Tamara Mijovic

Autoimmune sensorineural hearing loss: the otology–rheumatology interface

Autoimmune sensorineural hearing loss (SNHL) is a rare clinical entity characterized by a progressive fluctuating bilateral asymmetric SNHL that develops over several weeks to months. Vestibular symptoms, tinnitus and aural fullness are present in up to 50% of patients. Due to the lack of specific diagnostic tests, both clinical suspicion and responsiveness to corticosteroids are the pillars for the diagnosis of autoimmune SNHL. The evaluation of patients in whom this condition is suspected should include a detailed history and physical examination, an audiogram, an MRI and a limited laboratory workup to exclude secondary causes of hearing loss. The low frequency of this condition, the heterogeneity in the designs of the available studies and the absence of randomized trials comparing treatment responses and assessing long-term outcomes are some of the factors accounting for the limited evidence to guide the clinician in the approach to the diagnosis and treatment of autoimmune SNHL.

Body Mass Index in the Evaluation of Thyroid Cancer Risk

BACKGROUND Obesity has been linked to numerous diseases including thyroid cancer, but the exact nature of the relationship, especially with respect to patients with thyroid nodules, remains unclear. The objective of this study was to evaluate the impact of body mass index (BMI) on thyroid cancer risk in a population of patients with indeterminate cytology on fine-needle aspiration biopsy (FNAB). METHODS A total of 253 consecutive patients with indeterminate thyroid nodule FNABs who underwent total thyroidectomy in a tertiary care teaching hospital between 2002 and 2007 were reviewed. Height and weight reported on the anesthesia summary were recorded for each patient. Malignancy rates were calculated for the underweight, normal, overweight, and obese groups stratified according to their BMI. Subanalyses according to age and sex were also performed. RESULTS The risk of malignancy tended to be lower in obese patients compared to patients with BMIs in the underweight, normal, and overweight ranges (52% vs. 61%, p = 0.195). In men, a BMI classified as obese was associated with a significantly lower rate of malignancy (36% vs. 72%, p = 0.003). Women older than 45 years were a subgroup in which higher malignancy rates were associated with obesity (65% vs. 54%, p = 0.293). Conversely, in men over the age of 45 years and women under 45 years, a BMI in the obesity range was linked to a lower incidence of malignancy (20% vs. 68% p = 0.009 and 36% vs. 68% p = 0.043, respectively). When older women were excluded from the population studied, the rate of malignancy in obese patients was 36% versus 70% in nonobese patients (p = 0.002) with an associated reduction of 5% in the risk of malignancy per increased unit of BMI. CONCLUSIONS For patients with FNAB results of indeterminate significance, a higher BMI correlates with lower rates of thyroid malignancy for all patients except women over the age of 45 years.

What are thyroidectomy patients really concerned about

Objective. To better appreciate perioperative concerns affecting patients considering thyroidectomy and to understand how they may vary according to patient characteristics. Study Design. Cross-sectional analysis. Setting. Tertiary referral center. Subjects and Methods. The authors recruited patients scheduled for thyroid surgery at the McGill University Thyroid Cancer Center. A total of 148 patients completed the 18-item Western Surgical Concern Inventory–Thyroid (WSCI-T) questionnaire. Psychometrics of the WSCI-T were assessed through a principal component analysis with varimax rotation and reliability analyses. Independent-samples t tests and 2-tailed Pearson correlations were ran, identifying areas of elevated concerns and their relationship to gender, age, and surgical procedure (total vs hemithyroidectomy). Results. The principal component analysis revealed the presence of 3 domains of presurgical concerns on the WSCI-T: Surgery-Related Concerns, Psychosocial Concerns, and Daily-Living Concerns. Reliability coefficients for the WSCI-T Total and subscales were satisfactory. Responses on the WSCI-T indicated on average a moderate overall level of concerns before thyroidectomy. Surgery-Related Concerns was the highest domain of concerns, followed by Daily-Living and Psychosocial Concerns, respectively. Patients were mainly worried about the nodule being cancerous, experiencing a change in voice, and surgical complications. Areas of minor concern included being judged or treated differently, becoming depressed, and feeling embarrassed. Women had higher overall levels of concern than men did. Although there were no significant differences in overall levels of concern according to age and surgical procedure, differences were noted at a subscale and item level. Conclusion. This study establishes a mean that will permit adequate physician counseling and a better management of patients’ perioperative worries.

