Richard J. Payne

Laryngeal inflammation assessed using the reflux finding score in obstructive sleep apnea

OBJECTIVES: To evaluate the relationships between laryngeal inflammation assessed using the Reflux Finding Score (RFS), laryngeal sensory function, and apnea severity in patients with obstructive sleep apnea (OSA). METHODS: Endoscopic sensory testing (EST) was performed with subsequent blinded scoring from video of RFS. An RFS > 7 was indicative of increased inflammatory change. RESULTS: Of 34 patients evaluated, 29 had OSA (apneahypopnea index [AHI] ≥ 15 events/h) at polysomnography. Increased inflammation was present in 26/29 (90%), with changes suggestive of laryngopharyngeal reflux. There were significant correlations between: inflammation and OSA severity (eg, RFS vs AHI, r = 0.57, P < 0.001); inflammation and laryngeal sensory impairment (EST detection threshold and pressure required to elicit the laryngeal adductor reflex, LAR); and the degree of sensory impairment and OSA severity. CONCLUSIONS: Laryngeal inflammation is prevalent among OSA patients and correlates with laryngeal sensory dysfunction, attenuation of the LAR, and apnea severity. EBM rating: C-4

Thyroid gland management in total laryngectomy: Meta-analysis and surgical recommendations

Objectives: 1) Review the incidence of thyroid gland invasion by squamous cell laryngeal carcinoma reported in the literature. 2) Assess the association between thyroid gland invasion and anatomical characteristics of the laryngeal tumor. Data Sources: MEDLINE (1967-2007) and EMBASE (1980-2007). These databases were supplemented with 61 patients from McGill University who underwent total laryngectomy with hemi- or total thyroidectomy from 2001-2006. Review Methods: Systematic review for series of laryngeal carcinoma that commented on thyroid gland invasion according to tumor subsite and pathological characteristics. Total laryngectomy specimens for primary laryngeal squamous cell carcinoma with concomitant thyroid resection were included in the analysis. Results: In total, eight series (n = 399) were included in the meta-analysis. Thyroid gland invasion was present in 33 laryngectomy specimens (8%); the principal method of invasion of the gland was by direct extralaryngeal extension. Subglottic extension > 10 mm (OR 7.22 [2.05 to 25.46]; P = 0.002), transglottic tumors (OR 3.23 [1.16 to 9.00]; P = 0.025), and subglottic subsite (OR 5.66 [1.34 to 23.87]; P = 0.018) were all significantly associated with thyroid gland invasion. Cartilaginous invasion by tumor was not a significant predictor of thyroid gland invasion (P > 0.05). Conclusions: Thyroid gland invasion is not a general feature of squamous cell laryngeal carcinoma. When present, it is strongly associated with anteroinferior spread of advanced laryngeal tumors. Thyroidectomy may only be required during total laryngectomy for transglottic tumors, subglottic tumors, and tumors with subglottic extension >10 mm.

Prediction of hypocalcemia after using 1- to 6-hour postoperative parathyroid hormone and calcium levels:an analysis of pooled individual patient data from 3 observational studies

Parathyroid hormone (PTH) levels up to 6 hours postthyroidectomy have been shown to have excellent predictive power in determining hypocalcemia. In this study, we investigate the usefulness of combining calcium and PTH to increase the predictive power.

Cost savings associated with post-thyroidectomy parathyroid hormone levels

OBJECTIVES: A 1-hour post-thyroidectomy parathyroid hormone (PTH) level of ≤8 ng/L is predictive of patients who will develop hypocalcemia and guides early supplementation with calcium and vitamin D. However, most hypocalcemic patients fail to meet this criterion. The goal of this study was to determine whether PTH ≤ 15 ng/L could be used as a better predictor of hypocalcemia. STUDY DESIGN, SUBJECTS, AND METHODS: This retrospective study involved 270 thyroidectomy patients (2004-2006). PTH and calcium levels, length of admission, supplementation, and rates of hypocalcemia were recorded. RESULTS: Forty-three percent (26/60) of patients developing hypocalcemia met the PTH ≤ 8 ng/L cut-off. In contrast, 80% (48/60) of patients developing hypocalcemia had a PTH ≤ 15 ng/L. Two point two percent of patients had a 1-hour PTH ≤ 15 ng/L and failed to develop hypocalcemia, for a specificity of 97%. CONCLUSIONS: A 1-hour PTH cut-off of ≤15 ng/L for prophylactic supplementation should allow the prevention of the majority of cases of hypocalcemia, leading to significant cost savings by shortening hospital stays.

