Evaluation of the Management of Asymptomatic Unilateral Tonsillar Enlargement-Can We Avoid Diagnostic Surgery?

Unilateral tonsillar enlargement (UTE) generally prompts suspicion of malignancy and tonsillectomy is often performed for histological diagnosis. This may be unnecessary in asymptomatic patients. We performed a retrospective study of all patients who had asymptomatic UTE and underwent tonsillectomy over a 5-year period. We found no malignancies in our cohort of 78 patients. 22 out of 74 (29.7%) patients had a difference of 50% or more in the size of their tonsils. Around 1 in 4 patients had an inaccurate clinical diagnosis of UTE compared to the final size of their tonsil specimens. In a comprehensive literature review, only 2 out of 1152 patients (0.17%) were found to have lymphoma with UTE as the only presenting symptom and no other suspicious features. There can be huge variability between the size of normal tonsils. UTE alone without any other concerning features should prompt clinicians to consider other management options such as a period of observation rather than diagnostic tonsillectomy.

Rigid versus flexible endoscopy for managing ingested foreign bodies-can we improve pathways?

PURPOSE: This study aims to evaluate management pathways, outcomes and safety of rigid endoscopy (RE) and flexible endoscopy (FE) for the treatment of impacted foreign bodies of the upper gastrointestinal tract (UGIT) in adults. METHODS: Retrospective study, included all patients undergoing RE or FE for impacted UGIT foreign body over an 11-year-period. RESULTS: A total of 144 patients were included (95 FE and 49 RE). FE were performed under local anaesthetic or sedation, and RE under GA. Success rate of FE and RE were 95.8% and 95.9% respectively. During FE an intra-procedural biopsy was performed in 45/95 (47.3%); with 26/95(27.4%) identifying mucosal pathology. Complications was significantly higher in patients having RE (40.8% versus 6.3%, p = .001). CONCLUSION: FE and RE are effective for the therapeutic management of impacted UGIT foreign bodies. However, FE can be performed under LA and was associated with fewer complications, favouring FE where possible as a first line option.

Day-case discharge criteria and safety of children undergoing adenoidectomy and tonsillectomy for obstructive symptoms-A systematic review.

OBJECTIVES: Obstructive sleep apnoea (OSA) is a common indication for adenoidectomy and tonsillectomy in children. Traditional practice involves overnight admission to monitor for respiratory complications. However, there is a shift towards same-day discharge in selected patients. This systematic review aims to critically evaluate day-case criteria and safety in children with OSA undergoing adenotonsillectomy. DESIGN: We performed a systematic search of EMBASE, Medline and the Cochrane library. All data collected were independently validated for accuracy. Quality assessment of included articles was performed. The protocol was registered with PROSPERO. RESULTS: A total of 15 studies were included (10 731 patients). There was heterogeneity in methods used to ascertain OSA, day-case discharge criteria and lack of prospective discharge protocol. The proportion of children considered for planned day-case surgery ranged from 28.7%-100% based on individual criteria, with an average rate of successful same-day discharge of 96.1% in these patients. The reported rates of post-operative respiratory adverse events and need for airway intervention were 0%-27.3% and 0.4%-6.8%, respectively. There was no reported mortality. The studies were considered low to medium on quality assessment. CONCLUSION: There is a lack of prospective data on day-case criteria and systematic assessment of post-operative complications in children with OSA undergoing adenoidectomy and tonsillectomy. However, current literature suggests that day-case surgery is safe in carefully selected patients. Better characterisation of patient-specific risk factors is needed to develop an optimal criteria-based timeline for safe discharge. This has the potential to improve confidence and uptake across units.

The utility of liver function tests and abdominal ultrasound in infectious mononucleosis-A systematic review.