Fine-needle aspiration biopsies in the management of indeterminate follicular and Hurthle cell thyroid lesions

Objectives: To determine the value of fine-needle aspiration biopsies (FNABs) of the thyroid and stratify the risk of malignancy within the indeterminate FNAB diagnostic category at our institution. Study design: Case series with chart review of preoperative FNABs of consecutive patients who underwent total thyroidectomy between 2005 and 2007. Subjects and Methods: A total of 115 cases were reviewed, and FNABs were categorized into four groups: benign, positive or suspicious for malignancy, indeterminate (follicular or Hurthle cell lesions), and nondiagnostic. Cytohistologic correlation was then established. Results: The accuracy of FNAB in detecting thyroid malignancy was 88 percent with false-negative and false-positive rates of 13 percent and 7 percent, respectively. Overall, 52 percent of the indeterminate cases were carcinomas (48 percent of follicular lesions and 62 percent of Hurthle cell lesions). In the presence of cytologic atypia, the rate of malignancy increased to 75 percent and 83 percent for the follicular and Hurthle cell lesions, respectively. Conclusions: FNAB is an accurate and helpful method for the evaluation of thyroid nodules with results directly correlating with management. Surgery should be considered for FNABs categorized as indeterminate, especially in the presence of cytologic atypia. Because of the high false-negative rate, benign FNABs require close follow-up with ultrasound examination and periodic biopsies.

Head movements in patients with vestibular lesion: a novel approach to functional assessment in daily life setting.

Objectives (1) To determine if head movements in patients with vestibular deficiency differ from those in normal subjects during daily life activities. (2) To assess if these differences can be correlated with patients’ perception of dizziness-induced handicap. Study Design Prospective matched-pairs study Setting Tertiary referral center Patients Thirty-one vestibular schwannoma patients with documented postoperative unilateral vestibular loss and their age-, gender-, and physical activity level–matched controls with symmetric vestibulo-ocular reflexes. Interventions Head movements during 10 tasks from daily life were recorded using body-worn movement sensors. Main Outcome Measures The time to complete the task, the average head velocity and acceleration during each task, and the number of head turns performed were compared between cases and controls. These measures were then correlated with the self-reported Dizziness Handicap Inventory (DHI) scores of the patients. Results Patients with a unilateral vestibular deficit took significantly longer to perform most daily life activities compared to controls. Their head movements, however, were not always slower. They adopted a different movement strategy, in certain instances less efficient and more disorganized. Dimensions of movement are not all affected equally after a unilateral vestibular loss with evidence of clear clustering of the differences within dimensions across tasks. There was no correlation between the DHI and patients’ performance in those tasks. Conclusion Vestibular loss, even when compensated, affects patients’ movements, which can be measured in an ambulatory setting of daily life activities. The differences in movements associated with vestibular loss do not correlate with the degree of self-reported handicap.

Sentinel Lymph Node Biopsy in Well Differentiated Thyroid Cancer

The management of occult cervical lymph node metastasis in well-differentiated thyroid cancer (WDTC) is controversial. Given the risks of hypocalcemia, recurrent laryngeal nerve injury, and increased operative time with a central compartment neck dissection (CCND), a routine adoption of prophylactic lymph node dissection has not been accepted by many as a standard management for occult metastasis (Henry et al., 1998; Pereira et al., 2005; Shen et al., 2010). Conversely, other thyroid surgeons feel that the complication rate is low and that the benefits of CCND outweigh the risks (Anand et al., 2009; Haigh et al., 2000; Keleman et al., 1998; Pelizzo et al., 2001; Pitman et al., 2003; Rettenbacher et al., 2000). As a result, sentinel lymph node biopsy (SLNB) has gained an increase in popularity in recent years.

Synchronous airway lesions in children: An analysis of characteristics and comorbidities

OBJECTIVES To analyze the characteristics and the associated medical co-morbidities in children with synchronous airway lesions (SALs) found during rigid bronchoscopy. METHODS Retrospective case series and chart review of patients who were found to have more than one airway lesion after undergoing airway evaluation via rigid endoscopy at a tertiary care pediatric hospital between 2001 and 2011. Patient demographics, presence of associated non-airway pathologies, and the number and types of airway lesions were collected. For analysis, airway lesions were classified based on the anatomical subsites involved (supraglottic, glottic, subglottic, tracheal and bronchial). RESULTS Out of 592 rigid bronchoscopies performed, there were 73 cases with SALs (12.3%). Of these, only 20% of patients were term infants without associated congenital anomalies. Over 70% of patients with SALs have combinations of lesions involving the trachea, subglottis and supraglottis. Neurological anomalies and GERD were both independently associated with a three-time increase in the odds of having synchronous involvement of these three anatomical subsites (OR 3.15, 95% CI 1.06-9.41; OR 3.0, 95% CI 1.05-8.50, respectively). Glottic lesions were present in 28.7% of patients. Prematurity and cardiac anomalies were both associated with tendency of doubling the odds of glottic lesions (OR 2.34, 95% CI 0.84-6.52; OR 2.0, 95% CI 0.76-5.60, respectively). Overall, almost 10% of newly diagnosed lesions in context of SALs required an additional intervention. CONCLUSIONS The majority of patients with SALs are either born prematurely or have associated congenital anomalies. In SAL patients with associated neurological anomalies or GERD, the lesions are more likely to be localized to the supraglottis, subglottis and trachea whereas prematurity and cardiac anomalies could both be increasing the odds of a glottic lesion. High suspicious index should be kept in mind when rigid bronchoscopy is performed to not miss an associated lesion.

