The Applications and Potential Developments of Ultrasound in Oral Cancer Management

Oral cancer is endemic and causes a great burden in Southern Asia. It is preferably treated by surgery with/without adjuvant radiotherapy (RT) or chemoradiation therapy, depending on the stage of the disease. Close or positive resection margin and cervical lymph node (LN) metastasis are important prognostic factors that have been presented to be related to undesirable locoregional recurrence and poor survival. Ultrasound (US) is a simple, noninvasive, time-saving, and inexpensive diagnostic modality. It can depict soft tissues very clearly without the risk of radiation exposure. Additionally, it is real-time and continuous image is demonstrated during the exam. Furthermore, the clinician can perform US-guided fine needle aspiration (FNA) or core needle biopsy (CNB) at the same time. US with/without US-guided FNA/CNB is reported to be of value in determining tumor thickness (TT), depth of invasion (DOI), and cervical LN metastasis, and in aiding the staging of oral cancer. DOI has a relevant prognostic value as reported in the eighth edition of the American Joint Committee on Cancer staging of oral cancer. In the present review, we describe the clinical applications of US in oral cancer management in different phases and potential applications in the future. In the pretreatment and surgical phase, US can be used to evaluate TT/DOI and surgical margins of oral cancer in vivo and ex vivo. The prediction of a malignant cervical LN (nodal metastasis) by the US-based prediction model can guide the necessity of FNA/CNB and elective neck dissection in clinical early-stage oral cancer. In the posttreatment surveillance phase, US with/without US-guided FNA or CNB is helpful in the detection of nodal persistence or LN recurrence, and can assess the possibility and extent of carotid artery stenosis after irradiation therapy. Both US elastography and US swallowing assessment are potentially helpful to the management of oral cancer.

Treatment Options and Voice Outcomes for Patients With Unilateral Vocal Fold Paralysis After Thyroidectomy

Objectives

This study investigated the treatment options and clinical outcomes of voice therapy (VT), hyaluronic acid (HA) injection, autologous fat injection (FI), and medialization thyroplasty (MT) in patients with unilateral vocal fold paralysis (UVFP) after thyroidectomy.

Study Design

Retrospective case series.

Setting

A tertiary teaching hospital.

Methods

This study included 51 patients with post-thyroidectomy UVFP who underwent VT (n = 20), HA injection (n = 14), FI (n = 12), or MT (n = 5) from January 2016 to June 2021. The treatment outcomes were evaluated using 10-item voice handicap index (VHI-10), maximal phonation time (MPT), and auditory perceptual rating using GRB scales (i.e., grade, roughness, and breathiness) before and 3 to 6 months after treatment.

Results

Patients received HA injection presented a significantly shorter interval after thyroidectomy (mean: 4.6 months), followed by VT (6.7 months), FI (12.3 months), and MT (22.4 months). The results exhibited improvement in most of the outcomes after all of the four treatments. Additional comparisons indicated that VHI-10 scores improved the most among patients receiving MT, followed by HA, FI, and VT. The differences of MPT and GRB scores among the 4 treatment groups were non-significant.

Conclusions

The results revealed that VT, HA, FI, and MT can all improve the voice outcomes of patients with post-thyroidectomy UVFP. The optimal treatment approach should be individualized according to the patient's preference and vocal demand, and the interval between thyroidectomy and intervention.

Point-of-care ultrasound in otolaryngology and head and neck surgery: A prospective survey study

PURPOSE

The ultrasound applications, examination facilities and methods used by otolaryngology and head and neck surgeons may vary and be different. This study was conducted to assess the methods used for head-and-neck point-of-care ultrasound (POCUS).

METHODS

This prospective survey study was conducted from 1 July 2018 to 31 December 2019. The surgeons of otolaryngology and head neck surgery who used POCUS in their daily practice were recruited for analyses.

RESULTS

In total, 30 male and 14 female surgeons who used neck POCUS were recruited. Thirty-nine (89%) surgeons placed patients in a supine position with the head toward the operator. Forty (91%) surgeons performed US-guided fine needle aspiration (FNA), and 35 (80%) surgeons did not use local anesthesia during US-FNA. Thirty-nine (88%) surgeons used the long-axis method to harvest the specimen, and forty-one (93%) used a free-hand method. Most surgeons (25, 57%) used 22G needles for US-FNA, and 29 (66%) used 18G for US-guided core-needle biopsy (CNB). For the cost analysis, reimbursements for US-related procedures were relatively cheaper than those for computer tomography (CT) and magnetic resonance imaging (MRI).

CONCLUSION

POCUS can be performed by otolaryngology and head and neck specialists with a wide scope of applications and in a cost-effective manner.

