JAMA Otolaryngology–Head & Neck Surgery Current Issue

About This Journal

Wed, 01 May 2013 00:00:00 GMT

Analysis of the 3-Dimensional Fluid-Attenuated Inversion-Recovery (3D-FLAIR) Sequence in Idiopathic Sudden Sensorineural Hearing Loss 3D-FLAIR in Idiopathic Sudden Hearing Loss

Berrettini S, Seccia V, Fortunato S, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

The unpredictability of idiopathic sudden sensorineural hearing loss (ISSNHL) presents a challenge to preventive care. Our study confirms the potentially important role of the 3-T magnetic resonance imaging (MRI), and in particular of the 3-dimensional fluid-attenuated inversion-recovery (3D-FLAIR) sequence, in the diagnosis and prognosis of ISSNHL to guide medical treatment.

Objective

To confirm the diagnostic, clinical, and prognostic role of 3D-FLAIR MRI in patients with idiopathic sudden sensorineural hearing loss (ISSNHL).

Design, Setting, and Patients

Retrospective study in a tertiary referral center with a consecutive sample of 23 patients diagnosed as having unilateral ISSNHL from January 2010 to March 2011.

Exposures

Patients underwent 3D-FLAIR MRI at 3 T to evaluate ISSNHL, and the MRI images were compared with those belonging to a random group of 20 age-matched healthy patients.

Main Outcomes and Measures

Precontrast and postcontrast high-intensity 3D-FLAIR MRI findings in patients with ISSNHL and the correlation with clinical findings.

Results

Thirteen patients showed high-intensity signals in the affected inner ear on precontrast and postcontrast 3D-FLAIR MRI (57%). From the analysis of different MRI sequences, we posited 3 radiologic patterns likely correlated with mild hemorrhage, acute inflammation, and presence or absence of blood-labyrinth or nerve barrier (BLB) breakdown. Hypersignal on 3D-FLAIR MRI was positively associated with pretreatment hearing loss (P = .04) and presence of vertigo (P = .04). A strict correlation also existed between distribution of the signal (vestibule, semicircular canals) and clinical features (vertigo) (P = .04).

Conclusions and Relevance

Use of 3D-FLAIR MRI at 3 T may contribute to the elucidation of pathologic conditions in the inner ears of patients with ISSNHL and provide new radiologic indicators (mild hemorrhage, acute inflammation, presence or absence of BLB breakdown) that might assume the role of prognostic factors.

Blood Loss During Endoscopic Sinus Surgery With Propofol or Sevoflurane A Randomized Clinical Trial Blood Loss During Endoscopic Sinus Surgery

Chaaban MR, Baroody FM, Gottlieb O, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Total intravenous anesthesia (TIVA) with propofol has been associated with reduced operative time, decreased perioperative risks, and decreased intraoperative blood loss compared with inhalational anesthesia (IA). During endoscopic sinus surgery (ESS), reduced bleeding from the mucosal surfaces could improve visualization of the anatomy and decrease the risk of serious complications.

Objective

To compare blood loss during ESS between patients receiving TIVA with propofol and those receiving IA with sevoflurane.

Design, Setting, and Participants

Prospective, randomized study of 33 patients undergoing ESS in an academic medical center.

Interventions

Patients received either TIVA or IA.

Main Outcomes and Measures

The primary outcome was rate of blood loss in milliliters per hour. The secondary outcomes included the quality of visibility measured by the surgeon's numeric rating score, ease of anesthesia as measured by the anesthesiologist's numeric rating score, and total blood loss.

Results

The mean (SEM) blood loss per hour in the TIVA group was 78.5 (14) mL/h, and in the IA group it was 80.3 (17) mL/h (P = .93). A post hoc subgroup analysis found that in patients with a Lund-Mackay score of 12 or lower, the propofol TIVA group had a lower rate of blood loss compared with the sevoflurane IA group (mean blood loss, approximately 18 mL/h vs approximately 99 mL/h). The anesthesiologist's numeric rating score was significantly higher (indicating greater ease of performance) in the IA group than in the TIVA group. There was no statistically significant difference in the surgical numeric rating score between the 2 groups.

