Design  Inception cohort.

Setting  Head and neck surgery unit at a national oncologic center.

Patients  Patients with a histologically confirmed diagnosis of stage N0 papillary thyroid cancer but no previous oncologic treatment, no recurrent tumor, and no distant metastasis.

Intervention  Central neck dissection intended as curative treatment.

Main Outcome Measure  Disease-free survival. Demographic, clinical, therapeutic, pathologic, and neck recurrence information was also collected.

Results  A total of 266 patients were included. Mean (SD) follow-up time was 6.9 (4.3) years. Ninety percent of patients had a follow-up longer than 2 years. Prophylactic central neck dissection was performed in 136 patients (51.3%). Of those patients who underwent central neck dissection, 112 had metastatic lymph nodes (82.3%). Neck recurrence occurred in 45 patients (16.9%). Overall, 5-year neck disease–free survival was 86.8%; it was 88.2% in the central neck dissection group vs 85.6% in the group that did not undergo central neck dissection (P = .72). In the multivariate analysis, factors related to central neck dissection were macroscopic extrathyroidal extension (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.19-3.79) and multifocality (OR, 3.96; 95% CI, 2.08-7.53). In Cox multivariate analysis for disease-free survival, central neck dissection did not show any significant effect.

Conclusion  Prophylactic central neck dissection did not show any advantage in the rate of neck recurrence in patients with N0 clinical stage disease.

Design  Retrospective analysis of patients treated for PTC between 1993 and 2008.

Setting  Academic institution.

Patients  All patients diagnosed with PTC who underwent surgical therapy at our institution.

Main Outcome Measures  Recurrence, hypocalcemia, hypoparathyroidism, and recurrent laryngeal nerve (RLN) injury.

Results  A total of 136 patients were treated for PTC, 26 of whom were excluded because their initial resection was performed at another institution. Of the 110 patients who underwent initial surgical therapy, CND was performed in 22 patients (20%), 18 with and 4 without enlarged nodes at the time of surgery. A mean (SD) of 11 (4) lymph nodes were removed, and lymph node metastases were identified in 17 patients (77%). One patient developed a recurrence in the lateral neck at 15 months' follow-up. Eighty-eight patients had no abnormal lymph nodes and did not undergo CND, 2 of whom developed a recurrence (2%) (P = .49) in the central neck at 14 months' and 11 years' follow-up. Permanent RLN injury occurred in no patient who underwent CND and in 1 patient without a CND (1%). Transient hypocalcemia occurred in 19 patients who underwent CND (86%) compared with 54 patients without a CND (61%) (P = .01). Permanent hypoparathyroidism occurred in 1 patient who underwent a CND (5%).

Conclusion  After total thyroidectomy and CND, recurrence in the central neck is uncommon, but hypocalcemia is more common, raising questions about the use of routine CND in patients with PTC.

Design  Retrospective medical record study.

Setting  Academic research.

Patients  From March 1, 1983, to September 30, 2008, 2677 patients underwent thyroidectomy. Of these, 1638 patients had surgical information about at least 1 RLN. A total of 1081 patients underwent bilateral operations. During the last 5 years of the study, intraoperative laryngeal nerve monitoring was performed in selected patients using a commercially available system.

Main Outcome Measures  Information was obtained regarding 2154 RLNs.

Results  A total of 1390 RLNs (64.53%) had ELB. Among 447 patients in whom intraoperative laryngeal nerve monitoring was used, the anterior branches usually exhibited more electrophysiologic activity.

Conclusions  Extralaryngeal branching was found in 64.53% of RLNs in this case series. In recent patients with intraoperative laryngeal nerve monitoring, electrophysiologic activity was observed in the branches, particularly the anteriorly situated ones. Recognition of this frequent anatomical configuration and meticulous preservation of all branches are of paramount importance to decrease postoperative morbidity associated with thyroidectomy.

Design  Retrospective review of medical records.

Setting  University teaching hospital.

Patients  The records of all 194 patients who underwent successful initial parathyroidectomy for nonfamilial HPT in 2007 and 2008 by 1 surgeon were reviewed.

Main Outcome Measures  Intraoperative PTH level was measured prior to incision (baseline); at excision of the abnormal gland; at 5, 10, 15, and 20 minutes after excision; and at various additional times as needed. Of the patients, 71% underwent minimally invasive parathyroid exploration. Calcium, PTH, and 25-hydroxyvitamin D levels were measured during the first month after surgery in all patients and after 3 months or more in 80%. Patients were divided into 5 groups depending on the following final IOPTH levels: lower than 10 pg/mL (group l) (to convert PTH to nanograms per liter, multiply by 1.0); 10 to 19 pg/mL (group 2); 20 to 29 pg/mL (group 3); 30 to 39 pg/mL (group 4); and 40 pg/mL or higher (group 5).

Results  Of the patients, 82% had a single adenoma, 9% had double adenomas, and 9% had 3 or more abnormal glands. The final IOPTH/baseline IOPTH value in groups 1 to 5 was 7%, 11%, 16%, 23%, and 26%, respectively. There was no significant difference in the preoperative calcium among the groups. All 3 patients with persistent HPT and 5 patients with PPTH were in group 5. One of the 96 patients in groups 1 and 2 and 5 of the 72 patients in groups 3 and 4 had PPTH at the last evaluation.

Conclusion  Patients with a final IOPTH level of 40 pg/mL or higher are at higher risk of having persistent HPT and should be followed up closely and indefinitely following parathyroidectomy.

Design  Retrospective review.

Patients  The medical records of 738 consecutive patients who had undergone surgery for HPT. After excluding revision surgical procedures, secondary and tertiary HPT, unavailable intraoperative parathyroid (PTH) data, concomitant thyroid disease requiring thyroidectomy, and patients without preoperative MIBI or US, 428 patients (58%) were included in the study.

Results  The mean decrease in PTH level was 85%. Of the 428 patients with primary HPT included in the study, 209 patients (49%) had localizing, concordant preoperative MIBI and US. A decline of more than 50% in iPTH levels was observed in 202 patients (97%) after removal of parathyroid tissue localized by MIBI and US. The procedures for 4 patients were converted to bilateral neck explorations after the postexcision PTH level failed to drop less than 50%.

Conclusions  Our results show that iPTH monitoring may be eliminated in MIP surgery in a carefully selected group of patients who have preoperative, localizing MIBI with concordant US. This potentially allows an increase in operating room efficiency and a decrease in costs while performing MIP.

Design  Retrospective study.

Setting  State university hospital.

Patients  Fifty-six patients with head and neck squamous cell cancer and N2 disease treated with chemoradiotherapy were evaluated for persistent or recurrent neck disease. Tumor characteristics analyzed were primary site, T category, nodal size (<3 cm or ≥3 cm), nodal necrosis based on hypodensity of one-third or more of the node, and type of N2 disease (N2a, N2b, or N2c). Forty-eight of the 56 patients underwent CT-PET to determine treatment response after chemoradiotherapy. Clinical examination, imaging, and pathologic specimens were used to confirm disease recurrence.

Main Outcome Measures  The number of recurrence events, disease-free interval, and positive posttreatment CT-PET result in the neck.

Results  Most patients had oropharyngeal tumors (n = 37; 66%), T2 tumors (n = 21; 38%), nodes 3 cm or larger (n = 43; 77%), positive necrosis (n = 40; 71%), and N2c disease (n = 28; 50%). Multivariate analysis determined that no factors were significant predictors of recurrence, except for positive posttreatment PET results (P < .001). Comparison of CT-PET with nodal recurrence demonstrated a sensitivity of 82%, a specificity of 97%, a negative predictive value of 95%, and a positive predictive value of 90%.

Conclusion  Posttreatment neck dissections may not be indicated for patients with N2 disease and a negative CT-PET result, even in patients with nodal necrosis and nodes 3 cm or larger.

Design  Retrospective analysis with a median follow-up of 24 months.

Setting  Academic, tertiary referral center.

Patients and Interventions  Thirty-one patients who were treated with concomitant intra-arterial CRT underwent PET-CT 6 to 8 weeks after the completion of treatment. Patients with findings on the physical examination, CT, or PET-CT indicative of persistent disease underwent appropriate surgical intervention for pathological assessment. Patients with a complete clinical response were observed with routine follow-up physical examination for disease recurrence. No evidence of disease at least 6 months after the completion of PET-CT was considered confirmation of complete clinical response.

Main Outcome Measures  Presence or absence of residual or recurrent disease during the follow-up period was used to calculate the sensitivity, specificity, and positive and negative predictive values of PET-CT for the primary site and the neck.

Results  Assessment of tumor response at the primary site with PET-CT had a sensitivity, specificity, and positive and negative predictive values of 83%, 54%, 31%, and 92%, respectively. In patients with pretreatment N1 to N3 disease, the sensitivity, specificity, and positive and negative predictive values of posttreatment PET-CT were 75%, more than 94%, more than 75%, and 94%, respectively, and the specificity and negative predictive value for patients with pretreatment N0 disease in the neck were 92% and more than 92%, respectively.

Conclusions  Negative PET-CT findings accurately determine early disease response at the primary site and in the neck. False-positive findings are common at the primary site. Patients with a negative PET-CT finding after the completion of intra-arterial CRT do not require surgical intervention.

Design  Histologic analysis of prospectively collected specimens and retrospective medical chart review.

Setting  Tertiary referral center.

Subjects  Sixty-nine patients with OP-SCCA treated from January 1, 2002, through June 1, 2008.

Intervention  Definitive RT, with or without chemotherapy and with or without neck dissection (ND).

