Search

Introduction Multifocality is increasingly observed in papillary thyroid carcinoma (PTC) due to improvements in imaging and histopathological analysis. However, its significance in management, particularly as a sole risk-factor, remains controversial. This study aimed to investigate the prognostic value of multifocality in predicting recurrence following thyroid lobectomy in a contemporary group of PTC patients managed in the UK. Methods Patients with PTC in NHS Lothian (2009-19) and Guys and St Thomas NHS Foundation Trust (2012-19) were identified. Categorical variables were compared using Chi-squared or Fisher’s exact test. Five-year recurrence free survival (RFS) were analysed using Kaplan-Meier method and compared using log-rank. Results Of 828 patients; 492 (59%) had unifocal and 336 (41%) multifocal disease on final pathology. A higher rate of pathological nodal disease (22%v36%,p

Purpose of Review Recently, there has been an expansion of novel technologies in simulation training. Different models target different aspects of training. The aim of this review was to examine existing evidence about training simulators in rhinology, their incorporation into real training programmes and translation of these skills into the operating room. The first part focuses on the virtual and augmented reality simulators. The second part describes the role of physical (i.e. non-computer-based) models of endoscopic sinus surgery. Recent Findings Virtual reality simulators are still evolving and facing challenges due to their inherent cost and lack of realism in terms of the type of haptic feedback they provide. On the other hand, augmented reality seems to be a promising platform with a growing number of applications in preoperative planning, intraoperative navigation and education. Limitations in validity, registration error and level of evidence prevent the adoption of augmented reality on a wider scale or in clinical practice. Summary Simulation training is a maturing field that shows reasonable evidence for a number of models. The incorporation of these models into real training programmes requires further evaluation to ensure that training opportunities are being maximized.

Purpose of ReviewRecently, there has been an expansion of novel technologies in simulation training. The aim of this review was to examine existing evidence about training simulators in rhinology, their incorporation into real training programmes and translation of these skills into the operating room. The first part focuses on the virtual and augmented reality simulators. The second part describes the role of physical (i.e. non-computer-based) models of endoscopic sinus surgery.Recent FindingsWe learned that an ideal sinus surgery model would score highly in all standard measures of validity whilst maintaining an attainable cost. This is a challenging goal that is worthy of pursuit given that simulation training has been shown to be cost-effective option in other domains. Non-AR or VR models are attractive ways to fill gaps in simulation training whilst reducing compared with computer-based models.SummaryIn an era of improved computer technology and improved 3D printing, it will be increasingly important to focus on both the manufacture and validation process. One area that will benefit from further technological advancement is the realistic simulation of bleeding as this would obviate the need for animal models. Future studies on ESS simulation will also need to robustly demonstrate the validity of each model with the emphasis on the ability of a model to predict performance in operative environment.

OBJECTIVE Management of recurrent laryngeal cancer presents a major challenge, and salvage laryngectomy is complicated by previous oncologic treatments. Thyroidectomy as part of salvage laryngectomy adds a nonnegligible degree of morbidity. The purpose of this study is to assess the rate of thyroid gland invasion in patients undergoing salvage laryngectomy to determine relevant predictive factors. STUDY DESIGN Case series with chart review. SETTING Department of Otorhinolaryngology, Head and Neck Surgery, Guy's Hospital, London, United Kingdom. METHODS A retrospective review of patients undergoing salvage laryngectomy between 2009 and 2019 was undertaken. Preoperative cross-sectional imaging and histopathological analysis were performed to define evidence and predictors of thyroid gland invasion (TGI). RESULTS Fifty-one patients had salvage laryngectomy. Histological evidence of TGI was found in 4 patients (7.8%). No significant relationship was found between histological TGI and subsite of primary carcinoma, degree of differentiation, T staging, or radiological TGI. Preoperative computed tomography had a high negative predictive value for TGI. CONCLUSION Thyroidectomy should be carefully considered in patients undergoing salvage laryngectomy, and its extent should be defined on an individual basis. Total thyroidectomy should not routinely be performed in salvage laryngectomy or pharyngolaryngectomy in patients with no preoperative radiological evidence of TGI on cross-sectional imaging, unless there is intraoperative evidence of TGI.

