea or a tumor that abuts both structures on imaging. Primary tracheal tumors and a nontumorous lesion, as well as benign thyroidal masses, mimicked invasive thyroid carcinoma in this preoperative setting. CONCLUSIONS Various entities other than thyroid cancer can masquerade as invasive thyroid cancer. In patients with an FNA showing thyroid tissue or suggesting PTC, but also have obstructive or other airway symptoms, physician awareness is needed to consider the distinct possibility of a primary tracheal lesion. Obtaining the correct preoperative diagnosis is essential for accurate surgical planning for patients with tracheal tumors.

Medical Information Exchange: Pattern of Global Mobile Messenger Usage among Otolaryngologists.

Objective Information technology has revolutionized health care. However, the development of dedicated mobile health software has been lagging, leading to the use of general mobile applications to fill in the void. The use of such applications has several legal, ethical, and regulatory implications. We examined the experience and practices governing the usage of a global mobile messenger application (WhatsApp) for mobile health purposes in a national cohort of practicing otolaryngologists in Israel, a known early adaptor information technology society. Methods Cross-sectional data were collected from practicing otolaryngologists and otolaryngology residents via self-administered questionnaire. The questionnaire was composed of a demographic section, a section surveying the practices of mobile application use, mobile health application use, and knowledge regarding institutional policies governing the transmission of medical data. Results The sample included 22 otolaryngology residents and 47 practicing otolaryngologists. Of the physicians, 83% worked in academic centers, and 88% and 40% of the physicians who worked in a hospital setting or a community clinic used WhatsApp for medical use, respectively. Working with residents increased the medical usage of WhatsApp from 50% to 91% (P = .006). Finally, 72% were unfamiliar with any institutional policy regarding the transfer of medical information by personal smartphones. Discussion Mobile health is becoming an integral part of modern medical systems, improving accessibility, efficiency, and possibly quality of medical care. Implications for Practice The need to incorporate personal mobile devices in the overall information technology standards, guidelines, and regulation is becoming more acute. Nonetheless, practices must be properly instituted to prevent unwanted consequences.

Recurrent pleomorphic adenoma: is treatment considerably delayed thus affecting surgical morbidity?

Abstract Objective: To examine the incidence of late presentation of patients with recurrent pleomorphic adenoma (RPA) of the parotid gland. Methods: This is a retrospective analysis of patients treated in our center. We examined patients demographics, disease characteristics, treatment, and outcome and as well as the time period length from the first discovery of a recurrent mass until seeking treatment at our clinic and its effect on morbidity. Results: A total of 30 patients were included. 26% underwent initial enucleation in other institutions. In eight patients (26%), the recurrence of the mass was second or higher. The patients average time period length until seeking treatment was 2.48 years, with 33% of patients showing a time period length of over three years. Multifocal tumor, tumor diameter larger than 2 cm and facial nerve involvement were found in 15 (50%),16 (53.3%) and seven (25%) patients respectively. Patients delay of presentation by ≥3 years was associated with a tumor size of ≥2 cm (Relative Risk [RR] = 2, p = .02). Patients delay of presentation by ≥2 years was also associated with a trend towards a higher rate of post-operative facial nerve palsy (RR = 3.37, p = .07, CI = 0.88–12.85). Conclusion: Most patients with RPA were presented late, thus affecting disease extent and surgical morbidity.