Main Outcome Measure  Presence of a viable tumor in post-RT ND specimen.

Results  Tissue specimens from 69 patients with OP-SCCA treated primarily with RT, with or without chemotherapy, were evaluated. Of these, 47 (68.1%) were strongly and diffusely positive for p16 expression by immunohistochemical analysis, signifying human papillomavirus positivity. Patients with p16-positive and p16-negative tumors (hereinafter, p16+ and p16–, respectively) had similarly sized primary tumors on presentation, but p16+ primary tumors were associated with more advanced neck disease (nodal stages N2c-N3; 31.9% vs 4.5% for p16– tumors) and more contralateral nodes (27.7% vs 4.5% for p16– tumors). Forty-seven patients (59.0%) underwent planned posttreatment ND (a total of 55 NDs). The NDs performed for p16– tumors were significantly more likely to have viable tumor in the specimen (50.0% vs 18.0% for p16+ tumors; P  = .02). In addition, p16+ necks with residual viable cancer were characterized by incomplete response on post-RT imaging, tobacco and alcohol use, and extracapsular spread on pretreatment imaging.

Conclusions  In conjunction with other clinical parameters, p16 status can help predict the need for post-RT ND in patients with OP-SCCA. Although close observation may be warranted in selected patients with p16+ tumors, patients with p16– tumors are at much higher risk for residual neck disease, even when initial nodal disease is less advanced.

Design  Retrospective review of data from a prospectively collected database of patients with locoregionally advanced head and neck cancer treated as part of a phase 2 study of induction chemotherapy followed by concurrent CRT. The results of post-CRT neck computed tomography (CT) imaging and pathologic analysis of the neck dissection specimens were compared to evaluate correlation between radiographic and pathologic response.

Results  Forty-nine patients underwent 61 hemineck dissections. Overall, 209 neck levels were dissected. Radiologic complete response in the neck was achieved in 39 patients, all of whom had pathologic specimens negative for tumor cells. Ten patients (20%) had a total of 14 neck levels with residual disease on CT imaging. Five (50%) of these 10 patients were found to have residual tumor cells on pathologic analysis. Tumor cells were contained only to those levels found positive on CT imaging; they were present in 7 (50%) of the 14 positive levels.

Conclusions  Neck levels with residual disease on post-CRT CT imaging warrant removal. However, neck levels without evidence of disease on post-CRT CT imaging are unlikely to harbor cancer, which lends further support to the concept of basing neck dissection on post-CRT staging and performance of limited neck dissections for patients with limited residual disease.

Objectives  To examine the effect of radiation therapy on HPV-positive and HPV-negative tumors in immune-competent and immune-incompetent mice and to examine responses in human cancer cell lines.

Design  Prospective in vivo murine model.

Main Outcome Measures  Survival and tumor growth.

Results  For human and murine transformed cell lines, HPV-positive cells were more resistant to radiation and cisplatin therapy compared with HPV-negative cells. In vivo, HPV-positive tumors were more sensitive to radiation, with complete clearance at 20 Gy, compared with their HPV-negative counterparts, which showed persistent growth. Cisplatin in vivo cleared HPV-positive tumors but not HPV-negative tumors. However, neither radiation or cisplatin therapy cured immune-incompetent mice. Adoptive transfer of wild-type immune cells into immune-incompetent mice restored HPV-positive tumor clearance with cisplatin therapy.

Conclusions  The HPV-positive tumors are not more curable based on increased epithelial sensitivity to cisplatin or radiation therapy. Instead, radiation and cisplatin induce an immune response to this antigenic cancer. The implications of these results may lead to novel therapies that enhance tumor eradication for HPV-positive cancers.

Design  Outcome cohort study.

Setting  Tertiary care Department of Veterans Affairs hospital.

Patients  A consecutive sample from 1981 through 2006 of 683 patients treated for oropharyngeal SCC was screened, and 141 patients with tonsillar SCC without distant metastatic spread and a minimum of 2 years of follow-up were included.

Main Outcome Measures  Disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS).

Results  Disease-free survival was significantly better in cohort II (treated during or after 1997) compared with cohort I (treated before 1997) (2- and 5-year DFS, 82% vs 64% and 67% vs 48%; P = .02). Disease-specific survival was better in the surgical vs nonsurgical group (2- and 5-year DSS, 77% vs 46% and 67% vs 30%; P < .001), as was the OS (2- and 5-year OS, 66% vs 41% and 45% vs 23%; P = .005). In subjects with early-stage disease, OS and DSS were not different regardless of treatment type. In subjects with late-stage disease treated most recently (time cohort II), there was significantly better DSS in those receiving surgical vs nonsurgical treatment (2-year DSS, 70% vs 43%; P = .045). Nonsmokers had better OS (94 months vs 41 months; P = .001) and lower incidence of recurrence (8% vs 44%; P = .02).

Conclusion  In veterans treated for tonsillar SCC, we advocate the consideration of a treatment plan that includes surgery for patients presenting with advanced-stage SCC of the tonsil, even in patients with notable comorbidities.

Design  Retrospective analysis of medical records.

Setting  Tertiary care referral center.

Patients  One hundred eleven patients who underwent supracricoid partial laryngectomy from January 1, 1993, through December 31, 2008.

Main Outcome Measures  Relationship between postoperative pulmonary complications and perioperative risk factors, such as age, sex, chronic lung disease, smoking status, tumor site, tumor stage, preoperative irradiation, extent of surgery, reconstruction method, and pulmonary function tests.

Results  Thirty-six patients (32.4%) developed postoperative pulmonary complications. Significant correlations were found among age (P = .002), chronic lung disease (P = .005), smoking status (P = .02), and postoperative pulmonary complications. Cricohyoidopexy (P = .008) and ipsilateral arytenoidectomy (P = .03) were associated with postoperative pulmonary complications. The multivariate analysis showed a significant association of the postoperative pulmonary complications with age (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.2-11.7 in patients 60 to 69 years old; and OR, 7.1; 95% CI, 1.3-37.6 in patients 70 to 79 years old) and cricohyoidopexy (OR, 4.4; 95% CI, 1.1-18.1).

Conclusion  Patients 60 years or older and patients with cricohyoidopexy are at high risk of having postoperative pulmonary complications after supracricoid partial laryngectomy.

Design  Retrospective review.

Setting  Academic tertiary referral hospital.

Patients  Between December 1992 and March 2007, a total of 87 patients underwent reirradiation (64 for cure and 23 for palliation).

Intervention  Patients underwent reirradiation with (n = 38) or without salvage surgery (n = 49). After January 2000 there was increased use of concurrent platinum-based chemotherapy (80% vs 5%) and intensity-modulated radiation therapy (82% vs 0%).

Main Outcome Measures  Early and late toxic effects of treatment by Radiation Therapy Oncology Group criteria, tracheostomy retention, gastrostomy tube dependence, and survival.

Results  The median follow-up among patients alive at last contact was 5.0 years. Compared with reirradiation without surgery, postoperative reirradiation was associated with increased early grade 3 to grade 5 toxic effects (50% [19 of 38] vs 29% [14 of 49], P = .04) and with longer median survival (17.3 vs 8.9 months, P < .001). Free-flap reconstruction decreased early toxic effects in the surgical cohort by 16% (from 60% [9 of 15] to 43% [10 of 23], P = .32). Gastrostomy tube dependence (P = .05) and tracheostomy retention (P = .04) have increased since 2000. The median survival for curative patients was 12.5 months. The estimated 2-year survival was 25%, and the estimated 5-year survival was 8%.

Conclusions  Reirradiation represents the only chance for cure in patients with unresectable disease. After surgery, reirradiation is performed in patients at high risk of locoregional recurrence and may increase acute toxic effects. However, free-flap reconstruction may reduce toxic effects. Functional outcomes have declined since 2000 likely because of the addition of concurrent platinum-based chemotherapy. Future research may define the subpopulation of postoperative patients for whom survival benefits most outweigh reirradiation toxic effects.

Design  Retrospective cohort study.

Setting  The Johns Hopkins Medical Institutions, Baltimore, Maryland.

Patients  Patients who underwent total laryngectomy and TEP between January 1, 1998, and December 31, 2008, were divided into 3 subgroups according to primary treatment: surgery (n = 81), radiotherapy (n = 61), and chemoradiotherapy (n = 32).

Main Outcome Measures  Number of weeks before leakage through the TEP, occurrence of leakage around the TEP, TEP dislodgement, and size changes 6 months or longer after laryngectomy.

Results  A total of 174 patients met the study criteria. Of the 81 patients who underwent primary surgery, 81% (n = 66) underwent adjuvant therapy with postoperative radiotherapy or chemoradiotherapy. The incidence of leakage around the prosthesis, prosthesis dislodgement, and size changes 6 months or longer after laryngectomy were significantly higher for patients who required salvage total laryngectomy after chemoradiotherapy or radiotherapy (P < .05). In addition, significantly more patients who underwent salvage total laryngectomy required extended laryngectomy or free tissue reconstruction.

Conclusions  Voice prosthesis complications are more frequently encountered in those who require salvage laryngectomy. Understanding the potential for such complications reinforces the need for close communication and follow-up with these patients by the speech language pathologist.

Design  Prospective case-control study.

Setting  Yenepoya Medical College Hospital, a tertiary referral hospital.

Patients  Patients 5 to 26 years old with chronic tonsillitis with or without adenoiditis.

Interventions  Tonsillectomies were performed under general anesthesia by surgeons using cold steel instruments via a standard capsular dissection technique, and adenoids were removed by curettage.