INTRODUCTION: A large proportion of patients with infectious mononucleosis (IM) have abnormal liver function tests (LFT) at presentation. There is no guideline regarding the management and follow-up of these patients. Some patients also have abdominal ultrasound (US) due to deranged LFT, the need for this practice is unclear. The aim of this systematic review was to evaluate the evidence base on LFT assessment in IM, time to resolution of derangement, and the role of abdominal US. METHODS: A systematic search of PubMed, EMBASE and the Cochrane library was done. Two authors independently screened records for eligibility using pre-defined criteria. We included both adult and paediatric populations. Quality assessment of included studies was done. RESULTS: A total of 3924 patients were included from 32 studies, of which LFT values were reported on 2779 patients. A combination of typical clinical features, heterophile antibodies and Epstein-Barr virus-specific antibodies were used to ascertain diagnosis. The following proportion of patients had abnormal LFT: aspartate transaminase (57%); alanine transaminase (62%); alkaline phosphatase (65%); bilirubin (16%); gamma-glutamyltransferase (41%). Reported median (interquartile range) time to resolution of LFT was 8 (6-12) weeks (n = 438). Maximum time to resolution was >6 months. Clinical hepatomegaly and splenomegaly were found in 35% and 44% of patients, respectively. Enlarged liver and spleen on US were seen in 16 of 29 and 38 of 38 of patients, respectively. There were no reports of decompensated liver disease. CONCLUSION: Current evidence questions the need for routine assessment of LFT in immunocompetent patients presenting with IM; serial LFT assessments following initial abnormalities are not required in immunocompetent patients with subclinical derangement of LFT; routine US abdomen in IM to evaluate for derangement of LFT is not required.

A systematic review of the feasibility and safety of day case nasal and/or palatopharyngeal surgery in patients with obstructive sleep apnoea.

INTRODUCTION: Recent guidelines suggest obstructive sleep apnoea (OSA) is not an absolute contraindication for same day discharge following surgery. The aim of this systematic review was to examine the feasibility and safety of day case nasal and/or palatopharyngeal surgery in patients with OSA. METHODS: We performed a systematic search of PubMed, EMBASE and the Cochrane library. Quality assessment of included studies was performed. The protocol of this systematic review was registered with PROSPERO (CRD42021273451). RESULTS: A total of 1836 patients from 10 observational studies were included. There were 268 (15.4%) nasal surgeries, 738 palatopharyngeal surgeries (42.4%) and 735 (42.2%) combined nasal and palatopharyngeal surgery. The majority of patients had moderate to severe OSA. A total of 860 patients (49.8%) were successfully discharged as day cases. There were no standard criteria for daycase surgery. Post-anaesthetic respiratory events were reported in 86/1750 (4.9%) patients. Oxygen desaturation was the most common respiratory event (83.7%, n = 72). There was no mortality reported. CONCLUSION: Current data suggests day surgery is feasible in carefully selected patients with OSA undergoing nasal and/or palatopharyngeal surgery. Further well-designed prospective studies with an emphasis on the systematic assessment of complications are required to establish safety and daycase criteria.

Systematic review of incidence, risk factors, prevention and treatment of post-laryngectomy hypoparathyroidism.

PURPOSE: Post-laryngectomy hypoparathyroidism is associated with significant short- and long-term morbidities. This systematic review aimed to determine incidence, risk factors, prevention and treatment of post-laryngectomy hypoparathyroidism. METHODS: Medline, EMBASE and the Cochrane library were searched for relevant articles on hypocalcaemia and/or hypoparathyroidism after laryngectomy or pharyngectomy. Two authors independently screened titles and abstracts from the search. Data from individual studies were collated and presented (without meta-analysis). Quality assessment of included studies was undertaken. The review protocol was registered in the PROSPERO database (CRD42019133879). RESULTS: Twenty-three observational studies were included. The rates of transient and long-term hypoparathyroidism following laryngectomy with concomitant hemi- or total thyroidectomy ranged from 5.6 to 57.1% (n = 13 studies) and 0 to 12.8% (n = 5 studies), respectively. Higher transient (62.1-100%) and long-term (12.5-91.6%) rates were reported in patients who had concomitant oesophagectomy and total thyroidectomy (n = 4 studies). Other risk factors included bilateral selective lateral neck dissection, salvage laryngectomy and total pharyngectomy. There is a lack of data on prevention and management. CONCLUSION: Hypoparathyroidism occurs in a significant number of patients after laryngectomy. Patients who underwent laryngectomy with concomitant hemithyroidectomy may still develop hypoparathyroidism. Research on prevention and treatment is lacking and needs to be encouraged.