Comparison of the Incidence of Postoperative Hypocalcemia following Total Thyroidectomy vs Completion Thyroidectomy

Objective To study the rate of postoperative hypocalcemia following completion thyroidectomy (CT), in comparison with the hypocalcemia rate following total thyroidectomy (TT). Study Design and Setting A retrospective study, performed at the McGill University Thyroid Cancer Center, Montreal, Quebec, Canada, from 2007 to 2012. Subjects and Methods Medical records of adult patients undergoing CT and TT operated by a single surgeon were reviewed. Data were extracted for demographics, postoperative calcium levels, surgical logs, and final surgical pathology. Hypocalcemia was defined as corrected serum calcium level ≤1.90 mmol/L, with concurrent serum parathyroid hormone <8 ng/L, and/or any signs or symptoms of hypocalcemia. Results There were 68 CTs and 146 TTs. Transient hypocalcemia occurred in 1 of 68 (1.5%) and 18 of 146 (12.5%) patients in the CT and TT groups, respectively. The rate of hypocalcemia was significantly lower in the CT compared with the TT group (P = .02). In both groups, there were no cases of permanent hypocalcemia. Conclusion The risk of transient of hypocalcemia in patients undergoing CT is significantly lower than the rate of hypocalcemia in patients undergoing TT.

Determinants of Urolithiasis Before and After Parathyroidectomy in Patients With Primary Hyperparathyroidism

OBJECTIVEnTo assess the determinants of urolithiasis in patients with primary hyperparathyroidism (PHPT) before and after parathyroidectomy (PTX).nnnMETHODSnInstitutional Research Ethics approval was obtained. A retrospective review was performed for patients presenting with PHPT to the stone, surgical oncology, and otolaryngology clinics at 2 tertiary-care centers from January 2006 to November 2011. Demographic, clinical, and surgical data were collected together with 24-hour urine collections before and after PTX.nnnRESULTSnOf 332 patients undergoing PTX, 255 (68.2% female patients) had PHPT. Mean age was 60.3 years (range, 18-91). Before PTX, renal calcification was detected in 51 (20%) patients, nephrolithiasis in 48 (18.8%), and nephrocalcinosis in 3 (1.2%) patients. Compared with PHPT patients without stones, PHPT patients with stones were significantly younger (56.4 vs 61.3 years, P=.02), less likely to be female (54.9% vs 71.9%, P=.03), and had significantly lower levels of vitamin D (19.7 vs 23.5 ng/mL, P=.03). Nine patients (3.5%) developed stones after PTX and were found to have significantly higher post-PTX total serum calcium levels when compared with those without stones. Although hypercalciuria was detected in 62% of pre-PTX stone formers, none of those who tested had post-PTX hypercalciuria (P<.001). On multivariate regression analysis, post-PTX stone formation was associated with male gender (adjusted odds ratio [95% confidence interval]: 6.8 [5.3-7.2], P=.01) and post-PTX hypercalcemia (adjusted odds ratio [95% confidence interval]: 1.48 [1.33-2.12], P=.02).nnnCONCLUSIONnPre-PTX urolithiasis was associated with younger age, male gender, and lower levels of vitamin D, whereas post-PTX urolithiasis was independently predicted by male gender and hypercalcemia.

Intraoperative parathyroid hormone level in parathyroidectomy: which patients benefit from it?

BackgroundIntraoperative parathyroid hormone level (IOPTH) is withdrawn during parathyroidectomy to confirm the success of the procedure. Recently, the importance of IOPTH has been put to question. The purpose of this study is to determine whether IOPTH is necessary for all patients undergoing parathyroidectomy in the presence of frozen section.Materials and methodsA cohort study of parathyroidectomies was performed in three university affiliated hospitals during 2007-2012. The patients were divided into two groups. Group 1: Patients with two preoperative concordant imaging localizing a hyperactive gland. Group 2: Patients without two concordant imaging. A comparison of benefit of IOPTH was carried out. Frozen section results were also analyzed to determine sensitivity and predictability of a parathyroid adenoma.ResultsThe study considered 221 patients having parathyroidectomies for primary hyperparathyroidism (PHPT). Of them, 10 were excluded due to incomplete data. Among the remaining, 186 had 2 concordant imaging preoperatively localizing an adenoma. 93.5% of whom were found intraoperatively in that location. IOPTH was not found to be of importance in 98.92% of the preoperative localized adenomas in the presence of frozen section. IOPTH added an estimate of 30.9xa0minutes on average to the surgery time.ConclusionThis study demonstrates that the added operating time associated with IOPTH may not be justified for patients undergoing parathyroidectomy who have 2 concordant imaging preoperatively in the presence of frozen section. This study suggests a simple algorithm, The McGill Parathyroid Protocol (MPP), to help in approaching PHPT patients undergoing parathyroidectomy.