Main Outcome Measures  Acoustic analysis of 6 parameters (fundamental frequency, jitter, shimmer, harmonics: noise ratio, long-term average spectrum, and nasalance) 4 weeks after surgery compared with 1 day before surgery.

Results  Postoperatively, shimmer altered in males, and hypernasality was eliminated in almost all cases. None of the other associations were significant statistically.

Conclusions  Chronic tonsillitis and tonsillar hypertrophy cause alterations in some acoustic measurements, which make the voice dysharmonic and harsh. Tonsillectomy eliminates nasalance and lowers shimmer. Overall, it does not significantly alter dysphonia owing to disease.

Design  Prospective prior-posterior study.

Setting  Academic research.

Participants  We evaluated beliefs prior and posterior to the 2004 trial regarding the benefits of adenotonsillectomy in a random sample of 120 Dutch otolaryngologists and 120 Dutch general practitioners.

Main Outcome Measure  Physicians were asked to give their estimates of the probability of recovery during 1 year after adenotonsillectomy or a nonsurgical strategy in 3 scenarios of children aged 3 to 4 years with recurrent throat infection, upper respiratory tract infection (with or without fever), or sleep-related breathing disorder.

Results  Ninety-four percent of otolaryngologists (n = 46) and 31% of general practitioners (n = 14) were familiar with the 2004 trial results. Posterior beliefs of otolaryngologists and general practitioners did not differ substantially from prior beliefs; overall expectations regarding the benefits of adenotonsillectomy remained high.

Conclusion  Dissemination of the 2004 trial results did not seem to affect the beliefs of physicians regarding the benefits of adenotonsillectomy.

Trial Registration  isrctn.org Identifier: ISRCTN04973569

Design  Retrospective review of patients treated for microcystic lymphatic malformations of the tongue. Lymphatic malformations were classified into the following 4 groups according to their extent: isolated superficial microcystic lymphatic malformations of the tongue (stage I); isolated lymphatic malformations of the tongue with muscle involvement (stage II; stage IIA, involving a part of the tongue; stage IIB, involving the entire tongue); microcystic lymphatic malformations of the tongue and the floor of mouth (stage III); and extensive microcystic lymphatic malformations involving the tongue, floor of mouth, and further cervical structures (stage IV).

Patients  Twenty patients with microcystic lymphatic malformation of the tongue.

Main Outcome Measures  Medical records were reviewed for demographic data and extent and treatment of the lymphatic malformations.

Results  Three patients had stage I disease; 5 patients, stage II; 3 patients, stage III; and 9 patients, stage IV. In 6 patients, the lymphatic malformations could be completely removed by carbon dioxide laser surgery; the remaining 13 patients had persistent disease.

Conclusions  The initial stage seems to predict outcome. Carbon dioxide laser therapy provides good results primarily in stages I and IIA lymphatic malformations. In advanced lymphatic malformations (stages IIB, III, and IV), an interdisciplinary approach is necessary, because complete surgical excision is often impossible owing to the diffuse growth behavior, and therefore recurrence and persistence are common.

Design  A prospective, randomized, placebo-controlled trial.

Setting  Academic medical center.

Patients  Forty-nine patients were enrolled in the study. Preoperative demographic information was obtained.

Interventions  Tonsillectomy with or without adenoidectomy was performed by the senior author (J.J.) using electrocautery. Patients were randomized to receive either a 3- or 7-day course of amoxicillin.

Main Outcome Measures  Parents were asked to record the following information: analgesic use for the first 7 postoperative days, postoperative days the child initiated his or her usual diet and level of activity, and medical treatment for oral hemorrhage or dehydration.

Results  Of the 49 patients, 26 were randomized to receive 7 days of postoperative antibiotics (group A) and 23 to receive 3 days of antibiotics, followed by 4 days of placebo (group B). Results were obtained for 47 of the enrolled patients (96%). No statistically significant difference was noted between the 2 groups with regard to postoperative pain or time to resumption of a normal diet and level of activity.

Conclusion  A 3-day course of antibiotics following pediatric tonsillectomy is as effective as a 7-day course with regard to postoperative analgesic use and resumption of normal diet and level of activity.

Trial Registration  clinicaltrials.gov Identifier: NCT00662987

Design  Retrospective review of medical records.

Setting  Referral center.

Participants  Two hundred ten patients with CRS who underwent OMU CT and olfactory function tests were included in this study.

Main Outcome Measures  All the paranasal sinuses were graded via the Lund-Mackay scoring system. The olfactory cleft was graded on a scale of 0 to 4 according to its opacification. Olfactory function was evaluated by the butanol threshold test (BTT) and the 16-odor identification test (OIT).

Results  The radiologic grade of the olfactory cleft was more significantly correlated with olfactory function than the grades of the paranasal sinuses. In patients without allergy, the BTT and OIT scores were inversely correlated with the CT score of the olfactory cleft. However, in patients with allergy, only the BTT score had a negative correlation with the CT score of the olfactory cleft, whereas the OIT score did not. The OIT score showed a significant negative correlation with the opacification of the olfactory cleft in the mild and moderate CRS group only, whereas the BTT score showed a significant negative correlation in all stages of CRS.

Conclusions  The opacification of the olfactory cleft had a negative correlation with the olfactory function scores in patients with CRS. The olfactory cleft findings on OMU CT may give some clues to the olfactory function in patients with CRS.

Design  Retrospective study.

Setting  University of California, San Diego, Medical Center.

Patients  One hundred two patients with chronic rhinosinusitis operated on between July 1, 2005, and June 30, 2006, by 3 Postgraduate-Year II head-and-neck-surgery residents.

Intervention  Endoscopic sinus surgery.

Main Outcome Measures  Operative times, blood loss, case complexity, and anesthetic components were recorded and analyzed.

Results  One hundred two patients with chronic rhinosinusitis with and without polyposis received operative management. Mean operative time, with the inclusion of injection (10 minutes) and image guidance setup (5 minutes), was 77 minutes. Estimated blood loss averaged 42 mL for patients with chronic rhinosinusitis and 58 mL for patients with chronic rhinosinusitis and nasal polyps. The mean intraoperative blood pressure was 101/65 mm Hg. No major complications occurred.

Conclusions  Endoscopic sinus surgery may be safely performed by Postgraduate-Year II head-and-neck-surgery residents by means of hypotensive anesthesia techniques and image guidance. Outcome analysis demonstrates minimal blood loss, efficient operative times, and no significant complications.

Design  Randomized trial.

Setting  Academic research.

Patients  Seventy-one patients who were diagnosed as having postviral olfactory loss.

Main Outcome Measures  All patients underwent olfactory function tests, including the butanol threshold test (BTT) and the cross-cultural smell identification test (CCSIT), and follow-up tests were performed 4 weeks later. In the interim, 28 patients were treated with prednisolone for 2 weeks (monotherapy), and the other 43 patients were treated with prednisolone for 2 weeks plus G biloba for 4 weeks (combination therapy). All patients used mometasone nasal spray twice daily for 4 weeks.

Results  Scores on the BTT and CCSIT significantly increased after treatment in both groups (P < .001 for both). The mean (SD) BTT score changes were 1.4 (2.2) in the monotherapy group and 2.2 (2.9) in the combination therapy group (P = .22). The mean (SD) CCSIT score changes were 0.9 (1.7) in the monotherapy group and 1.9 (2.7) in the combination therapy group (P = .11). On the BTT, the treatment response (defined as a score increase of ≥3) rates were 32% (9 of 28) in the monotherapy group and 37% (16 of 43) in the combination therapy group (P = .66), and the odds ratio was 1.25 (95% confidence interval, 0.46-3.42). On the CCSIT, the treatment response rates were 14% (4 of 28) in the monotherapy group and 33% (14 of 43) in the combination therapy group (P = .08), and the odds ratio was 2.89 (95% confidence interval, 0.84-9.97).

Conclusions  Olfactory function in patients with postviral olfactory loss was significantly improved by both treatment modalities. Although the treatment response was not statistically different between the monotherapy group and the combination therapy group, the addition of G biloba showed a tendency of greater efficacy in the treatment of postviral olfactory loss.

Design  Double-blind, randomized clinical trial.

Setting  Tertiary referral center.

Patients  A total of 140 patients undergoing FESS randomly divided into 2 groups, with group 1 receiving lidocaine hydrochloride, 2%, with 1:100 000 epinephrine and group 2, lidocaine, 2%, with 1:200 000 epinephrine.

Main Outcome Measures  Baseline and postinjection hemodynamic parameters were recorded at 1-minute intervals for 5 minutes. Patient demographics, the extent of surgery, and the presence of polyps were recorded in both groups. Hemodynamic and hemostatic parameters and intraoperative blood loss were compared.

Results  Significant hemodynamic fluctuations were noted following injection of lidocaine, 2%, with 1:100 000 epinephrine (group 1). Increases in heart rate and systolic, diastolic, and mean arterial blood pressure were noted in group 1 patients. The increase was found to be significant (P < .001) in the first and second minutes after injection and decreased to baseline level by the fifth minute. This fluctuation was not noted in group 2 patients, who received lidocaine, 2%, with 1:200 000 epinephrine. Using a standardized scale to assess surgical bleeding, no statistical difference in the 2 groups was observed (P > .05).

Conclusion  Submucosal injection of lidocaine, 2%, with 1:200 000 epinephrine during FESS does not lead to hemodynamic fluctuations or increased intraoperative bleeding compared with lidocaine, 2%, with 1:100 000 epinephrine.

