Objective/Hypothesis
To examine the clinical features of benign intratracheal thyroid (ITT) and their management strategies and outcomes.
Study Design
Case series study.
Methods
This systemic review ...was conducted in two international academic centers. This review includes 43 patients: one new case from the Massachusetts Eye and Ear Infirmary, four new cases from Beijing Tongren Hospital, and 38 previously published cases. We analyzed these 43 cases and summarized the patients' epidemiological data, clinical features, and treatment regimens.
Results
ITTs were less common in men than in women (male:female ratio of 3:10). ITT was observed in patients as young as neonates and as old as 85 years. Orthotopic thyroid nodules were present in 55.8% of the patients with ITT. Malignancy was incidentally found in 4.6% of all ITTs. Imaging examinations showed that the ITTs were typically attached to the posterolateral/lateral tracheal wall of the first, second, or third tracheal rings. Tissue attachment between the ITT and normal thyroid lobes was seen in 59.5% of the patients. Thirty‐seven patients underwent surgery: 30 underwent open surgery, and seven underwent endoscopic debulking resections. One neonate received thyroid suppression therapy. One patient with ITT and papillary thyroid cancer was treated with radiotherapy and ultimately died after recurrence.
Conclusions
Surgical resection is an effective treatment for benign ITT. We hypothesized that abnormalities during the embryonic development of Berry's ligament might play a role in ITT pathogenesis.
Level of Evidence
NA Laryngoscope, 131:E2609–E2617, 2021
Background
Recurrent laryngeal nerve (RLN) invasion by thyroid carcinoma represents an advanced disease status with potentially significant co‐morbidity.
Methods
In a retrospective single‐center ...study, we included patients with invaded RLNs operated on while using nerve monitoring techniques. We studied pre‐, intra‐, and postoperative parameters associated with postoperative vocal cord paralysis (VCP); 5‐year recurrence‐free survival (RFS); and 5‐year overall survival (OS) in addition to two subgroup analyses of postoperative VCP in patients without preoperative VCP and based on source of RLN invasion.
Results
Of 65 patients with 66 nerves‐at‐risk, 39.3% reported preoperative voice complaints. Preoperative VCP was documented in 43.5%. The RLN was invaded by primary tumor in 59.3% and nodal metastasis in 30.5%. Papillary thyroid carcinoma was the most common pathologic subtype (80%). After 6 months, 81.8% had VCP. Complete tumor resection of the RLN was not associated with 5‐year RFS (p = 0.24) or 5‐year OS (p = 0.9). Resecting the RLN did not offer statistically significant benefit on 5‐year RFS (p = 0.5) or 5‐year OS (p = 0.38). Radioactive Iodine (RAI) administration was associated with improvement in 5‐year RFS (p = 0.006) and 5‐year OS (p = 0.004). Patients without preoperative VCP had higher IONM amplitude compared with patients with VCP. After a mean follow‐up of 65.8 months, 35.9% of patients had distant metastases, whereas 36.4% had recurrence.
Conclusion
Preoperative VCP accompanies less than half of patients with RLN invasion. Invaded RLNs may have existent electrophysiologic stimulability. Complete tumor resection and RLN resection were not associated with better 5‐year RFS or OS, but postoperative RAI was.
Level of Evidence
4 Laryngoscope, 132:2285–2292, 2022
Objectives
Endocrine surgery is emerging as a dedicated subspecialty in otolaryngology. We assess the impact of an endocrine surgeon on an academic otolaryngology department's thyroid and parathyroid ...surgery volume.
Methods
A retrospective study of overall endocrine caseloads and resident case logs at a single academic center in the Midwest was performed. All thyroid and parathyroid cases performed by the otolaryngology department at an academic center from 2011 to 2017 were reviewed. In September 2012, an otolaryngologist who had completed an American Head and Neck Society endocrine surgery fellowship joined the faculty. The volume of endocrine surgery performed by the residents was also analyzed. Comparison of means and linear regression models were performed.