The SARS-CoV-2 (COVID-19) pandemic is having a large effect on the management of cancer patients. This study reports on the approach and outcomes of cancer patients receiving radical surgery with curative intent between March and September 2020 (in comparison to 2019) in the European Institute of Oncology, IRCCS (IEO) in Milan and the South East London Cancer Alliance (SELCA). Both institutions implemented a COVID-19 minimal pathway where patients were required to self-isolate prior to admission and were swabbed for COVID-19 within 72 h of surgery. Positive patients had surgery deferred until a negative swab. At IEO, radical surgeries declined by 6% as compared to the same period in 2019 (n = 1477 vs. 1560, respectively). Readmissions were required for 3% (n = 41), and &lt, 1% (n = 9) developed COVID-19, of which only one had severe disease and died. At SELCA, radical surgeries declined by 34% (n = 1553 vs. 2336). Readmissions were required for 11% (n = 36), &lt, 1% (n = 7) developed COVID-19, and none died from it. Whilst a decline in number of surgeries was observed in both centres, the implemented COVID-19 minimal pathways have shown to be safe for cancer patients requiring radical treatment, with limited complications and almost no COVID-19 infections.

PURPOSE: Traditional critical care dogma regarding the benefits of early tracheostomy during invasive ventilation has had to be revisited due to the risk of COVID-19 to patients and healthcare staff. Standard practises that have evolved to minimise the risks associated with tracheostomy must be comprehensively reviewed in light of the numerous potential episodes for aerosol generating procedures. We meet the urgent need for safe practise standards by presenting the experience of two major London teaching hospitals, and synthesise our findings into an evidence-based guideline for multidisciplinary care of the tracheostomy patient. METHODS: This is a narrative review presenting the extensive experience of over 120 patients with tracheostomy, with a pragmatic analysis of currently available evidence for safe tracheostomy care in COVID-19 patients. RESULTS: Tracheostomy care involves many potentially aerosol generating procedures which may pose a risk of viral transmission to staff and patients. We make a series of recommendations to ameliorate this risk through infection control strategies, equipment modification, and individualised decannulation protocols. In addition, we discuss the multidisciplinary collaboration that is absolutely fundamental to safe and effective practise. CONCLUSION: COVID-19 requires a radical rethink of many tenets of tracheostomy care, and controversy continues to exist regarding the optimal techniques to minimise risk to patients and healthcare workers. Safe practise requires a coordinated multidisciplinary team approach to infection control, weaning and decannulation, with integrated processes for continuous prospective data collection and audit.

A 32-year-old man was found to have a nasal mass on DOTATATE positron emission tomography (PET) scan to investigate the cause of his syndrome of inappropriate antidiuretic hormone secretion (SIADH). The patient presented 6 years earlier with malignant hypertension followed by a second emergency admission for hyponatraemia. Multiple scans and blood tests over 6 years yielded no cause for his SIADH. Nasendoscopy was unremarkable. A PET scan prompted endoscopic sinus surgery which resulted in the resection of a mass in the anterior hiatus semilunaris. The histological findings were fitting with a diagnosis of a neurocytic-type tumour favouring an olfactory neurocytoma. Following resection, the patient remains well and is cured of his SIADH. An olfactory neurocytoma although rare should be considered as a benign differential for a mass in the nasal space. This case demonstrates how an olfactory neurocytoma can present as a cause of SIADH.