Conclusions and Relevance

In this comparative study, our results did not show any difference in blood loss and surgical conditions between the TIVA and IA groups. Even further study is not likely to show a difference in blood loss between TIVA and IA during ESS.

Blue-footed Boobies

Wed, 01 May 2013 00:00:00 GMT

Photographer: Michael D. Landman, MD, Tarzana, California. “This picture was taken during a trip to the Galapagos where these sea birds have no fear of humans and allow for close observation and photography. Their blue feet are due to carotenoid pigments in their diets. In the mating dance, the male shows off his feet, which attracts the female (studies suggest) in proportion to the intensity of the color.”

Dexamethasone for the Prevention of Recurrent Laryngeal Nerve Palsy and Other Complications After Thyroid Surgery A Randomized Double-Blind Placebo-Controlled Trial Dexamethasone for Recurrent Laryngeal Nerve Palsy

Schietroma M, Cecilia E, Carlei F, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Recurrent laryngeal nerve dysfunction and hypoparathyroidism are well-recognized, important complications of thyroid surgery. The duration of convalescence after noncomplicated thyroid operation may depend on several factors, of which pain and fatigue are the most important. Nausea and vomiting occur mainly on the day of operation. Glucocorticoids are well known for their analgesic, anti-inflammatory, immune-modulating and antiemetic effects. However, there is little information in the literature on the use of steroids in thyroid surgery, and the information that is available is conflicting.

Objective

To investigate whether preoperative dexamethasone could improve surgical outcome in patients undergoing thyroid surgery.

Design

A randomized double-blind placebo-controlled trial. A 30-day follow-up for morbidity was performed in all cases.

Setting

All patients were hospitalized in a public hospital.

Participants

From June 2008 through August 2011, 328 patients were randomized to receive either intravenous dexamethasone, 8 mg, administered 90 minutes before skin incision, or saline solution (placebo).

Interventions

Intravenous dexamethasone, 8 mg.

Main Outcomes and Measures

The primary end points were temporary or permanent recurrent laryngeal nerve palsy. Transient and definitive hypoparathyroidism, pain and fatigue scores, nausea, and the number of vomiting episodes were also registered. Preoperatively and at several times during the first 24 postoperative hours, we measured C-reactive protein, interleukin 6, and interleukin 1β levels.

Results

In the dexamethasone group, the rate of temporary recurrent laryngeal nerve palsy (4.9%) was significantly lower compared with the placebo group (8.4%) (P = .04). Also, postoperative transient biochemical hypoparathyroidism occurred more frequently in the placebo group (37.0%) than in the dexamethasone group (12.8%). Dexamethasone use significantly reduced postoperative levels of C-reactive protein (P = .01) and interleukin 6 and interleukin 1β (P = .02), fatigue (P = .01), and overall pain during the first 24 postoperative hours (P = .04), as well as the total analgesic (ketorolac tromethamine) requirement (P = .04). Dexamethasone use also reduced nausea and vomiting on the day of operation (P = .045).

Conclusions and Relevance

Preoperative administration of dexamethasone, 8 mg, reduced postoperative temporary recurrent laryngeal nerve palsy and hypoparathyroidism rates and reduced pain, fatigue, nausea, and vomiting after thyroid surgery. However, these data require further analysis in randomized prospective studies.

Trial Registration

clinicaltrials.gov Identifier:NCT01690806

Hemispheric Dominance and Cell Phone Use Hemispheric Dominance and Cell Phone Use

Seidman MD, Siegel B, Shah P, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

A thorough understanding of why we hold a cell phone to a particular ear may be of importance when studying the impact of cell phone safety.

Objective

To determine if there is an obvious association between sidedness of cell phone use and auditory hemispheric dominance (AHD) or language hemispheric dominance (LHD). It is known that 70% to 95% of the population are right-handed, and of these, 96% have left-brain LHD. We have observed that most people use their cell phones in their right ear.