Results
From 2011 to 2012, the department performed a mean of 77 thyroid and 11.5 parathyroid surgeries annually. After the endocrine surgeon joined the department, this increased to an average of 212.8 thyroidectomies (P < 0.01) and 72.4 parathyroidectomies (P < 0.01) a year. The head and neck surgeons and generalists still performed an average of 42.4 thyroidectomies and 2.6 parathyroidectomies a year. For graduating residents, the average number of thyroid/parathyroid cases increased from 42.5 in 2012 to 151 in 2016.
Conclusion
The addition of a fellowship‐trained endocrine surgeon substantially increased the thyroid and parathyroid surgical volume of the otolaryngology department. Importantly, generalists and head and neck surgeons in the department continued to perform a significant number of these cases. Departments seeking similar surgical growth and expanded resident experience may consider the value of engaging a dedicated endocrine surgeon.
Level of Evidence
4
Laryngoscope, 130:832–835, 2020
Identification and preservation of parathyroid glands (PGs) remain challenging despite advances in surgical techniques. Considerable morbidity and even mortality result from hypoparathyroidism caused ...by devascularization or inadvertent removal of PGs. Emerging imaging technologies hold promise to improve identification and preservation of PGs during thyroid surgery.
This narrative review (1) comprehensively reviews PG identification and vascular assessment using near-infrared autofluorescence (NIRAF)-both label free and in combination with indocyanine green-based on a comprehensive literature review and (2) offers a manual for possible implementation these emerging technologies in thyroid surgery.
Emerging technologies hold promise to improve PG identification and preservation during thyroidectomy. Future research should address variables affecting the degree of fluorescence in NIRAF, standardization of signal quantification, definitions and standardization of parameters of indocyanine green injection that correlate with postoperative PG function, the financial effect of these emerging technologies on near-term and longer-term costs, the adoption learning curve and effect on surgical training, and long-term outcomes of key quality metrics in adequately powered randomized clinical trials evaluating PG preservation.
In the light of novel cancer immune therapies, the status of antitumor inflammatory response and its regulation has gained much attention in patients with lung cancer. Ample datasets exist for ...non-small-cell lung cancer, but those for pulmonary neuroendocrine tumors are scarce and controversial. Here, tumor-associated inflammation, CD8+ cell infiltration and PD-L1 status were evaluated in a cohort of 57 resected carcinoids and 185 resected neuroendocrine carcinomas of the lung (58 large cell carcinomas and 127 small cell carcinomas). Data were correlated with clinicopathological factors and survival. Moderate or high tumor-associated inflammation was detected in 4 carcinoids (7%) and in 37 neuroendocrine carcinomas (20%). PD-L1 immunoreactivity was seen in immune cells of 73 (39%) neuroendocrine carcinomas, while tumor cells were labeled in 21 (11%) cases. Inflammatory cells and tumor cells in carcinoids lacked any PD-L1 expression. In neuroendocrine carcinomas, PD-L1 positivity in immune cells, but not in tumor cells, was associated with intratumoral CD8+ cell infiltration (P < 0.001), as well as with the severity of tumor-associated inflammation (P < 0.001). In neuroendocrine carcinomas, tumor-associated inflammation and PD-L1 positivity in immune cells correlated with prolonged survival and the latter factor was also an independent prognosticator (P < 0.01, hazard ratio 0.4 for overall survival, P < 0.001 hazard ratio 0.4 for disease-free survival). Taken together, in neuroendocrine tumors, antitumor inflammatory response and PD-L1 expression are largely restricted to neuroendocrine carcinomas, and in this tumor entity, PD-L1 expression in inflammatory cells is positively correlated to patient survival.
Objectives/Hypothesis
The objective was to identify whether injury of the external branch of the superior laryngeal nerve (EBSLN) or changes in EBSLN parameters after dissection during ...thyroidectomies correlate with changes in voice quality postoperatively.
Study Design
Prospective multicenter case series.
Methods
A prospective multicenter study was conducted on patients undergoing thyroidectomies with intraoperative nerve monitoring. Electromyography waveforms of EBSLN stimulation before (S1) and after superior pole dissection (S2) were evaluated using endotracheal tube (ETT) and cricothyroid intramuscular (CTM) electrodes. Voice outcomes were assessed using Voice‐Related Quality of Life Surveys and Voice Handicap Index.
