Garth Essig

Fine Needle Aspiration and Medullary Thyroid Carcinoma: The Risk of Inadequate Preoperative Evaluation and Initial Surgery When Relying Upon FNAB Cytology Alone

OBJECTIVES To evaluate the diagnostic accuracy of fine-needle aspiration biopsy (FNAB) to preoperatively diagnose medullary thyroid cancer (MTC) among multiple international centers and evaluate how the cytological diagnosis alone could impact patient management. METHODS We performed a retrospective chart review of sporadic MTC (sMTC) patients from 12 institutions over the last 29 years. FNAB cytology results were compared to final pathologic diagnoses to calculate FNAB sensitivity. To evaluate the impact of cytology sensitivity for MTC according to current practice and to avoid confounding results by local treatment protocols, changes in treatment patterns over time, and the influence of ancillary findings (e.g., serum calcitonin), therapeutic interventions based on FNAB cytology alone were projected into 1 of 4 treatment categories: total thyroidectomy (TT) and central neck dissection (CND), TT without CND, diagnostic hemithyroidectomy, or observation. RESULTS A total of 313 patients from 4 continents and 7 countries were included, 245 of whom underwent FNAB. FNAB cytology revealed MTC in 43.7% and possible MTC in an additional 2.4%. A total of 113 (46.1%) patients with surgical pathology revealing sMTC had FNAB findings that supported TT with CND, while 37 (15.1%) supported TT alone. In the remaining cases, diagnostic hemithyroidectomy and observation were projected in 32.7% and 6.1%, respectively. CONCLUSION FNAB is an important diagnostic tool in the evaluation of thyroid nodules, but the low sensitivity of cytological evaluation alone in sMTC limits its ability to command an optimal preoperative evaluation and initial surgery in over half of affected patients.

Protein S deficiency in pregnancy

The case of a primigravid patient with protein S deficiency, a rare disorder resulting in recurrent venous thrombosis, was managed with prophylactic heparin therapy and elective pregnancy termination. Although rarely diagnosed, protein S deficiency may become more commonly identified with wider application of protein S assays.

Fetal heart rate during breech delivery

The fetal heart rate during breech deliveries was monitored electronically and compared to fetal heart rate variations occurring during delivery of cephalic presentations. Fetal bradycardia accompanied all breech deliveries. Comparable drops in fetal heart rate occurred at similar stages of delivery in both cephalic and breech presentations. Recovery to normal levels occurred more rapidly and Apgar scores were generally higher after cephalic delivery than after breech delivery. Delivery time was longer for breech than for cephalic presentations and a correlation between delivery time and fetal heart rate recovery time is suggested.

An electron microscopic study of fetal capillary basal laminas of “normal” human term placentas

Electron microscopic examination of terminal (free-floating) villi of definable normal human term placentas emphasizes the variable fine structural appearance of the fetal capillary basal lamina (FL). The FL assumes both a unilaminar and multilamellar configuration in each placenta examined; the multilamellar portions are usually composed of individual layers which tend to branch and anastomose. The constant indentification of collagen fibrillar profiles between these electron-dense layers argues against the notion that the multilamellar portions of the FL arise via a simple splitting or disaggregation of pre-existing unilaminar FLs.

Ectopic mediastinal goiter successfully managed via cervical approach: Case report and review of the literature

Ectopic mediastinal goiter is a rare entity that presents diagnostic and treatment challenges to the clinician.

Lingual thyroid: an unusual and surgically curable cause of sleep apnoea in a male

IntroductionLingual thyroid is a rare embryological abnormality that occurs as a result of failed descent of the thyroid gland.Case reportWe report the case of a 39-year-old male with an incidental finding of a lingual thyroid during intubation for surgery for lower limb fractures. A sleep study indicated an RDI of 38.6, consistent with severe sleep apnoea. The ectopic thyroid was excised via a suprahyoid approach, with resolution of apnoeic symptoms post-operatively. A follow-up sleep study subsequent to his operation confirmed an RDI of 3.7.ConclusionThis is the first time a lingual thyroid causing sleep apnoea has been studied with pre- and post-treatment sleep studies. This is also the first recorded instance of lingual thyroid causing sleep apnoea has been recorded in a male.

