Irina Chaikhoutdinov

Impact of the pediatric tonsillectomy and polysomnography clinical practice guidelines

OBJECTIVE To evaluate the effect of the recently published guidelines on Tonsillectomy in Children and Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children on physician practice patterns. STUDY DESIGN Cross-sectional survey. METHOD Survey of members of the American Academy of Otolaryngology-Head and Neck Surgery. SETTING Academic tertiary referral center. RESULTS A total of 280 physicians completed the survey, with a response rate of 41.7%. 93% of respondents had read the clinical practice guidelines. Many respondents had completed a pediatric otolaryngology fellowship (46%). A large group of physicians (46%) continue to prescribe antibiotics within 24h after surgery. One-third of respondents stopped prescribing antibiotics because of the guidelines. Discord between severity of symptoms and tonsil size was the most common reason cited for ordering a polysomnogram prior to tonsillectomy (76%). The most common reason cited for admission post-tonsillectomy was age less than 3 (40%). Less than half of physicians prescribe NSAIDs for pain control (43.8%) despite its safety profile, and only 23% reported that the guidelines influenced their use of NSAIDs postoperatively. Most respondents use intra-operative steroids (90%) as recommended. CONCLUSION The guidelines are intended to provide evidence based direction in tonsillectomy practices and improve referral patterns for polysomnography prior to tonsillectomy. The majority of the surveyed otolaryngologists reviewed these guidelines and some have changed their practice secondary to the guidelines. However, many physicians continue to prescribe post-operative antibiotics and do not use NSAIDs.

Characteristics of Incidentally Discovered Thyroid Cancer

IMPORTANCE The incidence of thyroid cancer has been steadily increasing; however, no clear reason for the increase in incidence has been identified. OBJECTIVES To compare incidentally discovered (ID) thyroid cancer via non-thyroid-related imaging with nonincidentally discovered (NID) thyroid cancer, as well as determine if differences in tumor characteristics and patient presentation in ID thyroid cancer may help elucidate the increasing incidence of this disease. DESIGN, SETTING, AND PARTICIPANTS Retrospective medical record review at an academic tertiary care medical center of 31 patients with ID thyroid cancer and 207 patients with NID thyroid cancer evaluated at our institution during a 12-month period. MAIN OUTCOMES AND MEASURES Patient demographics, tumor pathology, stage, tumor size, invasion, and metastasis were recorded. RESULTS Mean age at diagnosis was 56.4 years for the ID group and 41.8 years for the NID group (P < .001). The ID group was 54.8% male compared with 13.5% in the NID group (P < .001). The ID group had higher stage disease compared with the NID group (P = .003). There was no difference in tumor size (P = .91), invasion (P = .76), lymph node involvement, or distant metastases (P > .99). CONCLUSIONS AND RELEVANCE Patients with ID thyroid cancer tend to be older at presentation, have higher stage disease, and are more likely to be male compared with patients with NID thyroid cancer. There does not appear to be a significant difference in the size, pathology, or behavior of the tumor at presentation between ID and NID thyroid cancers. These findings imply that improved detection may not represent the only cause of the increased incidence of thyroid cancer.

Association of Thyroid Nodule Size and Bethesda Class With Rate of Malignant Disease

IMPORTANCE The ability to accurately stratify patients with thyroid nodules (TNs) preoperatively is imperative because most TNs are benign. The reliability of fine-needle aspiration biopsy (FNAB) in large TNs has been questioned in recent literature. OBJECTIVE To determine whether TN size affects the reliability of FNAB results, and to determine the rates of malignant disease of each Bethesda class at Penn State Medical Center. DESIGN, SETTING, AND PARTICIPANTS Retrospective electronic medical record review of patients undergoing FNAB followed by thyroidectomy from March 2010 through December 2013 at an academic, tertiary referral center. A total of 297 patients with 326 TNs were identified as part of a consecutive series. MAIN OUTCOMES AND MEASURES The primary outcome was to determine the rate of malignant disease of TNs smaller than 3.0 cm or 3.0 cm or larger and of each Bethesda class. Statistical analysis included χ(2) tests. The secondary outcome was to develop logistic regression models to estimate the probability of malignant disease on final pathologic diagnosis as predicted by TN size as well as TN size in conjunction with Bethesda class. RESULTS Of the 297 patients, 233 were female (78.4%). The mean (SD) age was 51.0 (15.4) years. Of the 326 TNs, 143 were malignant on surgical histopathologic analysis (43.7%). The mean TN size was 2.0 (1.4) cm. Rates of malignant disease for Bethesda classes 1 to 6 were 0% (95% CI, 0%-26.0%), 6.0% (95% CI, 1.7%-14.6%), 30.2% (95% CI, 18.3%-44.3%), 23.5% (95% CI, 14.8%-34.2%), 72.4% (95% CI, 52.8%-87.3%), and 98.8% (95% CI, 93.5%-99.9%), respectively. Overall sensitivity and specificity (excluding class 1 TNs) were 97.2% and 36.8%, respectively. The false-negative rate of benign cytologic results was 6.0% (95% CI, 1.7%-14.6%); only 1 false-negative result occurred in TNs 3.0 cm or greater. Of the TNs smaller than 3.0 cm, 48.4% were malignant compared with 33.3% of TNs 3.0 cm or greater (P = .049). Both Bethesda class and TN size were significant variables (P < .05) within our logistic regression models indicating that higher Bethesda class and TN size smaller than about 2.0 cm were associated with increased probabilities of malignant disease. CONCLUSIONS AND RELEVANCE Our results suggest that smaller TNs (smaller than about 2.0 cm) are associated with increased probabilities of malignant disease irrespective of Bethesda class. Routine diagnostic thyroid lobectomy solely owing to TN size of 3.0 cm or greater need not be performed.

