Karen Watters

Thyrotropin and thyroid cancer diagnosis: a systematic review and dose-response meta-analysis

CONTEXT TSH is the major growth factor for thyrocytes and may have a causative role in thyroid cancer. OBJECTIVE The objective of the study was to systematically assess the association between serum TSH and thyroid cancer. DATA SOURCES The MEDLINE and EMBASE databases were searched using synonyms for TSH and thyroid cancer, supplemented with reference list searches and author contact. STUDY SELECTION Prospective cohort, case-control, and cross-sectional studies were identified with TSH the exposure and thyroid cancer the outcome. DATA EXTRACTION Three reviewers independently extracted data. Studies reporting odds ratio (OR) for TSH levels and thyroid cancer were analyzed via meta-analysis and generalized least-squares trend estimation for dose-response relationships. DATA SYNTHESIS Data extracted from 28 studies included a total of 42,032 subjects and 5,786 thyroid cancer cases. Dose-response spline analysis revealed a nonlinear relationship (P < 0.001). For TSH levels less than 1 mU/liter, the OR for thyroid cancer was 1.72 (1.42, 2.07) per milliunits per liter. However, the relationship changed for TSH levels 1 mU/liter and greater, with the OR thereafter being 1.16 (1.12, 1.21) per milliunits per liter. Studies controlling for autoimmunity reported the lowest OR [TSH below 2.5 mU/liter, OR 1.23 (1.02-1.47) per milliunits per liter; TSH 2.5 mU/liter or greater, OR 0.98 (0.89-1.09) per milliunits per liter]. Six groups assessed serum TSH in relation to markers of poor thyroid cancer prognosis, with three showing significant positive relationships. CONCLUSIONS Higher serum TSH concentration is associated with an increased risk of thyroid cancer. Thyroid autoimmunity may partially explain the association, but further epidemiological assessment is required. Future clinical research should investigate the validity of including serum TSH in diagnostic nomograms, its prognostic importance, and the potential for therapeutic TSH suppression in thyroid cancer prevention.

Diagnosis and management of type 1 laryngeal cleft

Posterior laryngeal clefts have been reported as exceptionally rare congenital anomalies. We demonstrate that type 1 posterior laryngeal clefts are more common than previously described, by reporting a series of 12 type 1 posterior laryngeal clefts diagnosed at our institution over a 12-month period. Typically, type 1 posterior laryngeal clefts are managed conservatively. In our series, 75% of the clefts were treated successfully with endoscopic repair, following failure of conservative management. This suggests surgical repair may be warranted in a greater number of type 1 posterior laryngeal clefts in an attempt to prevent associated morbidity, secondary to aspiration, pneumonia and respiratory distress. We highlight the importance of educating other paediatric specialities in maintaining a high index of suspicion for the presence of a posterior laryngeal cleft when treating patients with suggestive symptoms. This leads to early referral and diagnosis.

Superior semicircular canal dehiscence presenting as postpartum vertigo.

Objective: To describe the clinical and diagnostic features of superior semicircular canal dehiscence (SSCD) in patients with postpartum vertigo. Study Design: Retrospective review, meta-analysis. Setting: Tertiary neurotologic and audiologic center. Patients: Two women who presented with a history of acute postpartum vertigo and SSCD confirmed on high-resolution computed tomography (CT) were included. Our meta-analysis of the surgical SSCD literature comprised a total of 43 patients. Intervention: Patients with postpartum vertigo and SSCD underwent a complete medical evaluation, audiometric testing, CT imaging, magnetic resonance imaging studies, vestibular evoked myogenic potential testing, and laser Doppler vibrometer testing. Case 2 was managed with a middle fossa craniotomy and SSCD repair. Results: The first patient presented with normal hearing and aural fullness, autophony, and sound sensitivity of the left ear. A 1-mm left-sided SSCD was seen on CT imaging. She is being managed conservatively. The second patient had left-sided conductive hearing loss with sound and pressure sensitivity. The contralateral ear was congenitally deaf. CT imaging revealed a 4-mm left-sided SSCD. Because of her disabling symptoms, the patient underwent a middle fossa craniotomy and superior canal plugging. Her vestibular symptoms resolved with improvement in hearing. Vestibular evoked myogenic potential and laser Doppler vibrometer testing in both cases were consistent with SSCD. Conclusion: This is the first description of patients with SSCD presenting after childbirth and should be included in the differential diagnosis of acute postpartum vertigo or disequilibrium. SSCD plugging can provide a stable repair with resolution of symptoms, reversal of diagnostic indicators, and hearing improvement.

Laryngeal cleft: Evaluation and management

OBJECTIVES Review the latest diagnostic and treatment modalities for laryngeal and laryngotracheoesophageal clefts as they can be a major cause of respiratory and feeding morbidity in the infant and pediatric population. METHODS Literature review of published reports. RESULTS The presentation of laryngeal cleft usually involves respiratory symptoms, such as stridor, chronic cough, aspiration, and recurrent respiratory infections. Clefts of the larynx and trachea/esophagus can occur in isolation, as part of a syndrome (Opitz-Frias, VATER/VACTERL, Pallister Hall, CHARGE), or with other associated malformations (gastrointestinal, genitourinary, cardiac, craniofacial). This publication reviews the presenting signs/symptoms, diagnostic options, prognosis, and treatment considerations based on over a decade of experience of the senior author with laryngeal clefts. CONCLUSIONS Type I laryngeal clefts can be managed medically or surgically depending on the degree of morbidity. Types II, III, and IV require endoscopic or open surgery to avoid chronic respiratory and feeding complications.

