Indeterminate thyroid nodules (Thy3): malignancy rate and characteristics in a study of 118 patients.

INTRODUCTION: Thyroid nodules are common, and the combined use of ultrasound and fine needle aspiration cytology provides useful information on their malignancy risk. The Thy reporting system is widely used in the United Kingdom, with malignancy rates for Thy3 cytology being quoted between 5% and 30%. This study aims to establish the risk of thyroid cancer in operated patients with Thy3 cytology and correlate it with patient demographics and nodule size. METHODS: This is a retrospective observational study of all thyroidectomies that took place in a single institution over a 3-year period (2019-2022). Those with a preoperative cytology of Thy3 were analysed further and in particular, nodule size, final histology and patients' demographics were documented. RESULTS: Some 260 thyroidectomies were performed during the study period. Of these, 118 patients had Thy3 cytology. In the Thy3a group (n = 70), the malignancy rate was 27.1%. The average age of those with thyroid cancer was 51.4 vs 51.2 years for those with benign disease. The nodule size was under 40mm for both groups (36mm vs 39.7mm). In the Thy3f group (n = 48), the malignancy rate was 43.8%. The average age of those with thyroid cancer was 53.5 vs 56.2 years for those with benign disease. The nodule size was similar (24.5mm vs 27.6mm). CONCLUSIONS: In this study, one in three patients with Thy3 cytology was diagnosed with thyroid cancer. We urge local units to analyse their data, to aid patients' informed decision-making. Within the subgroups, there was no significant difference in average nodule size or patients' age.

Using a 4K three-dimensional exoscope system (Vitom 3D) for mastoid surgery during the coronavirus disease 2019 pandemic.

OBJECTIVE: Microscopic surgery is currently considered the 'gold standard' for middle-ear, mastoid and lateral skull base surgery. The coronavirus disease 2019 pandemic has made microscopic surgery more challenging to perform. This work aimed to demonstrate the feasibility of the Vitom 3D system, which integrates a high-definition (4K) view and three-dimensional technology for ear surgery, within the context of the pandemic. METHOD: Combined approach tympanoplasty and ossiculoplasty were performed for cholesteatoma using the Vitom 3D system exclusively. RESULTS: Surgery was performed successfully. The patient made a good recovery, with no evidence of residual disease at follow up. The compact system has excellent depth of field, magnification and colour. It enables ergonomic work, improved work flow, and is ideal for teaching and training. CONCLUSION: The Vitom 3D system is considered a revolutionary alternative to microscope-assisted surgery, particularly in light of coronavirus disease 2019. It allows delivery of safe otological surgery, which may aid in continuing elective surgery.

Extended role of transnasal oesophagoscopy: a review of the literature.

BACKGROUND: Advances in endoscopic technology have allowed transnasal oesophagoscopy to be used for a variety of diagnostic and therapeutic procedures. METHOD: A review of the literature was carried out to look into the extended role of transnasal oesophagoscopy within otolaryngology, using the Embase, Cinahl and Medline databases. RESULTS: There were 16 studies showing that transnasal oesophagoscopy is safe and cost effective and can be used for removal of foreign bodies, tracheoesophageal puncture, laser laryngeal surgery and balloon dilatation. CONCLUSION: This study presents a summary of the literature showing that transnasal oesophagoscopy can be used as a safe and cost-effective alternative or adjunct to traditional rigid endoscopes for therapeutic procedures.

The incidence of post-thyroidectomy hypocalcaemia: a retrospective single-centre audit.

INTRODUCTION: The aim of this single centre retrospective observational record-based audit was to assess the incidence of post-thyroidectomy hypocalcaemia. The setting was a district general hospital in Hertfordshire covering a population of 500,000 people. A total of 196 patients who had had total or completion thyroidectomy during a five-year period were included in the study. MATERIALS AND METHODS: The primary outcome measure was to determine the rate of biochemical and symptomatic hypocalcaemia in patients undergoing total or completion thyroidectomy. Secondary outcome measures assessed time taken for biochemical and clinical hypocalcaemia to resolve, whether malignancy affected the rate of hypocalcaemia and if removal of parathyroid glands during surgery were a predictor of hypocalcaemia. RESULTS: The overall incidence of post-thyroidectomy hypocalcaemia (PTHC) within 24 hours was 21.4%. The incidence increased from 6 hours (13.8%) to 24 hours post-thyroidectomy (15.8%) and there was evidence of both transient and delayed PTHC within the first 24 hours. By 6 months post-surgery, 3.6% remained hypocalcaemic and required continual oral supplementation. Patients with benign thyroid disease had a higher risk of PTHC (P = 0.04) and patients younger than 50 years of age had a higher risk of symptomatic hypocalcaemia (P = 0.016). Other clinical factors including sex, type of surgery, neck dissection, oral calcium and/or vitamin D supplementation and inadvertent histological parathyroid gland excision were not associated with an increased incidence of PTHC or symptomatic hypocalcaemia. CONCLUSIONS: Our audit shows that the rate of PTHC within our population was below the national average with higher risk in benign thyroid disease.