Introduction: The coronavirus pandemic has resulted in unprecedented rates of patients requiring intubation and ventilation over a short period of time. The authors present 3-month data on airway, voice and swallow outcomes for this cohort to better understand the impact of COVID-19 critical illness on laryngotracheal morbidity. Methods: An observational cohort study was performed on all patients discharged following critical illness at our tertiary institution over a 2-month period (1st March 2020 - 30th April 2020). Patients were stratified on the basis of primary diagnosis: COVID-19 pneumonitis, Non-COVID-19 respiratory failure and non-respiratory. Our primary outcome measure was reported airway, voice, and swallow dysfunction during inpatient admission and on 6-12 week Critical Illness Recovery Clinic follow up. Endoscopic findings of patients referred onward to our Multidisciplinary Laryngology-Speech Therapy Clinic were recorded.Results: 141 patients were included in our study. During inpatient admission there were no statistically significant differences in reported rates of airway, voice, or swallow dysfunction. In Critical Illness Recovery Clinic, there were markedly higher rates of reported airway, voice and swallow dysfunction in the COVID-19 pneumonitis cohort, although these rates only reached statistical significance in respect to airway outcomes (airway p=0.038, voice p=0.064, swallow p=0.240). 100% of patients reviewed to date in the Laryngology-Speech Therapy Clinic following COVID-19 critical illness had clinically significant laryngeal pathology.Conclusion: Our data highlights an impending surge in COVID-19 related laryngotracheal morbidity. Robust, prospective screening and clear referral pathways for all patients following COVID-19 critical illness are essential to identifying and managing this cohort.

Single-session, dual-site robotic surgery for synchronous malignancies is not widely reported. To our knowledge, there are no previous reports of transoral robotic surgery (TORS) and robot-assisted thoracic surgery (RATS) in a single sitting. A 49-year-old male presented with a neck lump. Biopsies and imaging proved synchronous primaries of the tonsil and lung. The morbidity of primary dual-site chemoradiotherapy, or open surgery, presented a management challenge. We therefore opted for sequential robotic resections, in a single sitting. The patient was discharged on Day 6 post-operatively and was able to start radiotherapy less than 3 weeks post-operatively. Undertaking TORS and RATS in a single sitting is feasible and safe. This approach allowed fast-tracking of adjuvant oncological therapy, arguably conveying the greatest chance of cure. We detail the rationale and utility of this novel approach and describe the surgical and anaesthetic challenges of two teams undertaking sequential robotic procedures in a single sitting.

Background Previous studies have reported that there is little correlation between sino-nasal outcome test (SNOT-22) score in chronic rhinosinusitis (CRS) and objective radiological scoring, although conclusions vary. We aimed to investigate whether comorbid anxiety and depression, which are highly prevalent in patients with CRS may cause symptom amplification and account for the lack of correlation in previous studies. Methodology 100 patients with CRS were evaluated using the General Anxiety Disorder-7 (GAD-7), Patient Health Question- naire-9 (PHQ-9) and SNOT-22 questionnaires as well as the Lund Mackay Score (LMS). Results Overall correlation analysis did not show a significant relationship between SNOT-22 and LMS scores. Subgroup analysis of patients who do not suffer with anxiety and depression showed a significant correlation between SNOT-22 and LMS scores. The nasal domain of the SNOT-22 showed strongest correlation to LMS in this patient group. We also observed a significant difference in both median SNOT-22 and LMS between patients who suffered both anxiety and depression and patients without either co- morbidity. Conclusion When CRS patients who do not have anxiety and depression are analysed in isolation, or when these conditions are controlled in a multivariable regression, there is a significant correlation between radiological findings and symptom score. This correlation is absent in patients with co-morbid anxiety and depression. Anxiety and depression should be considered in patients in whom there is a mismatch in symptom and radiological disease severity as it is associated with symptom amplification.

