Take Your Otolaryngology Knowledge to the Next Level

Children with repaired cleft palate have chronic Eustachian-tube dysfunction due to aberrant tensor veli palatini mechanics, resulting in a 70 – 90 % prevalence of otitis media with effusion (OME) beyond early childhood. pubmed.ncbi.nlm.nih.govncbi.nlm.nih.gov Current multidisciplinary guidelines for OME and tympanostomy tubes state that recurrent or persistent effusion causing ≥ 20 dB hearing loss warrants repeat tube placement, regardless of previous extrusion. pubmed.ncbi.nlm.nih.govpubmed.ncbi.nlm.nih.gov Although adenoidectomy combined with tubes reduces future OME for most children aged ≥ 4 years, cleft-palate patients face a substantially higher risk of postoperative velopharyngeal insufficiency (VPI) and hypernasal speech. pmc.ncbi.nlm.nih.govsciencedirect.compubmed.ncbi.nlm.nih.gov Long-acting fluoroplastic “T-tubes” provide durable ventilation for 18–24 months, significantly improving audiometric thresholds without exposing the child to the speech risks associated with adenoid removal. pmc.ncbi.nlm.nih.govhealth.ucdavis.edu Evidence for paediatric balloon Eustachian-tube dilation remains limited to small, older-child cohorts (mean age ≈ 10 years) with no data in cleft populations, so it is not recommended first-line. pubmed.ncbi.nlm.nih.govsciencedirect.com Long-term macrolide prophylaxis is discouraged because of modest efficacy and growing antimicrobial-resistance concerns. entnet.org

• Why the other options are incorrect
  • Option a: Adenoidectomy can improve OME, but in cleft-palate patients it carries a 5 – 25 % risk of inducing clinically significant VPI; short-acting tubes alone give less durable ventilation. sciencedirect.compubmed.ncbi.nlm.nih.gov
  • Option b: Balloon dilation lacks robust paediatric RCT data and is not endorsed by current guidelines for this age or diagnosis. pubmed.ncbi.nlm.nih.govsciencedirect.com
  • Option d: Extended azithromycin courses offer only marginal reduction in effusion episodes and raise resistance concerns. entnet.org
  • Option e: Partial adenoid reduction preserves some adenoid pad but still risks VPI and, without tubes, does not address the immediate conductive loss. pmc.ncbi.nlm.nih.govsciencedirect.com

Further Reading:

1. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: Otitis media with effusion (update). Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1-S41.

2. Flynn T, Möller C. Management of otitis media with effusion in children with cleft palate: systematic review. Cleft Palate Craniofac J. 2014;51(1):E1-E13.

3. American Academy of Otolaryngology–Head and Neck Surgery Foundation. Clinical practice guideline: Tympanostomy tubes in children (update). Otolaryngol Head Neck Surg. 2022;166(2 Suppl):S1-S55.

Additional Concepts:
• Pathophysiology in cleft palate – Abnormal insertion of the tensor veli palatini into a repaired palate disrupts Eustachian-tube opening, leading to chronic negative middle-ear pressure and effusion. pubmed.ncbi.nlm.nih.gov

• Risk of VPI after adenoidectomy – The adenoid pad contributes to velopharyngeal closure; its removal in cleft-palate patients can unmask or worsen hypernasality and nasal air escape. pmc.ncbi.nlm.nih.govpubmed.ncbi.nlm.nih.gov

• Choice of ventilation device – Fluoroplastic T-tubes, with flanges resisting extrusion, produce longer ventilation and fewer repeat anaesthetics but require surveillance for blockage or persistent perforation. pmc.ncbi.nlm.nih.govhealth.ucdavis.edu

• Emerging therapies – Balloon dilation of the cartilaginous Eustachian tube shows promise in adolescents, but controlled data in younger or syndromic children are insufficient for guideline endorsement.

