Phillip Huyett

Utility of Fine-Needle Aspiration Biopsy in the Evaluation of Pediatric Head and Neck Masses

Objectives Fine-needle aspiration biopsy (FNAB) has a well-established role in the evaluation of an adult head and neck mass (HNM) but remains underused in children. The objectives of this study were to assess the diagnostic accuracy, safety profile, use of anesthesia, and influence on surgical decision making of FNAB of HNM in the pediatric population. Study Design Case series with chart review. Setting Tertiary care children’s hospital. Subjects and Methods In total, 257 consecutive patients with HNM who underwent 338 FNABs from July 2007 to July 2014 were reviewed. Patients ranged in age from 0 to 21 years (mean, 9.3 years); lesions ranged in size from 0.3 to 12.5 cm (mean, 2.4cm). Fine-needle aspiration biopsies were performed in the interventional radiology suite, operating room, clinic, or ward. Results The most common patient final diagnoses included reactive lymphadenopathy (n = 99, 38.5%), benign thyroid colloid nodule (n = 31, 12.1%), malignancies (n = 21, 8.2%), and atypical mycobacterial infection (n = 15, 5.8%). On surgical histopathologic and clinical follow-up, overall sensitivity of FNAB was 94.6% and specificity was 97.7%. The complication rate was 2.1%, and general anesthesia or sedation was used for 73% of FNAB. Surgery occurred only 9 times following the 191 patients with negative FNAB results, indicating that 95.3% of unnecessary surgeries were avoided with the assistance of the FNAB result. Conclusions Fine-needle aspiration biopsy is an accurate and safe diagnostic tool for guiding management of persistent lymphadenopathy, thyroid nodules, and other HNM in pediatric patients. Negative FNABs can often obviate the need for surgical intervention.

Perineural Invasion in Parotid Gland Malignancies

Objectives To investigate the clinical predictors and survival implications of perineural invasion (PNI) in parotid gland malignancies. Study Design Case series with chart review. Setting Tertiary care medical center. Subjects and Methods Patients with parotid gland malignancies treated surgically from 2000 to 2015 were retrospectively identified in the Head and Neck Cancer Registry at a single institution. Data points were extracted from the medical record and original pathology reports. Results In total, 186 patients with parotid gland malignancies were identified with a mean follow-up of 5.2 years. Salivary duct carcinoma (45), mucoepidermoid carcinoma (44), and acinic cell carcinoma (26) were the most common histologic types. A total of 46.2% of tumors were found to have PNI. At the time of presentation, facial nerve paresis (odds ratio [OR], 64.7; P < .001) and facial pain (OR, 3.7; P = .002) but not facial paresthesia or anesthesia (OR, 2.8, P = .085) were predictive of PNI. Malignancies with PNI were significantly more likely to be of advanced T and N classification, be high-risk pathologic types, and have positive margins and angiolymphatic invasion. PNI positivity was associated with worse overall (hazard ratio, 2.62; P = .001) and disease-free survival (4.18; P < .001) on univariate Cox regression analysis. However, when controlling for other negative prognosticators, age, and adjuvant therapy, PNI did not have a statistically significant effect on disease-free or overall survival. Conclusions PNI is strongly correlated with more aggressive parotid gland malignancies but is not an independent predictor of worse survival. Facial paresis and pain were predictive of PNI positivity, and facial paresis correlated with worse overall and disease-free survival.

Sinus opacification in the intensive care unit patient

The significance of sinus opacification in intensive care unit (ICU) patients remains uncertain. Our objectives were to determine the baseline incidence and risk factors associated with the development of radiographic sinus abnormalities in the ICU population.

Radiographic Mastoid and Middle Ear Effusions in Intensive Care Unit Subjects.