Purpose COVID-19 patients requiring mechanical ventilation can overwhelm existing bed capacity. We aimed to better understand the factors that influence the trajectory of tracheostomy care in this population to facilitate capacity planning and improve outcomes. Methods We conducted an observational cohort study of patients in a high-volume centre in the worst-affected region of the UK including all patients that underwent tracheostomy for COVID-19 pneumonitis ventilatory wean from 1st March 2020 to 10th May 2020. The primary outcome was time from insertion to decannulation. The analysis utilised Cox regression to account for patients that are still progressing through their tracheostomy pathway. Results At the point of analysis, a median 21 days (IQR 15–28) post-tracheostomy and 39 days (IQR 32–45) post-intubation, 35/69 (57.4%) patients had been decannulated a median of 17 days (IQR 12-20.5) post-insertion. The overall median age was 55 (IQR 48–61) with a male-to-female ratio of 2:1. In Cox regression analysis, FiO2 at tracheostomy ≥ 0.4 (HR 1.80; 95% CI 0.89–3.60; p = 0.048) and last pre-tracheostomy peak cough flow (HR 2.27; 95% CI 1.78–4.45; p = 0.001) were independent variables associated with prolonged time to decannulation. Conclusion Higher FiO2 at tracheostomy and higher pre-tracheostomy peak cough flow are associated with increased delay in COVID-19 tracheostomy patient decannulation. These finding comprise the most comprehensive report of COVID-19 tracheostomy decannulation to date and will assist service planning for future peaks of this pandemic.

Objectives We aimed to audit current United Kingdom (UK) practice of Head and Neck Cancer (HNC) post-treatment surveillance against national guidelines, and determine the outcomes of these practices in detecting recurrence. Design National cross-sectional study of current HNC surveillance practice. Setting UK HNC outpatient departments. Participants HNC patients reviewed for post-treatment surveillance. Main outcome measures Compliance with UK multidisciplinary guidelines, and rates of cancer recurrence detection by time, clinic type and symptoms. Results Data were analysed from 5,123 consultations across 89 UK centres. 30% of consultations were in dedicated multidisciplinary clinics, with input from Allied Health Professionals (AHPs) available on the day in 23% of all consultations. Recurrence was suspected in 344 consultations and investigated with MRI in 29.6% (n=102) and PET-CT in 14.2% (n=49). Patient education regarding recurrence symptoms, and smoking and alcohol advice, was provided in 20.4%, 6.2%, and 5.3% of cases, respectively. Rates of recurrence detected were 35% in expedited appointments and 5.2% in planned follow-ups (p=0.0001). Of the expedited appointments, 63% were initiated by patients and 37% by clinicians. Recurrence was higher in those with new symptoms (7.1% versus 2.2%). The strongest predictors of recurrence were dyspnoea (positive predictive value (PPV)=16.2%), neck pain (PPV=10.4%) and mouth/throat pain (PPV=9.2%). Conclusions Dedicated multidisciplinary clinics comprise a minority of consultations for HNC surveillance in the UK, with low availability of AHPs. PET-CT and MRI were underutilised for the investigation of suspected recurrence. There may be scope for greater emphasis on patient education and consequent patient-initiated symptom driven follow-up.

Objective:This paper objectively evaluates current information available to the general public related to glue ear on the World Wide Web.Methods:The term ‘glue ear’ was typed into the 3 most frequently used internet search engines – Google, Bing and Yahoo – and the first 20 links were analysed. The first 400 words of each page were used to calculate the Flesch–Kincaid readability score. Each website was subsequently graded using the Discern instrument, which gauges quality and content of literature.Results:The websites Webmd.boots.com, Bupa.co.uk and Patient.co.uk received the highest overall scores. These reflected top scores in either readability or Discern instrument assessment, but not both. Readability and Discern scores increased with the presence of a marketing or advertising incentive. The Patient.co.uk website had the highest Discern score and third highest readability score.Conclusion:There is huge variation in the quality of information available to patients on the internet. Some websites may be accessible to a wide range of reading ages but have poor quality content, and vice versa. Clinicians should be aware of indicators of quality, and use validated instruments to assess and recommend literature.