Management of pinna haematoma study (MaPHaeS): A multicentre retrospective observational study.

OBJECTIVES: To assess current variation in the management of pinna haematoma (PH) and its effect on outcomes. DESIGN: Multicentre retrospective observational record-based study. SETTING: Eleven hospitals around the UK. PARTICIPANTS: Eighty-three patients above the age of 16 with PH. OUTCOME MEASURES: The primary outcome measure was recurrence rate of PH over a 6-month period post-treatment, assessed by treatment type (scalpel incision vs needle aspiration). Secondary outcome measures assessed the impact of other factors on recurrence, infection and cosmetic complications of PH over a period of 6 months. RESULTS: After adjusting for confounding factors, involvement of the whole ear, and management within an operating theatre were associated with a lower rate of recurrence of pinna haematoma. The drainage technique, suspected aetiology, choice of post-drainage management, grade and specialty of practitioner performing drainage, the use of antibiotic cover and hospital admission did not affect the rate of haematoma recurrence, infection or cosmetic complications. CONCLUSIONS: Where possible PH should be drained in an operating theatre. Multicentre randomized controlled trials are required to further investigate the impact of drainage technique and post-drainage management on outcome.

An exploratory investigation of personality types attracted to ENT.

BACKGROUND: Careers in medicine are embarked on by people with various personalities, with highly strung and motivated characters usually drawn to surgery. This study was conducted to identify the personality types of ENT surgeons in comparison to a control group of foundation doctors. METHOD: A validated personality questionnaire was distributed to ENT specialty trainees and two cohorts of foundation doctors between October 2013 and November 2015. The questionnaires were scored and individuals were categorised as having either type A or type B personalities. RESULTS: Response rates were 90 per cent (26 out of 29) for ENT specialty trainees and 76 per cent (79 out of 104) for foundation doctors. There was a significantly higher proportion of type A personalities in the ENT specialty trainees compared to the foundation doctors (18 out of 26 ENT specialty trainees vs 32 out of 79 foundation doctors; p = 0.01, chi-square = 6.4708). There were no associations between personality type and grade, gender or subspecialty of interest. CONCLUSION: ENT surgeons are more likely to be of type A personality in comparison to foundation doctors. This could be a reflection of the recruitment process into the specialty or a characteristic of individuals that get drawn to ENT.

Occupational musculoskeletal pain amongst ENT surgeons - are we looking at the tip of an iceberg?

OBJECTIVE: Surgeons are exposed to a variety of occupational risks, including work-related musculoskeletal disorders. This study investigated the prevalence of these latter disorders amongst UK ENT surgeons and compared this with the existing literature. METHODS: A survey containing questions on work-related musculoskeletal disorders was distributed to the entire membership of ENT-UK electronically, with the assistance of its Survey Guardian. A literature review on the subject was then performed. RESULTS: A total of 323 completed questionnaires were received (a 24 per cent response rate). Work-related musculoskeletal disorders had been experienced by 47.4 per cent of respondents. There were no statistical differences between the occurrence of work-related musculoskeletal disorders and: grade, length of time spent in the specialty or the subspecialty of respondents. Eighty-five per cent of affected surgeons sought treatment, with 22.9 per cent taking time off work and six surgeons retiring early. The literature review only identified five related studies. CONCLUSION: Despite the scarcity of studies, work-related musculoskeletal disorders are common amongst ENT surgeons in the UK. Such disparity highlights the need for more research and appropriate ergonomic intervention within the specialty.

Incidence and reporting of sharps injuries amongst ENT surgeons.

BACKGROUND: Sharps injuries are a common occupational hazard amongst surgeons. Limited work has been conducted on their effects within the ENT community. METHODS: A literature review was performed and a survey on sharps injuries was distributed to the entire membership of ENT-UK electronically. RESULTS: The literature review revealed 3 studies, with 2 of them performed more than 20 years ago. A total of 323 completed questionnaires were returned (24 per cent response rate). Of the respondents, 26.6 per cent reported having experienced sharps injuries. There was no statistical difference between the occurrence of sharps injuries and the grade, length of time spent in the specialty or subspecialty of respondents. Only 33.7 per cent of afflicted clinicians reported all their injuries as per local institutional policies. No seroconversions were reported. CONCLUSION: The study found poor evidence on sharps injuries amongst ENT surgeons, and low reporting rates that were comparable to other studies conducted in the UK. This highlights the need for further research and increasing awareness on sharps injuries regulations within the specialty.

Impact of Otolaryngology in the diagnosis of early oesophageal malignancy.