Design

An Internet survey was e-mailed to individuals through surveymonkey.com. The survey used a modified Edinburgh Handedness Inventory protocol. Sample questions surveyed which hand was used to write with, whether the right or left ear was used for phone conversations, as well as whether a brain tumor was present.

Setting

General community.

Participants

An Internet survey was randomly e-mailed to 5000 individuals selected from an otology online group, patients undergoing Wada testing and functional magnetic resonance imaging, as well as persons on the university listserv, of which 717 surveys were completed.

Main Outcome and Measure

Determination of hemispheric dominance based on preferred ear for cell phone use.

Results

A total of 717 surveys were returned. Ninety percent of the respondents were right handed, and 9% were left handed. Sixty-eight percent of the right-handed people used the cell phone in their right ear, 25% in the left ear, and 7% had no preference. Seventy-two of the left-handed respondents used their left ear, 23% used their right ear, and 5% had no preference. Cell phone use averaged 540 minutes per month over the past 9 years.

Conclusions and Relevance

An association exists between hand dominance laterality of cell phone use (73%) and our ability to predict hemispheric dominance. Most right-handed people have left-brain LHD and use their cell phone in their right ear. Similarly, most left-handed people use their cell phone in their left ear. Our study suggests that AHD may differ from LHD owing to the difference in handedness and cell phone ear use. Literature suggests a possible relationship between cell phone use and cancer. The fact that few tumors were identified in this population does not rule out an association.

Inclusion of Extracapsular Spread in the pTNM Classification System A Proposal for Patients With Head and Neck Carcinoma Extracapsular Spread in pTNM Classification System

de Juan J, García J, López M, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

The inclusion of data about the presence of metastatic neck nodes with extracapsular spread (ECS) in the neck dissection improves the prognostic classification of patients with head and neck squamous cell carcinoma (HNSCC).

Objective

To evaluate the prognostic capacity of ECS in patients with HNSCC, and to analyze the usefulness of including this information in the pathological classification of patients treated with a neck dissection.

Design

Retrospective unicenter study performed from 1985 through 2007.

Setting

Tertiary referral center.

Participants

A total of 1190 patients with HNSCC treated with a neck dissection.

Intervention

Unilateral or bilateral neck dissection .

Main Outcomes and Measures

Adjusted survival and local, regional, and distant metastases-free survival. Patients were classified according to a recursive partitioning analysis (RPA) method, considering pN category and number of neck nodes with ECS as the independent variables.

Results

Five-year adjusted survival for patients without metastatic nodes in the neck dissection (pN0) was 85.5%, for patients with neck node metastases without ECS (pN+/ECS−) it was 62.5%, and for patients with neck node metastases with ECS (pN+/ECS+) it was 29.9%. There were significant differences in survival between patients with pN0 lesions and pN+/ECS− (P < .001), and between patients with pN+/ECS− and those with pN+/ECS+ (P < .001). According to the RPA method, we propose classifying patients according to 4 categories: category I, pN0 lesions; category II, pN1/ECS+ or pN+/ECS−; category III, pN2-3/1 node and ECS+; and category IV, pN2-3/2 or more nodes and ECS+. The RPA-derived classification achieved a better prognostic discrimination than the pTNM classification.

Conclusions and Relevance

The inclusion of information about ECS in the neck dissection improved the prognostic classification of patients with HNSCC in relation to the pTNM classification.

Modern Thyroidectomy and the Tailored Surgical Approach Thyroid Surgery

Randolph GW. — Wed, 01 May 2013 00:00:00 GMT

Through the work of Theodor Kocher, MD, in the early 1900s, thyroid surgery became elevated to a safe and even triumphant treatment form. Given that surgical complications are low, expert surgeons have pushed the frontiers of modern thyroidectomy. They have investigated novel approaches whose emergence has paralleled modern thyroidectomy and taken advantage of technical advances in optics, hemostatic devices, and robotics. With these trends, there has been increased attention toward optimization of the cosmetic scar result at thyroidectomy, with many of these procedures focused on achieving a small or distant scar. All these issues are expertly reviewed in Terris's article “Surgical Approaches to the Thyroid Gland: Which Is the Best for You and Your Patient?”