Dysequilibrium in a 5-year-old child with intrameatal vascular loops bilaterally

A 5 year-old boy was rather healthy until one month ago when loss of balance and muscle tone was noted by the parents. A battery of tests comprising electroencephalography, audiometry, caloric test and ocular vestibular evoked myogenic potential (oVEMP) test were performed, yet all tests showed normal responses. Conversely, cervical VEMP (cVEMP) test showed delayed responses bilaterally. MR imaging demonstrated bilaterally intrameatal vascular loops extending into both internal auditory canals. After a 3-month medication, delayed cVEMPs were resolved and returned to normal cVEMPs bilaterally, accompanied by subsidence of dysequilibrium.

Increased risk of depression in patients with acquired sensory hearing loss: A 12-year follow-up study

Acquired sensory hearing loss (SHL) is suggested to be associated with depression. However, some studies have reported conflicting results. Our study investigated the relationship between the prevalence of SHL and the incidence of depression over 12 years of follow-up by using data from the Taiwan National Health Insurance Research Database (NHIRD). We sought to determine the association between SHL and subsequent development of depression and discuss the pathophysiological mechanism underlying the association.Patients with SHL were identified from the NHIRD (SHL cohort). A non-SHL cohort, comprising patients without SHL frequency-matched with the SHL patients according to age group, sex, and the year of diagnosis of SHL at the ratio of 1:4, was constructed, and the incidence of depression was evaluated in both cohorts. A multivariable model was adjusted for age, sex, and comorbidity.The SHL cohort and non-SHL cohort comprised 5043 patients with SHL and 20,172 patients without SHL, respectively. The incidences density rates were 9.50 and 4.78 per 1000 person-years in the SHL cohort and non-SHL cohort, respectively. After adjustment for age, sex, and comorbidities, the risk of depression was higher in the SHL cohort than in the non-SHL cohort (hazard ratio = 1.73, 95% confidence interval = 1.49-2.00).Acquired SHL may increase the risk of subsequent depression. The results demonstrated that SHL was an independent risk factor regardless of sex, age, and comorbidities. Moreover, a strong association between hearing loss and subsequent depression among Taiwanese adults of all ages, particularly those aged ≤49 and >65 years and without using steroids for the treatment of SHL was observed. Prospective clinical and biomedical studies on the relationship between hearing loss and depression are warranted for determining the etiopathology.

Long Term Outcome of Routine Image-enhanced Endoscopy in Newly Diagnosed Head and Neck Cancer: a Prospective Study of 145 Patients

Synchronous second primary tumors (SPTs), especially esophageal squamous cell neoplasia (ESCN), in patients with head and neck squamous cell carcinoma (HNSCC) are not uncommon. Image-enhanced endoscopy (IEE) screening may identify SPTs while there is no evidence to support its benefit. We prospectively recruited an adult cohort with newly-diagnosed HNSCC for IEE screening of upper gastrointestinal (UGI) tract neoplasia. 145 HNSCC patients were recruited. 22 (15.2%) patients had synchronous UGI tract neoplasia, including 20 ESCNs and 2 gastric adenocarcinoma. At a median follow-up of 2.72 (±1.73) years, the 3-year overall survival (OS) rate was 0.71. HNSCC patients with synchronous ESCN/UGI tract neoplasia had poorer prognosis than those without (multivariate analysis, hazard ratio [HR] 2.75/2.79, 95% confidence interval [CI] 1.11~6.82/1.15~6.80, p = 0.03/0.02). HNSCC patients with advanced (stage III&IV) ESCN had worst survivals (p < 0.001). Among those with synchronous ESCNs, hypopharyngeal cancers were associated with poorer prognosis when compared with oral cancers (HR 2.36, 95% CI 1.08~5.15, p = 0.03). IEE screening for UGI SPTs in HNSCC patients could be used for risk stratification and prognosis prediction. HNSCC patients with advanced ESCN had the worst prognosis. Further studies are needed to demonstrate the survival benefits from IEE screening.

Treatment Outcomes of Injection Laryngoplasty Using Cross-Linked Porcine Collagen and Hyaluronic Acid

Objective

To investigate the treatment outcomes and prognostic factors of injection laryngoplasty (IL) using cross-linked porcine collagen (PC) and hyaluronic acid (HA) in unilateral vocal fold paralysis (UVFP).

Study Design

Case series with chart review.

Setting

A tertiary teaching hospital.

Subjects and Methods

This study reviewed 60 consecutive patients with UVFP who underwent IL with PC (n = 33) or HA (n = 27). Objective evaluations included maximal phonation time (MPT) and 10-item voice handicap index (VHI-10). Kaplan-Meier method was applied to evaluate the subjective treatment outcomes according to the patients’ self-assessment of symptom recurrence via chart review for the follow-up period of 15 months. Log-rank tests were applied to evaluate the association between clinical factors and subjective treatment outcomes.