The lower (vertical) island trapezius myocutaneous flap is classically a type II flap whose dominant circulation arises from the dorsal scapular artery (DSA)—the deep branch of, or a vessel that may originate separately from, the transverse cervical system. Cadaveric and angiographic studies show the DSA supplies the distal two-thirds of the trapezius muscle and its overlying skin, making it the critical pedicle for the lower island variant. PMCCarver College of Medicine Preserving this artery (and its paired vein) ensures reliable perfusion along the flap’s long arc of rotation to reach posterior scalp or cervico-thoracic defects. JAMA NetworkPMC

Why the other options are incorrect

• Superficial cervical artery (SCA) supplies the superior trapezius (often used for the superior trapezius flap) and is only a minor or secondary inflow for the lower portion; basing the flap solely on the SCA risks distal necrosis. VulaPlastic Surgery Key

• Posterior intercostal perforators contribute segmental flow but cannot sustain the entire musculocutaneous island once it is elevated and rotated; they are considered tertiary vessels. Lippincott Journals

• Thoracodorsal artery is the principal pedicle of the latissimus dorsi flap, not the trapezius. Lippincott Journals

• Suprascapular artery mainly vascularises supraspinatus/infraspinatus and is not a dominant source for trapezius-based flaps. Plastic Surgery Key

Further Reading:

1. Netterville JL, Wood DE. The lower trapezius island myocutaneous flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1991;117:1122-1129.

2. Kim JT, et al. The trapezius muscle flap: a viable alternative for posterior scalp and neck reconstruction. Arch Plast Surg. 2016;43:45-53.

3. Disa JJ, Cordeiro PG. Atlas of Regional and Free Flaps for Head and Neck Reconstruction. Lippincott Williams & Wilkins; 2023.

Additional Concepts:
• Anatomical variability: Up to 50 % of individuals show dominance of the DSA, while others have a dominant transverse cervical artery; recognising this variability with Doppler or CT-angiography guides safe flap design. PMCScienceDirect
• Shoulder morbidity: Because the spinal accessory nerve supplies the upper trapezius, meticulous dissection around the nerve during flap harvest minimises postoperative shoulder droop and abduction weakness; studies report low functional impairment when the nerve is preserved. NCBIMedscape
• Arc of rotation optimisation: Narrowing the muscle around the pedicle and, when necessary, dividing distal muscular attachments to the vertebral spines and scapular spine can extend reach without kinking the vascular pedicle. Medicine LibreTextsPMC
• Salvage utility: The lower island trapezius flap is particularly useful after free-flap loss or in previously irradiated fields because it brings well-vascularised tissue from outside the primary radiation zone and can be harvested without microvascular anastomosis.

Growth-hormone (GH) excess is a well-recognised driver of accelerated craniofacial FD expansion and is independently associated with optic-nerve compromise and vision loss; normalising GH with somatostatin analogues or GH-receptor blockade reduces lesion growth and defers, or even obviates, the need for surgery. Wiley Online LibraryOxford Academic

a. Immediate decompression is reserved for symptomatic optic neuropathy with documented visual decline; prophylactic decompression in asymptomatic patients does not improve outcomes and carries operative risks. PubMedE-ACFS
c. Bisphosphonates can relieve FD bone pain and modestly reduce bone turnover but have not been shown to prevent craniofacial lesion expansion or protect vision. ScienceDirectPMC
d. Radiotherapy is contraindicated because it confers a substantial risk of sarcomatous transformation in FD and offers no proven benefit for optic-canal disease. PMC
e. Observation alone ignores a modifiable systemic risk factor (GH excess) that is likely to accelerate dysplastic growth and jeopardise vision. Oxford Academic

Further Reading:

1. Lee JS, FitzGibbon EJ, Butman JA, et al. Normal vision despite narrowing of the optic canal in fibrous dysplasia. N Engl J Med. 2002;347(21):1670-4.

2. Stanton RP, Ippolito E, Springfield D, Lindaman L. Optic nerve compression in craniofacial fibrous dysplasia. Plast Reconstr Surg. 2007;120(6):1957-62.