Pathology Quiz Case 1

Bhandarkar V, Kwong K, Micale M, et al. — Wed, 01 May 2013 00:00:00 GMT

A 10-year-old girl presented with a 4-month history of a large oropharyngeal mass and a left-side upper neck mass that remained stable in size since its discovery. The patient complained of dysphagia without significant weight loss but denied dyspnea, dysphonia, or otalgia. The patient was otherwise healthy, up-to-date on immunizations, and had no prior tobacco exposure.

Pathology Quiz Case 1: Diagnosis

Wed, 01 May 2013 00:00:00 GMT

Diagnosis: Hyalinzed spindle cell tumor with giant rosettes (HSCTGR)

Pathology Quiz Case 2

Zhao XC, McHugh J, Thorne MC. — Wed, 01 May 2013 00:00:00 GMT

An 11-year-old girl was referred to our institution with an 18-month history of a right facial mass, accompanied by ipsilateral nasal obstruction. She had undergone 2 surgical procedures for removal of the mass prior to referral, 1 via an endoscopic approach and 1 via a sublabial approach. She presented 4 months following her most recent surgical procedure, with physical examination revealing expansion of the maxilla, mild proptosis of the right eye, and an intraoral polypoid mass protruding through the posterior aspect of her previous sublabial incision. Nasal endoscopy revealed a mass emanating from the maxillary sinus and filling the middle meatus. Coronal computed tomography with soft-tissue windows shows an approximately 6-cm expansile mass centered within the right maxillary sinus, with gross local invasion through the orbital floor, into the nasal cavity, and through the posterolateral maxillary sinus wall (Figure 1). Surgical resection was performed through a combined endoscopic, sublabial, and transconjunctival approach.

Pathology Quiz Case 2: Diagnosis

Wed, 01 May 2013 00:00:00 GMT

Diagnosis: Extranodal Rosai-Dorfman disease (RDD) of the maxillary sinus

Pathology Quiz Case 3

Hobson CE, Chiosea S, Mohan N, et al. — Wed, 01 May 2013 00:00:00 GMT

A 43-year-old man presented with complaints of severe left otalgia, left otorrhea, and bilateral hearing loss. The patient had previously failed medical treatment for otitis media and had undergone a left mastoidectomy at an outside facility. Postoperatively, he developed a delayed facial palsy and recurrent symptoms. One month prior to his mastoidectomy, the patient underwent endoscopic sinus surgery, excision of a nasal mass, and left tympanostomy tube placement. A review of systems revealed bilateral knee pain, and he reported a family history of rheumatoid arthritis. His history was otherwise unremarkable.

Pathology Quiz Case 3: Diagnosis

Wed, 01 May 2013 00:00:00 GMT

Diagnosis: Wegener granulomatosis

Radiology Quiz Case 1

Atmakuri M, Garritano FG, Kanekar SG, et al. — Wed, 01 May 2013 00:00:00 GMT

A 45-year-old woman with no significant medical history was referred for evaluation for episodic vertigo. She began to experience episodes of vertigo, fluctuating right-sided hearing loss, tinnitus, aural fullness, nausea, and vomiting starting in March 2011. Since that time she experienced multiple recurrences of these episodes, each lasting from several seconds to several hours before spontaneously resolving. She had a severe attack in July 2011, after which her hearing loss persisted despite resolution of her other symptoms, and it was for this that she sought evaluation.

