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Introduction Hyperthyroidism (HT) has been associated with no insignificant rates of thyroid malignancy. There are no current specific guidelines that suggest routine preoperative imaging for thyroid nodules in patients with Grave's disease. We therefore performed a systematic review assessing rates of thyroid malignancy in patients undergoing surgery for different causes of HT: Grave's disease (GD), toxic adenoma (TA) and toxic multinodular goitre (TMNG). Methods Major databases (MEDLINE, PubMed and the Cochrane library) were searched to identify eligible studies. Results After searching and appraising, 33 papers were found to be eligible for analysis. The mean overall rate of malignancy was 8.5% (range 0.8%-32.4%). The mean rates based on histological subtype were as follows: papillary thyroid cancer (PTC), 3.1% (range 0%-13.2%); micropapillary carcinoma (mPTC), 5.1% (range 0%-16.9%); and follicular thyroid cancer (FTC), 0.8% (range 0%-4.4%). In those patients who had preoperative imaging, mean malignancy rates were higher in patients with pre-identified nodules (19.8%) compared to those without any nodules (8.7%). Mean rates were lower in patients with GD/diffuse goitre (5.9%) compared to patients with TA (6.5%) and TMNG (12%). Conclusion Hyperthyroidism is associated with notable rates of thyroid cancer, although the mechanisms for this are not clear. The presence of nodules increases this risk. This review raises the question for considering preoperative assessment of nodules in all patients undergoing surgery for HT, in order to correctly assess and evaluate any patients with suspected concurrent thyroid malignancy, before proceeding with surgery.

A woman in her 50s was referred with suspected thyroid malignancy and underwent total thyroidectomy. Immunohistochemical analysis revealed IgG4-positive Hashimoto’s thyroiditis. IgG4-related thyroid disease is poorly understood, and thought to encompass various entities including IgG4-positive Hashimoto’s thyroiditis, Fibrosing Variant of Hashimoto’s thyroiditis, Reidel’s thyroiditis and Graves’ disease with elevated IgG4 levels. Furthermore, it may be associated with a systemic fibrosing condition called ‘IgG4-related sclerosing disease’. The clinical significance of IgG4-positive thyroid disease, however, remains unclear.

Background: FESS encompasses numerous component procedures including antrostomy, ethmoidectomy, sphenoidotomy and frontal sinusotomy. The extent of FESS procedure will vary between patients depending on indications, imaging and surgical experience. Each procedure is remunerated according to procedural components with each component assigned an OPSC-4 cost code. In NHS hospitals, this relies on clinical coders’ interpretation from the operation note, and may potentially be subject to incorrect coding and remuneration. Background: We have devised a FESS documentation tool which includes a tick box system for each component and allied procedures performed, together with relevant OPSC-4 codes.The aim of this novel FESS operation note is to improve accuracy of coding for procedures, avoid misinterpretations and ensure accurate remuneration for FESS procedures. Design: Retrospective quality improvement study. Methods: The tool was implemented in our hospital in April 2019. Codes and costs applied to each patient undergoing FESS for a 6-month period between April to October 2019 were compared for all cases performed during the same 6 month period in 2018. Data review of coding information was performed between the two time periods including T-test analysis to calculate for statistical significance. Results: 66 patients underwent FESS in 2018 compared to 70 patients in 2019, during the equivalent 6 month period. The tool was not used in two cases in the 2019 cohort. In 2018, the average cost applied to each FESS case was £1,676, compared to £1,953 per patient in the 6 months after the tool was implemented. This resulted in an average uplift of £277 in revenue per patient where the tool was used (p=0.003), due to more accurate capture and coding of FESS component parts. On average ,approximately 140 patients undergo FESS per year in our department; using the newly devised FESS documentation tool, we can estimate a potential increase in revenue of £38,780 per annum for FESS procedures alone. Conclusion: Our novel documentation tool has improved the clarity of recording endoscopic sinus surgery allowing more accurate interpretation and application of OPSC-4 coding. It also aids in understanding complex composite procedures and can be extended to other surgical specialties.

We present a rare case of a 31-year-old patient with Graves’ disease with agenesis of the left thyroid lobe. The patient was managed with a right hemithyroidectomy and isthmusectomy as definitively treatment of Graves’ disease. The patient had an uneventful postoperative outcome and the histology was benign and consistent with Graves’ disease. This is a rare case in the literature of Graves’ disease with unilateral thyroid agenesis, and to our knowledge is the first reported case from the UK.

