Patrick C. Walz

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.

Comparison of Long-term Quality-of-Life Outcomes in Vestibular Schwannoma Patients

Objective To compare long-term quality-of-life outcomes in vestibular schwannoma patients managed with observation, microsurgery, or stereotactic radiation. Study Design ross-sectional survey with retrospective chart review. Setting Tertiary care center. Subjects and Methods The Penn Acoustic Neuroma Quality of Life (PANQOL) survey was mailed to 600 patients treated for vestibular schwannoma. Patients were separated by treatment and subsequently subdivided by years of follow-up (0-5, 6-10, and >10 years). Composite quality-of-life (cQOL) scores and subscores for hearing, balance, facial nerve, pain, anxiety, energy, and general health were calculated. Scores were compared among treatment groups as a whole, among treatment groups at each time interval, and within treatment groups over time using a 2-tailed analysis of variance and paired t test. Results The survey return rate was 49%, and the mean follow-up was 7.9 years. The only significant difference in cQOL occurred at 0 to 5 years, where stereotactic radiation scores were better than both microsurgery and observation (P = .009). No significant differences were detected in cQOL after 5 years. Within the radiation group, cQOL was significantly lower at 6 to 10 years than at 0 to 5 years (P = .013). At no point was cQOL for stereotactic radiation less than that for observation or microsurgery. Conclusions Long-term (>5 years) quality-of-life outcomes measured by the PANQOL in vestibular schwannoma patients show no significant differences between stereotactic radiation, observation, and microsurgical intervention. Studies are needed to fully evaluate very-long-term QOL for patients with vestibular schwannoma.

Three-Dimensional Segmented Volumetric Analysis of Sporadic Vestibular Schwannomas: Comparison of Segmented and Linear Measurements

Objective To compare 3-D segmented volumetric analysis of vestibular schwannomas (VS) with traditional linear tumor measurement on serial magnetic resonance imaging (MRI) studies to assess volume and growth rates. Study Design Case series with retrospective chart review. Setting Tertiary care medical center. Methods This analysis identified 24 VS patients clinically followed with serial gadolinium enhanced images. Maximum linear dimensions (MLD) were obtained from gadolinium-contrasted T1 sequences from 3 serial MRI scans per RECIST guidelines. MLD was cubed (MLD3) and orthogonal analysis (OA) was carried out to provide volumetric estimates for comparison with segmented data. Segmented volumetric analysis (SVA) was performed with semi-automated 3-D conformal procedure. Tumor volume, percentage change in volume, and interval percentage change were compared using paired 2-tailed t tests. Results The average interval between MRIs was 2.6 years. Volume estimates differed significantly between SVA and OA and MLD3 at all intervals. Linear growth measurements averaged 0.5 mm/y (5.4%). Volumetric growth was 50 mm3/y (22.8%) with SVA, 110 mm3/y (19.6%) with OA, and 210 mm3/y (14.4%) with MLD3 estimates. Differences between MLD and both MLD3 and SVA were significant, but significance between MLD3 and SVA was only identified in interval analysis. Progression was identified in 75% more patients with SVA than OA, MLD3, or MLD. Conclusions VS assume complex configurations. Linear measurements inaccurately estimate tumor volume and growth compared with segmented analysis. SVA is a useful clinical tool that accurately assesses tumor volume. Use of outcomes such as tumor volume and percentage of volume change may be more sensitive in assessing tumor progression compared with linear measurements.

Voice related quality of life in pediatric patients with a history of prematurity

OBJECTIVE To determine incidence of dysphonia in patients with history of prematurity and evaluate the correlation between dysphonia and risk factors unique to premature infants. The aim of this study is to determine parent-perceived vocal quality in patients with history of prematurity and whether duration of intubation, number of intubations, and incidence of patent ductus arteriosus repair were correlated with these perceptions. METHODS Cohort study of premature patients presenting to outpatient clinics from January 2010 to January 2013 in tertiary care center. Patients gestational age ≤37 weeks at birth without history of tracheostomy or known vocal fold pathology were eligible. A volunteer sample was obtained from patients presenting in Otolaryngology clinics from January 2010 to January 2013 whose parents agreed to complete surveys. Outcomes were assessed via parental completion of pediatric voice outcomes score (pVOS) and pediatric voice-related quality of life (pVRQOL) instruments. The primary outcome assessed was the incidence of dysphonia in infants with a history of prematurity without known vocal pathology. Additionally, patient factors associated with dysphonia were evaluated. The hypothesis tested was formulated prior to data collection. RESULTS Sixty-nine participants were included. Mean age at follow-up was 28 (3-197) months. Mean gestational age was 29 (23-37) weeks. Mean intubation duration was 3 (0-22) weeks and median number of intubations was 1 (range 0-5). Voice outcome scores varied widely with pVRQOL scores demonstrating a mean of 89.2±18.1 (25-100) and pVOS with a mean of 11.4±2.2 (0-13). Univariate analysis utilized Spearman correlation coefficients for continuous variables and Wilcoxon Two-sample test for categorical groups. Significance was set at p<0.05. All significant univariate associations were placed in a multivariate model. Duration of intubation ≥4 weeks was the only factor which correlated with dysphonia on multivariate analysis (p=0.0028, OR=6.4, 95% CI=1.9-21.6). CONCLUSIONS The data suggest that prolonged intubation is associated with poorer long term parent-perceived voice quality in premature patients. Further study is required to correlate parent perceptions with objective vocal quality data and physical findings of vocal pathology. These data may increase the clinicians suspicion for and evaluation of dysphonia in this population.

