Ziad E. Deeb

Tall cell variant: An aggressive form of papillary thyroid carcinoma

Twenty-four cases of the tall cell variant (TCV), a subset of papillary thyroid carcinoma, were identified in a group of 624 patients with thyroid cancer. All pathology specimens were reviewed, and each patients carcinoma was categorized according to characteristics on presentation, local recurrence, distant metastases, follow-up, and tumor-related mortality. The TCV group was compared with a historical control group (Mazzaferri and Jhiang: 1355 patients). The TCV group had a statistically higher percentage of stage 3 and 4 carcinoma, extrathyroidal invasion, and tumor size less than 1.5 cm than the control group. There was no statistical relationship between age greater than 50 years and stage in the TCV group. No relationship could be found between TCV histology and recurrence or mortality. These findings, combined with those of studies that link stage on presentation to poor outcomes, have led to our conclusion that TCV is an aggressive malignancy warranting appropriate treatment and close follow-up.

Acute epiglottitis in the adult

Acute epiglottitis may be fatal when diagnosis is delayed. The literature stresses data that does not help to predict impending airway obstruction in patients who present with a sore throat, the most consistent presenting symptom among patients with acute epiglottitis. In this review of 80 cases of epiglottitis in adults, almost all patients who presented within eight hours from onset of symptoms required airway intervention, while the majority of those who presented more than eight hours after onset of symptoms never developed acute upper respiratory obstruction and were treated medically or had supportive treatment only. Artificial airway was indicated in all patients who had drooling. There were no fatalities in this series, however, we recommend keeping all patients with acute epiglottitis in an intensive care unit for at least 24 hours after admission.

Meta-analysis of endoscopic versus sublabial pituitary surgery†‡

To determine whether the endoscopic or sublabial transseptal transsphenoidal approach for pituitary surgery has superior outcomes or decreased complication rates.

Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema: A Multicenter Review and an Algorithm for Airway Management

Angioedema is a nonpitting edema of which the presentation ranges from benign facial swelling to airway obstruction managed by intubation or tracheotomy. The presentation of this disease is reviewed, and a treatment algorithm based on initial signs and symptoms is proposed for proper airway management. We performed a retrospective review of 108 patients treated in 2 tertiary care centers in the Washington, DC, area over a 5-year period. Ninety-eight patients (90.7%) were African-American, and 81 (75%) were female. Seventy-four patients (68.5%) were taking angiotensin-converting enzyme inhibitors (ACEIs). A classification system was developed based on the location of the edema at initial presentation: 1) isolated facial swelling and oral cavity edema, excluding the floor of the mouth; 2) floor of mouth and/or oropharyngeal edema, and 3) oropharyngeal edema with glottic and/or supraglottic involvement. Fourteen patients (13%) needed airway intervention, 2 of whom underwent a cricothyrotomy after a failed intubation attempt. Eleven (78.6%) were taking ACEIs. The indication for each intubation was massive tongue and floor of mouth edema. The patients were extubated 48 to 72 hours later. No patient demonstrated symptom progression after medical treatment was initiated. Therapy included discontinuation of the ACEI or other inciting agent, a high-humidity face tent, an initial dose of intravenous antihistamines, and a continued course of intravenous steroids. Within 48 hours, most patients had a resolution of their edema. Only cases of significant tongue and oropharyngeal edema took longer than 48 hours to resolve. The ACEIs are a common cause of angioedema. Left untreated, angioedema may progress to involve the oropharynx and supraglottis, resulting in a life-threatening airway compromise. Marked floor of mouth and tongue edema are the indications for airway intervention. An algorithm based on the initial presentation is essential for proper airway and patient management. Once treatment has begun, angioedema is nonprogressive and often resolves within 24 to 48 hours.

Clinical experience with angiotensin-converting enzyme inhibitor–induced angioedema

OBJECTIVES To understand the presentation and clinical course of angiotensin-converting enzyme (ACE) inhibitor-induced angioedema and to determine management factors associated with progression to airway compromise. STUDY DESIGN AND SETTING Retrospective chart review of patients taking ACE inhibitors who presented to the emergency department with angioedema between December 1999 and July 2004 (n = 228). Clinical presentation, treatment, and clinical course were analyzed. RESULTS The oral cavity was the most common location of upper-airway angioedema. Twenty-two (10%) patients required intubation, and all were intubated within 12 hours of presentation. Of the patients who required intubation, those who were started on an H1 -blocker were extubated earlier than those not on an H1 -blocker (P = 0.05). CONCLUSION The locations of swelling and drooling on admission are predictive of the need for intubation. Other aspects of presentation, treatment, and disposition can help in management decisions for this potentially fatal condition. SIGNIFICANCE This is the largest series to date of ACE inhibitor-related angioedema that challenges theories on the etiology and treatment of this condition.