Autoscope: automated otoscopy image analysis to diagnose ear pathology and use of clinically motivated eardrum features

In this study, we propose an automated otoscopy image analysis system called Autoscope. To the best of our knowledge, Autoscope is the first system designed to detect a wide range of eardrum abnormalities by using high-resolution otoscope images and report the condition of the eardrum as “normal” or “abnormal.” In order to achieve this goal, first, we developed a preprocessing step to reduce camera-specific problems, detect the region of interest in the image, and prepare the image for further analysis. Subsequently, we designed a new set of clinically motivated eardrum features (CMEF). Furthermore, we evaluated the potential of the visual MPEG-7 descriptors for the task of tympanic membrane image classification. Then, we fused the information extracted from the CMEF and state-of-the-art computer vision features (CVF), which included MPEG-7 descriptors and two additional features together, using a state of the art classifier. In our experiments, 247 tympanic membrane images with 14 different types of abnormality were used, and Autoscope was able to classify the given tympanic membrane images as normal or abnormal with 84.6% accuracy.

Detection of eardrum abnormalities using ensemble deep learning approaches.

In this study, we proposed an approach to report the condition of the eardrum as “normal” or “abnormal” by ensembling two different deep learning architectures. In the first network (Network 1), we applied transfer learning to the Inception V3 network by using 409 labeled samples. As a second network (Network 2), we designed a convolutional neural network to take advantage of auto-encoders by using additional 673 unlabeled eardrum samples. The individual classification accuracies of the Network 1 and Network 2 were calculated as 84.4%(± 12.1%) and 82.6% (± 11.3%), respectively. Only 32% of the errors of the two networks were the same, making it possible to combine two approaches to achieve better classification accuracy. The proposed ensemble method allows us to achieve robust classification because it has high accuracy (84.4%) with the lowest standard deviation (± 10.3%).

Postoperative bradycardia following adenotonsillectomy in children: Does intraoperative administration of dexmedetomidine play a role?

INTRODUCTION Dexmedetomidine is a novel pharmacologic agent that has become a frequently used adjunct during care of pediatric patients with obstructive sleep apnea (OSA) undergoing tonsillectomy. While generally safe and effective, dexmedetomidine is associated with adverse effects of hypotension and bradycardia from its central sympatholytic effects. Due to safety concerns, our institution routinely admits patients with OSA for overnight cardiorespiratory monitoring following tonsillectomy. With such monitoring, we have anecdotally noted bradycardia in our patients and sought to investigate whether this was related to the increased use of intra-operative dexmedetomidine. METHODS We retrospectively reviewed records over an 11-month period to compare the incidence of postoperative bradycardia following hospital admission for tonsillectomy in patients who received dexmedetomidine versus those who did not. RESULTS The study cohort included 921 patients (371 received dexmedetomidine and 550 did not). Bradycardia was asymptomatically noted in 66 patients (7.2%). No patient required medical intervention for the bradycardia or developed clinical symptoms. There was no association of bradycardia with the intra-operative administration of dexmedetomidine (8.9% of patients who received dexmetomidine vs. 9.4% who did not). In multivariable analysis, bradycardia was more common among older patients, with the administration of topical or injected lidocaine, and with specific associated procedures (inferior turbinate coblation with out-fracture or direct laryngoscopy and bronchoscopy). CONCLUSION The increased incidence of asymptomatic bradycardia in our post-adenotonsillectomy patients seemed to relate more to increased utilization of postoperative cardiac telemetry, and did not appear associated with the use of dexmedetomidine use intra-operatively.

Outcomes in pediatric patients with recreational vehicle related forceful head impact

PURPOSE To compare outcomes in pediatric patients suffering forceful head impact during recreational vehicle use to patients with forceful head impact from other mechanisms. METHODS Retrospective cohort study of all patients 3-18 years old who suffered forceful head impact (any traumatic mechanism strong enough to result in a face or skull fracture) in our institutional trauma registry between January 2011 and September 2013. RESULTS Out of 252 events involving forceful head impact, 64 events were a result of riding a recreational vehicle. Although there is no difference in rates of temporal bone fractures, recreational vehicle accidents have higher rates of otic capsule violation (21% vs. 5%) and higher rates of hearing loss (30% vs 16%) compared to patients with forceful head impact from other mechanisms. All incidents of otic capsule violation and sensorineural hearing loss in recreational vehicle accidents were associated with a temporal bone fracture. CONCLUSION Despite the increasing use of head protective gear while operating a recreational motor vehicle there is still heightened risk for temporal bone fractures and subsequent hearing loss. The comparative associations in this study suggest that helmets used with recreational vehicles do not protect the temporal bone thus leaving vital structures within the otic capsule at risk for damage and long term consequences. When treating these patients Otolaryngologists should be aware of the elevated risk of otic capsule violation and late hearing loss with temporal bone fractures.