Ian J. Witterick

Thyroid calcification and its association with thyroid carcinoma.

Calcification within the thyroid gland may occur in both benign and malignant thyroid disease, and its detection on ultrasonography is frequently dismissed by many clinicians as an incidental finding of little significance. As a tertiary referral center, most of our thyroid patients will have had thyroid ultrasonography before being referred to us, and in our experience, the incidence of malignancy in a thyroid nodule containing calcification seems to be higher than that in the average thyroid nodule. To assess this risk, we conducted this retrospective review.

Canadian clinical practice guidelines for acute and chronic rhinosinusitis

This document provides healthcare practitioners with information regarding the management of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) to enable them to better meet the needs of this patient population. These guidelines describe controversies in the management of acute bacterial rhinosinusitis (ABRS) and include recommendations that take into account changes in the bacteriologic landscape. Recent guidelines in ABRS have been released by American and European groups as recently as 2007, but these are either limited in their coverage of the subject of CRS, do not follow an evidence-based strategy, or omit relevant stakeholders in guidelines development, and do not address the particulars of the Canadian healthcare environment.Advances in understanding the pathophysiology of CRS, along with the development of appropriate therapeutic strategies, have improved outcomes for patients with CRS. CRS now affects large numbers of patients globally and primary care practitioners are confronted by this disease on a daily basis. Although initially considered a chronic bacterial infection, CRS is now recognized as having multiple distinct components (eg, infection, inflammation), which have led to changes in therapeutic approaches (eg, increased use of corticosteroids). The role of bacteria in the persistence of chronic infections, and the roles of surgical and medical management are evolving. Although evidence is limited, guidance for managing patients with CRS would help practitioners less experienced in this area offer rational care. It is no longer reasonable to manage CRS as a prolonged version of ARS, but rather, specific therapeutic strategies adapted to pathogenesis must be developed and diffused.Guidelines must take into account all available evidence and incorporate these in an unbiased fashion into management recommendations based on the quality of evidence, therapeutic benefit, and risks incurred. This document is focused on readability rather than completeness, yet covers relevant information, offers summaries of areas where considerable evidence exists, and provides recommendations with an assessment of strength of the evidence base and degree of endorsement by the multidisciplinary expert group preparing the document.These guidelines have been copublished in both Allergy, Asthma & Clinical Immunology and the Journal of Otolaryngology-Head and Neck Surgery.

Combined Corticosteroid and Antiviral Treatment for Bell Palsy: A Systematic Review and Meta-analysis

CONTEXT New evidence has emerged regarding the use of corticosteroids and antiviral agents in Bell palsy. OBJECTIVE To estimate the association of corticosteroids and antiviral agents with the risk of unsatisfactory facial recovery in patients with Bell palsy. DATA SOURCES The search included MEDLINE, EMBASE, CENTRAL, PsychInfo, CINAHL, Web of Science, PAPERSFIRST, PROCEEDINGSFIRST, and PROQUEST to identify studies up to March 1, 2009. STUDY SELECTION AND DATA EXTRACTION Eligible studies were randomized controlled trials comparing treatment with either corticosteroids or antiviral agents with a control and measuring at least 1 of the following outcomes: unsatisfactory facial recovery (> or = 4 months), unsatisfactory short-term recovery (6 weeks to < 4 months), synkinesis and autonomic dysfunction, or adverse effects. Two reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus. RESULTS Eighteen trials involving 2786 patients were eligible. Regression analysis identified a synergistic effect when corticosteroids and antiviral agents were administered in combination compared with alone (odds ratio for interaction term, 0.54 [95% confidence interval {CI}, 0.35-0.83]; P = .004). Meta-analysis using a random-effects model showed corticosteroids alone were associated with a reduced risk of unsatisfactory recovery (relative risk [RR], 0.69 [95% CI, 0.55-0.87]; P = .001) (number needed to treat to benefit 1 person, 11 [95% CI, 8-25]), a reduced risk of synkinesis and autonomic dysfunction (RR, 0.48 [95% CI, 0.36-0.65]; P < .001) (number needed to treat to benefit 1 person, 7 [95% CI, 6-10]), and no increase in adverse effects. Antiviral agents alone were not associated with a reduced risk of unsatisfactory recovery (RR, 1.14 [95% CI, 0.80-1.62]; P = .48). When combined with antiviral agents, corticosteroids were associated with greater benefit (RR, 0.48 [95% CI, 0.29-0.79]; P = .004) than antiviral agents alone. When combined with corticosteroids, antiviral agents were associated with greater risk reduction of borderline significance compared with corticosteroids alone (RR, 0.75 [95% CI, 0.56-1.00]; P = .05). CONCLUSIONS In Bell palsy, corticosteroids are associated with a reduced risk of unsatisfactory recovery. Antiviral agents, when administered with corticosteroids, may be associated with additional benefit.