Trial Registration  clinicaltrials.gov Identifier: NCT00852410

Design  Prospective study.

Setting  Academic research center.

Patients  A total of 28 patients with nasal obstruction due to inspiratory nasal valve collapse were included in this study.

Intervention  Radiofrequency-induced thermotherapy.

Main Outcome Measures  Visual analog scale score.

Results  Severity of obstruction scores improved in all patients, with the mean score improving at the left nostril from 8.2 before treatment to 3.4 after treatment and at the right nostril from 8.9 before treatment to 4.1 after treatment. The outcomes were measured using visual analog scale score before treatment and at 16 weeks after treatment. Improvement was shown in severity of obstruction (P < .001).

Conclusions  This new method appears to be safe, quick, bloodless, and painless. These good, encouraging preliminary results must be confirmed by further study and long-term follow-up.

Design  Retrospective medical chart review with a mean follow-up of 25.6 months.

Setting  Departments of Ophthalmology and Otolaryngology, University of Washington, Seattle.

Patients  Five individuals seen at the University of Washington Medical Center from November 2003 through December 2005 with visual disturbance caused by orbital apex lesions as documented by preoperative magnetic resonance imaging or computed tomographic scan.

Intervention  All patients underwent endoscopic decompression of the medial wall of the orbital apex with incision of the periorbita.

Main Outcome Measures  Postoperative visual acuity, presence or absence of a relative afferent pupillary defect, color vision, and visual field were recorded.

Results  All 5 patients presented with visual field deficits, 4 of whom improved postoperatively. Three patients had dyschromatopsia preoperatively, 2 of whom improved postoperatively. Visual acuity improved or stabilized in 4 of 5 patients postoperatively. One patient had progressive visual loss during the course of her follow-up, which, after obtaining postoperative imaging, was attributed to inadequate decompression of the apex at its most posterior aspect. This same patient also developed postoperative sinusitis that resolved with antibiotic treatment. Two patients developed diplopia, 1 in primary gaze requiring treatment with prismatic lenses. All patients presented with and maintained normal intraocular pressures.

Conclusion  Orbital apex lesions can often be effectively and relatively safely treated by endoscopic decompression alone.

Design  Retrospective cohort analysis.

Setting  Tertiary care cancer center.

Patients  The study included 461 patients who underwent laryngectomy. Eighty of them underwent salvage surgery with primary pharyngeal closure.

Interventions  Of the 80 patients, 69 (86%) underwent primary pharyngeal closure alone and 11 (14%) underwent a PMMF, which was used to buttress the pharyngeal suture line.

Main Outcome Measure  Two hundred thirty-six variables were recorded for each patient. Complications related to pharyngeal closure were measured.

Results  Sixty-four percent of the patients who underwent PMMF also underwent chemoradiation therapy as the initial definitive treatment compared with 25% in the non-PMMF group (P = .03). On multivariate analysis, chemoradiation therapy was the only independent predictor of pharyngocutaneous fistula formation (relative risk, 1.82; P = .02). Nevertheless, the pharyngocutaneous fistula rate was similar in the PMMF (27%) and the non-PMMF (24%) groups. Furthermore, similar durations of tube feeding, days to oral feeding, and hospitalization period were recorded in both groups.

Conclusion  The PMMF should be used judiciously as a surgical adjunct in high-risk patients, with the goal of minimizing the risk for the development of a pharyngocutaneous fistula.

Design  Retrospective medical record study.

Setting  Academic head and neck oncology practice.

Patients  A total of 183 consecutive patients with metastatic carcinoma of the neck from an unknown primary tumor during a 10-year period, after exclusion of those with previous history of head and neck cancer, a primary tumor site evident on physical examination, or primary tumors of the neck.

Main Outcome Measures  Identification of primary tumor location by various imaging modalities and panendoscopy with directed biopsies.

Results  Primary tumor location was identified in 84 patients (45.9%). Preoperative imaging (computed tomography [CT], magnetic resonance imaging, positron emission tomography [PET], and/or PET-CT fusion scan) identified sites suggestive of primary tumor location in 69 patients. Subsequent directed biopsy of these sites yielded positive results in 42 cases (60.9%). The rate of successful identification of a primary tumor for each of the imaging modalities was as follows: CT scan of the neck, 14 of 146 patients (9.6%); magnetic resonance imaging of the neck, 0 of 13 patients (0%); whole-body PET scan, 6 of 41 patients (14.6%); and PET-CT fusion study, 23 of 52 patients (44.2%) (P = .001). The highest yield in identifying primary tumor sites was obtained in patients who had undergone PET-CT plus panendoscopy with directed biopsies with or without tonsillectomy: 31 of 52 patients (59.6%).

Conclusion  Diagnostic workup including PET-CT, alongside panendoscopy with directed biopsies including bilateral tonsillectomy, offers the greatest likelihood of successfully identifying occult primary tumor location.

Design  Meta-analysis examining 33 articles published since 1990.

Patients  A total of 678 patients with ENB with 79 patients with neck metastases occurring 6 or more months after the initial diagnosis.

Interventions  Patients were grouped according to treatment with surgery, radiotherapy, or combined surgery and radiotherapy.

Main Outcome Measures  The rate of successful salvage of late neck metastases, defined as disease-free survival for at least 1 year, was compared for the 3 treatment groups.

Results  The rate of cervical metastases was 20.2%, with a 12.4% rate of late neck metastases. The combined successful salvage rate for late neck metastases with surgery, radiation, or combined therapy was 31.2%. An odds ratio (OR) analysis revealed that surgery plus radiation provided a statistically significant increase in the rate of successful salvage in patients with late neck metastases, with an OR of 8.6 vs single modality therapy and a number-needed-to-treat of 3. We found no difference in the OR for successful salvage for surgery alone vs radiation alone (OR, 1.5).

Conclusion  Treatment of neck metastases occurring 6 or more months after an initial diagnosis of ENB with combined surgery and radiotherapy provides a statistically significant survival advantage vs single-modality therapy.

Design  Immunohistochemical analyses of a retrospective cohort.

Setting  University-affiliated hospital.

Patients  One hundred twenty-four patients with OSCC.

Main Outcome Measure  The prognostic value of -catenin expression on disease-specific survival in different T and N category groups in patients with OSCC.

Results  Reduced expression of -catenin correlated with poor tumor differentiation of OSCC (P = .04). Patients with reduced -catenin expression in the primary tumor had significantly more frequent lymph node metastasis than did patients with normal -catenin expression (P = . 03). Reduced expression of -catenin (004) but not of -catenin (P = .25) or β-catenin (P = .48) correlated with poor clinical outcome. Reduced -catenin expression predicted poor disease-specific survival also in the 92 patients with T1 or T2 tumors (P = . 02). In multivariate analysis, advanced T category (P = . 04), neck lymph node metastases (P = . 01), and reduced -catenin expression (P = . 05) were independently related to poor survival.

Conclusions  Reduced expression of -catenin was associated with poor differentiation of OSCC, with neck lymph node metastases, and, more importantly, with poor disease-specific survival. Loss of -catenin expression seems to contribute to metastatic properties of OSCC. Evaluation of the expression pattern of -catenin may be useful for predicting outcome in patients with OSCC.

Design  Prospective analysis of a consecutive single-surgeon series of patients undergoing thyroid surgery at an academic health center.

Setting  Tertiary care health center.

Patients  The study included patients aged 21 to 35 years and patients 65 years and older who underwent thyroidectomy.

Main Outcome Measures  Pathology reports, complications (including rates of temporary and permanent hypocalcemia and temporary and permanent true vocal fold [TVF] paralysis), and need for admission or readmission were included in the analysis.

Results  There were 86 youthful patients who underwent thyroidectomy between November 2003 and December of 2007; 44 elderly patients underwent surgery during that same time frame. There were no deaths in either cohort, no hematomas, and no cases of permanent TVF paralysis. The elderly patients had a similar rate of complications when compared with the youthful patients, including transient hypocalcemia (12.5% vs 11.1%, respectively) and temporary TVF paresis (2.9% vs 3.9%), but a higher rate of readmission (4.5% vs 1.2%, P = .26).

Conclusions  Thyroid surgeons will be faced more often with the prospect of elective thyroid surgery in patients of advanced age as an increasingly aged population emerges and the prevalence of thyroid nodules and thyroid cancer increases. Thyroid surgery in elderly patients is safe and no more dangerous than surgery in youthful patients. There is a slightly higher rate of readmission.

Design  Prospective inception cohort (median follow-up, 7 years).

Setting  Multi-institutional cooperative group study (Eastern Cooperative Oncology Group 4393/Radiation Therapy Oncology Group 9614) involving 17 academic medical centers.

Patients  A total of 560 patients with new-onset or recurrent HNSCC enrolled during a 7-year period.

Interventions  Surgical resection with curative intent with or without adjuvant or previous radiotherapy or chemotherapy.

Main Outcome Measures  Clinical staging and pathological staging and the component TN tumor categories were compared with overall and disease-specific survival. Association of survival with staging was derived by means of the proportional hazards model.

Results  Of the 501 cases in which both clinical and pathological staging was available, a disparity was found between at least 1 component tumor category assigned by the 2 methods in almost 50% of cases. Both methods showed a strong association of stage with overall survival for the cohort at large. However, pathological nodal category was a superior predictor (P < .001 vs P = .005), whereas there was an advantage to pathological tumor category in predicting disease-specific survival (P = .01).