3. Javaid MK, Boyce A, Appelman-Dutchin A, et al. Best practice management guidelines for fibrous dysplasia/McCune-Albright syndrome. Orphanet J Rare Dis. 2019;14(1):139.

Additional Concepts:
• Endocrine modifiers of FD activity – GH excess and, less commonly, hyperthyroidism amplify cyclic AMP signalling in osteogenic precursors, accelerating lesion expansion; endocrine control is therefore central to craniofacial FD management. Oxford Academic
• Prophylactic optic-nerve decompression – Large series and meta-analyses show no visual advantage over observation in asymptomatic patients and higher complication rates, so current guidelines discourage it. New England Journal of MedicineE-ACFS
• Medical bone-active agents – Intravenous bisphosphonates reduce bone turnover markers and pain but do not halt craniofacial growth; denosumab is experimental and may cause rebound hypercalcaemia when stopped. PMCOxford Academic
• Surgical principles in craniofacial FD – Definitive contouring or resection is best delayed until skeletal maturity to reduce recurrence; early surgery without addressing systemic drivers (e.g., GH excess) is prone to regrowth.

In this clinical scenario, the patient presents with elevated thyroglobulin (Tg) levels and a negative iodine-131 scan, which suggests iodine-refractory disease, meaning the cancer is no longer iodine-avid and may not respond to further iodine therapy. Given this, the most appropriate next step is to perform an 18F-FDG PET/CT scan (Option c), as this imaging modality is highly effective in detecting metabolically active lesions in iodine-refractory thyroid cancer. FDG-PET is particularly useful in identifying recurrent or metastatic disease when traditional iodine imaging is negative, because it detects areas of high glucose metabolism typical of de-differentiated cancer cells. Studies have shown that FDG-PET/CT has high sensitivity and specificity for detecting recurrent or metastatic disease in patients with elevated Tg and negative iodine scans.

• Option a (Repeat iodine-131 scan with TSH stimulation) is incorrect because the absence of iodine uptake on the previous scan indicates iodine-refractory disease. Repeating the iodine scan would likely yield the same negative result, as iodine uptake is no longer present in the tumor cells.

• Option b (Fine-needle aspiration biopsy of the thyroid bed) is not the most appropriate next step in this situation, as the patient has already undergone radioiodine therapy, and neck ultrasound has shown no suspicious lymphadenopathy. Moreover, biopsy may not provide additional useful information given the elevated Tg levels and negative iodine scan.

• Option d (Neck MRI for detailed soft tissue evaluation) is less appropriate than FDG-PET/CT, which can offer whole-body imaging to detect distant metastasis and recurrent lesions beyond the neck, whereas MRI is typically used for detailed local evaluation of soft tissue masses in the neck.

• Option e (CT chest with contrast to evaluate lung metastasis) is a possible choice if the primary concern is lung metastasis, but a whole-body imaging modality such as FDG-PET/CT is more comprehensive and has higher sensitivity for detecting recurrent disease in various locations, including the lungs.

Further Reading:

1. Miller ME, Chen Q, Elashoff DA, et al. Positron emission tomography-computed tomography in the management of differentiated thyroid cancer: An evidence-based review and analysis of its impact on patient management and outcomes. Thyroid Journal, 2012;22(3):234-241.

2. Treglia G, Sadeghi R, Schalin-Jäntti C, et al. Diagnostic performance of fluorine-18-fluorodeoxyglucose positron emission tomography in patients with suspected recurrent medullary thyroid carcinoma: A meta-analysis and systematic review. Endocrine Journal, 2015;49(1):1-10.

3. Dong MJ, Liu ZF, Zhao K, et al. Role of fluorodeoxyglucose-PET versus PET/computed tomography in detection of recurrent or metastatic differentiated thyroid carcinoma: A meta-analysis of eight studies including 222 patients. Thyroid Journal, 2010;20(10):1097-1103.

Additional Concepts:

• Iodine-Refractory Thyroid Cancer:
  Iodine-refractory differentiated thyroid cancer (DTC) occurs when tumor cells lose the ability to concentrate iodine due to de-differentiation. These tumors no longer respond to radioiodine therapy, and alternative treatments, such as external beam radiation therapy or systemic therapies, may be required.