Radiology Quiz Case 1: Diagnosis

Wed, 01 May 2013 00:00:00 GMT

Diagnosis: Suspected arachnoid cyst of the right cerebellopontine angle

Radiology Quiz Case 2

Viets R, Scherl S, Clain JB, et al. — Wed, 01 May 2013 00:00:00 GMT

A 51-year-old man presented with a history of dysphagia and dysarthria. On physical examination, he was found to have a palpable mass in the left submandibular space, extending into the floor of the mouth. Tongue fasciculations and decreased movement of the tongue were also noted. A contrast-enhanced computed tomographic examination demonstrated a hypodense multilobulated mass in the left submandibular space with extension into the floor of the mouth and lateral displacement of the mylohyoid muscle (Figure 1 and Figure 2). Subsequent contrast-enhanced magnetic resonance imaging (MRI) scan demonstrated a T2 hyperintense and enhancing lesion centered in the left submandibular space with extension into the genioglossus and floor of the mouth (Figure 3 and Figure 4). A fine needle aspiration indicated a salivary gland neoplasm. The preoperative differential diagnosis centered on pleomorphic adenoma, while primary malignant lesion, metastatic disease to the submandibular gland and infection were considered less likely.

Radiology Quiz Case 2: Diagnosis

Wed, 01 May 2013 00:00:00 GMT

Diagnosis: Hypoglossal nerve schwannoma of the submandibular space

Real-Time Subglottic Stenosis Imaging Using Optical Coherence Tomography in the Rabbit Real-Time Subglottic Stenosis Imaging

Lin JL, Yau AY, Boyd J, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Subglottic stenosis (SGS) is a severe, acquired, potentially life-threatening disease that can be caused by endotracheal tube intubation. Newborns and neonates are particularly susceptible to SGS owing to the small caliber of their airway.

Objective

To demonstrate optical coherence tomography (OCT) capabilities in detecting injury and scar formation using a rabbit model. Optical coherence tomography may provide a noninvasive, bedside or intensive care unit modality for the identification of early airway trauma with the intention of preventing progression to SGS and can image the upper airway through an existing endotracheal tube coupled with a small fiber-optic probe.

Design

Rabbits underwent suspension laryngoscopy with induction of of SGS via epithelial injury. This model was used to test and develop our advanced, high-speed, high-resolution OCT imaging system using a 3-dimensional microelectromechanical systems-based scanning device integrated with a fiber-optic probe to acquire high-resolution anatomic images of the subglottic epithelium and lamina propria.

Setting

All experiments were performed at the Beckman Laser Institute animal operating room.

Intervention or Exposure

Optical coherence tomography and endoscopy was performed with suspension laryngoscopy at 6 different time intervals and compared with conventional digital endoscopic images and histologic sections. Fifteen rabbits were killed at 3, 7, 14, 21, and 42 days after the induction of SGS. The laryngotracheal complexes were serially sectioned for histologic analysis.

Main Outcome and Measure

Histologic sections, endoscopic images, and OCT images were compared with one another to determine if OCT could accurately delineate the degree of SGS achieved.

Results

The rabbit model was able to reliably and reproducibly achieve grade I SGS. The real-time OCT imaging system was able to (1) identify multiple structures in the airway; (2) delineate different tissue planes, such as the epithelium, basement membrane, lamina propria, and cartilage; and (3) detect changes in each tissue plane produced by trauma. Optical coherence tomography was also able demonstrate a clear picture of airway injury that correlated with the endoscopic and histologic images. With subjective review, 3 patients had high correlation between OCT and histologic images, 10 demonstrated some correlation with histologic images, and 2 showed little to no correlation with histologic images.

Conclusions and Relevance

Optical coherence tomography, coupled with a fiber-optic probe, identifies subglottic scarring and can detect tissue changes in the rabbit airway to a depth of 1 mm. This technology brings us 1 step closer to minimally invasive subglottic airway monitoring in the intubated neonate, with the ultimate goal of preventing SGS and better managing the airway.

Surgical Approaches to the Thyroid Gland Which Is the Best for You and Your Patient?

Terris DJ. — Wed, 01 May 2013 00:00:00 GMT

Hypothesis: Novel surgical approaches to the thyroid gland are appropriate and safe in a modern endocrine practice.