Results

Objective outcome measurements revealed significantly improved MPT and VHI-10 at 1, 3, and 6 months posttreatment, with nonsignificant differences between the PC and HA groups. Subjective treatment outcomes also revealed a nonsignificant difference between the 2 groups. The median symptom-free durations were 10.9 and 14.4 months for the PC and HA groups, respectively. Subsequent analyses failed to identify prognostic significance of sex, time to treatment, etiology, side, injection approaches, and the presence of aspiration. No significant adverse effects occurred during the follow-up period.

Conclusion

This study demonstrated comparable subjective and objective improvements following IL using PC or HA in patients with UVFP. No significant prognostic factor of IL was discovered in the present research. Porcine collagen and HA as medium duration materials might play a role in the future of IL.

Augmentation of ocular vestibular-evoked myogenic potentials via bone-conducted vibration stimuli in Ménière disease

OBJECTIVE

The asymmetry ratio of ocular vestibular-evoked myogenic potential (oVEMP) >40% is interpreted as augmented or reduced response depending on whether the nI-pI amplitude of the lesion ear is larger or smaller than that of the opposite ear, respectively. This study compared unilateral Ménière disease patients with augmented oVEMPs vs reduced oVEMPs to elucidate the mechanism of augmented oVEMP.

STUDY DESIGN

Case series with chart review.

SETTING

University hospital.

METHODS

Forty patients with unilateral definite Ménière disease were enrolled in this study, including 20 patients with augmented oVEMPs and another 20 patients with reduced oVEMPs in the hydropic side. All patients underwent audiometry, caloric test, and oVEMP and cervical VEMP (cVEMP) tests via bone-conducted vibration stimuli. Then, the oVEMP and cVEMP test results were compared with the stage of Ménière disease, respectively.

RESULTS

The augmented group had earlier nI and pI latencies and larger nI-pI amplitude of oVEMPs compared with the reduced group. Caloric test also revealed a significant difference in abnormal responses between the augmented and reduced groups. However, both groups did not differ significantly in the abnormal percentage of cVEMP test results. A significant trend to decline in the prevalence of augmented oVEMPs was noted from stages I to III-IV but not in that of abnormal cVEMPs.

CONCLUSION

The augmented oVEMPs have earlier latencies and larger amplitudes compared with the reduced oVEMPs, indicating that a relatively larger population of intact utricular afferents is activated during the early stage of Ménière disease.

Ligands of macrophage scavenger receptor induce cytokine expression via differential modulation of protein kinase signaling pathways

Our previous works demonstrated that ligands of macrophage scavenger receptor (MSR) induce protein kinases (PKs) including protein-tyrosine kinase (PTK) and up-regulate urokinase-type plasminogen activator expression (Hsu, H. Y., Hajjar, D. P., Khan, K. M., and Falcone, D. J. (1998) J. Biol. Chem. 273, 1240--1246). To continue to investigate MSR ligand-mediated signal transductions, we focus on ligands, oxidized low density lipoprotein (OxLDL), and fucoidan induction of the cytokines tumor necrosis factor-alpha (TNF) and interleukin 1 beta (IL-1). In brief, in murine macrophages J774A.1, OxLDL and fucoidan up-regulate TNF production; additionally, fucoidan but not OxLDL induces IL-1 secretion, prointerleukin 1 (proIL-1, precursor of IL-1) protein, and proIL-1 message. Simultaneously, fucoidan stimulates activity of interleukin 1-converting enzyme. We further investigate the molecular mechanism by which ligand binding-induced PK-mediated mitogen-activated protein kinase (MAPK) in regulation of expression of proIL-1 and IL-1. Specifically, fucoidan stimulates activity of p21-activated kinase (PAK) and of the MAPKs extracellular signal-regulated kinase (ERK), c-Jun NH(2)-terminal kinase (JNK), and p38. Combined with PK inhibitors and genetic mutants of Rac1 and JNK in PK activity assays, Western blotting analyses, and IL-1 enzyme-linked immunosorbent assay, the role of individual PKs in the regulation of proIL-1/IL-1 was extensively dissected. Moreover, tyrosine phosphorylation of pp60Src as well as association between pp60Src and Hsp90 play important roles in fucoidan-induced proIL-1 expression. We are the first to establish two fucoidan-mediated signaling pathways: PTK(Src)/Rac1/PAK/JNK and PTK(Src)/Rac1/PAK/p38, but not PTK/phospholipase C-gamma 1/PKC/MEK1/ERK, playing critical roles in proIL-1/IL-1 regulation. Our current results indicate and suggest a model for MSR ligands differentially modulating specific PK signal transduction pathways, which regulate atherogenesis-related inflammatory cytokines TNF and IL-1.