The Prognosis of Skip Metastasis in Papillary Thyroid Microcarcinoma Is Better Than That of Continuous Metastasis

CONTEXT

A few papillary thyroid microcarcinomas (PTMCs) may have skip metastasis (SLNM), but the risk factors remain controversial and the prognosis is unclear.

OBJECTIVES

To investigate the incidence, lymph node metastasis (LNM) patterns, risk factors, and prognosis of SLNM in PTMCs.

METHODS

We reviewed the medical records of PTMC patients who underwent thyroid surgery in our institution. Analyses of risk factors were performed for SLNM. Recurrence-free survival (RFS) of SLNM, central lymph node metastasis (CLNM), and continuous metastasis (CLNM and lateral lymph node metastasis [CLNM + LLNM]) were compared after propensity score matching (PSM).

RESULTS

SLNM was detected in 1.7% (50/3923) and frequently involved level III (66.7%). Compared with CLNM + LLNM, SLNM had more LNM at a single level (P < 0.01) and less LNM at 2 levels (P < 0.05). A tumor size of 0.5 to 1 cm (odds ratio [OR], 2.26; 95% CI, 1.27-4.00) and location in the upper pole (OR, 3.30; 95% CI, 2.02-5.40) were independent risk factors for SLNM. A total of 910 (23.2%) PTMCs with LNM were included in the prognostic analysis. At a median follow-up of 60 months, the RFS of SLNM did not differ from that of CLNM (P = 0.10) but was significantly higher than that of CLNM + LLNM (P < 0.01) after using PSM.

CONCLUSIONS

When the tumor size is 0.5 to 1 cm or its location is in the upper pole, we must remain vigilant to SLNM in PTMC. Because its prognosis is comparable to that of only CLNM and better than that of CLNM + LLNM, less intensive treatment should be considered.

Long-term outcomes and prognostic factors in papillary thyroid microcarcinoma patients with distant metastases

PURPOSES

Distant metastasis from papillary thyroid microcarcinoma (PTMC) is extremely rare and the long-term outcomes and independent prognostic factors remain unclear. The present study aimed to investigate clinicopathological characteristics and evaluate the long-term outcomes and prognostic factors of PTMC patients with distant metastases (DM) who underwent surgery and radioactive iodine (¹³¹I) treatment.

METHODS

We retrospectively reviewed the medical records of 13,441 patients with thyroid cancer (including 1697 cases with PTMC) who underwent ¹³¹I treatment at our institution between January 2008 and December 2019. PTMC patients with distant metastases with sufficient clinical follow-up data were enrolled in this cohort study. The overall survival (OS) and progression-free survival (PFS) were analyzed by the Kaplan-Meier method and the prognostic factors were assessed by Cox proportional hazards.

RESULTS

Thirty-three PTMC patients with DM were enrolled in this study. The median follow-up was 75 months (range: 5-151 months). The 5-year and 10-year OS rates were 96.97 and 81.41%, respectively, and the 5-year and 10-year PFS rates were 90.46 and 69.68%, respectively. Multivariate analysis showed that male sex (P = 0.005), radioactive iodine refractory PTMC (P = 0.033), and symptomatic DM (P = 0.022) were significantly associated with worse 10-year PFS in PTMC patients with DM. No independent predictor related to poor 10-year OS was found in the present study.

CONCLUSIONS

The prognosis of PTMC patients becomes worse after the development of DM. Male sex, radioactive iodine refractory PTMC, and symptomatic DM were identified as independent factors associated with PFS.

Overexpression of Tbx3 is correlated with Epithelial-Mesenchymal Transition phenotype and predicts poor prognosis of colorectal cancer

AIMS

To investigate the clinical significance of Tbx3 in colorectal cancer (CRC) and the possible association between Tbx3 expression and Epithelial- Transition Mesenchymal (EMT) phenotype.

METHODS

Quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) and western blotting were employed to evaluate the expression of Tbx3 in 30 fresh CRC and matched normal tissues. Using immunochemistry, protein level of Tbx3 and EMT markers (E-cadherin and N-cadherin) were identified in 150 pairs of paraffin-embedded specimen.

