Russel Kahmke

Utility of Intraoperative Frozen Sections during Thyroid Surgery

Objective. To describe the usefulness of intraoperative frozen section in the diagnosis and treatment of thyroid nodules where fine needle aspirate biopsies have evidence of follicular neoplasm. Study Design. Retrospective case series. Methods. All patients have a fine needle aspirate biopsy, an intraoperative frozen section, and final pathology performed on a thyroid nodule after initiation of the Bethesda System for Reporting Thyroid Cytopathology in 2009 at a single tertiary referral center. Sensitivity, specificity, positive predictive value, and negative predictive value are calculated in order to determine added benefit of frozen section to original fine needle aspirate data. Results. The sensitivity and specificity of the frozen section were 76.9% and 67.9%, respectively, while for the fine needle aspirate were 53.8% and 74.1%, respectively. The positive and negative predictive values for the fine needle aspirates were 25% and 90.9%, respectively, while for the frozen sections were 27.8% and 94.8%, respectively. There were no changes in the operative course as a consequence of the frozen sections. Conclusion. Our data does not support the clinical usefulness of intraoperative frozen section when the fine needle aspirate yields a Bethesda Criteria diagnosis of follicular neoplasm, suspicious for follicular neoplasm, or suspicious for malignancy at our institution.

FoxP3 and indoleamine 2,3-dioxygenase immunoreactivity in sentinel nodes from melanoma patients

OBJECTIVE 1) Assess FoxP3/indoleamine 2,3-dioxygenase immunoreactivity in head and neck melanoma sentinel lymph nodes and 2) correlate FoxP3/indoleamine 2,3-dioxygenase with sentinel lymph node metastasis and clinical recurrence. STUDY DESIGN Retrospective cohort study. METHODS Patients with sentinel lymph node biopsy for head and neck melanoma between 2004 and 2011 were identified. FoxP3/indoleamine 2,3-dioxygenase prevalence and intensity were determined from the nodes. Poor outcome was defined as local, regional or distant recurrence. The overall immunoreactivity score was correlated with clinical recurrence and sentinel lymph node metastasis using the chi-square test for trend. RESULTS Fifty-six sentinel lymph nodes were reviewed, with 47 negative and 9 positive for melanoma. Patients with poor outcomes had a statistically significant trend for higher immunoreactivity scores (p=0.03). Positive nodes compared to negative nodes also had a statistically significant trend for higher immunoreactivity scores (p=0.03). Among the negative nodes, there was a statistically significant trend for a poor outcome with higher immunoreactivity scores (p=0.02). CONCLUSION FoxP3/indoleamine 2,3-dioxygenase immunoreactivity correlates with sentinel lymph node positivity and poor outcome. Even in negative nodes, higher immunoreactivity correlated with poor outcome. Therefore higher immunoreactivity may portend a worse prognosis even without metastasis in the sentinel lymph node. This could identify a subset of patients that may benefit from future trials and treatment for melanoma through Treg and IDO suppression.

What are the diagnostic criteria for migraine-associated vertigo?†

BACKGROUND Migraines are very common and occur with a lifetime prevalence of 13% to 16% in the general population. Vertigo is also common, and the lifetime prevalence is 7%. When comparing the prevalence of these two conditions, the expected combination should be 1.1%. The association is closer to 3.2%, with migraineurs 3.8 times more likely to suffer from vertigo than those without migraines. Although there are increasing data to suggest a more than casual relationship between migraines and vestibular and nonvestibular forms of dizziness and vertigo, clinicians are left with the task of diagnosing and treating these patients. Currently, there is no unifying term or internationally approved criterion for migraineassociated vertigo. Without such criteria, determination of the pathophysiology and appropriate treatment regimens for these patients will continue to be elusive.

Trends in Otolaryngology Consultation Patterns at an Academic Quaternary Care Center

Importance The consultation patterns of an otolaryngology–head and neck surgery service have not previously been reported. The time, resources, and attention required to operate such a consultation service are unknown. Objective To assess trends in otolaryngology–head and neck surgery consultations conducted in emergency departments (EDs) and inpatient services. Design, Setting, and Participants A retrospective analysis was conducted of the medical records of patients at a quaternary care center receiving inpatient otolaryngology consultations from January 1 to December 31, 2014. Exposure Clinical evaluation and bedside and operative procedures performed by the otolaryngology–head and neck surgery service. Main Outcomes and Measures Demographics, reason for consultation, diagnosis, bedside procedures, operative interventions, and admission variables. Results A total of 1491 consultations were completed for adult (1091 [73.2%]; 854 men and 637 women; mean [SD] age 50.3 [19.3] years) and pediatric (400 [26.8%]; 232 boys and 168 girls; mean [SD] age, 4.0 [5.2] years) patients. Of the 1491 consultations, 766 (51.4%) originated from inpatient teams vs 725 (48.6%) from the ED. A total of 995 of all consultations (66.7%) resulted in a bedside procedure, and 243 (16.3%) required operative intervention. Consultations regarding airway evaluation (362 [47.3%] vs 143 [19.7%]), management of epistaxis (78 [10.2%] vs 33 [4.6%]), and rhinologic evaluation (79 [10.3%] vs 18 [2.5%]) were more frequent from inpatient teams than from the ED. Consultations regarding management of head and neck infections (162 [22.3%] vs 32 [4.2%]), facial trauma (235 [32.4%] vs 16 [2.1%]), and postoperative complications (73 [10.1%] vs 2 [0.3%]) were more frequent in the ED. Of the 725 consultations performed in the ED, 212 patients (29.2%) required hospitalization. Conclusions and Relevance The consultation volume of an otolaryngology–head and neck surgery service requires significant time and resources. Consultations are most often for rhinologic or laryngologic issues and are reflective of the clinical setting in which the patient is evaluated. Cost savings may be realized by increasing health care access points for nonurgent concerns that can be evaluated in an outpatient setting.