• Thyroglobulin as a Tumor Marker:
  Serum thyroglobulin (Tg) is a sensitive marker for detecting residual or recurrent thyroid cancer following surgery and radioiodine therapy. Elevated Tg levels in the absence of iodine uptake suggest the presence of recurrent or metastatic disease, especially when thyroid-stimulating hormone (TSH) levels are low or suppressed.

• FDG-PET in Thyroid Cancer Imaging:
  FDG-PET scanning uses the increased glucose metabolism of tumor cells to detect areas of active disease. In iodine-refractory DTC, FDG-PET can identify metabolically active lesions, guiding further management decisions, such as surgery, systemic therapy, or external beam radiation therapy.

Sarcoidosis-associated hypercalcemia results from unregulated extrarenal 1-α-hydroxylase activity in activated macrophages within granulomas, leading to excessive calcitriol and increased intestinal calcium absorption. Corticosteroids directly suppress macrophage 1-α-hydroxylase, decrease calcitriol production, enhance renal calcium excretion, and simultaneously treat the underlying multisystem granulomatous inflammation. Prednisone 20–40 mg daily is the recommended initial dose for significant extrapulmonary sarcoidosis or steroid-responsive hypercalcemia. PMCPMCPMCOxford Academic

Why other options are incorrect:

• Calcitonin (a) provides only transient reduction in serum calcium via inhibition of osteoclastic bone resorption and has no effect on calcitriol overproduction, so relapse is expected once therapy is stopped. Oxford Academic

• Zoledronic acid (b) is effective for malignancy-related hypercalcemia by blocking osteoclastic activity but similarly fails to address the calcitriol-driven mechanism in sarcoidosis. Oxford Academic

• High-dose cholecalciferol (d) would worsen hypercalcemia because additional substrate is converted to calcitriol in granulomatous tissue. PMC

• Parotidectomy (e) may debulk parotid disease but neither corrects systemic hypercalcemia nor modifies sarcoid activity, and surgery is reserved for refractory mass-effect after failed medical therapy. ERS Publications

Further Reading:

1. Baughman RP, Valeyre D, Korsten P, et al. ERS clinical practice guidelines on treatment of sarcoidosis. Eur Respir J. 2021;58(6):2004079. ERS Publications

2. Tebben PJ, Singh RJ, Kumar R. Vitamin D-mediated hypercalcemia: mechanisms, diagnosis, and treatment. Endocr Rev. 2016;37(5):521-547. Oxford Academic

3. Judson MA. The treatment of pulmonary and extrapulmonary sarcoidosis. Med Clin North Am. 2020;104(3):425-439. PMC

Additional Concepts:
• Granulomatous hypercalcemia physiology – Activated macrophages within sarcoid granulomas express 1-α-hydroxylase independent of feedback control, producing excess calcitriol; glucocorticoids down-regulate this enzyme and rapidly normalize calcium levels. ScienceDirectOxford Academic

• Steroid-sparing strategies – For patients who cannot taper below physiologic steroid doses, methotrexate, azathioprine, mycophenolate mofetil, or biologic TNF-α inhibitors (e.g., adalimumab) are recommended second-line agents to control disease and limit steroid toxicity. stopsarcoidosis.orgbjo.bmj.comChest Journal

• Biopsy site selection in salivary sarcoidosis – Minor labial-salivary-gland biopsy provides 58–70 % sensitivity with negligible morbidity, whereas parotid biopsy increases diagnostic yield but carries higher risk of facial-nerve injury and sialocele; conjunctival or transbronchial biopsies can augment sensitivity in disseminated disease. PMCreumatologiaclinica.org

• Prognostic role of calcitriol levels – Elevated serum 1,25-dihydroxy-vitamin D correlates with chronic treatment requirements and multi-organ involvement, serving as a biomarker for aggressive sarcoidosis phenotypes that may benefit from early immunosuppression.