RESULTS

The results of qRT-PCR and western blotting showed that Tbx3 expression was higher in CRC tissues than in corresponding normal tissues. The statistical analysis based on immunohistochemical evaluation suggested that Tbx3 aberrant expression was significantly associated with tumor size (P=0.049), differentiation (P=0.032), invasion (P=0.019), lymph node metastasis (P=0.049) and TNM stage (P=0.018). Patients who displayed high expression of Tbx3 may achieve a poorer overall survival (OS) and disease-free survival (DFS), compared to those with low expression of Tbx3. This tendency was also observed in patients with intermediate levels of disease (II and III stage). The multivariate analysis indicated Tbx3 expression could independently predict the outcome of CRC patients. Interestingly, correlation analysis suggested Tbx3 expression was negatively correlated with E-cadherin expression, but positively correlated with N-cadherin expression.

CONCLUSION

Tbx3 may promote CRC progression by involving EMT program and has the potential to be an effective prognostic predictor for CRC patients.

Critical evaluation of neurolaryngological disorders

Otolaryngological examinations, videostroboscopic image analysis, and laryngeal electromyography were used as a test battery for a critical evaluation in 80 patients. Vocal fold movements were categorized into mobility, restricted mobility, immobility with different positions, and overactive movement. Laryngeal electromyographic examinations were conducted in all patients, and the results were classified into normal, neuropathic, and myopathic patterns. The electromyographic data were integrated with videostroboscopic findings, interpreted with knowledge of biomechanical and electrophysiological mechanisms of the larynx, and correlated clinically with underlying diseases. It is suggested that neurolaryngological procedures are most clinically useful when dictated by a decision-making algorithm.

Laryngeal reflexomyographic responses in rabbits: a neurolaryngological study of glottal movement

The role of the laryngeal reflex in glottal movement has been reported, but its mechanism remains unclear. To further investigate the neurophysiological characteristics of glottal movement, we recorded the laryngeal reflexomyographic responses (LRMRs) to electrical stimulation of the superior laryngeal nerve (SLN) in rabbits. The procedure involved simultaneous recording of the LRMRs from the thyroarytenoid muscles by means of bipolar hooked wire electrodes after electrical stimulation to the SLN. The results demonstrated characteristic patterns of the responses, consisting of R1 and R2, similar to those found in humans. The R1 response was obtained with a latency of 10.7 +/- 0.78 ms. The ipsilateral R2 response was obtained with a latency of 43.76 +/- 4.67 ms in all rabbits, and the contralateral R2 response with a latency from 42.6 to 50.2 ms in 4 rabbits. It was concluded that LRMRs may serve as a potential central laryngeal function test in the investigation of glottal movement control.

Critical evaluation of deafness

OBJECTIVE

The purpose of this study is to investigate the clinical aspects of profound hearing loss (PHL) and their significance for defining deafness.

METHODS

The audiological data were reviewed from 3660 patients who were evaluated in the Otolaryngology Clinic at Louisiana State University in Shreveport, LA, over a 5-year period. The medical charts from the patients were also reviewed for the information of medical diagnosis, surgical records and radiological findings.

RESULTS

There were 34 patients identified with bilateral PHL or deaf, 177 patients with unilateral PHL and 123 patients with borderline PHL. Congenital hearing loss and unknown-cause hearing loss in this series were predominant with 267 cases (79.9%). A surgical management was indicated in 39 cases (11.7%) including middle ear infection, ossicular chain abnormalities and auditory nerve/brainstem tumors.

CONCLUSION

This study suggests that audiometrically PHL should be thoroughly evaluated to detect reversible or remediable conditions by surgical and medical approaches. The diagnosis of deafness should be confirmed by an integration of the audiological data and medical documents including surgical and radiological findings. Aural rehabilitation program should be designed for deaf patients with varied etiology and degree of residual peripheral hearing sensitivity following medical clearance.

Neurotologic evaluation of facial nerve paralysis caused by gunshot wounds

Facial nerve injury is one of the most common neurotologic sequelae of a gunshot wound (GSW) to the head or neck. However, few neurotologic studies have been performed on the nature and time course of such facial nerve impairments. This study was designed to characterize the neurotologic manifestations and time course of facial nerve paralysis caused by GSWs to the head and neck. We conducted a battery of electrodiagnostic tests on 10 patients who had experienced traumatic facial paralysis due to a GSW to the head or neck. The etiologies of facial nerve paralysis--including direct injury, compression, fracture, and concussion of the temporal bone--were demonstrated by audiologic, radiologic, and surgical findings. Hearing loss and other cranial nerve injuries were also seen. Six of the 10 patients experienced a complete paralysis of the facial nerve and a poor recovery of its function. We also present a comprehensive case report on 1 patient as a means of discussing the evaluation of facial nerve function during the course of management.