Conclusions  Both staging methods are useful in predicting survival, whereas information gained at neck dissection regarding nodal metastases provides some refinement in prognostic results. These findings demonstrate the need for enhanced methods of tumor assessment and apparent benefit of data gathered at neck dissection for accurate disease assessment and stratification.

Design, Setting, and Patients  Using the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked database, we identified Medicare beneficiaries 66 years or older who were diagnosed as having local or regional head and neck cancer from January 1, 1997, through December 31, 2003. For each case, we calculated the timing and duration of radiotherapy using Medicare claims data. We then performed logistic regression analyses to estimate the association between tumor and clinical characteristics and early discontinuation of and/or interruptions in radiotherapy.

Main Outcome Measure  Completion of uninterrupted radiotherapy.

Results  A substantial proportion of patients (39.8% overall) had interruptions in radiotherapy and/or incomplete therapy. Altogether, 70.4% of surgical patients completed radiotherapy with no interruptions compared with 52.0% of nonsurgical patients (² = 78.17; P < .001). Surgery was associated with an increased likelihood of completing uninterrupted radiotherapy for all tumor sites. Comorbidity, chemotherapy, and regional disease were all associated with a decreased likelihood of completing radiotherapy at a subset of sites.

Conclusions  Failure to complete uninterrupted radiotherapy is common among Medicare enrollees with head and neck cancer. Surgery before radiotherapy is associated with an increased likelihood of completing radiotherapy. At a subset of sites, chemotherapy is associated with a decreased likelihood of completing radiotherapy. Further research is needed to identify factors associated with noncompletion of radiotherapy among nonsurgical patients and patients who receive chemotherapy.

Design and Setting  A phase 2 study in a multi-institutional setting within the Southwest Oncology Group.

Patients  Thirteen individuals who met the following entry criteria: newly diagnosed, previously untreated squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx; selected stage III or IV disease without distant metastases; and surgically resectable disease.

Interventions  Surgery, perioperative INGN 201 gene therapy, and postoperative chemoradiotherapy.

Main Outcome Measures  Overall patient status, tumor status, adverse effects, accrual rate, and percentage of patients successfully receiving the required doses of INGN 201.

Results  All 13 patients received surgery and perioperative INGN 201 injections in the primary tumor bed and the ipsilateral neck. In addition, 3 patients received injections in the contralateral neck. Three patients did not receive chemoradiotherapy. One patient had a grade 2 fistula of the oral cavity. Of the 10 patients with evaluable data, 2 experienced grade 4 adverse events, 1 owing to hypokalemia, hyponatremia, vomiting, leukopenia, and neutropenia and 1 owing to increased aspartate aminotransferase and alanine aminotransferase levels. Seven other patients experienced grade 3 adverse events. The estimate of 1-year progression-free survival is 92%.

Conclusions  This trial demonstrated the feasibility of handling and delivering a very complex gene vector safely in multiple cooperative group institutions without significant incident. Intraoperative INGN 201 gene therapy is technically feasible, but it has many logistical problems when performed in a multi-institutional setting. Regulatory requirements might have hindered accrual in this multi-institutional setting. Disease control seems to be promising; however, no definitive conclusion can be made with this small sample size.

Trial Registration  clinicaltrials.gov Identifier: NCT00017173

Design  Retrospective review of CT, intraoperative, and pathologic findings.

Setting  Tertiary care academic medical center.

Patients  Thirty-four patients who underwent 43 planned post-CRT hemi-neck dissections for pretreatment N2 or greater disease.

Results  Of the 43 neck dissections, 39 (91%) were selective neck dissections, 2 (5%) were modified radical dissections, and 2 (5%) were radical neck dissections. The IJV was removed in 6 of the 39 selective neck dissections (15%), in 1 of the 2 modified radical dissections, and in both of the 2 radical neck dissections. The SCM was removed in the 2 modified radical dissections and 2 radical neck dissections. The IJV was removed in 7 of the 9 dissections (78%) in which the IJV was abnormal on preoperative CT (filling defect or thrombosed) vs 2 of the 34 dissections (6%) with a normal IJV on CT (P < .001; positive predictive value, 78%; negative predictive value, 94%). The SCM was removed in 4 of the 11 dissections (36%) in which the tissue plane between the carotid sheath and the SCM was indistinct on CT vs 0 of the 32 dissections with a radiographically normal SCM tissue plane (P = .003; positive predictive value, 36%; negative predictive value, 100%). In 27 patients with pre-CRT CTs for comparison, the IJV normalized in 3 of the 8 patients (38%) with an abnormal IJV on pre-CRT CT, and the tissue plane around the SCM normalized in 15 of the 24 patients (63%) with an indistinct tissue plane on pre-CRT CT.

Conclusions  Filling defects or thrombosis of the IJV is highly predictive of need for removal intraoperatively, which may affect planning especially in bilateral neck dissections in which an effort may be made to preserve at least 1 vein. Presence of a clear tissue plane between the SCM and carotid sheath predicts the ability to preserve this muscle. Changes in the status of the IJV and SCM seen on CT that occur as a result of CRT may make preservation of these structures more feasible, even in patients with advanced neck disease.

Design  Retrospective medical record analysis.

Setting  Regional hospital.

Patients  From March 2000 to March 2006, 118 patients with HNSCC had undergone esophagoscopy as part of the disease workup. Three patients had double head and neck primary tumors. Sixty-five patients also underwent chromoendoscopy with Lugol's iodine solution.

Main Outcome Measures  The incidence of simultaneous esophageal cancer diagnosed on esophagoscopy. Additional esophageal lesions of clinical significance discovered during chromoendoscopy were also evaluated.

Results  Clinically important esophageal lesions were found in 12 patients (10%)—9 carcinomas and 3 dysplastic lesions. Chromoendoscopy was useful in 5 of these 12 cases, detecting 3 dysplastic lesions not visualized by ordinary esophagogastroduodenoscopy and additional lesions in 2 patients with esophageal carcinoma. Of the patients in whom isolated oral cavity SCC was considered, the incidence of synchronous esophageal lesions was only 1.5%. Sex (P = .02), younger age (P = .04), alcohol drinking (P = .047), and tumor sites (P = .002) were significant predictors of synchronous esophageal lesions on univariate analysis. On multivariate analysis, only tumor site remained a significant risk factor (P = .009).

Conclusions  Clinically important esophageal lesions rarely coexists with oral cavity SCC, for which the benefit of routine esophagogastroduodenoscopy is questionable. Chromoendoscopy enhances the identification of early but clinically important esophageal abnormalities if esophagoscopy is performed for SCC in the larynx, hypopharynx, and oropharynx.

Design  Prospective case series.

Setting  Tertiary care academic medical center.

Patients  The study population comprised 25 patients (21 men and 4 women; mean age, 55.3 years) presenting from January 1998 to January 2001 with oropharyngeal squamous cell carcinoma. A comparison was performed based on the percentage of resection of the soft palate (group 1, ≤50% palate; group 2, >50% palate).

Interventions  Of the 25 patients, 24 (96%) received radiotherapy. The donor sites were radial forearm for 23 of 25 patients (92%) and lateral arm for 2 of 25 patients (8%). The mean area was 92 cm² (range, 25-150 cm²), and the mean length of the velopharyngoplasty component of the oropharyngoplasty was 2.15 cm (range, 1-3 cm).

Main Outcome Measures  Gastrostomy tube dependence, major and minor complications, time to oral intake, speech and swallowing assessment, and quality-of-life assessment.

Results  Of the 25 patients, 2 (8%) remain gastrostomy dependent; 6 (24%) developed major complications; and 7 (28%) developed minor complications. Speech in both groups 1 and 2 was considered understandable most of the time, with occasional repetition. The group 1 patient with a median assessment score could eat a solid diet without restriction of place or person, whereas the group 2 patient with a median assessment score could eat a soft, moist diet with selected persons in selected places.

Conclusion  Integration of oropharyngoplasty with template-based revascularized free tissue transfer produced speech results that were independent of palate defect size, and swallow function test results were similar to other published reconstructive techniques.

Design  The expression of FGF-BP mRNA in HNSCC was studied in 35 primary and 8 metastatic HNSCC specimens and 7 control tissues using in situ hybridization and reverse transcriptase–polymerase chain reaction (RT-PCR). Microvessels in tumor specimens were identified with endothelial cell markers (von Willebrand factor [vWF] and CD34-specific antibodies). Correlates between FGF-BP and microvessel counts were evaluated statistically.

Setting  University of Minnesota Hospitals and Clinics.

Patients  Forty-two surgically treated patients with HNSCC.

Interventions  The patients were routinely treated in the study hospitals and clinics.

Main Outcome Measures  The expression of FGF-BP and angiogenesis in tumors were evaluated.

Results  In situ hybridization and RT-PCR demonstrated that FGF-BP mRNA transcripts were expressed in 34 of 35 primary HNSCC specimens and 5 of 8 metastatic tumor specimens but not in adjacent control tissues. The microvessel counts in HNSCC specimens were closely related to the expression level of FGF-BP (P < .001).

Conclusion  The expression of FGF-BP is statistically linked to the angiogenesis of HNSCC, suggesting that FGF-BP participates in the angiogenesis of HNSCC.

Design  A prospective cohort study with a mean follow-up of 12 months.

Setting  An academic, pediatric, tertiary referral center.

Patients  All eligible children were prospectively recruited from January 1, 2007, through October 31, 2008. Ten children aged 9 to 33 months who had congenital inner ear malformations, including common cavity, incomplete partition, and cochleovestibular hypoplasia, participated.

