Background: Subcutaneous cervical emphysema is a clinical sign associated with many conditions, including laryngotracheal trauma, pneumothorax and necrotizing deep tissue infections. Case presentation: We discuss a case of a 76-year-old man presenting with extensive cervical emphysema a few hours after a minor dental filling procedure. The CT-scan revealed a significant amount of air within the cervical and mediastinal spaces, reaching lobar bronchi. Vitals were within normal values Bloodwork demonstrated an elevation of creatinine kinase (3718; normal < 150) and mild leukocytosis (WBC = 11.6). We decided to proceed to an urgent cervical exploration to exclude necrotizing fasciitis. This revealed air but no tissue necrosis nor abnormal fluid. The patient improved clinically and was discharged two days later with oral antibiotics. Although cervicofacial subcutaneous emphysema following dental procedures has been reported, it is usually less extensive and involving more invasive procedures using air-driven handpieces. Conclusion: As an otolaryngologist confronted with extensive subcutaneous emphysema following a potential entry route for an aggressive infection, given the seriousness of this diagnosis, the decision of whether or not to perform a diagnostic surgical exploration should remain.
BackgroundTo date, no single molecular marker has been demonstrated as clinically useful in differentiating malignant from benign thyroid nodules when a fine needle aspiration falls in the “unknown significance” categories of the Bethesda Classification. PACE4, a member of the proprotein convertase family of enzymes, has been shown to play a major role in the pathogenesis of prostate cancer, through the formation of an oncogenic isoform named PACE4-altCT. PACE4 isoforms have also been suggested to play a role in other cancers, including thyroid cancer, but have never been investigated in a detailed manner. Our objective is to compare the histochemical distribution of the two major PACE4 isoforms in benign and malignant thyroid nodules, in order to determine their potential usefulness as discriminatory biomarkers.MethodsThyroid tissues of patients who underwent thyroidectomy were classified according to final pathology. Corresponding tissue sections were immunostained, using two previously validated antibodies raised against the C-terminal end of the two PACE4 isoforms, namely the full-length PACE4 protein (PACE4-FL) and its alternative isoform (PACE4-altCT). Nodules were compared with adjacent normal parenchyma and immunostaining was rated as “low” or “high” by a head and neck pathologist.ResultsNon-lesional thyroid parenchyma did not express PACE4-FL (p = 0.002). As a group, malignant (n = 17) nodules expressed PACE4-FL significantly more than benign (n = 24) nodules (percentage of high immunostaining: 52.9% vs 4.2%; p = 0.001). Reciprocally, there was a statistically lower expression of PACE4-altCT in malignant nodules than in adjacent non-lesional parenchyma (p = 0.014). The specificity of a high PACE4-FL immunostaining in determining malignancy was 95.8% (95% CI, 78.9% to 99.9%).ConclusionThis study supports the previously described relationship between PACE4-FL and PACE4-altCT through alternative splicing. It also suggests that PACE4-FL is a promising biomarker for thyroid malignancy. Its high specific expression for malignancy could make it an interesting “rule in” test for thyroid cancer. Further prospective, quantitative studies are currently being designed to address how measurements of PACE4 isoforms could be used in a clinical setting.Trial registrationThis study does not report the results of a health care intervention on human participants. It was nonetheless registered on ClinicalTrials.gov under reference number NCT03160482.Electronic supplementary materialThe online version of this article (10.1186/s40463-018-0311-x) contains supplementary material, which is available to authorized users.
Background: Post-operative radiotherapy (PORT) volumes and dose to target structures likely influence swallowing function and quality of life following transoral robotic surgery (TORS). The aim of this study is to analyse disease control and swallowing outcomes in patients undergoing TORS for oropharyngeal squamous cell carcinoma (OPSCC) to determine the impact of omitting the primary site from the PORT treatment volume. Methods: Prospectively collected data from patients that underwent TORS between March 2013 and April 2021 were reviewed. Patients were categorized into three groups: (1) no PORT, (2) PORT to the neck alone or (3) PORT to the primary site and neck. Survival curves were generated according to the Kaplan-Meier method and swallowing was assessed using the Functional Oral Intake Scale, Public Status Scale Head and Neck, MD Anderson Dysphagia Inventory and feeding tube/gastrostomy dependence. Results: A total of 121 patients underwent TORS, of which 103 met inclusion criteria with a median follow up of 2.6 years. No patients developed local recurrence. The 3-year regional control rates were 90%, 100% and 100% for groups 1, 2 and 3, respectively. Disease-specific survival was 97% over the study period. Patients that received PORT to both the primary site and the neck (group 3) had worse swallowing outcomes at 12 months. Conclusion: Following TORS for OPSCC, avoiding PORT to the primary site, in appropriately selected patients, appears to be oncologically safe and is associated with superior swallowing outcomes.
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