Primary Hyperparathyroidism: Outcomes of Repeated Imaging After Initial Negative Radiological Localization.

BACKGROUND: Radiological localization imaging aids in the identification of abnormal parathyroid glands resulting in primary hyperparathyroidism (PHPT), thereby facilitating minimally invasive parathyroid surgery. Sometimes initial imaging may fail to identify the abnormal gland and imaging may therefore be repeated. This study explored patient outcomes of repeated parathyroid localization imaging, after initial negative gland localization, at a United Kingdom institution. METHODOLOGY: Data was retrospectively collected and analyzed for patients with PHPT undergoing repeated imaging during a five-year period (2015-2020). The total number of episodes of scanning, types of scans performed, the time interval between scans and the imaging success of gland localization were recorded. We explored the reasons for repeated imaging and attempted to identify any factors that might predict subsequent positive radiological localization. RESULTS: A total of 45 patients were identified who underwent repeated localizing imaging after first localizing imaging was negative. Of these, 39 did not undergo surgery despite repeat imaging being undertaken; 11 out of these 39 patients (28%) had subsequent positive localization scans. Again, a large proportion of patients were managed conservatively, despite the repeated sets of imaging being done. Patients undergoing three or four sets of repetitive imaging did not have imaging or surgical success. CONCLUSION: A streamlined parathyroid pathway should be followed whereby patients should be triaged for suitability for surgery prior to repeated imaging. A second set of scans should be offered when patients are unsuitable for conservative management and are willing and fit to undergo surgery. There is no merit to repeating imaging more than twice.

Sonographic appearances of hobnail papillary thyroid carcinoma: A case report of a rare tumour.

Introduction: Hobnail papillary thyroid carcinoma is a rare, recently described papillary thyroid carcinoma variant, with potential for a more aggressive clinical course of disease and poorer prognosis. Case report: A 53-year-old man presented with a left thyroid mass. The ultrasound features of this mass included a predominantly cystic appearance with mobile internal echoes, vascularised internal septations, and murally based solid material. These ultrasound features were not deemed malignant by classification standards, which led to the patient being managed with active surveillance. However, the mass grew quickly and the patient underwent diagnostic hemithyroidectomy which led to hobnail variant papillary thyroid carcinoma being found on pathology. Discussion: The ultrasound features of the hobnail variant of papillary thyroid carcinoma have not been previously described in detail in the literature and, in this case, are features that would not be deemed malignant by classification standards. The rapid growth of the mass is what led to clinical suspicion of malignancy and resulted in diagnosis. Conclusion: The hobnail variant of papillary thyroid carcinoma may not have typical ultrasound findings associated with malignancy. Careful clinical correlation is advised in order to discern this difficult diagnosis and to facilitate appropriate treatment.

Metastatic parathyroid cancer: a rare cause of hypercalcaemia.

A 45-year-old man presenting with abdominal pain was found to have severe hypercalcaemia with elevated parathyroid hormone. Investigations revealed a parathyroid mass and bone metastases consistent with metastatic parathyroid carcinoma. The patient underwent parathyroidectomy, with histology confirming a right inferior parathyroid carcinoma. His postoperative management was complicated by severe hypercalcaemia refractory to medical therapy, owing to the metastases continuing to produce parathyroid hormone. Despite palliative radiotherapy to the metastases, the patient died within 3 months from end-organ failure related to hypercalcaemia.

Role of corticosteroids in Functional Endoscopic Sinus Surgery--a systematic review and meta-analysis.