Incidence of Retrocochlear Pathology Found on MRI in Patients With Non-Pulsatile Tinnitus.

Objective: To identify the incidence of retrocochlear pathology on MRI in patients with non-pulsatile tinnitus. Study Design: Retrospective review. Setting: Tertiary referral center. Patients: Adults with MRIs performed between March 1, 2008 and February 1, 2014 for non-pulsatile tinnitus with or without hearing loss. Intervention: MRI. Main Outcome Measure: Incidence of retrocochlear pathology. Results: Of the 218 patients who met inclusion criteria, 198 (91.3%) had unremarkable MRIs. Six patients (2.7%) had MRI findings that accounted for their tinnitus. Of these patients, five had unilateral tinnitus with asymmetric hearing loss because of acoustic neuroma found on MRI. One patient presented with bilateral tinnitus with asymmetric hearing loss and was found to have a right acoustic neuroma. Twenty (9.2%) patients had bilateral or unilateral tinnitus without hearing loss, all with unremarkable MRIs. Fourteen patients (6.4%) had incidental findings including two acoustic neuromas that were identified contralateral to the side of presenting tinnitus. Conclusions: Imaging should be used judiciously in the evaluation of tinnitus. Patients with unilateral tinnitus and asymmetric hearing loss were most likely to have abnormal findings. The majority of MRIs performed for tinnitus were normal in our study. Given the low incidence of MRI findings in the workup of tinnitus, every effort should be made to optimize screening protocols. Noncontrasted fast spin-echo T2-weighted MRI should be used to assess patients with tinnitus when there is low suspicion for retrocochlear pathology. Patients with unilateral non-pulsatile tinnitus with symmetric hearing may be observed, but clinical judgement should determine the need for further imaging.

Dysphagia, hoarseness, and globus in a postoperative patient☆

Sore throat, hoarseness, and dysphagia are known and recognized postoperative complications of laryngeal mask airway use during operative procedures. The patients symptoms, present immediately after surgery, are thought related to airway manipulation. Airway foreign bodies, although low on the differential, can cause similar symptoms. We present a case of a single patient who presented to a tertiary care center after an elective outpatient procedure with postoperative sore throat, hoarseness, and dysphagia. A foreign body was found lodged in the patients hypopharynx. The differential diagnosis of sore throat, hoarseness, and dysphagia in the postoperative patient is explored in further detail.

Laser-Assisted Indocyanine Green Dye Angiography for Postoperative Fistulas After Salvage Laryngectomy

Importance Pharyngocutaneous fistula formation is an unfortunate complication after salvage laryngectomy for head and neck cancer that is difficult to anticipate and related to a variety of factors, including the viability of native pharyngeal mucosa. Objective To examine whether noninvasive angiography with indocyanine green (ICG) dye can be used to evaluate native pharyngeal vascularity to anticipate pharyngocutaneous fistula development. Design, Setting, and Participants This cohort study included 37 patients enrolled from June 1, 2013, to June 1, 2016, and follow-up was for at least 1 month postoperatively. The study was performed at the University of Alabama at Birmingham, a tertiary care center. Included patients were those undergoing salvage total laryngectomy who were previously treated with chemoradiotherapy or radiotherapy alone. Exposures The ICG dye was injected intraoperatively, and laser-assisted vascular imaging was used to evaluate the native pharyngeal mucosa after the ablative procedure. The center of the native pharyngeal mucosa was used as the reference to compare with the peripheral mucosa, and the lowest mean ICG dye percentage of mucosal perfusion was recorded for each patient. Main Outcomes and Measures The primary outcome was the formation of a postoperative fistula, which was assessed by clinical and radiographic assessment to test the hypothesis formulated before data collection. Results A total of 37 patients were included (mean [SD] age, 62.3 [8.5] years; 32 [87%] male and 5 [14%] female); 20 had a history of chemoradiotherapy, and 17 had history of radiotherapy alone. Thirty-four patients (92%) had free flap reconstruction, and 3 had primary closure (8%). Ten patients (27%) developed a postoperative fistula. No significant difference was found in fistula rate between patients who underwent neck dissection and those who did not and patients previously treated with chemoradiotherapy and those treated with radiotherapy alone. A receiver operator characteristic curve was generated to determine the diagnostic performance of the lowest mean ICG dye percentage of mucosal perfusion determined by fluorescence imaging, which was found to be a threshold value of 26%. The area under the curve was 0.85 (95% CI, 0.73-0.97), which was significantly greater than the chance diagonal. The overall mean lowest ICG dye percentage of mucosal perfusion was 31.3%. The mean lowest ICG dye percentage of mucosal perfusion was 22.0% in the fistula group vs 34.9% in the nonfistula group (absolute difference, 12.9%; 95% CI, 5.1%-21.7%). Conclusions and Relevance Patients who developed postoperative fistulas had lower mucosal perfusion as detected by ICG dye angiography when compared with patients who did not develop fistulas.