The Early History of the Cochlear Implant A Retrospective The Early History of the Cochlear Implant

Mudry A, Mills M. — Wed, 01 May 2013 00:00:00 GMT

Importance

Histories of cochlear implant (CI) technology have often been inaccurate owing to the confusion of terms and anatomical situations or to biased reporting. This retrospective, published shortly after the death of inventor William F. House—and more than 50 years after placement of the first CI—offers a precise account of the early experimental period.

Objective

To clarify the first steps in the development of the CI, ie, an electrical stimulating device partially inserted into the cochlea.

Evidence Review

Literature review based on published data, oral history material, interviews, and written contact with protagonists.

Findings

The first CI was implanted by William House and John Doyle of Los Angeles, California, in 1961. In 1964, Blair Simmons and Robert White of Stanford University, Stanford, California, placed a 6-channel electrode through the promontory and vestibule directly into the modiolus. The next step in the development of the CI was its clinical trial on a cohort of patients. Robin Michelson, Robert Schindler, and Michael Merzenich at the University of California, San Francisco, conducted these experiments in 1970 and 1971. In 1973, the first international conference on the “electrical stimulation of the acoustic nerve as a treatment for profound sensorineural deafness in man” was organized in San Francisco. At the same time, Claude Henry Chouard in France and Graeme Clark in Australia began their research. The final step in the establishment of CI as a clinically feasible technology involved the independent evaluation of implant users. The first such evaluation—the result of a 1975 request from the National Institutes of Health—was published in 1977 by Robert Bilger and coworkers at the University of Pittsburgh, Pittsburgh, Pennsylvania.

Conclusions and Relevance

Inspired by French experiments with electrode implantation at the VIII nerve, the initial practical development of the CI is nonetheless a Californian story, divided between the House group at Los Angeles and teams at Stanford University and UCSF.

The Significance of Cochlear Implant History The Significance of Cochlear Implant History

Niparko JK. — Wed, 01 May 2013 00:00:00 GMT

In their report, Mudry and Mills provide a richly detailed description of the early development of cochlear implantation. Refinements have since propelled this implantable technology and its processing strategies to address not only clinical deafness but severe and selected high-frequency sensorineural hearing losses. The result has been one of the most consequential developments in modern medicine. Thus, the historical treatment by Mudry and Mills is an important contribution to our literature.

Treatment Patterns and Survival Among Low-Income Medicaid Patients With Head and Neck Cancer Treatment Patterns & Survival in Medicaid Patients

Subramanian S, Chen A. — Wed, 01 May 2013 00:00:00 GMT

Importance

Medicaid beneficiaries by definition are low income but they are not necessarily a homogeneous group. No study has assessed differences and disparities among Medicaid beneficiaries with head and neck cancers.

Objective

To examine predictors of treatment receipt and mortality among Medicaid patients with head and neck cancer.

Design

Retrospective cohort study using Medicaid claims linked with cancer registry data for 2 states, California and Georgia, for the years 2002 through 2006.

Setting

Inpatient and ambulatory care.

Participants

Medicaid beneficiaries aged 18 to 64 years diagnosed as having head and neck cancer (N = 1308) were included. Descriptive statistics and multivariate regression models analyzed the likelihood of treatment receipt and survival.

Main Outcomes and Measures

Receipt of treatment and 12- and 24-month mortality.

Results

Fewer than one-third of Medicaid patients with cancer received a diagnosis at an early stage. Overall, black patients were less likely to get surgical treatment and more likely to die than white patients, even after controlling for demographics, stage at diagnosis, and tumor site. Older age and disability status also increased 12-month mortality. Patients in California, who were alive for at least 12 months, have approximately half the odds of dying within 24 months compared with those in Georgia.

Conclusions and Relevance

Concrete steps should be taken to address the significant racial disparities observed in head and neck cancer outcomes among Medicaid beneficiaries. Further research is needed to explore the state-level policies and attributes to examine the startling differences in mortality among the state Medicaid programs analyzed in this study. Pooled comparisons of Medicaid beneficiaries with individuals covered by other types of insurance could mask important disparities among Medicaid beneficiaries, which need to be acknowledged and addressed to improve outcomes for these low-income patients with head and neck cancer.