Carcinoma of the maxillary antrum: a retrospective analysis of 110 cases

BACKGROUND AND PURPOSE Cancer of the maxillary antrum is a rare disease with a variety of treatment options. The present study was undertaken to review the outcome of patients with carcinoma of the maxillary antrum managed at a single institution. MATERIALS AND METHODS A retrospective analysis of 110 cases of carcinoma of the maxillary antrum managed with curative intent during the time period 1976-1993 was performed. There were 33 females and 77 males; the median age was 64 years (range 38-89). The median follow-up time was 4 years (range from 2 months to 17 years). The majority of patients presented with locally advanced disease (78 T4 tumours); nodal involvement was observed in 17/110 cases. Histologic subtypes included in the analysis were limited to squamous cell carcinoma (95 cases) and undifferentiated carcinoma (15 cases). Patients were managed with either primary radiation therapy with surgery reserved for salvage (83/110) or with a planned combined approach with surgery and either pre or postoperative radiation (27/110). RESULTS The actuarial 5-year cause-specific survival rate was 43%. The 5-year local control rate was 42%. Of 63 patients with local failure, 25 underwent salvage surgery with a subsequent 5-year cause-specific survival of 31%. Multiple regression analysis of patient, disease and treatment related variables identified local disease extent and nodal disease at presentation as the only variables independently associated with cause-specific survival. CONCLUSIONS This analysis indicates that survival from carcinoma of the maxillary antrum is poor with outcome strongly related to local disease extent. The best treatment strategy for this disease remains undefined. Salvage surgery can result in prolonged survival in selected patients experiencing local failure.

Parathyroid Hormone as a Predictor of Hypocalcemia after Thyroidectomy

Objectives: The aims of this study are to ascertain whether parathyroid hormone (PTH) assay before total/completion thyroidectomy followed by levels immediately thereafter in the recovery room and the morning after surgery are a reliable predictor of hypocalcemia at our institution. In addition, to determine the feasibility of early discharge home from hospital after total thyroidectomy on the basis of postoperative PTH levels.

Patterns of Care in Elderly Head-and-Neck Cancer Radiation Oncology Patients: A Single-Center Cohort Study

PURPOSE To compare the patterns of care for elderly head-and-neck cancer patients with those of younger patients. METHODS AND MATERIALS A retrospective review was conducted of all new mucosal head-and-neck cancer referrals to radiation oncology between July 1, 2003 and December 31, 2007 at our institution. The clinical characteristics, treatment pattern, tolerance, and outcomes were compared between the elderly (aged ≥75 years) and younger (aged <75 years) cohorts. RESULTS A total of 2,312 patients, including 452 (20%) elderly and 1,860 (80%) younger patients, were studied. The elderly patients were more likely to be women (36% vs. 27%, p <.01) and to have other malignancies (23% vs. 13%, p <.01), Stage I or II disease (38% vs. 32%, p <.01), and N0 status (56% vs. 42%, p <.01). Treatment was less often curative in intent (79% vs. 93%, p <.01). For the 1,487 patients who received definitive radiotherapy (RT), no differences were found between the elderly (n = 238) and younger (n = 1,249) patients in treatment interruption, completion, or treatment-related death. Within the subset of 760 patients who received intensified treatment (concurrent chemoradiotherapy or hyperfractionated accelerated RT), no difference was seen between the elderly (n = 46) and younger (n = 714) patients in treatment interruption, completion, or treatment-related death. After a median follow-up of 2.5 years, the 2-year cause-specific survival rate after definitive RT was 72% (range, 65-78%) for the elderly vs. 86% (range, 84-88%) for the younger patients (p <.01). CONCLUSION Elderly head-and-neck cancer patients exhibited different clinical characteristics and experienced different patterns of care from younger patients. Although age itself was an adverse predictor of cause-specific survival, its effect was modest. Elderly patients selected for definitive RT or intensified RT showed no evidence of impaired treatment tolerance.