Calcium, vitamin D or recombinant parathyroid hormone for managing post-thyroidectomy hypoparathyroidism.

BACKGROUND: Post-surgical hypoparathyroidism is a common complication after thyroid surgery. The incidence is likely to increase given the rising trend in the annual number of thyroid operations being performed. Measures to prevent post-thyroidectomy hypoparathyroidism including different surgical techniques and prophylactic calcium and vitamin D supplements have been extensively studied. The management of post-thyroidectomy hypoparathyroidism however has not been extensively evaluated. Routine use of calcium and vitamin D supplements in the postoperative period may reduce the risk of symptoms, temporary hypocalcaemia and hospital stay. However, this may lead to overtreatment and has no effect on long-term hypoparathyroidism. Current recommendations on the management of post-thyroidectomy hypoparathyroidism is based on low-quality evidence. Existing guidelines do not often distinguish between surgical and non-surgical hypoparathyroidism, and transient and long-term disease.The aim of this systematic review was to summarise evidence on the use of calcium, vitamin D and recombinant parathyroid hormone in the management of post-thyroidectomy hypoparathyroidism. In addition, we aimed to highlight deficiencies in the current literature and stimulate further work in this field. OBJECTIVES: The objective of this systematic review was to assess the effects of calcium, vitamin D and recombinant parathyroid hormone in managing post-thyroidectomy hypoparathyroidism. SEARCH METHODS: We searched CENTRAL, MEDLINE, PubMed, Embase as well as ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 17 December 2018 (except Embase, which was last searched on 21 December 2017). No language restrictions were applied. SELECTION CRITERIA: We planned to include randomised control trials (RCTs) or controlled clinical trials (CCTs) examining the effects of calcium, vitamin D or recombinant parathyroid hormone in people with temporary and long-term post-thyroidectomy hypoparathyroidism. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles, abstracts and full texts for relevance. MAIN RESULTS: Database searches yielded a total of 1751 records. We retrieved potentially relevant full texts and excluded articles on the following basis: not a RCT or CCT; intervention, comparator or both did not match prespecified criteria; non-surgical causes of hypoparathyroidism, and studies on prevention. None of the articles was eligible for inclusion in the systematic review. AUTHORS' CONCLUSIONS: This systematic review highlights a gap in the current literature and the lack of high-quality evidence in the management of post-thyroidectomy temporary and long-term hypoparathyroidism. Further research focusing on clinically relevant outcomes is needed to examine the effects of current treatments in the management of temporary and long-term post-thyroidectomy hypocalcaemia.

First impressions count: does FAIRness affect adaptation of clinical clerks in their first clinical placement?

BACKGROUND: FAIRness (Feedback, Activity, Individualisation, Relevance) teaching is a structured program, comprising series of classes in which student work is anonymised and reviewed by the whole class, as well as students receiving private feedback on their written work. The class work emphasises logic, structure and order in history and examination, with a diagnostic and management focus. AIM: The effect of FAIRness teaching methods on the adaptation of medical students entering their first clinical rotations was studied. METHODS: 18 students in FAIRness placements and 72 students in conventional placements, all in medical/surgical units in the same University teaching hospital were studied. They completed questionnaires relating to effectiveness and quality of clinical teaching. Some students additionally attended focus groups, at the start of placement to discuss their expectations, and after 3 weeks, to discuss their adaptation to the clinical learning environment. RESULTS: All students entering clinical placements had low expectations of their future teaching. Students in standard placements still expressed negative attitudes after 3 weeks, while students on FAIRness placements felt positive. Students in FAIRness placements scored significantly higher on questions related to feedback and review of student work. CONCLUSION: FAIRness teaching practices help students to adapt to their first clinical placements.

Nasal septal abscess following septoplasty in a patient with type 2 diabetes mellitus.