BACKGROUND: This study was conducted to determine the incidence of and risk factors associated with the development of radiographic mastoid and middle ear effusions (ME/MEE) in ICU patients. METHODS: Head computed tomography or magnetic resonance images of 300 subjects admitted to the University of Pittsburgh Medical Center neurologic ICU from April 2013 through April 2014 were retrospectively reviewed. Images were reviewed for absent, partial, or complete opacification of the mastoid air cells and middle ear space. Exclusion criteria were temporal bone or facial fractures, transmastoid surgery, prior sinus or skull base surgery, history of sinonasal malignancy, ICU admission < 3 days or inadequate imaging. RESULTS: At the time of admission, 3.7% of subjects had radiographic evidence of ME/MEE; 10.3% (n = 31) of subjects subsequently developed new or worsening ME/MEE during their ICU stay. ME/MEE was a late finding and was found to be most prevalent in subjects with a prolonged stay (P < .001). Variables associated with ME/MEE included younger age, the use of antibiotics, and development of radiographic sinus opacification. The proportion of subjects with ME/MEE was significantly higher in the presence of an endotracheal tube (22.7% vs 0.6%, P < .001) or a nasogastric tube (21.4% vs 0.6%, P < .001). CONCLUSIONS: Radiographic ME/MEE was identified in 10.3% of ICU subjects and should be considered especially in patients with prolonged stay, presence of an endotracheal tube or nasogastric tube, and concomitant sinusitis. ME/MEE is a potential source of fever and sensory impairment that may contribute to delirium and perceived depressed consciousness in ICU patients.

Quality Assessment of the Clinical Practice Guideline for Tympanostomy Tubes in Children

Objectives To determine the association between the introduction of statements 6 and 7 in the 2013 clinical practice guideline (CPG) for tympanostomy tubes in children and the identification of preoperative middle ear fluid (acute otitis media / otitis media with effusion [AOM/OME]) in children undergoing bilateral myringotomy and tube (BMT) placement. Study Design Case series with chart review. Setting Tertiary care children’s medical center. Subjects and Methods Patients who underwent BMT for recurrent AOM were retrospectively reviewed. We examined 240 patients before (BG; 2012) and 240 patients after (AG; 2014) the introduction of the CPG. Results The baseline characteristics of the 2 groups were comparable. The total annual number of BMT placements performed at our institution decreased from 3957 (BG) to 3083 (AG). There was no significant increase in the rate of preoperative AOM/OME identification following CPG introduction (BG 78.3% vs AG 83.3%, P = .164). The rate of identification of AOM/OME in the operating room (OR) increased from 54.2% (BG) to 71.3% (AG, P < .001). The rate of identification of AOM/OME both in the clinic and in the OR increased from 55.1% (BG) to 71.3% (AG, P < .001). Cases with concordant clinic and OR AOM/OME occurred among younger children (P = .045), those with fewer episodes of AOM (P = .043), and those with shorter time between the clinic and OR dates (P = .008). Conclusions Following the introduction of the CPG, there was no change in the rate of identification of AOM/OME prior to recommending BMT placement in children with recurrent AOM. The lack of improved compliance with statements 6 and 7 may be related to multiple clinician- and patient-derived factors.

Risk of Postoperative Complications in Patients with Obstructive Sleep Apnea following Skull Base Surgery

Objectives Obstructive sleep apnea (OSA) presents several challenges in skull base surgery, including increased intracranial pressure, worsened OSA with nasal packing, and avoidance of positive airway pressure (PAP) therapy postoperatively. The objective of this study was to examine the risk of postoperative complications in a skull base population with OSA in which PAP therapy is withheld. Study Design Retrospective cohort study. Setting Tertiary care hospital. Subjects and Methods Medical records of 414 adult patients undergoing anterior skull base procedures between January 1, 2014, and January 7, 2017, were retrospectively reviewed. Revision surgeries, skull base infections, sinus surgery, and orbital cases were excluded. Results Fifty-four (13.0%) patients with a diagnosis of OSA were identified. While the known patients with OSA were more likely to require postoperative supplemental oxygen (odds ratio [OR], 4.29; 95% confidence interval [CI], 2.38-7.75; P < .001), there was no increased risk of serious respiratory events or cerebrospinal fluid leak (CSF). To address the likely underdiagnosis of OSA in this cohort, subgroup analyses were performed of patients at high risk for OSA (body mass index >30 kg/m2 and hypertension) and demonstrated an increased risk of serious respiratory events (OR, 4.41; 95% CI, 1.24-15.7; P = .034) and CSF leak (13.6% vs 4.7%; P = .018). Conclusions Skull base patients with known OSA can be successfully managed with diligent care in the perioperative period when PAP therapy is withheld. However, OSA is likely underdiagnosed in the skull base population, and patients at high risk for undiagnosed OSA may be at the greatest risk for respiratory complications and CSF leak. Increased presurgical awareness and implementation of a perioperative management algorithm is needed.