Highlights • Tongue base radiofrequency ablation may introduce infection to a thyroglossal cyst. • This can be managed with antibiotics and ultrasound-guided needle aspiration. • Caution is required in radiofrequency therapy for patients with thyroglossal cysts., Introduction Radiofrequency ablation treatment of the tongue base can be used either alone or as part of a multilevel approach in the treatment of snoring. This involves the generation of thermal energy around the circumvallate papillae of the tongue. Potential complications include ulceration, dysphagia, haematoma and abscess formation. Presentation of case We present the case of a 50-year-old patient who developed an anterior neck swelling following a second application of radiofrequency ablation therapy to the tongue base for snoring. This was secondary to an infection of a previously undiagnosed thyroglossal cyst. The patient made a full recovery following intravenous antibiotic therapy and ultrasound-guided needle aspiration. Discussion Thyroglossal tract remnants are thought to be present in seven percent of the adult population. An infection in a thyroglossal tract cyst has not previously been reported following radiofrequency ablation of the tongue base. Given the relatively high complication rate of tongue base radiofrequency ablation in some series, this complication may be under-recognised. Conclusion An infected thyroglossal tract cyst should be suspected in patients with anterior neck swellings following radiofrequency ablation therapy to the tongue base. We advise caution when performing this procedure on patients with known thyroglossal tract remnants though there is insufficient evidence to suggest that this procedure is contraindicated.

A man in his early 30s presented with right-sided preauricular swelling and facial oedema. He had a history of acid injury to his right ear as a child resulting in pinna deformity and subsequent blind sac closure of the external auditory canal. Imaging showed abnormal ear anatomy and abnormal density of the right parotid gland. Antibiotic therapy prevented progression but did not resolve the symptoms. Therefore, the infected area was surgically drained. This showed an underlying cholesteatoma, a benign but locally destructive condition where keratinising squamous epithelium grows in the middle ear and mastoid. The infected region was drained and the cholesteatoma was excised. This led to full resolution of the infection. The patient is awaiting a follow-up diffusion-weighted MRI. This case was unusual as the disease had extended beyond the ear and we therefore wish to alert clinicians to cholesteatoma as a possible cause of facial swelling.

Objective To determine the construct validity of cadaveric temporal bones in mastoidectomy training. Study Design A prospective observational study. Methods Trainees from the North London otolaryngology training program performed step-wise modified radical mastoidectomy on cadaveric temporal bones under faculty supervision. Performance was assessed using a validated mastoidectomy assessment tool. A longitudinal assessment of nine trainees was also carried out over two sessions separated by 12 months. The main outcomes measures were task-specific (TS) and global skills (GS). Results Twenty-six intermediate and eight novice trainees participated and were assessed by a minimum of two assessors each. Intermediate trainees performed significantly better than novices in TS and GS (P

Objectives:Determine the outcome and cause of negligence claims relating to thyroid surgery in the National Health Service (NHS).Methods:A request was submitted to the NHS Litigation Authority for claims relating to thyroid surgery between 1995 and 2013 by searching for the key words: “thyroid,” “endocrine,” or “neck.” Claims were analyzed for cause of injury, type of injury, outcome of claim, and costs.Results:Of 132 cases, 90% were closed with 55% of closed claims leading to payment of damages and 72% of closed claims leading to payment of any sort (including settlement out of court). Fifty-two percent of claims were related to complications of surgery with the rest being related to errors in diagnosis and treatment. Lack of informed consent was claimed in 11 cases. The most common injuries claimed were vocal cord dysfunction (n = 28) followed by endocrine disturbance such as hypocalcemia or hypothyroidism (n = 20). Eight fatalities occurred, of which 7 were due to hematoma and one was due to hypocalcem...