Urinary Iodine Excretion After Contrast Computed Tomography Scan Implications for Radioactive Iodine Use Radiographic Contrast and Radioactive Iodine Use

Nimmons GL, Funk GF, Graham MM, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Patients who undergo radiographic studies with contrast receive an enormous bolus of iodine. This can delay subsequent use of radioactive iodine (RAI) therapy because the iodine can compete for uptake. There is a paucity of literature on the minimum interval between contrast administration and RAI therapy.

Objective

To better characterize how long it takes for the iodine load from an intravenous contrast bolus to clear from the body.

Design, Setting, and Participants

A prospective cohort of 21 adults undergoing intravenous contrast CT studies at a tertiary academic medical center; exclusion criteria included history of thyroid disease or thyroidectomy, history of renal insufficiency, pregnancy, and other contrast administration within 1 year.

Intervention

Morning urine samples were taken before the scan for analysis and then every 2 weeks thereafter for 12 weeks.

Results

The median baseline iodine level was 135 μg/L (range, 29-1680 μg/L), and median peak level was 552 μg/L (range, 62-6172 μg/L). Median time for urinary iodine level to normalize was 43 days, with 75% of subjects returning to baseline within 60 days, and 90% of subjects within 75 days. Baseline iodine level was a significant predictor of postcontrast iodine levels. Age, sex, weight, and estimated glomerular filtration rate were not significant.

Conclusions and Relevance

These results may be used for guidance on the timing of RAI use following contrast exposure. The practice at our institution is to wait 2 months and then check a 24-hour urinary iodine level. This alleviates concerns about contrast use in patients with thyroid carcinoma interfering with adjuvant radioiodine therapy.

Use of Adjuvant Intralesional Bevacizumab for Aggressive Respiratory Papillomatosis in Children Aggressive Respiratory Papillomatosis in Children

Rogers DJ, Ojha S, Maurer R, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Juvenile recurrent respiratory papillomatosis (RRP) can be an aggressive disease process necessitating frequent trips to the operating room with multiple anesthetics for tumor debulking and airway preservation. Adjuvant therapy, such as that which is reported in this article, may help reduce the number of operative procedures affected children need each year and therefore may also affect their overall quality of life (QOL).

Objective

To describe our experience with intralesional bevacizumab (Avastin) treatment for children with severe RRP by comparing median number of surgical procedures per year, median duration of time between procedures, Derkay staging, and voice QOL before and after bevacizumab treatment.

Design

Prospective, consecutive case series.

Setting

Tertiary care aerodigestive center.

Participants

Ten children, aged 18 months to 18 years, with severe RRP necessitating more than 4 operative interventions in 1 year whose parents (or legal guardians) consented to intralesional bevacizumab treatment.

Interventions

Intralesional bevacizumab administered at concentration of 2.5 mg/mL for 3 consecutive injections (with 532-nm pulsed KTP [potassium titanyl phosphate] laser when necessary) at intervals of 2 to 3 weeks.

Main Outcome Measures

Time between surgical procedures, number of procedures per year, Derkay staging, total Pediatric Voice-Related Quality of Life (PVRQOL) score, Emotional PVRQOL score, and Physical PVRQOL score defined by comparing the year leading up to first of 3 bevacizumab injections with the year following the third bevacizumab injection.

Results

The median duration of time between surgical procedures increased by 5.9 weeks after bevacizumab (P = .002). The median number of procedures per year decreased by 4 (P = .002). Derkay staging decreased by 6 (P = .03). The median total PVRQOL score increased by 25.5 (P = .02), the median Emotional PVRQOL score increased by 11.3 (P = .047), and the median Physical PVRQOL score increased by 14.3 (P = .047).

Conclusions and Relevance

Intralesional bevacizumab treatment may increase duration of time between surgical procedures and decrease number of procedures per year, while improving voice QOL.