Second tympanostomy tube placement in children with recurrent acute otitis media

To determine the rate and predictors of electing for a second bilateral myringotomy and tympanostomy tube placement (BMT) in children with recurrent acute otitis media (RAOM).

Accuracy of chest X-Ray measurements of pediatric esophageal coins

OBJECTIVE To determine the accuracy of chest x-ray measurements in children using ingested radiopaque foreign bodies of known size. METHODS A database of foreign body ingestions at a tertiary care childrens hospital was queried from 2013 to 2016 for children who had ingested a US coin, had a pre-operative chest x-ray and documentation of coin type at the time of endoscopic removal. Four blinded research subjects measured the coin diameter on chest x-ray using iSite PACS software and based on the measurement, predicted the coin type. Measurements were compared to the known coin diameters published by the US Mint. RESULTS A total of 51 patients with sixteen esophageal quarters (diameter 24.26 mm), fourteen nickels (21.21 mm), fourteen pennies (19.05 mm) and seven dimes (17.91 mm) were included in the study. The four subjects had a mean accuracy of 60.3% (range 49.0%-72.5%) in predicting the correct coin type. Across all raters, there was poor agreement for pennies (kappa = 0.161) and dimes (kappa = 0.131), fair agreement for nickels (kappa = 0.259), good agreement for quarters (kappa = 0.687), and fair agreement overall (kappa = 0.371). The study measurements overestimated the coin size in 203 of the 204 measurements by a mean of 1.84 mm (range -0.31-3.85 mm). The mean size discrepancy was larger (2.40 vs. 1.30 mm, p < 0.001) and accuracy of coin type identification was worse (44.6% vs. 74.1%, p = 0.001) in children <4 years old. CONCLUSIONS Measurement of esophageal coins on chest x-ray is relatively inaccurate and overestimates the size in the majority of cases. Clinicians should use caution when performing fine measurements on chest x-rays, especially in children younger than 4 years old.

Obstructive sleep apnea in the irradiated head and neck cancer patient

To assess the prevalence of obstructive sleep apnea (OSA) in head and neck cancer (HNSCC) patients treated with radiation therapy.

A Model for Perineural Invasion in Head and Neck Squamous Cell Carcinoma

Perineural invasion (PNI) is found in approximately 40% of head and neck squamous cell carcinomas (HNSCC). Despite multimodal treatment with surgery, radiation, and chemotherapy, locoregional recurrences and distant metastases occur at higher rates, and overall survival is decreased by 40% compared to HNSCC without PNI. In vitro studies of the pathways involved in HNSCC PNI have historically been challenging given the lack of a consistent, reproducible assay. Described here is the adaptation of the dorsal root ganglion (DRG) assay for the examination of PNI in HNSCC. In this model, DRG are harvested from the spinal column of a sacrificed nude mouse and placed within a semisolid matrix. Over the subsequent days, neurites are generated and grow in a radial pattern from the cell bodies of the DRG. HNSCC cell lines are then placed peripherally around the matrix and invade preferentially along the neurites toward the DRG. This method allows for rapid evaluation of multiple treatment conditions, with very high assay success rates and reproducibility.