A man in his 50s with type 2 diabetes mellitus (T2DM) presented with a nasal septal abscess 3 weeks following septoplasty. Diabetes mellitus has been reported in association with nasal septal abscess, thought to be due to a relative immunodeficient state. We present an unusual, delayed presentation of nasal septal abscess following septoplasty and performed a literature review. Nasal septal abscess is rare. It is associated with significant complications if not diagnosed and management expediently. The association between T2DM and nasal septal abscess following septoplasty emphasises the importance of good perioperative blood sugar control and postoperative nasal care and raises the question of empirical antibiotics in this group.

Paratracheal lymph node dissection during total (pharyngo-)laryngectomy: A systematic review and meta-analysis.

OBJECTIVES: The objective of this review was to determine the rate and risk factors of paratracheal lymph node (PTLN) involvement during total laryngectomy (TL) or total pharyngolaryngectomy (TPL). In addition, we aimed to assess its prognostic significance in terms of survival and peristomal recurrence. METHODS: A comprehensive electronic search was performed on PubMed, EMBASE, and CENTRAL databases. We searched for studies reporting outcomes of PTLN dissection during radical laryngeal surgery for squamous cell carcinoma of the larynx, hypopharynx or cervical oesophagus. RESULTS: We included a total of ten studies (838 patients). The overall rate of PTLN dissection positivity was 18.6% (20.7% for primary TL, 8.7% for salvage TL). Random-effects meta-analysis identified T4 stage, N+ stage of the lateral neck, subglottis involvement and primary tumour arising from the hypopharynx or cervical oesophagus as significant risk factors for PTLN involvement. CONCLUSIONS: This meta-analysis allowed to better define the risk of PTLN involvement during TL or TPL, in a bid to guide indication for PTLN dissection. There is a need for further large studies reporting rigorously the outcomes of PTLN dissection in order to establish stronger evidence-based recommendations.

Outcomes and complications of incisionless otoplasty - A retrospective observational study and a review of the literature.

INTRODUCTION: Incisionless otoplasty is a more recently described technique to correct prominent ears. It is thought to provide a more natural cosmetic look, easier to perform, and achieve quicker recovery when compared to conventional otoplasty. The safety and efficacy of the procedure is not well characterised as there is limited data on outcomes and complications. METHODS: This was a retrospective study to evaluate outcomes and complications of incisionless otoplasty. We included all children who underwent incisionless otoplasty by a single surgeon over a 9-year period at a tertiary paediatric ear, nose and throat (ENT) unit. RESULTS: A total of 32 children were included in this study (62 ears operated on). Using facial dimension measurements to analyse preoperative and postoperative photographs, the proportion of prominent ears reduced from 43/56 (76.8%) to 8/45 (17.8%). The children reported good cosmetic outcomes in 38/40 (95.0%) ears. Assessment of preoperative and postoperative photographs considered 34/39 (87.2%) to have good cosmetic result. The following rates of complications were observed: infection, 6/62 (9.7%); blistering, 14/62 (22.6%); bleeding, 1/62 (1.6%); suture breakage/extrusion, 8/62 (21.9%); skin necrosis, 1/62 (1.6%). Further otoplasty procedures were done on five ears (8.3%). CONCLUSIONS: Incisionless otoplasty was associated with high success and satisfaction rates. A previously undescribed complication of early postoperative erythema, swelling and blistering may be unique to this technique. This procedure should be further evaluated to identify risk factors and preventative measures to reduce complications.

Simultaneous presentation of parathyroid carcinoma, papillary thyroid cancer and ACTH-independent hypercortisolism due to benign cortical adenoma.