Clinical interpretations of transient otoacoustic emissions

PURPOSE

The purpose of this study was to characterize the relation of different ordinal patterns of transient otoacoustic emissions (TEOAES) with respect to underlying otologic disorders and auditory status.

PATIENTS AND METHODS

The results of TEOAEs in 225 patients with various auditory disorders were investigated and compared with normative data established from 90 subjects of various ages. TEOAEs were categorized according to four patterns: (1) normal (general response level within 90% of normative data, (2) reduced amplitude (general response level was > or =2 dB peak sound pressure level (pSPL), but less than the mean -1.64 SD of the normative data), (3) abnormal morphology of frequency spectrum (general response level was within normal limits, but reduced at > or =2 individual octave frequencies between 1,000 and 5,000 Hz), and (4) total absence (response level <2 dB pSPL).

RESULTS

This study showed that the normal pattern of TEOAEs, in terms of response amplitude, varied with age. Our results further indicated that a reduced amplitude pattern of TEOAEs was noted in patients with a mild sensorineural hearing loss (SNHL), negative tympanometric pressure, a pressure-equalization tube, and Meniere's disease. TEOAEs provided good frequency-specific information for patients with a noise-induced hearing loss. All patients with ossicular chain abnormalities, more than moderate SNHL, and a middle ear mass or effusion had total absence of TEOAEs. Patients with acoustic neuroma and brainstem lesions presented a complex profile of TEOAEs. In the follow-up of auditory function in patients undergoing otologic surgery, different patterns of TEOAEs between the preoperative and postoperative recordings were evident, which correlated with the hearing thresholds and middle ear status. The abnormal findings of TEOAEs due to specific auditory diseases were discussed.

CONCLUSION

The interpretation of TEOAEs can be facilitated through an analysis of specific patterns and in combination with other audiologic tests.

Current evaluation of pseudohypacusis: strategies and classification

Some cases of pseudohypacusis may involve medicolegal aspects and require a confirmed and quantitative diagnosis. These challenging cases must be identified, and then evaluated with basic audiologic and sophisticated electrophysiologic tests. Data on 64 patients with pseudohypacusis collected over a 4-year period are reported. A classification system was developed from an analysis of these cases and is presented for clinical evaluation and diagnosis. In many cases, conventional audiologic evaluation involving pure tone and speech audiometry may be adequate and sufficient for diagnosis. In more complex cases, evoked otoacoustic emissions (EOAEs) and auditory brain stem responses (ABRs) are needed for confirmation of peripheral auditory sensitivity. We found that EOAEs were the most rapid economical, and objective method, and confirmed the diagnosis of hearing loss in 78.1% of cases. Fifteen percent of subjects required ABRs to substantiate the diagnosis. The reliability of basic audiologic tests based on previous clinical investigations and data from the literature are discussed. We conclude that a thorough knowledge and understanding of pseudohypacusis is essential to verify the existence of pseudohypacusis, to determine its type, and to quantify the auditory thresholds.

Characterization of acoustic reflex latency in normal-hearing subjects

Acoustic reflex latency (ARL) has been suggested as an indicator in otoneurological diagnosis. However, limited normative data are available. Conflicting evidence exists regarding the effect of stimulus parameters such as frequency on ARL. In addition, there has been little research investigating the effects of ipsilateral and contralateral stimulation on ARL. In view of these problems, ARL was measured in 30 normal-hearing subjects using 500, 1000, 2000, 4000 Hz tones, low-pass noise, high-pass noise, broadband noise and clicks as activating stimuli. Six parameters of ARL: 10%-on latency, 90%-on latency, 10%-off latency, 90%-off latency, rise time and fall time, were recorded using computerized equipment and analyzed in correlation to the activating frequency and intensity. This study indicated that 500 Hz, 1000 Hz tones, and band noise were more effective in eliciting measurable ARL, whereas 4000 Hz tone and click produced a low percentage of measurable ARL. ARL was shown to increase as the stimulus frequency increased and stimulus intensity decreased. No statistically significant differences were found between the ipsilateral ARL and contralateral ARL.