Incidental Thyroid Nodules Incidence, Evaluation, and Outcome

Objective To examine patients with incidentally discovered thyroid nodules (IDTNs) with a focus on identification, evaluation, surgical intervention, and rates of malignancy. Study Design Case series with chart review. Setting Tertiary care medical center. Subjects and Methods A total of 1408 patients were identified by cross-referencing thyroid diagnosis codes with ultrasound (US) codes between July 2008 and June 2009. Information regarding demographics, follow-up, and outcomes was extracted from the medical record. Results A total of 249 patients with IDTNs were identified. Most were discovered on computed tomography (CT) scans (59.8%); the most common indication for obtaining imaging was for evaluation of an unrelated malignancy (26.9%). Malignant IDTNs were identified on 23.8% of positron emission tomography/CT scans and 6.8% of CT scans. Initial evaluation of IDTNs was performed by US in 62.2% and by US with fine-needle aspiration (FNA) in 36.1% of patients. The most common pathology on FNA of IDTNs was benign follicular nodule (64.1%) followed by papillary thyroid cancer (PTC; 13.5%); however, 31.7% of all cytology indicated suspicion for malignancy. Fifty-five patients (22.1%) were treated surgically. On final surgical pathology, 33 malignancies were present, of which 28 were PTC. The overall malignancy rate for incidental thyroid nodules was 13.3%. Conclusion We identified a malignancy of at least 13.3% in IDTNs, reaffirming that IDTNs should undergo thorough workup.

Impact of Genetic Targets on Therapy in Head and Neck Squamous Cell Carcinoma

Despite advances in surgical technique, radiation therapy and chemotherapy, the mortality from head and neck squamous cell carcinoma (HNSCC) has not improved significantly. Squamous cell carcinoma is caused by tobacco use, alcohol consumption and infection with high-risk types of human papillomavirus. It is the 6th most common cancer in the world, with upwards of 45,000 new cases reported yearly in the United States alone.In recent years, there has been a significant increase in the understanding of the molecular and genetic pathogenesis of head and neck cancer, shedding light on the unexpected heterogeneity of the disease. Genetic analysis has led to new classification schemes for HNSCC, with different subgroups exhibiting different prognoses. In addition, multiple targets in aberrant signaling pathways have been identified using increasingly sophisticated bio-informatics tools. Advances in technology have allowed for novel delivery mechanisms to introduce genetic material into cells to produce a therapeutic effect by targeting cancer cells via a number of different approaches.A pressing need to develop novel therapies to augment current treatment modalities has led to a number of translational studies involving gene therapy in the treatment of HNSCC. This article will focus on a review of the most recent developments in molecular biology of head and neck squamous cell carcinoma in regards to possible targets for gene therapy, as well as the array of novel therapeutic strategies directed at these targets.

The difficult neck in facelifting.

The management of the neck often presents the most challenging aspect of the facelift procedure. The aesthetic neck has a well-defined jaw line, a pleasing and adequate cervicomental angle, and visible definitions of the deeper lateral and midline structures, such as the sternocleidomastoid muscles and trachea. Several unfavorable anatomic characteristics will present that will compound the challenge. These characteristics are contrasted with ideal features and include the following: an excess of adipose tissue, an excess of either thin or thick inelastic skin, marked relaxation of the suspension structures of the neck with resultant platysma banding and jowling, and unfavorable skeletal features such as microgenia and hyoid malposition. These patients present for rhytidectomy with inadequate chin projection, an obtuse cervicomental angle, sagging skin, and a heavy neck. To maximize rhytidectomy results in these patients with difficult neck anatomy, special attention to the anatomy and application of recognized techniques in an individualized manner is recommended. This article reviews the issues encountered in the management of the difficult neck in facelifting, with special attention given to patients with a heavy neck.

Incidental Thyroid Nodules: Clinical Presentation and Outcomes

Objectives: Examine patients with incidentally discovered thyroid nodules (IDTNs) with focus on identification, evaluation, surgical intervention, and rates of malignancy. Methods: Retrospective chart review performed at a tertiary care medical center. Patients were identified by cross-referencing thyroid diagnosis codes with ultrasound (US) codes, identifying a total of 1408 thyroid patients evaluated between July 2008 and June 2009. Information regarding demographics, follow-up, and outcomes was extracted from the medical record. Results: A total of 249 patients with IDTNs were identified. Most were identified on chest CT (44.6%). Most commonly, imaging was obtained for evaluation of an unrelated malignancy (26.9%). Initial evaluation of IDTNs was performed by US in 62.2% and US with fine needle aspiration (FNA) in 36.1% of patients. Patients with US as the initial study appeared to undergo more studies than patients who underwent US/FNA. 170 (68.3%) underwent ultrasound (US)/FNA. The most common pathology was benign follicular nodule (64.1%) and papillary thyroid cancer (PTC) (13.5%). Fifty-five (22.1%) patients underwent thyroidectomy. Forty-seven patients underwent surgery for suspicion of malignancy. Preoperative FNA pathology was PTC in 22 patients, followed by follicular neoplasm in 17 patients. On final pathology, 33 malignancies were present. Of these, 28 were PTC. The overall malignancy rate for incidental thyroid nodules was 13.3%. Conclusions: This study identified a surprisingly high rate of malignancy of at least 13.3% in IDTNs, reaffirming that incidental thyroid nodules should undergo thorough workup. Obtaining US/FNA early in the workup appears to decrease the number of studies ordered.