Interventions  Bilateral cochlear implantation was performed sequentially with an interimplantation delay greater than 2 years in 7 children and less than 1 year in 1 child. Bilateral simultaneous implantation was performed in 2 children.

Main Outcome Measures  Complications, hearing outcomes, and balance outcomes.

Results  All children underwent successful implantation. Five children had a perilymph "gusher" (on 1 side only), and there were no other complications. All children had 22 active electrodes bilaterally and achieved speech reception. All 8 children who underwent closed-set speech perception testing scored above 75%, and 5 of the 7 children who underwent open-set testing achieved scores above 75%. Despite variable vestibular function before bilateral implantation, no prolonged imbalance occurred, although 3 children (30%) had transient unsteadiness for up to 2 weeks after the second implantation.

Conclusions  Bilateral cochlear implantation was performed safely and successfully in children with a spectrum of bilaterally anomalous cochleovestibular anatomy. Hearing outcomes suggest that these children should not be excluded from undergoing bilateral implantation. This study provides guidance on candidacy issues, surgical decision making, and surgical techniques in this group.

Design  Retrospective analysis.

Setting  Academic tertiary referral center.

Patients  Seventy-six patients (68 men and 8 women) who were treated with the MAD for OSA were included from September 1, 2005, through August 31, 2008.

Intervention  All patients underwent nocturnal polysomnography and SVF before and at least 3 months after receipt of the custom-made MAD. Sleep videofluoroscopy was performed before and after sleep induction and was analyzed during 3 states of awakeness, normoxygenation sleep, and desaturation sleep.

Main Outcome Measures  Changes in the length of the soft palate, retropalatal space, retrolingual space, and angle of mouth opening were evaluated during sleep events with or without the MAD.

Results  Without the MAD, the length of the soft palate and the angle of mouth opening increased during sleep events, especially in desaturation sleep, compared with the awake state. The retropalatal space and retrolingual space became much narrower during sleep compared with the awake state. The MAD had marked effects on the length of the soft palate, retropalatal space, retrolingual space, and angle of mouth opening. The retropalatal space and retrolingual space were widened, and the length of the soft palate was decreased. The MAD kept the mouth closed.

Conclusions  Sleep videofluoroscopy showed dynamic upper airway changes in patients with OSA, and the MAD exerted multiple effects on the size and configuration of the airway. Sleep videofluoroscopy demonstrated the mechanism of action of the MAD in patients with OSA. The MAD increased the retropalatal and retrolingual spaces and decreased the length of the soft palate and the angle of mouth opening, resulting in improvement of OSA.

Design  A prospective nonrandomized clinical study.

Setting  Tertiary care referral center.

Patients  Data from 47 patients with mild to moderate obstructive sleep apnea treated between January 1, 2003, and October 31, 2006, were reviewed.

Interventions  Twenty-six patients underwent TCRFTVR and 21 underwent nasal CPAP as a primary treatment modality.

Main Outcome Measures  Baseline and 12-month posttreatment measurements using the Epworth Sleepiness Scale and polysomnography were compared.

Results  The baseline characteristics of the groups were not significantly different. Both methods showed meaningful results for the Epworth Sleepiness Scale and polysomnography variables 12 months after treatment compared with baseline measurements. The results were not significantly different in the posttreatment intergroup comparisons. Treatment success rates were 52.4% for nasal CPAP and 53.8% for TCRFTVR (P = .92).

Conclusion  Similar comparison results with nasal CPAP in objective and subjective variables make single-stage, multilevel TCRFTVR a good alternative in primary treatment of mild to moderate obstructive sleep apnea.

Design  Using standard radiologic software, we obtained mean (SD) thickness measurements at the inferior or posterior borders of the mandible at the following 7 surgically useful sites: (1) the symphysis, (2) a point halfway between the symphysis and the mental nerve, (3) the mental nerve, (4) a point halfway between the mental nerve and the facial artery notch, (5) the facial artery notch, (6) the angle vertex, and (7) the ramus–condylar neck border.

Setting  University hospital.

Patients  A total of 150 dentate men and 75 dentate women aged 18 to 30 years who had undergone computed tomography of the head and neck region during the period of December 20, 2006 to February 20, 2007.

Main Outcome Measure  Thicknesses of 7 mandibular sites.

Results  Mean (SD) thicknesses at the 7 mandibular sites were as follows: symphysis, 14.03 (1.53) mm for men and 13.21 (1.46) mm for women; halfway between the symphysis and the mental nerve, 11.17 (1.37) mm for men and 10.00 (1.08) mm for women; mental nerve, 9.48 (1.28) mm for men and 8.72 (1.00) mm for women; halfway between the mental nerve and the facial artery notch, 10.33 (1.24) mm for men and 9.45 (0.92) mm for women; facial artery notch, 7.27 (0.82) mm for men and 7.10 (0.88) mm for women; angle vertex, 5.42 (0.90) mm for men and 5.39 (0.66) mm for women; and ramus–condylar neck border, 5.90 (0.86) mm for men and 5.85 (0.71) mm for women.

Conclusions  Clinical landmark areas in young dentate mandibles have mean thicknesses with limited SDs. The thickness measurements obtained at the sites in this study provide practical reference information for mandibular reconstruction and bicortical screw length estimation.

Data Sources  The MEDLINE database was systematically reviewed for articles reporting on the use of surgical procedures to treat sialorrhea published from January 1, 1963, to November 30, 2008.

Study Selection  Inclusion criteria included presence of data on the success of surgical treatment of sialorrhea, English language, sample size greater than 5, and presentation of extractable data regarding the subjective success of surgical management of sialorrhea.

Data Extraction  Data regarding demographic characteristics of study participants, follow-up duration, subjective success rates, and number and type of complications were extracted by blinded reviewers.

Data Synthesis  A total of 325 studies were identified on initial search. Abstract review reduced the sample to 46. Cross-referencing yielded an additional 4 articles, resulting in the final sample of 50 articles. Forty-seven studies were case series (Centre for Evidence-Based Medicine level 4 evidence), 2 were cohort studies (level 2), and 1 was a prospective cohort study (level 1b). Median sample size was 18 (range, 5-181), and median follow-up duration was 8.1 months (range, 0.1-50 months). Subjective success was reported in more than 50% of patients in 49 of 50 studies. Random-effects modeling estimated the overall subjective success rate for all procedures to be 81.6% (95% confidence interval, 77.5%-85.7%; P < .001). Bilateral submandibular gland excision and parotid duct rerouting appeared to have the highest subjective success rates at 87.8% (k = 8 studies; 95% confidence interval, 80.5%-95.1%; P <.001), and 4-duct ligation was the lowest at 64.1% (4 studies; 27.6%-100%; P = .001).

Conclusions  Most evidence regarding surgical outcomes of sialorrhea management is low quality and heterogeneous. Despite this, most patients experience a subjective improvement following surgical treatment.

Design  Retrospective clinical series.

Setting  Large urban community hospital.

Patients  Consecutive sample of 57 patients with nasolabial cysts treated from January 1, 2000, to February 29, 2008.

Interventions  Sublabial excision in 23 patients (sublabial group) and transnasal endoscopic marsupialization in 34 patients (transnasal group). Among 57 patients, 47 underwent preoperative computed tomography.

Main Outcome Measures  History, clinical presentation, preoperative condition, histopathologic findings, treatment, complications, and outcomes.

Results  The mean duration of surgery was 91.3 minutes in the sublabial group and 29.5 minutes in the transnasal group (P = .003). The hospitalization rate was 100% (23 of 23) in the sublabial group and 59% (20 of 34) in the transnasal group (P < .001). The medical costs were significantly lower in the transnasal group than in the sublabial group (P = .002). The follow-up period ranged from 6 to 85 months. Neither group of patients experienced any major complications or recurrences during the follow-up period.

Conclusion  Transnasal endoscopic marsupialization is an effective treatment for nasolabial cysts, is less costly, and has fewer complications than sublabial excision.

Design  Retrospective medical record review.

Setting  Military tertiary referral center.

Patients  Adult patients identified in our surgical database from June 1, 2000, through September 31, 2005, who had undergone tonsillectomy or uvulopalatopharyngoplasty with tonsillectomy (UPPPT) either alone or with synchronous nasal surgery.

Main Outcome Measures  The rate of posttonsillectomy hemorrhage was reviewed in all patients who underwent tonsillectomy or UPPPT at our medical center, and an investigation was conducted to determine whether synchronous nasal surgery altered this rate.

Results  A total of 1010 patients were included in this study, with a rate of posttonsillectomy hemorrhage of 5.5%. A total of 204 patients underwent synchronous nasal surgery. No significant difference was found between the hemorrhage rate in patients who underwent tonsillectomy or UPPPT alone and those who underwent synchronous nasal surgery (6.0% and 3.9%, respectively; P = .30). When these patients were further divided into those undergoing UPPPT and those undergoing synchronous nasal surgery, no significant difference in hemorrhage rate was found (6.2% and 2.0%, respectively; P = .06).

Conclusions  Synchronous nasal surgery does not appear to increase the rate of postoperative hemorrhage in patients who undergo tonsillectomy alone or in those who undergo UPPPT. This information may help persuade physicians to perform synchronous surgical procedures instead of staging surgical procedures. In this regard, the patient requires only 1 anesthetic and 1 postoperative course without the risk of increased postoperative hemorrhage.

Design  Retrospective study.

Setting  Tertiary referral and academic center.

Patients  Seven hundred twenty patients who underwent ossiculoplasty performed by a single surgeon from January 1, 1989, through December 31, 2006, and who were followed up for longer than 1 year.