Intraoperative Fluorescence Angiography for Head and Neck Reconstruction

Purpose of ReviewReconstruction of head and neck defects that cannot be closed primarily often requires the use of complex locoregional, pedicled, or microvascular flaps. Success of the reconstruction relies on the vascular supply of these flaps to prevent major and sometimes life-threatening wound complications. Intraoperative fluorescence angiography is an emerging aspect of the field that can be used as an adjunct to other methods to identify vascular compromise before, during, and after reconstruction.Recent FindingsLaser-assisted near-infrared angiography with intravenous indocyanine green (ICG) dye has been used to perform optical angiography in plastic surgery to help determine the recipient tissue perfusion at the defect site as well as the perfusion of the tissue used for reconstruction. This method allows for quantification of perfusion in skin and soft tissue reconstruction.SummaryLaser-assisted near-infrared angiography with intravenous ICG dye is fast, reliable, safe and can have many uses in head and neck reconstruction including the ability to quantitatively assess perfusion in perforators and angiosomes in flap design, prior to completion of harvest, during, and after the microvascular anastomosis, and in the distal edges of rotational and pedicled flaps. It can also be used to objectively view the native tissue prior to reconstruction, especially in patients with a history of radiation or chemotherapy.

The Role of Oxidative Stress in Idiopathic Sudden Sensorineural Hearing Loss and Meniere’s Disease

Methodological considerations and lack of understanding of disease mechanisms for both idiopathic sudden sensorineural hearing loss (ISSNHL) and Meniere’s disease (MD) have made clinical treatment studies challenging, and seemingly little progress has been made in developing more effective treatments or reducing societal impact of these disorders in recent years. The pathogenesis of ISSNHL and its treatment are controversial, although there is now good evidence to support the use of steroids delivered by the intratympanic route, particularly in the salvage situation. In recent years, there has been a growing body of evidence to suggest that free oxygen radicals play an important role in ISSNHL and that antioxidant treatment might be of benefit. We will review these studies. In the case of Meniere’s disease, we review evidence showing glutamate excitotoxicity and increased oxidative stress in animal models of endolymphatic hydrops (ELH). These changes result in downstream apoptotic processes within type 1 spiral ganglion cells which may be responsible for permanent hearing loss associated with this disorder. While more research is needed, there is evidence to support the hope that antioxidants may be effective in preventing or reducing long-term hearing loss in both ISSNHL and Meniere’s disease.

Vestibular Testing Data in Migraine-Associated Vertigo

Objectives: (1) Describe data on comprehensive vestibular testing in migraine-associated vertigo patients. (2) Delineate specific findings in vestibular testing that can assist in the diagnosis and treatment of migraine-associated vertigo. Methods: A retrospective case review of individuals diagnosed with migraine-associated vertigo after evaluation by an otologist, a neurologist, and who had vestibular testing between January 1, 2010, and June 31, 2012, at a tertiary referral center. Videonystagmography (VNG), sinusoidal harmonic acceleration (SHA) testing, and cervical vestibular evoked myogenic potential (cVEMP) testing were analyzed. Results: Eighty-three patients met inclusion criteria; 63 had a diagnosis of primary migraine-associated vertigo. An additional 20 patients had a secondary diagnosis including Ménières disease, intracranial hypertension, and a history of cranial surgery (secondary migraine-associated vertigo). The average patient was 49 years old, with 82% being female. There was no statistically significant difference between the 2 groups. Overall, 30% of migraine-associated vertigo patients had abnormal caloric testing with a 60% average unilateral weakness. The unilateral weakness was to the right 77% of the time. When VNG, SHA, and cVEMP testing were combined, 24 patients (29%) had an identifiable vestibular weakness; 75% had a peripheral source and 25% had central vestibular findings. A total of 50% of patients with a peripheral weakness were fully compensated, 33% were partially compensated, and 17% were poorly compensated. Conclusions: In patients with primary and secondary migraine-associated vertigo, approximately two-thirds of patients were found to have normal vestibular testing. When there was an identifiable vestibular weakness, 75% were peripheral with only 50% fully compensated.