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.

Characterization of laryngeal muscle stem cell survival and proliferation.

Objectives/Hypothesis: Laryngeal muscle and skeletal muscle stem cells (MSC) have been shown to differ in physiological basal activity and responsiveness to stimuli. Given these differences, it is the purpose of this investigation to characterize the in vitro proliferation and survival of laryngeal and skeletal MSC to determine whether intrinsic differences exist that may account for differences noted in vivo.

The Internet, Adolescent Males, and Homemade Blowgun Darts: A Recipe for Foreign Body Aspiration

We describe our experience with blowgun dart aspiration via an illustrative case series and review the resources available to teach children how to construct these objects. A 15-year-old boy presented with cough, wheeze, and eventually admitted to aspiration of a homemade blowgun dart. This instance heightened the awareness of our experience with blowgun dart aspiration as 3 cases presented within a 3-month period. Patients uniformly presented with cough and reported aspiration, and wheezing was noted in 2 of the 3. Although all ultimately admitted their behavior, 2 were initially reluctant to admit aspirating the blowgun dart. Radiographic findings of a needle-shaped metallic airway foreign body were consistent in all patients. Each admitted to finding instructions for blowgun dart construction on the Internet. Emergent rigid bronchoscopy with blowgun dart removal resulted in symptom resolution in all without complication. This represents the largest series of blowgun dart aspiration to date. During deep inhalation, when preparing to propel a blowgun dart, the vocal folds maximally abduct, leading to increased risk for aspiration. Twenty websites were identified providing instructions for the construction of homemade blowgun darts. With the accessibility of the Internet and number of instructional websites, this clinical entity may become more common in the future. Unfortunately, only a few of the websites provide any safety warnings. Certainly, prompt treatment can result in good outcomes; however, serious potential complications, including death, could occur especially given the hesitance our patients showed in divulging the truth of the inciting event.

Pediatric polysomnography for sleep-disordered breathing prior to tonsillectomy: a guideline review.

Snoring and other signs of sleep-disordered breathing (SDB) represent a common management challenge for the pediatrician, pulmonologist, anesthesiologist, and otolaryngologist. In 2011, the American Academy of Otolaryngology-Head and Neck Surgery published a clinical practice guideline for the treatment of patients with SDB. This guideline provides indications for polysomnography use in patients with SDB. In this article, we discuss the management of SDB in pediatric patients, which relies on the accurate assessment of symptoms of SDB, identification of comorbidities known to increase the severity of SDB, and appropriate preoperative assessment of the patient.

Pediatric head and neck masses. Preface

The subspecialty of Pediatric Otolaryngology Head and Neck surgery continues to change and evolve. The origin of this subspecialty can be traced to the studies and advancements made by Chevalier Jackson, MD (November 4, 1865 to August 16, 1958) in the early and middle portions of the twentieth century. His work primarily concerned pediatric bronchoesophagology and attracted students who devoted their practice and research to advance the techniques he pioneered. New standards of care began to emerge, which led to the establishment of societies and universitybased fellowship programs devoted to studying, describing, and treating otolaryngology diseases of children. As pediatric care became concentrated at major pediatric referral centers, practitioners recognized that there were many congenital lesions as well as benign and malignant tumors of the head and neck region that were unique to the pediatric population. This led to a renewed interest and investigation into the anatomic features, physiology, and treatment of these unique pediatric disorders, contributing to better patient outcomes. Having devotedmy professional career to the study and care of children with head and neck masses, I am pleased that there is continued interest in this subspecialty. This volumewas compiled as a testament to past and present efforts and to provide a framework that encourages others to make advancements in the development of pediatric otolaryngology and head and neck mass surgery.

Endoscopic Skull Base Surgery in the Pediatric Patient

Pathology along the anterior and posterior skull base has long posed challenges to surgeons due to the difficulty accessing these locations and complexity of the surrounding neurovascular anatomy. Initial surgical management of these disorders included open craniofacial approaches and/or craniotomy and these approaches are still utilized today for selected cases. However, advances in the later half of the 20th century in optics, endoscope design, and high definition digital images allowed the development of microscopic and, more recently, endoscopic approaches to the skull base. This technology was initially developed and used in adults, but has been adapted over time for use in the pediatric patient. In this chapter, the salient points regarding pediatric endoscopic skull base surgery will be reviewed to provide the reader a framework for understanding the indications, pertinent anatomy, preoper‐ ative evaluation, and intraoperative management of skull base pathology, highlight‐ ing challenges and circumstances unique to the pediatric population.