Main Outcome Measures  Hearing outcomes were considered successful if the postoperative air-bone gap was 20 dB or less. The prognostic factors were analyzed using multivariate analysis with logistic regression.

Results  Hearing outcomes were successful in 505 patients (70.1%). Presence of the stapes superstructure, presence of the malleus handle, normal mucosa, normal stapes mobility, and use of local anesthesia were significantly favorable predictive factors.

Conclusions  Multivariate analysis should be performed to investigate prognostic factors of favorable short-term hearing outcomes after ossiculoplasty. Better knowledge of these predictive factors may contribute to the surgeon's judgment and the information given to patients.

Design  Retrospective multivariate analysis of implant position related to skin thickness and clinical variables.

Setting  Tertiary referral center.

Patients  Random sample of 248 patients with bone-anchored hearing aids.

Interventions  Bone-anchored hearing aid implant placement by means of the linear incision technique.

Mean Outcome Measures  Type and number of skin reactions and implant loss.

Results  The mean (SD) distance from the external auditory ear canal to implant was 48.8 (8.0) mm (range, 29-84 mm). The mean skin thickness was 5.5 (1.9) mm. Severe skin reactions (Holgers classification, 2-4) were seen in 46 of the 248 patients (18.5%). Implant loss occurred in 4 patients (1.6%). Three implants were lost owing to failed osseointegration (1.3%), and another implant was removed because of deterioration of cochlear function (0.9%). No implant was lost as a result of infection.

Conclusion  Implant location and skin thickness were not correlated with implant loss or the frequency or degree of adverse skin reactions around the abutment.

Design  Prospective observational study.

Setting  Otolaryngology clinic at a tertiary care children's hospital.

Patients  Thirty-three infants with CP and middle ear effusions who underwent tympanostomy tube placement. Subjects were observed from the time of tube placement until 6 months after CP repair.

Main Outcome Measure  Incidence of otorrhea before and after CP repair.

Results  Subjects were observed a mean of 6.3 months before CP repair and 6 months after CP repair. Before CP repair, 11 of 33 infants (33%) had no episodes of otorrhea, compared with 22 of 33 (67%) after CP repair (P = .007). Fourteen infants (43%) had 2 or more episodes of otorrhea before CP repair compared with 2 (6%) after CP repair (P = .001). Before CP repair, significantly fewer tubes were patent at the time of the audiologic evaluation compared with after CP repair (39 of 62 [63%] vs 52 of 66 [79%]; P = .048). Average speech reception threshold for the infants with tympanostomy tubes before CP repair was 18.1 dB compared with 12.6 dB after CP repair (P = .01).

Conclusion  The incidence of otorrhea after tympanostomy tube placement before CP repair is higher than the incidence after CP repair, although more than half of all infants (19 [58%]) had either 1 or no episodes of otorrhea before CP repair.

Design  Nonrandomized controlled trial.

Setting  Department of Otolaryngology–Head and Neck Surgery, University of Genoa.

Patients  The study included 80 patients affected by nasal obstruction from hypertrophied inferior turbinates.

Interventions  Homogeneous patient groups A, B, C, and D underwent radiofrequency, high-frequency, and electrocautery treatments and partial inferior turbinotomy, respectively, to surgically reduce hypertrophied inferior turbinates.

Main Outcomes Measures  Prior to surgery and at 7-day and 2-month follow-up evaluations, patients' outcomes were assessed via visual analogue scale, nasal endoscopy, nasal monofilament test, nasal mucociliary transport time (NMTT), anterior active rhinomanometry, and histologic examination of microbiopsy specimens from the inferior turbinate mucosa.

Results  Compared with groups A, B, and C 2 months after surgery, group D showed a lower subjective assessment of symptoms score, normal NMTT (vs an increase in all other groups), lower stimulus to trigger a touch response at monofilament test (vs hyposensitivity in the other groups), and absence of histologic changes.

Conclusions  To our knowledge, no one has previously performed comparative studies to conclusively demonstrate which surgical technique is ideal. Our results show that the partial inferior nasal turbinotomy is the best method of treatment because it most effectively maintains satisfactory nasal physiologic integrity without damaging nasal mucosa or underlying nerves.

Design  Retrospective analysis of 12 patients.

Setting  Academic research.

Patients  A mixture of autologous fascia lata and fat was injected into the thyroarytenoid muscle of the paralyzed vocal fold in 12 patients.

Main Outcome Measures  Videolaryngostroboscopy was performed to observe the changes to the vocal fold. The patients' phonatory function before and after surgery was assessed by computerized acoustic analysis and by blinded perceptual evaluation.

Results  Videolaryngostroboscopy demonstrated that the paralyzed vocal folds in these patients were pushed medially after the procedure. Statistically significant improvements were found in the perturbation measurements (jitter and shimmer), harmonics to noise ratio, and maximum phonation time. Ratings by a panel of voice experts also showed each voice to be statistically significantly improved after the procedure. No complications were noted.

Conclusion  A combination of autologous fascia lata and fat injected into the vocal fold for unilateral vocal fold paralysis is a safe and effective therapy.

Design  Microscopic measurement of anatomical landmarks in cadaver sagittal head sections.

Setting  The anatomy department of a large university hospital.

Participants  Twenty adult cadaver sagittal head sections (12 right and 8 left) fixed with 10% formaldehyde solution were evaluated.

Intervention  During endoscopic dissections, the maxillary line, lacrimomaxillary suture, nasolacrimal duct, and lacrimal sac were exposed.

Main Outcome Measures  Greater knowledge of the relationship among anatomical structures.

Results  The entire lacrimal sac was in 2 of 20 sides anterior and in 3 of 20 sides posterior to the axilla of the middle nasal concha. The fornix of the lacrimal sac was situated above the axilla in all sides. We evaluated the localization of the lacrimal sac to the maxillary line, which is of clinical importance in intranasal osteotomy during dacryocystorhinostomy. In 17 of 20 sides it is possible to reveal the axilla of the middle nasal concha during osteotomy.

Conclusions  Underexposure or lack of true localization of the sac are the most frequently encountered reasons for dacryocystorhinostomy failure. The maxillary line and adhesion point of the middle nasal concha are the 2 most important landmarks in localization of the sac. A mucosal incision anterior to the maxillary line and dissection up to the point where the middle concha adheres, followed by osteotomy on the lacrimomaxillary suture, nearly always ensure the exposure of the sac.

Design  A controlled, prospective study.

Setting  A tertiary academic institution.

Patients  Normal sinus mucosa was obtained from the ethmoid sinus during surgery in 30 patients with blowout fractures. Inflammatory sinus mucosa was obtained from 30 patients undergoing endoscopic sinus surgery for chronic polypoid sinusitis.

Interventions  Reverse transcription–polymerase chain reaction, immunohistochemical analysis, and Western blotting.

Main Outcome Measures  Expression levels and distribution patterns of elafin and cystatin C in normal and inflammatory mucosa.

Results  Expression of elafin and cystatin C messenger RNAs and proteins analyzed by means of reverse transcription–polymerase chain reaction and Western blot was detected in all normal and inflammatory sinus mucosa tested. Their expression levels were increased in inflammatory vs normal mucosa. Elafin in normal and inflammatory sinus mucosa was distinctly expressed in goblet cells, which are increased in inflammatory sinus mucosa. Elafin in submucosal glands was usually weak in staining intensity, except for a few scattered submucosal glands showing moderate intensity in inflammatory sinus mucosa. Cystatin C was also localized in goblet cells and submucosal glands in normal and inflammatory mucosa. Staining intensity was increased more in inflammatory vs normal sinus mucosa.

Conclusion  Elafin and cystatin C may play an important role in the protection of normal sinus mucosa and further in regulation of the inflammatory condition in chronic sinusitis.

Design  Prospective case series.

Setting  Tertiary care teaching hospital.

Patients  Twenty-four patients with vocal fold polyp treated between March 1 and December 31, 2007.

Interventions  Percutaneous corticosteroid injection performed with the patient under topical anesthesia. Stroboscopic examination was carried out to evaluate the postoperative response.

Main Outcome Measures  The Grade of the Severity of Dysphonia, Roughness, Breathiness, Asthenicity, and Strain (GRBAS) scale and the Voice Handicap Index were used for subjective assessments. Phonatory results including maximum phonation time, mean flow rate, jitter, shimmer, and noise to harmonic ratio were also collected for objective evaluations.

Results  The surgery was completed smoothly in 22 of the 24 patients, typically within 20 minutes. No complications were noted. The overall response rate by stroboscopy was 91% (20 of 22 patients) and complete remission rate was 59% (13 of 22). A significant improvement was noted between preoperative and postoperative results on the GRBAS scale (P < .001, P < .001, P = .003, P = .001, and P = .002, respectively, for the 5 measures). Mean Voice Handicap Index (P = .001), maximum phonation time (P = .02), jitter (P = .006), shimmer (P = .001), and noise to harmonic ratio (P = .01) also improved significantly after percutaneous corticosteroid injection.

Conclusions  Percutaneous corticosteroid injection can be used to manage vocal fold polyps with low invasiveness and minimal morbidity. It offers a simple and cost-effective alternative to traditional direct microlaryngoscopic procedures.

Design  Retrospective case series.

Setting  Two tertiary care institutions.

Patients  All patients undergoing transnasal balloon dilation of the esophagus.

Main Outcome Measure  Complications.