BACKGROUND: The aim of our study is to systematically review the existing evidence on the role of corticosteroids in patients undergoing functional endoscopic sinus surgery (FESS). METHODOLOGY: Systematic search of MEDLINE (1950- 2014), EMBASE (1980-2014), metaRegister, Cochrane Library and ISI conference proceedings was carried out. RESULTS: Eighteen randomised controlled trials with 1309 patients were included. Use of local and/or systemic corticosteroids with FESS was reported in four categories; operative, anaesthesia related, post-operative outcomes and risk of recurrence. Meta-analysis for operative outcomes demonstrated that, mean operative time (MD -10.70 minutes; 95% CI -15.86, -5.55; P <0.0001) and mean estimated blood loss (MD -28.32 mls; 95% CI -40.93, -15.72; P <0.0001) was significantly lower; and surgical field quality (MD -0.81; 95% CI -1.32, -0.30; P = 0.002) was significantly better in corticosteroid group. Meta-analysis showed that post-operative endoscopic scores (SMD -0.39; 95% CI -0.60, -0.17; P = 0.0004) were significantly better in corticosteroid group compared to no corticosteroid group. There was no increase in risk of sinusitis (RR 0.64; 95% CI 0.32, 1.30; P = 0.22) between use of corticosteroids and no corticosteroids; There was no significant difference in recurrence risk of chronic rhinosinusitis (CRS) in mixed population studies (RR 0.77; 95% CI 0.35, 1.70; P = 0.52) between the two groups but analysis of studies reporting on chronic rhinosinusitis with nasal polyps (CRSwNP) (RR 0.64;95% CI 0.45,0.91;P=0.01) showed significant difference in favour of the corticosteroid group. CONCLUSION: Pre-operative use of local and/or systemic corticosteroids in FESS, results in significantly reduced blood loss, shorter operative time and improved surgical field quality. Studies are limited on the intra-operative use of corticosteroids to reduce postoperative pain. Postoperative corticosteroids improve postoperative endoscopic scores in CRS and recurrence rates in cases of CRSwNP.

Use of nurse-led telephone follow-up as a sole method of assessing patients after nasal surgery.

Patients undergoing nasal surgery have historically been routinely followed up in consultant led clinics some months after surgery. It has been noted that a significant proportion of these patients either did not attend these appointments or did not require them, impacting on the efficiency of ENT outpatient clinics. A quality improvement project was undertaken to assess this problem and to propose a new patient pathway whereby patients are contacted by ENT nursing staff by telephone three months following surgery. During these telephone conversations only 9.5% of patients requested outpatient follow-up and all of these patients were discharged upon their follow-up. The project demonstrates that nurse-led follow up is an efficient, effective and safe way of managing patient care post-nasal surgery.

The management of carotid artery rupture.

Carotid artery rupture is fortunately an uncommon complication of head and neck cancer treatment. Eleven episodes of carotid artery rupture following irradiation and major head and neck resection were identified over a 6-year period. We review our experience and discuss the predisposing factors that can cause this complication, important aspects of management and outcome. During this 6-year period, 11 episodes of carotid artery rupture were treated in our unit. All patients had received prior irradiation (more than 60 Gy) and undergone a major surgical resection or resections. The average age was 59 years; all patients had a salivary fistula, local infection and a manifest 'herald bleed' just before their major carotid artery rupture. These patients were resuscitated, taken to theatre and the neck explored, with control of the vessel and debridement of necrotic tissue. Soft tissue coverage was in the form of a flap. Many of the factors predisposing to carotid artery rupture can be ameliorated or treated early in order to avoid this complication. Early and aggressive nutritional support together with correction of haematological abnormalities promote wound healing and prevent tissue breakdown. The detection and treatment of infection also reduces fistula formation and wound compromise. We present our protocol for the early, aggressive management of these patients with carotid artery rupture.

Comparison of bipolar scissors and bipolar forceps in tonsillectomy.

Bipolar diathermy scissors tonsillectomy is a relatively new surgical technique. We conducted a prospective study of 90 patients to compare this technique with bipolar forceps tonsillectomy. We found that the use of the bipolar scissors required significantly less operating time (mean: 3.03 min less) and allowed patients to resume eating solid food more rapidly (mean: 40.35 min earlier). Bipolar scissors tonsillectomy was safe, and there were no intraoperative complications or primary hemorrhages. A postoperative follow-up telephone survey revealed that patients who underwent scissors tonsillectomy experienced no more morbidity than did the forceps group during the first 2 weeks after surgery. We conclude that bipolar scissors tonsillectomy is a safe and rapid technique that can be used successfully as an outpatient procedure.