Audiologic manifestations of Noonan syndrome

A comprehensive audiologic study of a family with Noonan syndrome is reported together with a review of 20 cases of this syndrome with regard to hearing sensitivity and middle ear status. An incidence of progressive sensorineural hearing loss at the high frequencies is found for 50% of the ears. It is emphasized that early audiologic management may improve the quality of life for patients with Noonan syndrome.

Audiologic Manifestations of Noonan Syndrome

A comprehensive audiologic study of a family with Noonan syndrome is reported together with a review of 20 cases of this syndrome with regard to hearing sensitivity and middle ear status. An incidence of progressive sensorineural hearing loss at the high frequencies is found for 50% of the ears. It is emphasized that early audiologic management may improve the quality of life for patients with Noonan syndrome.

Laryngeal evoked brainstem responses in humans: a preliminary study

Laryngeal evoked brainstem responses (LBRs) were recorded in normal human subjects in an attempt to develop a central laryngeal function test and enhance our understanding of neurolaryngologic disorders. The results showed that the human LBR consists of five positive peaks and five negative peaks reproducible within 10 ms after a vibratory stimulation to the superior laryngeal nerve (SLN). The waveform reproducibility was verified by blocking the SLN and topically anesthetizing the hypopharyngeal cavity. The morphology and latency of peak 5 were similar to results obtained in animal LBR experiments. It was concluded that a vibratory stimulation to the SLN was a noninvasive method to elicit far-field potentials from the central laryngeal pathway. These findings encourage further effort to establish normative data and explore clinical correlations.

Neurophysiological evaluation of acute facial paralysis in children

Objective evaluation of facial nerve paralysis represents a unique challenge to the clinician. Electroneurography (ENoG) and the acoustic reflex (AR) have been widely used as neurophysiological tests in an assessment of facial nerve function. However, ENoG or AR alone does not suffice diagnostic and prognostic purposes of facial function evaluation in children. To further investigate the diagnostic aspects of facial nerve paralysis, the prognostic value of AR and ENoG, and the time course of the disease in pediatric population, a series of 30 children with acute facial paralysis were investigated by correlation of findings from video-taped House-Brackmann facial grading system. AR and ENoG. The results showed that AR was absent or abnormal for thresholds in 68.2% of patients with Bell's palsy and normal middle ear function. Shorter duration and higher percentage of recovery were found in the children with a normal AR than those with an abnormal AR. Three children showed an abnormal tympanogram and hearing loss associated with acute facial paralysis. These findings should alert the clinician to the presence of a specific, treatable disease in the evaluation of Bell's palsy. The percentage of electroneurographic response varied with different days after onset. ENoG showed minimal responses at weeks 1 3 after onset of Bell's palsy in most patients. The study of the time-course in the children with Bell's palsy demonstrated a functional gap in the early (< 1 week) and late clinical stage (after 6 weeks) of the disease, suggesting that ENoG predicted well only during weeks 1-4 after onset. In general, ENoG showed a good recovery in children, however, recurrent Bell's palsy becomes a concern. The need for neurophysiological follow-up for possible incomplete recovery of the facial nerve is emphasized. It is recommended that AR and ENoG should be included in the diagnostic workup when evaluating pediatric facial function.

Audiological findings in glomus tumours

Glomus tumours involving the middle ear and the cerebellopontine angle are reported with emphasis on audiological findings. Magnetic resonance imaging (MRI), angiographic and pathological results are presented. Audiological tests, including impedance audiometry, evoked otoacoustic emissions and auditory brainstem responses, are valuable in evaluation of the effect of glomus tumours on the auditory system as well as their pathological extent.

