Spindle epithelial tumor with thymus-like elements (SETTLE) is a rare and morphologically unique biphasic pediatric thyroid tumor of low malignant potential. There are less than 50 cases reported in the literature and few reported metastases. Despite the common usage of needle aspiration for thyroid and lymph node evaluation, cytologic descriptions of SETTLE are rare and tend to focus on a hypercellular biphasic appearance. We report aspirate findings of early cystic lymph node metastases in a 14-year-old girl, showing abundant matrix and low cellularity. We propose that the lack of recognition of this abundant matrix and cystic ultrasound appearance (as well as rarity of this tumor) may account for the low number of cytologic descriptions in the literature. Improved recognition may lead to increased usefulness of aspiration in the diagnosis and follow-up of SETTLE. Laryngoscope, 128:E78-E82, 2018.

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Three female patients were initially given conservative ODDI. Two other patients underwent surgery as initial CNPAS treatment but were placed on ODDI afterward due to ongoing symptoms from nasal obstruction. See Table 1.Patient 1 presented after birth with cyanosis during feeding. CT showed 4.7mm pyriform aperture diameter and the interuncinate distance was 11mm. ODDI was begun after diagnosis and was tapered from two drops to one and from twice daily to once daily before she was removed. Improvement continued and surgery was unnecessary. At 1year, the PA diameter and interuncinate distance had increased to 8.8 and 15.5 mm.Patient 2 presented with nasal obstruction at birth with CNPAS. 5 days of Afrin raised the oxygen saturation percentage from the 70's to the high 90's, but obstruction and dysphagia persisted intermittently. The patient started ODDI and after 9 days was tapered to one drop per nostril per day. Nasal obstruction and feeding improved. She was eventually weaned off ODDI.Patient 3 presented at birth with sleep apnea, desaturations in the 80's, and nasal obstruction ODDI was commenced after diagnosis. At 2 weeks she was breathing freely through her nose, retractions subsided and dysphagia improved moderately. By two months, however, she was not receiving ODDI consistently due to caregiver noncompliance and her symptoms returned. After reinstating ODDI at one drop per nostril per day, symptoms again improved and stabilized. She was weaned completely off ODDI after 6 months.Patient 4 was intubated when 3 days old due to severe respiratory failure from CNPAS. Surgical correction was performed at six weeks. Nasal obstruction persisted post-surgically, however, and ODDI was instituted. After little improvement, his dose was increased to four times daily. The increase improved the obstruction and allowed adequate nasal breathing. Drops were tapered until 1.5 years old. After weaning ODDI, he was sleeping restlessly. Although he had no significant sleep apnea, sleep disordered breathing persisted, and at three years old this was treated with Flonase prn, which helped alleviate his symptoms.Patient 5 is a 4year old female who presented with obstructive sleep apnea, nasal obstruction, and a history of CNPAS. Although his outside CT was not available for review, he had undergone a sublabial repair at an outside institution, which initially improved his symptoms , but nasal obstruction and sleep disordered breathing eventually developed. He was treated with prn afrin postoperatively for several months, which was not successful at treating his symptoms. The child was a candidate for either surgical PA repair or ODDI with adenotonsillectomy. Her parents elected for the latter. Nasal obstruction continued, however, and she required valvular stenosis repair. Breathing had improved after this surgery and she required no further treatment for nasal obstruction. The patient was subsequently lost to follow up. Results ReferencesFive children evaluated for CNPAS at our tertiary referral center from 2006-2009 we...