Ultrasound-guided fine-needle aspiration and thyroid disease.

ABSTRACT BACKGROUND: Fine-needle aspiration represents a critical diagnostic test in determining proper management of thyroid disease and the use of ultrasound-guided fine-needle aspiration (USGFNA) has increased over the years. METHODS: A retrospective chart review of patients undergoing USGFNA. Two hundred fifteen patients underwent 234 procedures with 362 nodules aspirated within a 2 ½-year period. RESULTS: The mean ages of women and men were 51.9 and 57.8, respectively. The average size of nodules was 2.1 cm. A difficult to assess gland or nodule was the most common indication for USGF-NA (33%). The sensitivity was 88.2%, specificity was 80.0%, the PPV was 65.2%, the negative predictive value was 94.1%, and the accuracy was 82.5%. The cancer yield, inadequacy, and complication rates were 44%, 10.5%, and 8.5%, respectively. CONCLUSIONS: USGFNA aspiration is a safe and effective diagnostic modality in the management of thyroid disease, especially for nodules that are difficult to palpate.

Actinomycotic Osteomyelitis of the Facial Bones and Mandible

Actinomyces israelii is a part of the human oral flora and thus is more commensal than pathogenic. Oral trauma, accidental or purposeful, can precipitate its introduction into the soft tissues, to which infection is usually confined. The case presented is one in which, over a span of two decades (1956 to 1977), the extraction of a mandibular tooth resulted in a chronic actinomycotic osteomyelitis, destroying first the mandible, then both maxillae, and then the right zygoma, with decreased vision and proptosis despite repeated medical and surgical intervention. Adequate treatment required removal of the sequestrum and excision of all infected granulation tissue, scars, and involucra until healthy bone was exposed. Intravenous penicillin was administered for 2 weeks, followed by a 6-month course of oral penicillin. The patient was followed for 4 years and remained disease free.

BRONCHOGENIC CYSTS OF THE NECK IN ADULTS

Bronchogenic cysts are congenital sacs that result from maldevelopment of the primitive foregut. Although they occur predominantly in the chest, there are reports of lesions in extrathoracic locations. The majority of reported bronchogenic cysts located in the neck are found in the pediatric population; a review of the literature reveals few reports of bronchogenic cysts of the neck among adults. The diagnosis of a bronchogenic cyst relies on the histology and location of the lesion. Here, we review our experience in the diagnosis and management of 2 adult patients with pathologically proven bronchogenic cysts. Both patients presented with solitary neck masses that proved to be bronchogenic cysts on histologic examination. Our purpose is to define the histopathologic and clinical characteristics of bronchogenic cysts and discuss the features that distinguish them from other cervical cysts. In conclusion, congenital bronchogenic cysts can occur in the neck of adults and should be considered in the differential diagnosis of cystic cervical masses in adults, as well as children.

Infectious adult croup

From January 1980 to December 1987, seven patients with acute inflammatory swelling of the subglottic space were treated. Their ages ranged from 25 to 73 years. Medical history and symptomatology are similar to those characteristic of laryngotracheobronchitis (croup) in the pedi‐atric age groups (i.e, an antecedent common cold followed by a barking cough and varying symptoms of upper airway obstruction). Physical findings before and after treatment were confirmed and documented by anteroposterior radiographs of the neck. Three patients required airway intervention but there were no deaths. To our knowledge there are no previous reports in the English literature describing this entity in adults. The purpose of this presentation was to introduce physicians, in general, and otolaryngologists, in particular, to this potentially serious infection. Our limited experience suggests that the pathogenesis and management of croup in adults are very similar to those in children.

Tamoxifen therapy for Riedel's thyroiditis.

INTRODUCTION Riedel’s thyroiditis is an extremely rare condition. Although it is thought to be a benign condition, it can mimic carcinoma, and therefore an accurate diagnosis is necessary. With any patient who presents with a “woody” lump in the neck and a complaint of progressive pressure symptoms, Riedel’s thyroiditis should be in the differential diagnosis. We present a case of Riedel’s thyroiditis that originally underwent a tracheotomy to secure the airway and obtained tissue for a diagnosis. The patient was started on tamoxifen therapy postoperatively and had a complete remission of Riedel’s, thus enabling us to decannulate the patient.