3-phase dual-energy CT scan as a feasible salvage imaging modality for the identification of non-localizing parathyroid adenomas: a prospective study

ObjectivesAccurate pre-operative imaging of parathyroid adenomas (PAs) is essential for successful minimally invasive surgery; however, rates of non-localizing PAs can be as high as 18xa0%. Multiphasic dual-energy CT (DECT) has the potential to increase accuracy of PA detection by enabling creation of paired material maps and spectral tissue characterization. This study prospectively evaluated the utility of 3-phase DECT for PA identification in patients with failed localizatio n via standard imaging.MethodsPatients with primary hyperparathyroidism and non-localizing PAs underwent a 3 phase post-contrast DECT scan acquired at 25, 55, and 85xa0s. The scans were prospectively evaluated by two head and neck radiologists. Pre-operative localization was compared to intraoperative localization and final histopathology. A post-hoc DECT spectral density characterization was performed on pathologically-proven PAs.ResultsOut of 29 patients with primary hyperparathyroidism and non-localized PAs, DECT identified candidates in 26. Of the 23 patients who underwent parathyroidectomy, DECT provided precise anatomic localization in 20 patients (PPVu2009=u200987.0xa0%), one with multi-gland disease. The virtual unenhanced images were not found to be useful for diagnosis but successful diagnosis was made without an unenhanced phase regardless. Spectral analysis demonstrated a distinct spectral Hounsfield attenuation curve for PAs compared to lymph nodes on arterial phase images.Conclusion3-phase DECT without an unenhanced phase is a feasible salvage imaging modality for previously non-localizing parathyroid adenomas. Optimal interpretation is achieved based on a combination of perfusion characteristics and other morphologic features. Advanced spectral DECT analysis has the potential for further increasing accuracy of PA identification in the future.

The relationship between upper airway collapse and the severity of obstructive sleep apnea syndrome: a chart review

BackgroundWe sought to determine the ability of the endoscopic Mueller maneuver (MM) to predict the severity of OSAS based on upper airway (UA) collapse.MethodsThis chart review retrospectively analyzed the results of endoscopic Mueller maneuvers examining the UA on 506 patients suspected of having OSAS. There were 3 areas of UA collapse that were evaluated: velopharynx (VP), base of tongue (BOT), and lateral pharyngeal walls (LPW). A sleep study was done after the examination to assess the severity of OSAS based on the apnea-hypopnea index (AHI).ResultsA total of 506 patients met criteria for OSAS, with 194 mild cases (5u2009≤u2009AHIu2009<u200915), 163 moderate cases (15u2009≤u2009AHIu2009<u200930) and 149 severe cases (30u2009≤u2009AHI). At the VP, 30 patients had minimal collapse (mean AHIu2009=u200917); 41 patients had moderate VP collapse (mean AHIu2009=u200925); 392 patients had severe VP collapse (mean AHIu2009=u200927). At the BOT, 144 patients had minimal collapse (mean AHIu2009=u200919); 187 patients had moderate BOT collapse (mean AHIu2009=u200924); 175 patients had severe BOT collapse (mean AHIu2009=u200933). At the LPW, 158 patients had minimal collapse (mean AHIu2009=u200920); 109 patients had moderate LPW collapse (mean AHIu2009=u200925); 120 patients had severe LPW collapse (mean AHI =33). The correlations found between VP collapse, BOT collapse, and LPW collapse and OSAS severity were: ru2009=u20090.069 (95xa0% CI; −0.022, 0.16), ru2009=u20090.26 (95xa0% CI; 0.18, 0.34) and ru2009=u20090.22 (95xa0% CI; 0.12, 0.31), respectively.ConclusionsIn this study, the degree of collapse of the UA at all levels, especially at the BOT and LPW levels, correlate significantly with the severity of OSAS. The Mueller maneuver helped identify patients with severe sleep apnea based on UA collapse. The MM cannot be used to diagnose OSAS, but can be a valuable tool to help the physician estimate the severity of sleep apnea and the urgency to obtain a sleep study.

Role of computed tomographic cisternography in the management of cerebrospinal fluid rhinorrhea.

In a retrospective review of 13 patients, computed tomographic cisternography (CTC) was the primary imaging modality used for the detection of cerebrospinal fluid (CSF) leaks. In five of the cases, the diagnosis of CSF rhinorrhea was confirmed by the beta2-transferrin test. In the remaining cases, it was corroborated through endoscopic visualization, clinical history, and nuclear scanning. This study analyzes the efficacy of CTC in the detection of CSF leaks and discusses the different methods of computerized manipulation and reconstruction of the images for effective site localization. The study demonstrates that computerized reconstruction of images should be considered an integral part of CTC because it appears to be an inexpensive and simple diagnostic tool that improves on the accuracy of detection. Although T2-weighted magnetic resonance imaging may be helpful, this study emphasizes the efficacy of CTC in the diagnosis of CSF leaks. Using the techniques of image reconstruction improves on diagnostic precision with relatively little increase in cost, time, and labour. This study also introduces a diagnostic algorithm for otolaryngologists dealing with the challenge of identifying and locating CSF leaks.