Major patterns of laryngeal electromyography and their clinical application

Laryngeal electromyography (LEMG) is clinically valuable in the evaluation of laryngeal dysfunction and vocal fold immobility. To facilitate clinical application of this electrophysiologic test, a detailed description of modified LEMG techniques is presented. The techniques were applied for simultaneous bilateral recordings of the thyroarytenoid, cricothyroid, and posterior cricoarytenoid muscles. The basic patterns of LEMG are classified into three different types: normal, neuropathy, and myopathy. In an attempt to characterize these patterns, we have reported eight LEMG-documented cases: unilateral laryngeal paralysis, bilateral laryngeal paralysis, cricoarytenoid joint dislocation, cricoarytenoid joint ankylosis, laryngeal myopathy, pharyngeal paralysis (soft palate paralysis), spasmodic dysphonia, and unilateral laryngeal paralysis with anastomosis. The significance of the major LEMG patterns is discussed.

Effects of brain stem lesions on cochlear function: mechanism of hearing improvement after removal of a brain stem tumor

EOAEs are well correlated with changes of hearing sensitivity during the clinical course of brain stem lesions, as shown in this case study. They may serve as sensitive indicators to evaluate the possible effects of a brain stem lesion on cochlear function and monitor the attempted preservation of hearing during CPA or brain stem surgeries. It is thereby suggested that EOAEs should be included in an audiologic test battery in a differential diagnosis of retrocochlear lesions.

Time course of Bell palsy

This study was designed to quantitatively characterize the time course of facial palsy and the relationship between electroneurography and the facial nerve grading percentage as a function of onset time. Bilateral electroneurographic recordings during different stages in the course of the disease were repeated and compared with categorized videotaped facial movements using the House-Brackmann facial nerve grading system in 32 patients with Bell palsy. Preliminary results of this study demonstrate a time gap between the percentage of electroneurographic response and the category of the facial nerve grading system during the same period of disease progress. A theoretical model of the time course and specific patterns regarding the recovery of facial function is established. The theoretical time course of facial palsy is divided into 3 stages; preclinical, clinical, and postclinical. Based on the time course of electroneurographic and facial grading functions, the period between 10 and 14 days after onset was found to be most valuable for prediction of recovery. According to this theoretical model, a given time course pattern based on the results of serial electroneurographic recordings provides reliable prognostic information on recovery from Bell palsy.

Auditory and visual speech perception: confirmation of a modality-independent source of individual differences in speech recognition

Two experiments were run to determine whether individual differences in auditory speech-recognition abilities are significantly correlated with those for speech reading (lipreading), employing a total sample of 90 normal-hearing college students. Tests include single words and sentences, recorded on a videodisc by a male speaker [Bernstein and Eberhardt, Johns Hopkins Lipreading Corpus, The Johns Hopkins University, Baltimore, MD, 1986]. The auditory speech was presented with a white noise masker, at -7 dB Sp/N. The correlations between overall auditory and visual performance were 0.52 and 0.43 in the two experiments, consistent with the existence of a modality-independent ability to perceive linguistic "wholes" on the basis of linguistic fragments. Subjects in the second experiment also identified printed sentences, with 40%-60% portions of the printed characters deleted. Performance on this graphical "fragmented-sentences test" also correlated significantly with auditory speech recognition, providing a possible clue to the cognitive basis for the look-versus-listen correlation. The existence of a modality-independent source of variance in speech-recognition abilities may be a partial explanation of the difficulty in demonstrating strong associations between psychoacoustic measures of spectral or temporal acuity, and speech discrimination or identification. Female subjects in both experiments were significantly better lipreaders than their male counterparts.

Value of electromyography in differential diagnosis of laryngeal joint injuries after intubation

Laryngeal joint injury or arytenoid dislocation is not an uncommon complication resulting from intubation trauma, and is best evaluated by laryngeal electromyography (EMG) combined with laryngoscopic examinations. Two cases of cricoarytenoid joint injuries after intubation are reported along with laryngeal EMG findings. Early diagnosis of arytenoid dislocation is important for appropriate surgical management and better prognosis. However, the reported cases, because of delayed referrals, showed prolonged cricoarytenoid joint injuries associated with thyroarytenoid muscle denervation or myopathy, and resultant vocal fold immobility. The results of laryngeal EMG in cricoarytenoid joint injuries can be classified into three different patterns: 1) normal recruitment, 2) myopathy, and 3) denervation or reinnervation of the thyroarytenoid muscles. It is particularly valuable to sample different portions of the thyroarytenoid muscles with EMG in order to evaluate different patterns or pathologic changes of the muscles and nerve paralysis.