Results
A total of 131 at‐risk EBSLNs were evaluated in 80 patients. Two nerves showed loss of CTM twitch coupled with an absent S2 signal response. Complete EBSLN loss of signal was more likely with: 1) Cernea EBSLN anatomic classification Type 2B; 2) with a longer distance from the sternothyroid muscle insertion site; and 3) with larger lobar volumes (P < .05). Patients who experienced a more than 50% decrement in CTM amplitudes of S2 (n = 7) by CTM electrodes had a statistically significant decline in their voice outcomes compared to those who did not (n = 69) (P < .05).
Conclusions
Patients experienced worse voice outcomes when at least one EBSLN response amplitude decreased by more than 50% after dissection when measured by CTM needle electrodes. CTM needle electrodes have an ability to measure finer amplitude changes compared to ETT electrodes, may represent a safe method to deduce subtle EBSLN injuries, and may serve to optimize voice outcomes during thyroidectomy. CTM needle electrodes are safe and tolerated well.
Level of Evidence
4 Laryngoscope, 131:1436–1442, 2021
Objectives/Hypothesis
This study sought to determine whether comorbidities, race, and socioeconomic factors affect 5‐ and 10‐year survival outcomes for patients with salivary gland malignancies ...treated at a single large academic institution with a large African American population.
Study Design
A retrospective cohort study was performed of all patients with salivary gland malignancies, from 1990 to 2015, at a large academic medical center.
Methods
Standard statistical analysis was performed using Kaplan‐Meier survival curve analysis and Cox proportional hazard models.
Results
The overall 5‐ and 10‐year survival rates decreased with age ≥ 60 years (P < .001), stage 3 or 4 (P < .001), clinical T stage 3 or 4 (P < .001), and clinical N stage 1, 2, or 3 (P < .001). Living in a ZIP code with an increasing proportion of residents with a high school degree or less (P < .05), being male (P < .05), increasing age at the time of diagnosis (P < .001), and increasing Charlson comorbidity index (P < .05) detrimentally impacted survival at 5 and 10 years. Race was associated with socioeconomic variables, but race was not a prognostic indicator of survival.
Conclusions
Socioeconomic factors and comorbidities, not race, were negative prognostic indicators of survival of patients with salivary gland malignancies. Using race as a marker for socioeconomic status should be used with caution.
Level of Evidence
4. Laryngoscope, 127:2545–2550, 2017
Objectives
Neoadjuvant targeted therapy has emerged as a promising treatment strategy for locally aggressive thyroid cancer. Its impact on tumor and adjacent tissues remains a nascent area of study. ...Here we report on a series of six subjects with locally advanced thyroid cancer and recurrent laryngeal nerve (RLN) paralysis who experienced recovery of RLN function with neoadjuvant treatment and describe the morphologic and electrophysiologic characteristics of these recovered nerves.
Methods
This is a multicenter retrospective review. Descriptive analysis was conducted to examine the following parameters for recovered nerves: (1) nerve morphology, characterized as Type A (involving epineurium only) versus Type B (extending beyond epineurium); (2) proximal stimulability (normal vs. abnormal vs. absent); and (3) surgical management (resection vs. preservation).
Results
Six subjects with unilateral VFP were identified. Median time to return of VF mobility was 3 months (range 2–13.5). All nerves (100%) were noted to have Type A morphology at surgery. Proximal stimulability was normal in four subjects (66.7%), abnormal in one (16.7%), and absent in one (16.7%). Nerves that had improvement of function through neoadjuvant therapy were able to be surgically preserved in five subjects (83.3%).
Conclusions
This represents the first characterization of RLNs that have recovered function with neoadjuvant treatment of locally advanced thyroid cancer. Although much remains unknown, our findings indicate carcinomatous neural invasion is a reversible process and recovered nerves may demonstrate normal morphology and electrophysiologic activity.
Level of Evidence
4 Laryngoscope, 134:3415–3419, 2024
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