A 46-year-old woman presented with hypertension and renal disease. Investigations showed severe hypercalcaemia due to primary hyperparathyroidism. Imaging demonstrated renal calculi and an incidental left adrenal lesion. Additional biochemistry confirmed adrenocorticotropic hormone-independent hypercortisolism. Ultrasound and sestamibi scan found an enlarged right-sided parathyroid gland and a suspicious right thyroid nodule, biopsy of which suggested papillary carcinoma. The right parathyroid mass, right thyroid lobe and right central compartment tissue along with a segment of the right recurrent laryngeal nerve was resected en-bloc Completion thyroidectomy and left adrenalectomy were performed 6 months later. Histology showed parathyroid cancer, multifocal papillary thyroid cancer and adrenal clear cell cortical adenoma. Genetic tests were normal. There was no evidence of recurrence at 12 months follow-up. Parathyroid cancer should be suspected in the presence of significant hypercalcaemia, very high parathyroid hormone and end organ damage. Suspicious thyroid nodules on imaging should be appropriately investigated.

Incidence, prevalence and risk factors for post-surgical hypocalcaemia and hypoparathyroidism.

Hypocalcaemia following thyroid surgery is common and is associated with significant short and long term morbidity. Damage to or devascularisation of parathyroid glands is the predominant underlying mechanism; although other factors such as hungry bone syndrome may occasionally contribute to it in the immediate post-operative period. The reported incidence of post-surgical hypocalcaemia and/or hypoparathyroidism (PoSH) varies significantly in the literature; the variation thought to be at least partly due to differences in the definitions used. Figures on the prevalence of chronic or long term post-surgical hypocalcaemia in the population are unclear. Risk factors for PoSH have been extensively studied in recent years and may be classified into patient, disease and surgery related factors. Some risk factors are modifiable; but both modifiable and non-modifiable factors help in generating a risk profile that may be used to select patients for preventative measures and/or changes in surgical strategy. This narrative review discusses recent literature on the incidence, prevalence and risk factors for PoSH.

Long-term treatment-related morbidity in differentiated thyroid cancer: a systematic review of the literature.

BACKGROUND: Differentiated thyroid cancer (DTC) occurs in relatively young patients and is associated with a good prognosis and long survival. The management of this disease involves thyroidectomy, radioiodine therapy, and long-term thyroid-stimulating hormone suppression therapy (THST). The long-term effects of the treatment and the interaction between subclinical hyperthyroidism and long-term hypoparathyroidism are poorly understood. This review sought to examine the available evidence. METHODS: A PubMed search was carried out using the search terms "Thyroid Neoplasms" AND ("Thyroxine" OR "Hypocalcemia" OR "Thyrotropin"). Original English language articles published in the last 30 years studying the morbidity from thyroid-stimulating hormone (TSH) suppression and hypoparathyroidism following a surgery for DTC were retrieved and reviewed by 2 authors. RESULTS: Of the 3,000 results, 66 papers including 4,517 patients were selected for the present study. Studies reported on a range of skeletal (included in 34 studies, 1,647 patients), cardiovascular (17 studies, 957 patients), psychological (10 studies, 663 patients), and other outcomes (10 studies, 1,348 patients). Nine of 26 studies on patients who underwent THST showed a reduction in bone density, and 13 of 23 studies showed an increase in bone turnover markers. Skeletal effects were more marked in postmenopausal women. There was no evidence of increased fracture risk, and only little data were available on hypoparathyroidism. Four of five studies showed an increased left ventricular mass index on echocardiography, and one study showed a higher prevalence of atrial fibrillation (AF). There was little difference in basic physiological parameters and limited literature regarding symptoms or significant events. Six studies showed associations between long-term TSH suppression and impaired quality of life. Impaired glucose metabolism and prothrombotic states were also found in DTC patients. CONCLUSION: There is limited literature regarding long-term DTC treatment-related morbidity, particularly regarding the effects of long-term hypocalcemia. Most studies have focused on surrogate markers and not on clinical outcomes. A large prospective study on defined clinical outcomes would help characterize the morbidity of treatment and stimulate research on tailoring treatment strategies.

Impact of a novel teaching method based on feedback, activity, individuality and relevance on students' learning.