Hair cells are the mechanotransducing cells of the inner ear that are essential for hearing and balance. POU4F3 – a POU-domain transcription factor selectively expressed by these cells – has been shown to be essential for hair cell differentiation and survival in mice and its mutation in humans underlies late-onset progressive hearing loss (DFNA15). The downstream targets of POU4F3 are required for hair cell differentiation and survival. We aimed to identify such targets in order to elucidate the molecular pathways involved in hair cell production and maintenance. The orphan thyroid nuclear receptor Nr2f2 was identified as a POU4F3 target using a subtractive hybridization strategy and EMSA analysis showed that POU4F3 binds to two sites in the Nr2f2 5′ flanking region. These sites were shown to be required for POU4F3 activation as their mutation leads to a reduction in the response of an Nr2f2 5′ flanking region reporter construct to POU4F3. Immunocytochemistry was carried out in the developing and adult inner ear in order to investigate the relevance of this interaction in hearing. NR2F2 expression in the postnatal mouse organ of Corti was shown to be detectable in all sensory epithelia examined and characterised. These data demonstrate that Nr2f2 is a direct target of POU4F3 in vitro and that this regulatory relationship may be relevant to hair cell development and survival.

s / International Journal of Surgery 12 (2014) S13eS117 S40 typically incidental. Tissue received by the Pathologist is routinely sectioned and depending on macroscopic findings, part or all of the tissue is processed to be examined microscopically. We hypothesised incidence differs depending on howmuch thyroid tissue is processed for microscopic examination. Methods: All thyroid lobes and whole glands from NHS Greater Glasgow and Clyde hospitals received in a centralised Pathology laboratory between 1st June 2012 1st June 2013 were included. Results: N1⁄4267, 121 whole glands, 146 hemi-lobectomies. 36 patients had PMC, 18 of whom had surgery for benign disease. Incidence of PMC was 27% when the entire tissue was examined, and 19% when only part examinedmicroscopically in the total thyroidectomies (p1⁄40.325). In hemilobectomies, 8.4% and 5.7% were found to have PMC when all or part of the lobes were examined respectively (p1⁄40.522). Multifocal PMC was 30% in both groups, and metastatic in 3 cases. Conclusions: There is a wide variation in PMC depending on how much thyroid tissue is examined, suggesting it is under reported. However this was not significant and has limited clinical significance as PMC rarely metastasises. 0717: POST-THYROIDECTOMY PARATHYROID HORMONE LEVELS AS A TOOL TO GUIDE CALCIUM REPLACEMENT: IS THIS BEING USED IN PRACTICE? Chrysostomos Tornari, Samantha Field, Roy Farrell, Taran Tatla. Northwick Park Hospital, London, UK. Introduction: According to local guidelines, post-thyroidectomy parathyroid hormone (PTH) measurement can indicate the risk of subsequent hypocalcaemia and guide need for calcium replacement. Calcium replacement is not without risk and should be avoided without clear indication. Values of PTH >2 pmol/L should preclude empirical calcium replacement as patients in this range are extremely unlikely to become hypocalcaemic. We examined local adherence to these recommendations. Methods: Total and completion thyroidectomy procedures between October 2012 and December 2013 were identified from theatre records. Corresponding electronic patient records were reviewed for demographics, results and management. Results: During this period, 63 relevant thyroidectomies were performed. The average patient age was 53.6 years and 21% were male (n1⁄413). 59% of operations (n1⁄437) were for thyroid cancer and 22 were for multinodular goitre (35%). Other indications included thyroid nodules or ectopic thyroid. Of 57 patients who underwent PTH measurement 2.0 pmol/L. Two patients of these had mild postoperative hypocalcaemia (2.0-2.1) and one was symptomatic, requiring calcium replacement. However, fifteen patients (65%) were discharged on calcium replacement therapy. Conclusions: The incidence of excessive calcium replacement is high. Adherence to local guidelines could greatly reduce this. 1719: ARE FALLING RATES OF TONSILLECTOMIES CAUSING INCREASED RATES OF TONSIL RELATED MORBIDITY? Joanne Todd, Mark Wilkie, David Luff. Countess of Chester Hospital, Chester