Subglottic Stenosis in Wegener's Granulomatosis and the Nitinol Stent

INTRODUCTION Wegener’s granulomatosis is a systemic vasculitis characterized by necrotizing granulomas with vasculitis of the upper and lower airways and focal necrotizing glomerulonephritis. Otolaryngological manifestations of the disease were first described by Klinger in 1931. Wegener’s disease was once fatal. However, with the advent of long-term treatment with steroids and cyclophosphamide, individuals affected survive longer, and a broader spectrum of the disease is currently being displayed. Subglottic stenosis as a result of Wegener’s granulomatosis may occur following other manifestations of the disease or may present as the sole manifestation of the disease (“limited” Wegener’s granulomatosis). The incidence of subglottic stenosis in Wegener’s granulomatosis ranges from 8.5% to 23% in the literature. It is a significant cause of morbidity and mortality and typically does not respond to systemic chemotherapy. The management of subglottic disease in Wegener’s granulomatosis remains a therapeutic dilemma. Stenotic lesions are typically circumferential, with friable mucosa. Traditional treatment is chemotherapy; including corticosteroids, with immunosuppressants such as cyclophosphamide. Chemotherapeutic agents have well-described side effects when used indefinitely, including bladder carcinoma, myelodysplasia, and permanent sterility. Other treatments are mechanical subglottic dilation (with or without intratracheal injection of glucocorticoids) and laser therapy. These procedures are well tolerated but must be repeated frequently, with variable success. Tracheostomy is frequently required for airway protection when the stenosis becomes critical. Laser therapy is also only a temporary solution and ultimately creates more scar tissue and recurrent stenosis. Surgical options are limited by disease reactivation. We describe a procedure for maintaining long-term patency of the stenotic subglottic segment by, firstly dilating the affected segment and, secondly endoscopically inserting an Ultraflex (Boston Scientific Corporation) nitinol stent. To date, nitinol stents have mainly been used in more distal lesions in the tracheobronchial tree in Wegener’s disease.

Robotic surgery in otolaryngology and head and neck surgery: a review.

Recent advancements in robotics technology have allowed more complex surgical procedures to be performed using minimally invasive approaches. In this article, we reviewed the role of robotic assistance in Otolaryngology and Head and Neck Surgery. We highlight the advantages of robot-assisted surgery and its clinical application in this field.

Management of Congenital Tracheal Stenosis

Congenital tracheal stenosis (CTS) is a serious and rare condition. In most cases, stenotic lesions are composed of complete tracheal rings of cartilage. The severity of symptoms correlates with the length of affected trachea, the presence of concomitant respiratory conditions, degree of luminal narrowing, and any bronchial involvement. Critically, CTS is a disorder that can lead to life-threatening respiratory insufficiency in children. Thus, it is a clinical entity that demands timely diagnosis and treatment. This review will firstly discuss the anatomy and pathophysiology of CTS and outline the various clinical presentations associated with the disorder. In addition, methods of diagnosis and treatment strategies will be reviewed, with a focus on contemporary surgical techniques. Finally, postoperative care of patients with CTS will be reviewed, and a contemporary multidisciplinary management approach will be presented.

Minimally invasive approach to laryngeal cleft

Laryngeal cleft is a rare congenital anomaly that is recently being diagnosed with increased frequency. The objective of this report is to present a comprehensive description of endoscopic laser repair of a laryngeal cleft, using both the carbon dioxide (CO2) laser via a micromanipulator (Carl Zeiss Microimaging Inc., Thornwood, NY) and the flexible CO2 laser fiber (OmniGuide, Inc.; Cambridge, MA), from both an anesthesia and surgical perspective. Laryngoscope, 2013

Two-year mortality, complications, and healthcare use in children with medicaid following tracheostomy

To assess patient characteristics associated with adverse outcomes in the first 2 years following tracheostomy, and to report healthcare utilization and cost of caring for these children.

Pediatric Nodular Fasciitis in the Head and Neck: Evaluation and Management

IMPORTANCE Nodular fasciitis is a rare benign tumor that can present in the head and neck in children. A better understanding of this rare condition is critical to optimize management. OBJECTIVE To review the presentation, evaluation, diagnosis, and management of pediatric nodular fasciitis of the head and neck. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of all patients treated for nodular fasciitis of the head and neck over a 20-year period at a pediatric tertiary care center. INTERVENTION Surgical excision. MAIN OUTCOMES AND MEASURES Clinical data, including age, presenting symptoms, anatomical site(s), evaluation, treatment, and complications. RESULTS Fifteen children with pathologically confirmed nodular fasciitis of the head and neck were identified, including 8 boys and 7 girls. The median (range) age at diagnosis was 9.3 years (2 months to 18 years). Patients most commonly presented with a firm, enlarging soft-tissue mass. Two patients reported pain, and 1 patient presented with erythema. The most common location was the maxillofacial region (5 patients). Other locations included the scalp (3 patients), forehead (2 patients), neck (2 patients), mandible (1 patient), postauricular region (1 patient), and nasal dorsum (1 patient). One patient reported a preceding trauma, and 1 patient, a preceding infection. Presurgical imaging varied; imaging modalities used included computed tomography, magnetic resonance imaging, radiography, ultrasound, and sialography. All patients underwent surgical excision, which focused on excising the mass while preserving surrounding normal tissues. Mean (range) follow-up was 7.69 (0-46) months. Two minor complications were reported: 1 patient who underwent a near-total excisional biopsy experienced residual firmness and tenderness at the site of the lesion and another patient was left with an unfavorable cosmetic scar that necessitated intralesional steroid injection. No patient demonstrated recurrence at follow-up. CONCLUSIONS AND RELEVANCE Although an uncommon diagnosis, nodular fasciitis should be considered in the evaluation and treatment of head and neck soft-tissue masses in children. Preoperative imaging is nonspecific and variable. Pathological findings are necessary for diagnosis. Surgical excisional biopsy is curative, with no instances of recurrence in our series.