Results  Fifty-four transnasal esophageal balloon dilations were performed in 38 patients. The mean age of the cohort was 65 years (range, 13-88 years). Twenty-nine patients were male (76%). Twenty procedures were performed using only topical anesthesia in the office setting. Seven patients (18%) were postlaryngectomy, and 15 patients (39%) had a history of head and neck radiation therapy. The upper esophageal sphincter (UES) was the most frequent dilation site (63%), followed by proximal/mid esophagus (26%), lower esophageal sphincter (LES) (7.4%), and both the UES and LES (3.7%). Indications included cricopharyngeal dysfunction, benign stricture, web, and Schatzki ring. Two procedures (3.7%) were aborted secondary to self-limited laryngospasm or gagging. There were no clinically significant complications.

Conclusions  Transnasal esophageal balloon dilation can be performed in unsedated or sedated patients with a very low complication rate. The procedure is well tolerated in 96% of patients. This technique, formerly available only through larger caliber oral gastroscopes and under sedation, allows for office-based esophageal balloon dilation in an otolaryngology practice.

Design  Prospective trial.

Setting  A National Cancer Institute–designated cancer institute.

Patients  Patients with primary or recurrent moderate to severe oral or laryngeal dysplasia, CIS, or T1N0 carcinoma.

Intervention  Porfimer sodium, 2 mg/kg of body weight, was injected intravenously 48 hours before treatment. Light at 630 nm for photosensitizer activation was delivered from an argon laser or diode laser using lens or cylindrical diffuser fibers. The light dose was 50 J/cm² for dysplasia and CIS and 75 J/cm² for carcinoma.

Main Outcome Measures  Response was evaluated at 1 week and at 1 month and then at 3-month intervals thereafter. Response options were complete (CR), partial (PR), and no (NR) response. Posttreatment biopsies were performed in all patients with persistent and recurrent visible lesions.

Results  Thirty patients were enrolled, and 26 were evaluable. Mean follow-up was 15 months (range, 7-52 months). Twenty-four patients had a CR, 1 had a PR, and 1 had NR. Three patients with oral dysplasia with an initial CR experienced recurrence in the treatment field. All the patients with NR, a PR, or recurrence after an initial CR underwent salvage treatment. Temporary morbidities included edema, pain, hoarseness, and skin phototoxicity.

Conclusion  Photodynamic therapy with porfimer sodium is an effective treatment alternative, with no permanent sequelae, for oral and laryngeal dysplasia and early carcinoma.

Trial Registration  clinicaltrials.gov Identifier: NCT00530088

Design  Prospective, observational study.

Setting  Tertiary care institution.

Patients  A total of 339 patients with head and neck carcinomas who participated in the Department of Otolaryngology's Outcomes Assessment Project between February 28, 1998, and November 30, 2001. Of 355 patients enrolled during this period, 7 were omitted from the study because they presented with persistent disease and 9 were omitted owing to a lack of valid pain data. Data on health-related quality of life were collected from the remaining patients at diagnosis and then at 3, 6, 9, and 12 months after diagnosis.

Intervention  Administration of surveys and questionnaires.

Main Outcome Measures  The relationship of self-reported pain level with health-related quality of life during the first year, recurrence status, and 5-year disease-specific survivorship was determined through univariate and multivariate analyses.

Results  Pain was associated with age, general physical and mental health conditions, depressive symptoms, survival rate, and recurrence within the first year. The 5-year survival rate was 81.8% for patients with low posttreatment pain and 65.1% for those with high pain. Posttreatment pain and tumor site were independent predictors of recurrence. Pain level, age, and treatment modality were independent predictors of 5-year survival.

Conclusion  Because of its association with recurrence and survival, pain within the first year of treatment for head and neck cancer is an important symptom that should be appropriately monitored and managed during routine follow-up.

Design  A single-institution retrospective study.

Setting  Tertiary care cancer center.

Patients  The study included 64 patients with melanoma neck node metastasis who were treated with neck dissection between 1989 and 2004 in The Netherlands Cancer Institute, Amsterdam. Twenty-four patients were treated with surgery only (15 modified radical neck dissections [MRNDs] and 9 selective neck dissections [SNDs]) (S group), and 40 patients underwent surgery (28 MRNDs and 12 SNDs) and adjuvant radiotherapy (S+RT group).

Results  Prognostic factors, ie, number of nodes, size of nodes, and extracapsular extension, were worse in the S+RT group. With a median follow-up of 2.5 years, the 2-year ipsilateral regional recurrence (RR) rate was 18% in the S+RT group and 46% in the S group. This 28% difference in RR was not statistically significant (P = .16). However, evaluation of the effect of adjuvant RT in multivariate analysis revealed a significant reduction of the RR rate after correction for the number of involved nodes (P = .04). In the S group, SND was associated with a trend toward worse RR rate compared with MRND but was not statistically significant in univariate analysis (P = .08). The type of neck dissection did not influence the RR rate in the S+RT group (P = .60). Three of the 4 RRs occurred outside the dissected volume after SND in the S group.

Conclusions  Based on our findings, we conclude that, compared with extended neck dissection, SND leads to inferior regional control in patients with melanoma neck node metastasis who are not treated with RT, even those with low-risk neck disease. Furthermore, our results suggest that adjuvant RT improves regional control in patients with 2 or more involved nodes.

Design  Retrospective medical record review.

Setting  Academic tertiary care hospital.

Patients  The study population comprised 45 patients who underwent a major pharyngeal resection with or without a partial laryngeal resection (2 patients died perioperatively, leaving 43 to evaluate). The majority (n = 35 [81%]) had advanced (T3 or T4) primary tumors at presentation and underwent subsequent reconstruction using free tissue transfer at a tertiary care hospital.

Main Outcome Measures  The rate of functional larynx preservation, best swallow score based on the Functional Outcome Swallowing Scale, and need for tracheostomy. Thirteen independent variables relevant to function and 6 postoperative outcome variables were studied following treatment, and their correlation with laryngeal function was determined.

Results  Of the 43 patients, 35 (81%) had T3 (n = 9) or T4 (n = 26) squamous cell carcinoma at presentation. There was 100% flap survival. Thirty-one patients (72%) tolerated an oral diet, with 24 (56%) achieving an exclusively oral diet. Only a history of gastroesophageal reflux disease had a statistically significant correlation with poor swallowing; having had a cranial nerve removed did not achieve statistical significance (P = .06). The majority of patients had their best swallow by 10 months. Of the 43 patients, 42 (97%) achieved native laryngeal speech and 36 (84%) were decannulated. The need for a tracheostomy did not correlate with any of the preoperative independent variables.

Conclusions  Free tissue transfer allows for successful reconstruction of complex pharyngeal defects that functionally threaten the remaining larynx. In properly selected patients, functional laryngeal preservation, decannulation, and use of laryngeal speech can be reliably achieved. Excellent swallowing function can less reliably be predicted.

Design  Prospective analysis of plasma OPN levels, before and within 12 weeks after treatment, in a cohort of patients with HNSCC undergoing platinum-based chemoradiotherapy at our center.

Setting  Academic center.

Patients  Sixty-nine patients diagnosed as having HNSCC.

Interventions  Plasma levels of OPN were assessed before the start and after the conclusion of chemoradiotherapy by using an enzyme-linked immunosorbency assay kit. Chemoradiotherapy was exclusive (n = 52) or adjuvant to surgery (n = 17).

Main Outcome Measures  Levels of OPN were correlated with clinicopathological characteristics, response to treatment, and overall survival.

Results  Pretreatment plasma OPN levels were higher in patients with advanced T and N stages compared with patients with early stages (P = .009 and .07, respectively). Mean (SD) plasma levels of OPN measured before (102.5 [68.1] ng/mL) and after (104.0 [53.6] ng/mL) treatment did not differ (P = .18, paired t test). Pretreatment and posttreatment levels of OPN were lower in patients who achieved a complete response compared with those who failed to respond (75.0 [41.5] vs 131.2 [82.9] ng/mL [P = .005] and 86.8 [40.5] vs 141.6 [58.4] ng/mL [P = .004], respectively). Patients with high pretreatment OPN levels (>82.1 ng/mL) had shorter survival time (P < .001). Posttreatment OPN levels were marginally (P = .10) associated with survival time in univariate analysis.

Conclusions  In patients with HNSCC undergoing chemoradiotherapy, a low pretreatment plasma OPN level is associated with treatment response and better survival. Modulation of OPN levels by chemoradiotherapy may also be associated with outcome. Further studies with serial measurement of OPN levels are warranted in these patients.

Design  Retrospective study of surgical samples.

Setting  Head and Neck Surgery and Endocrinology Departments, Universidade de São Paulo Medical School Hospital.

Patients  Surgical specimens from 33 patients who had been observed for a mean of 76.8 months (range, 4-201 months) were immunohistochemically stained for MMP-2 and TIMP-2. Only patients whose clinical and pathologic data were complete and whose specimens were preserved were included in the study.

Main Outcome Measures  The ratio between the expressions of MMP-2 and TIMP-2 was based on a staining index (immunostaining extent and intensity) of each of the markers.

Results  Proportionally large expressions of TIMP-2 over MMP-2 correlated with low occurrences of positive findings on initial cervical examination for the presence of thyroid nodules and/or lymphadenopathy (P = .02) and cervical lymph node metastases (P < .001), conditions correlated with prognosis. A correlation with cure at the end of follow-up (P = .01) was also observed. (P< .05 was considered statistically significant.)

Conclusion  The ratio of MMP-2 to TIMP-2 expression is an additional and novel prognostic predictor of the outcome of medullary carcinoma treated surgically.