eMedicine创建于1996年，由近万名临床医师作为作者或编辑参与此临床医学知识库的建设，其中编辑均是来自美国哈佛、耶鲁、斯坦福、芝加哥、德克萨斯、加州大学等各分校医学院的教授或副教授。

eMedicine

ObjectiveThyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esop...

https://journals.sagepub.com/doi/pdf/10.1177/0194599813487301

Clinical Practice Guideline: Improving Voice Outcomes after Thyroid Surgery

The widespread availability of novel primary treatment approaches against oropharyngeal cancers has provided several potentially curative surgical and nonsurgical treatment options for patients, generating both hope and controversy. As treatment is usually curative in intent, management considerations must include consideration of primary tumor and nodal disease control as well as long-term toxicities and functional outcomes. Anatomical and functional organ preservation (speech and deglutition) remains of paramount importance to patients with oropharyngeal cancer and the physicians involved in their care, accounting for the growing popularity of chemoradiotherapy and transoral surgical techniques for this indication. These novel approaches have greatly diminished the role of open surgery as initial therapy for oropharyngeal cancers. Open surgery which is often reserved for salvage on relapse, may still be an appropriate therapy for certain early stage primary lesions. The growing treatment armamentarium requires careful consideration for optimal individualized care. The identification of oncogenic human papillomavirus as a predictive and prognostic marker in patients with oropharyngeal cancer has great potential to further optimize the choice of treatment. In this review, novel primary therapies against oropharyngeal squamous cell carcinoma are presented in the context of anatomical, quality of life, and emerging biological considerations.

Current trends in initial management of oropharyngeal cancer: the declining use of open surgery.

Squamous cell carcinoma of the hypopharynx represents a distinct clinical entity. Most patients present with significant comorbidities and advanced-stage disease. The overall survival is relatively poor because of high rates of regional and distant metastasis at presentation or early in the course of the disease. A multidisciplinary approach is crucial in the overall management of these patients to achieve the best results and maintain or improve functional results. Traditionally, operable hypopharyngeal cancer has been treated by total (occasionally partial) laryngectomy and partial or circumferential pharyngectomy, followed by reconstruction and postoperative radiotherapy in most cases. Efforts to preserve speech and swallowing function in the surgical treatment of hypopharyngeal (and laryngeal) cancer have resulted in a declining use of total laryngopharyngectomy and improved reconstructive efforts, including microvascular free tissue transfer. There are many surgical, as well as nonsurgical, options available for organ and function preservation, which report equally effective tumor control and survival. The selection of appropriate treatment is of crucial importance in the achievement of optimal results for these patients. In this article, several aspects of surgical and nonsurgical approaches in the treatment of hypopharyngeal cancer are discussed. Future studies must be carefully designed within clearly defined populations and use uniform terminology and standardized functional assessment and declare appropriate patient or disease endpoints. These studies should focus on improvement of results, without increasing patient morbidity. In this respect, technical improvements in radiotherapy such as intensity-modulated radiotherapy, advances in supportive care, and incorporation of newer systemic agents such as targeted therapy, are relevant developments.

/pdf/current-trends-in-initial-management-of-hypopharyngeal-5aqgabdizf.pdf

Current trends in initial management of hypopharyngeal cancer: The declining use of open surgery

Objective:To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.Background:Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in th

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

Objectives:

Laryngeal framework surgery, including medialization laryngoplasty (ML) and arytenoid adduction (AA), are common treatments for vocal fold paralysis and glottal incompetence. Little information is known about the incidence of ML/AA surgery nationwide, in particular the success and complication rates.



Methods:

A 25-item questionnaire was mailed to 6,644 Board-certified otolaryngologists.



Results:

The response rate was 25.7% (n = 1,707). Sixty-three percent perform ML and/or AA, representing 29,748 procedures. Experience with Silastic medialization implants has decreased over time, while utilization of other materials has increased. The overall complication rate was 15%, including 0.8% implant extrusion and 6% revision rates. The most common revision was placement of a larger implant (37% of all revisions). Airway compromise requiring intervention was observed in 2.2%, and suboptimal voice outcome in 4%. Although not statistically significant, a trend was observed of decreasing complication rate with increasing experience.



Conclusions:

Laryngeal framework surgeries are being performed with increasing frequency in the United States. The overall complication rate is slightly increased in the present study, but airway compromise and poor vocal outcome are decreased, and the need for revision surgery is unchanged. These findings suggest a continued high level of efficacy of these procedures. Laryngoscope, 2010

Analysis of laryngeal framework surgery: 10-year follow-up to a national survey.

Flexible laryngoscopy, the gold-standard evaluation of the larynx and the pharynx, is one of the most commonly performed procedures in otolaryngology. During the coronavirus disease 2019 (COVID-19) pandemic, flexible laryngoscopy represents a risk for patients and an occupational hazard for otolaryngologists and any clinic staff involved with the procedure or endoscope reprocessing. Here we present a set of recommendations on flexible laryngoscopy performance during the pandemic, including patient selection, personal protective equipment, and endoscope disinfection, based on a consensus reached during a virtual webinar on March 24, 2020, attended by approximately 300 participants from the American laryngology community.

https://journals.sagepub.com/doi/pdf/10.1177/0194599820921395

Flexible Laryngoscopy and COVID-19.