OBJECTIVE: This study examines the perceived impact of a novel clinical teaching method based on FAIR principles (feedback, activity, individuality and relevance) on students' learning on clinical placement. METHODS: This was a qualitative research study. Participants were third year and final year medical students attached to one UK vascular firm over a four-year period (N=108). Students were asked to write a reflective essay on how FAIRness approach differs from previous clinical placement, and its advantages and disadvantages. Essays were thematically analysed and globally rated (positive, negative or neutral) by two independent researchers. RESULTS: Over 90% of essays reported positive experiences of feedback, activity, individuality and relevance model. The model provided multifaceted feedback; active participation; longitudinal improvement; relevance to stage of learning and future goals; structured teaching; professional development; safe learning environment; consultant involvement in teaching. Students perceived preparation for tutorials to be time intensive for tutors/students; a lack of teaching on medical sciences and direct observation of performance; more than once weekly sessions would be beneficial; some issues with peer and public feedback, relevance to upcoming exam and large group sizes. Students described negative experiences of "standard" clinical teaching. CONCLUSIONS: Progressive teaching programmes based on the FAIRness principles, feedback, activity, individuality and relevance, could be used as a model to improve current undergraduate clinical teaching.

Phaeochromocytoma with hypercortisolism and hypercalcaemia.

We report a case of phaeochromocytoma associated with hypercortisolism and hypercalcaemia in a 62-year-old man. The patient presented to clinic, with a 3-year history of exertional headaches, and a 4-month history of increasing fatigue, sweating and palpitations, loss of appetite and weight, and sleepiness. He did not have a medical, family or social history that could account for these symptoms. 24 h urinary catecholamines, plasma metanephrines, 24 h urinary cortisol and adjusted serum calcium, were elevated. Overnight low-dose dexamethasone suppression test did not suppress morning plasma cortisol. Serum intact parathyroid hormone and parathyroid hormone-related peptide were low, and adrenocorticotropic hormone was normal. The patient was treated with intravenous 0.9% sodium chloride and disodium pamidronate to control hypercalcaemia. CT showed a 10 cm left adrenal mass. Following inpatient treatment with phenoxybenzamine, he underwent a left adrenectomy and histology confirmed a phaeochromocytoma. Postoperatively, he required long-term steroids for contralateral adrenal suppression. Adjusted serum calcium returned to normal postoperatively.

Effectiveness of preventative and other surgical measures on hypocalcemia following bilateral thyroid surgery: a systematic review and meta-analysis.

BACKGROUND: A variety of measures have been proposed to reduce the incidence of post-thyroidectomy hypocalcemia. The aim of this study was to perform a systematic review and meta-analysis of preventive and other surgical measures on post-thyroidectomy hypocalcemia as reported in the literature. METHODS: Comprehensive searches of the PubMed, EMBASE, and Cochrane databases were performed, and the quality of included papers was assessed using the Cochrane risk of bias tool or a modified Newcastle-Ottawa Scale (NOS). The results of all included studies were summarized, and meta-analyses were performed where appropriate. RESULTS: Thirty-nine randomized controlled trials (RCTs) and 37 observational studies were included. Measures studied included hemostatic techniques, extent of thyroidectomy and central neck dissection, surgical approach, calcium/vitamin D/thiazide diuretic supplements, parathyroid gland autotransplantation (PGAT) and intraoperative parathyroid gland (PG) identification, truncal ligation of inferior thyroid artery (ITA), preoperative magnesium infusion, and use of magnification loupes and Surgicel. Measures associated with significantly lower rates of transient hypocalcemia in meta-analysis were postoperative calcium and vitamin D supplementation compared to either calcium supplements alone (odds ratio (OR) 0.66; p=0.04) or no supplements (OR 0.34; p=0.007), and bilateral subtotal thyroidectomy (BST) compared to Hartley Dunhill (HD) procedure (OR 0.35; p=0.01). Meta-analyses did not demonstrate any measure to be significantly associated with a reduction in permanent hypocalcemia. CONCLUSION: This review identified postoperative calcium and vitamin D supplementation and bilateral subtotal thyroidectomy (over HD) as being effective in prevention of transient hypocalcemia. However, the majority of RCTs were of low quality, primarily due to a lack of blinding. The wide variability in study design, definitions of hypocalcemia, and methods of assessment prevented meaningful summation of results for permanent hypocalcemia.