Preoperative Radiotherapy for Adult Head and Neck Soft Tissue Sarcoma: Assessment of Wound Complication Rates and Cancer Outcome in a Prospective Series

Combination surgery and radiotherapy (RT) is frequently used in soft tissue sarcoma (STS). Because lower doses and smaller irradiation volumes are possible in preoperative RT (pre-op RT), this approach can be especially valuable in anatomic settings where critical organs are in close proximity to the RT target area. A recent multicenter phase III trial (SR.2 trial of the National Cancer Institute of Canada Clinical Trials Group) comparing pre-op RT against post-op RT for extremity STS has shown significantly higher major wound complication rates (35%) with pre-op RT. We postulated that wound complication rates may be less frequent in the head and neck with better vascularity and wider use of secondary wound reconstruction. Using a prospective database, we identified 40 consecutive patients with head and neck STS treated with pre-op RT (50 Gy) and subsequent (4 to 6 weeks later) resection between 1/89 and 8/99 in a single institution setting. Major wound complications (MWC) were classified by the identical criteria used in the SR.2 trial. Intracranial extension was evident in 5 patients, whereas 50% of the patients had large tumors (> 5 cm). Deep tumor was present in 34 (85%), and 6 (15%) were superficial to fascia. In this series, 31 patients (77.5%) had secondary reconstruction of the acquired soft tissue deficit. The actuarial 2-year local relapse-free rate was 80%, and the metastatic relapse-free rate was 85%. Major wound complications occurred in 8 of 40 patients (20%) within 120 days of surgery according to the SR.2 criteria: secondary wound surgery (3), readmission or prolonged hospital admission for wound care (2), deep packing (0), prolonged dressing changes (2), and invasive procedure for wound care (1). The latter was a minor wound management problem (a single outpatient drainage of a seroma) for the combined rate of 8/20 or 20%. Our findings show that (1) pre-op RT in head and neck STS is associated with lower rates of major wound complications compared to extremity cases; (2) pre-op RT provides high rates of local control in an adverse group of cases of adult head and neck STS; (3) the choice of scheduling of RT should be based on anatomic issues with emphasis on the trade-offs between RT doses and volumes versus wound morbidity for individual patients. This is especially important when tumor may be adjacent to critical head and neck structures which may be protected from the high-dose RT area.

Control of bleeding in endoscopic sinus surgery: Use of a novel gelatin-based hemostatic agent

OBJECTIVE To determine whether FloSeal Matrix Hemostatic Sealant is a safe and effective means of controlling bleeding post-endoscopic sinus surgery (ESS) and to assess postoperative healing. DESIGN Prospective clinical study. SETTING University of Toronto. METHODS Eighteen patients with FloSeal placed on a total of 30 operative sites post-ESS. Time to cessation of bleeding was assessed intraoperatively. Patients had the operative sites assessed at 30 days postoperatively. MAIN OUTCOME MEASURES Effectiveness of FloSeal in controlling bleeding and aiding in healing of the operative site. RESULTS FloSeal adequately controls postoperative bleeding in patients post-ESS. Healing was also not adversely affected. CONCLUSIONS FloSeal is a safe and effective treatment for controlling blood loss after EES. It may also provide support to the middle meatus as well as improve healing of the operative site compared with the use of traditional nasal packing. However, randomized clinical trials are needed to further evaluate this.

The role of panendoscopy in the management of mucosal head and neck malignancy-a prospective evaluation.

It is common practice for a panendoscopy to be included in the evaluation of patients with mucosal head and neck malignancies. Whether this intervention is efficient or cost‐effective has not been established in our patient population.

Abnormalities of the ARF-p53 pathway in oral squamous cell carcinoma

Oral squamous cell carcinoma (OSCC) is associated with heavy smoking and drinking, but the molecular pathway of tumorigenesis is not understood. Inactivation of the p53 tumor suppressor gene is likely to play an important role since p53 mutation is frequently found. The p14ARF tumor suppressor gene is functionally linked to p53, because it is activated by oncogenes and causes p53-dependent growth arrest and apoptosis. The relationship between p14ARF and p53 inactivation has not been described for OSCC. We studied 25 cases of OSCC to determine if there is an inverse correlation between p53 mutation and p14ARF inactivation by homozygous deletion or mutation. p53 mutation was found in 16 of 25 cases (64%), including nine missense and seven truncating mutations. While all cases with missense mutations showed abnormal accumulation of p53 protein, there were also five carcinomas which showed increased p53 staining in the absence of mutation. p14ARF deletion or mutation was found in eight cases (32%), six of which also demonstrated p53 mutation. Our findings indicate that OSCC often involves loss of both p14ARF and p53 function and suggest that inactivation of these two tumor suppressor genes are not functionally equivalent during tumorigenesis.