Objectives/Hypothesis:
An increasing number of laryngeal procedures are performed in the office. However, little is known about how well these procedures are tolerated and what factors determine success or failure.

Study Design:
Prospectively collected patient and physician surveys from five surgeons at two institutions describe patient tolerance of awake, in-office laryngeal procedures (AIOLPs).

Methods:
There were 154 procedures performed in a 6-month period, including vocal fold injection (VFI) (72%), laser treatment (19%), and transnasal esophagoscopy (3%). Average duration of procedure was 13 ± 8 minutes.

Results:
Patients reported an average of 37 of 100 on a discomfort scale, with 0 representing no discomfort and 100 representing maximal discomfort. Ninety-three percent of patients would undergo another procedure, and 96% would recommend AIOLPs to other patients. Procedures were completed successfully in 92%. Most common surgeon-reported difficulties included copious secretions and uncontrolled gag reflex. Procedures that involved such difficulties had a significantly lower rate of procedure completion, 73% vs. 96%, P = .0001. High preprocedure anxiety did not adversely impact patient comfort or procedure completion rate. There was no difference in discomfort scores based on VFI approach or patient familiarity with AIOLPs. There was a significant difference in discomfort score between patients with successful first-approach VFI and those who required a change in VFI approach, 36.0 vs. 61.3, respectively, P = .003. The rate of requiring a second and third VFI approach was 4.6% and 2.8%, respectively.

Conclusions:
This study encompasses multiple diagnoses, procedures, VFI techniques, and methods of anesthesia. AIOLPs are exceptionally well tolerated by patients, resulting in extremely high completion and satisfaction rates.

Patient tolerance of awake, in‐office laryngeal procedures: A Multi‐Institutional Perspective

OBJECTIVES/HYPOTHESIS The Voice Handicap Index-10 (VHI-10) is commonly used to measure patients' perception of vocal handicap. Clinical consensus has previously defined clinically meaningful improvement as a decrease ≥5. This study determines the minimal clinically important difference (MCID) for VHI-10 in patients with unilateral vocal fold paralysis (UVFP) using anchor-based methodology. STUDY DESIGN Prospective cohort questionnaire analysis. METHODS Two hundred eighty-one UVFP patients completed the VHI-10 on two consecutive visits (within 3 months). At the follow-up visit, patients answered an 11-point Global Rating of Change Questionnaire (GRCQ) scored from -5 to +5. Relationship between the GRCQ and change in VHI-10 was quantified using analysis of variance, and MCID for the VHI-10 was determined using receiver operating characteristic (ROC) curve analysis. RESULTS Overall mean VHI-10 change was -3.71 (standard deviation [SD] = 8.89) and mean GRCQ was 1.37 (SD = 2.51). Average interval between measurements was 1.73 months (SD = 0.83). Mean changes in VHI-10 scores were -7.45, -0.53, and +4.40 for patients whose GRCQ scores indicated improvement, no change, and worsening, respectively. Differences between mean scores were statistically significant (P < .001). Area under the ROC curve was 0.80, demonstrating the classification accuracy of VHI-10 change scores. A VHI-10 change of -4 was determined to be the optimal threshold that discriminated between improvement and no improvement (sensitivity and specificity 0.62 and 0.88, respectively). CONCLUSIONS The MCID for improvement in VHI-10 in UVFP patients is a decrease of 4. This information improves understanding of patients' response to treatment and allows comparison between different treatments. Future research should determine MCID for VHI-10 across all voice disorders. LEVEL OF EVIDENCE 4. Laryngoscope, 128:1419-1424, 2018.

Minimal clinically important difference of voice handicap index-10 in vocal fold paralysis

The terms used to describe vocal fold motion impairment are confusing and not standardized. This results in a failure to communicate accurately and to major limitations of interpreting research studies involving vocal fold impairment. We propose standard nomenclature for reporting vocal fold impairment. Overarching terms of vocal fold immobility and hypomobility are rigorously defined. This includes assessment techniques and inclusion and exclusion criteria for determining vocal fold immobility and hypomobility. In addition, criteria for use of the following terms have been outlined in detail: vocal fold paralysis, vocal fold paresis, vocal fold immobility/hypomobility associated with mechanical impairment of the crico-arytenoid joint and vocal fold immobility/hypomobility related to laryngeal malignant disease. This represents the first rigorously defined vocal fold motion impairment nomenclature system. This provides detailed definitions to the terms vocal fold paralysis and vocal fold paresis.

/pdf/nomenclature-proposal-to-describe-vocal-fold-motion-585tmy57g0.pdf

VyVy N. Young

Papers

Analysis of laryngeal framework surgery: 10-year follow-up to a national survey.

Flexible Laryngoscopy and COVID-19.

Patient tolerance of awake, in‐office laryngeal procedures: A Multi‐Institutional Perspective

Minimal clinically important difference of voice handicap index-10 in vocal fold paralysis

Nomenclature proposal to describe vocal fold motion impairment