INTRODUCTION: A large number of patients present in Otolaryngology clinics with vague upper gastro intestinal symptoms, some potentially originating from the oesophagus. In the United Kingdom there is no consensus for investigation protocols. The concern is that diagnosis of early oesophageal malignancy can be delayed with detrimental effects to the prognosis of the patient. The aim of this paper is to attempt to establish the impact of Ear Nose and Throat (ENT) work up in the diagnostic pathway of these patients. METHODS: Retrospective analysis of case notes of newly diagnosed oesophageal carcinoma over a 15 month period. RESULTS: Sixty five patients with a new diagnosis of oesophageal carcinoma were identified from the upper GI cancer network. A cohort of 7 patients was initially referred to ENT with related symptoms. Delays occurred at different stages during the course of their diagnostic pathways. Only 2 patients were diagnosed from ENT prior to referral to upper GI. CONCLUSION: We support the creation of one stop clinics incorporating the use of transnasal oesophagoscopy. The current literature is discussed.

Spontaneous resolution of cerebrospinal fluid otorrhoea in a patient with a Hyrtl's fissure.

OBJECTIVE: This paper reports a rare case of cerebrospinal fluid leak due to a Hyrtl's fissure and discusses the non-operative management of the case. Background and case report: Cerebrospinal fluid otorrhoea is a rare phenomenon arising from an abnormal communicating tract between the subarachnoid space and middle ear. Affected patients are at a higher risk of developing meningitis and other neuro-otological complications. There are four common congenital causes of cerebrospinal fluid otorrhoea in the region of a normal labyrinth. This paper describes a case of cerebrospinal fluid in the middle ear resulting from a Hyrtl's fissure, which resolved spontaneously. CONCLUSION: A literature search indicated this to be the first case with such a resolution without the need for any intervention.

Occupational health issues amongst UK doctors: a literature review.

BACKGROUND: Around 1.1 million people suffer from occupational health diseases in the UK. Work-related conditions reported by doctors include mental health disorders, musculoskeletal problems and skin disorders. AIMS: To investigate the prevalence of occupational illness in UK doctors from different specialties. METHODS: A literature search conducted on PubMed, EMBASE, MEDLINE® and Health Management Information Consortium (HMIC) identified relevant research about doctors between the years 1990 and 2013. RESULTS: Seventy-two papers were identified. The majority of studies were cross-sectional with no random ized controlled trials or meta-analyses found. Mental health issues including burnout were widely reported and were attributed to greater job constraints, managerial issues, difficulty with clinical cases and lack of job satisfaction. Substance abuse in doctors was reported to be a risk of maladaptive coping mechanisms and was associated with early retirement. Surgeons were reported as being at greatest risk of needle-stick injuries and musculoskeletal pain. Orthopaedic surgeons were reported to be at risk of noise-induced hearing loss as a result of the use of air-powered and electric drills. There was limited research found concerning contact dermatitis and work-related malignancies amongst doctors in the UK. CONCLUSIONS: Our literature review found research on UK doctors for a variety of work-related illnesses with the prevalence varying depending on both specialty and seniority. This could have adverse effects both on the individual and the provision of patient care. Further studies are required to investigate the epidemiology of noise-induced hearing loss, nosocomial infections, skin-related disorders and work-related malignancies.

Airway emergency from spontaneous haemorrhagic thyroid cancer.

Spontaneous thyroid haemorrhages are rare. There are reported cases occurring in thyroid nodules and cysts but none in thyroid malignancies. We describe a 48 year old who presented to the on-call ENT team with a rapidly progressing neck swelling that was interfering with his airway. After resuscitation, the patient underwent a right lobectomy to stop the bleeding. Histology showed a thyroid follicular carcinoma. As per the regional multidisciplinary team discussion, he underwent a completion thyroidectomy followed by radioactive iodine treatment. We conclude that spontaneous haemorrhages of the thyroid gland can occur in malignancies and stress the importance of early histological diagnosis.

Optimising endoscopic stapling of pharyngeal pouches.

BACKGROUND: Endoscopic hypopharyngeal diverticulotomy is now largely performed using an endoscopic stapling device. A poorly applied endoscopic stapling device can result in incomplete division of the cricopharyngeal bar, necessitating the application of a second set of staples. Applying more than one set of staples is associated with an increased risk of complications and greater cost. Small pharyngeal pouches are difficult to staple because of difficulties engaging the stapling device over the cricopharyngeal bar. METHOD: Two pairs of oesophageal forceps are used in conjunction with a 0 degree Hopkins rod to optimise the endoscopic stapling of small and large pharyngeal pouches. RESULTS AND CONCLUSION: Applying grasping forceps to the cricopharyngeal bar improves the accuracy of the stapling procedure, thus reducing the morbidity and cost associated with multiple staple applications.