Low Vitamin D and Risk of Post-thyroidectomy Hypocalcemia:

Objective: 1) Determine if low vitamin D reduces risk of post-thyroidectomy hypocalcemia. 2) Verify if this is an independent effect. Method: Retrospective study of 139 total thyroidectomy patients (October 2009-October 2011) at a McGill University teaching hospital. Preoperative 25-hydroxy-vitamin D (25OHD), calcium, and PTH were measured. Patients were assessed for postoperative hypocalcemia. Low vitamin D (LVD) was defined as 25OHD ≤70 nmol/L (28 ng/mL) and optimal vitamin D (OVD) was defined as 25OHD >70 nmol/L (28 ng/mL). Results: Hypocalcemia occurred in 3.2% (2 of 62) patients with LVD and 10.4% (8 of 77) patients with OVD (OR 0.2875, P = .124). No patients with vitamin D deficiency (VDD), defined as 25OHD ≤35 nmol/L (14 ng/mL), developed hypocalcemia. Univariate analysis did not show age, sex, malignancy, presence of thyroiditis, number of preserved parathyroids, parathyroid autotransplantation, preoperative PTH, or preoperative calcium to be significantly predictive. Multivariate analysis confirmed no confounding factors in vitamin D analysis, but also did not show any independent risk factors. Fisher analysis comparing total versus completion thyroidectomy was marginally significant (P = .064) for predicting hypocalcemia. Conclusion: Transient hypocalcemia appears to occur less frequently in patients with VDD, however in our limited study we were unable to elucidate whether this was significant. Future study observing a larger population and excluding completion thyroidectomy patients may help to clarify whether VDD impacts risk for hypocalcemia.

A closer look at subjective caloric sensations: Is there more to vertigo than spinning?

BACKGROUND There is a prevailing opinion that spinning sensations signify a peripheral vestibular pathology while non-spinning sensations are not of vestibular origin. OBJECTIVES 1) Characterize the subjective sensations reported by patients during caloric testing. 2) Assess if the sensation was correlated with the peak slow phase velocity (SPV). METHODS Retrospective chart review at a Canadian adult tertiary-quaternary care balance centre for patients undergoing diagnostic caloric testing between December 2014 and September 2015. RESULTS Of 163 patients included, 122 had normal calorics and 41 demonstrated unilateral weakness. Spinning/rotatory movements were the most commonly reported sensations (55-70%). No sensation was reported among 10-20% of patients. Other non-rotatory sensations were reported 20-25% of the time. Both lack of sensation and other sensations were more likely to be correlated with SPVs that were significantly lower than those associated with spinning/rotating sensations. However, 18% of patients with normal calorics and robust SPVs with warm irrigation still reported non-spinning sensations. CONCLUSIONS During caloric irrigation, subjective sensations other than spinning and rotating are reported 20-25% of the time and these tend to be associated with lower peak SPV. Non-spinning vertigo is not uncommon as a subjective description of vestibular sensation even in normal patients with strong SPVs.

The Value of FNABs in the Management of Thyroid Lesions

Objective Determine the value of fine-needle aspiration biopsies (FNAB), and stratify the risk of malignancy within the indeterminate FNAB diagnostic category at our institution. Methods The preoperative FNABs of 115 consecutive patients who underwent thyroidectomy at a teaching hospital between 2005 and 2007 were reviewed and categorized into 4 groups: negative for malignancy, positive or suspicious for malignancy, indeterminate, and nondiagnostic. The final histopathological diagnosis was then compared with the FNAB result. FNABs reported as follicular or Hurthle cell lesions were considered indeterminate diagnoses, and malignancy rates were calculated within this category. Results The FNAB results were as follows: 17% negative for malignancy, 35% positive or suspicious for malignancy, 40% indeterminate, and 8% nondiagnostic. The sensitivity of FNAB in detecting thyroid malignancy was 83%, specificity 92% and accuracy 85%. There were 9 discrepant cases giving a false negative rate of 17% and a false positive rate of 8%. Overall, 52% of the indeterminate cases were carcinomas, with a malignancy rate of 48% for the follicular lesions and 62% for the Hurthle cell lesions. When cytological atypia was present, the rate of malignancy increased to 75% and 83% for the follicular and Hurthle cell lesions, respectively. Conclusions Our study confirms that FNAB is an accurate and helpful method for the evaluation of thyroid nodules with results directly correlating with management. Moreover, surgery should be strongly considered for FNABs categorized as indeterminate cases, especially in the presence of cytological atypia. Due to the high false negative rate, benign FNABs require close follow-up and periodic rebiopsies.