Nursing staff play a crucial role in managing surgical patients in the postoperative period. However, with an increasing risk of subspecialty wards facing closure as a result of financial pressures within the NHS, the knowledge base and expertise of ward-based nursing staff of surgical subspecialties is becoming increasingly limited. Using patients undergoing thyroidectomy as an example, a quality improvement multidisciplinary audit is presented, which shows how simple targeted interventions through a multidisciplinary approach can help maintain high standards of patient care in a secondary care setting.

Objective:The endoscopic modified Lothrop procedure is mainly used for refractory frontal sinusitis. However, we have used it as an access procedure to facilitate treatment for an extended range of additional frontal sinus pathologies.Methods:A retrospective review of patients who underwent the endoscopic modified Lothrop procedure for ‘alternative’ frontal sinus pathologies was conducted. Patient data were reviewed. The main outcome parameter measured was signs of recurrence.Results:Twelve patients (6 males, 6 females) from a 7-year study period, with a mean age of 45.2 years (range, 16–78 years), were analysed. The surgical indications included frontoethmoidal mucoceles, cerebrospinal fluid leaks within the frontal sinus, cystic fibrosis, frontal sinus osteoma, frontal sinus ossifying fibroma and frontal silent sinus syndrome. The mean follow-up period was 33.3 months. There were no known recurrences.Conclusion:We have used the endoscopic modified Lothrop procedure for a range of frontal sinus pathologies, safely and effectively, with no peri-operative complications.

Objectives To assess olfactory outcomes in patients undergoing septorhinoplasty surgery in our unit. Design Prospective cohort study. Setting The Royal National Throat Nose and Ear Hospital, London. Participants Forty-three patients undergoing functional septorhinoplasty (Males = 26; mean age = 34.1 ± 12.2) were recruited into the study. Main outcome measures The primary outcome of olfactory function was assessed using ‘Sniffin sticks’. Our secondary outcomes were assessment of patient quality of life using the disease specific Sino-nasal Outcome Test-23 questionnaire (SNOT-23) and a visual analogue scale for sense of smell. These measures were repeated at 12 weeks post operatively. Results There was a significant change in the Sniffin’ sticks score post-operatively (8.3 versus 9.6; P

We present a case of an 80-year-old patient with three concurrent multiple atypical parathyroid adenomas. The patient was managed with bilateral parathyroid exploration and concurrent parathyroidectomy. Postoperative recovery was uneventful. Atypical parathyroid adenomas are a rare entity that are clinically difficult to distinguish from parathyroid carcinoma. Histological characteristics are similar however atypical adenomas lack complete capsular or vascular invasion and cannot be considered malignant. All reported cases of atypical parathyroid adenoma are solitary lesions. We present the first case of multiple concurrent atypical parathyroid adenomas.

Objectives To assess the reliability of nasal inspiratory peak flow (NIPF) in providing a clinically accurate objective measure following functional septorhinoplasty by comparing it to the validated disease-specific quality-of-life questionnaire, SNOT-22. Studies so far have demonstrated poor correlation between bilateral NIPF and symptom-specific nasal questionnaires following septorhinoplasty. Design To perform a prospective comparative analysis between NIPF and the validated disease-specific quality-of-life questionnaire SNOT-22 and to determine whether a correlation exists following septorhinoplasty surgery. Setting The Royal National Throat Nose and Ear Hospital, London. Participants A total of 122 patients (78 males, 44 females; mean age 33.5 ± 12.2 years) were recruited from the senior authors rhinology clinic and underwent functional septorhinoplasty surgery. Main outcome measures Preoperative and postoperative nasal inspiratory peak flow (NIPF) measurements were performed in addition to the completion of three subjective quality-of-life and symptom assessment tool questionnaires; Sinonasal Outcome Test 22 (SNOT-22), Nasal Obstruction Symptom Evaluation (NOSE) and Visual Analogue Scale (VAS: 0–10). Results The mean preoperative NIPF was 88.2 L/min, and the postoperative value was 101.6 L/min and showed a significant improvement following surgery (P = 0.0064). The mean total SNOT-22 score improved significantly from 48.6 to 26.6 (P

Dacryocystorhinostomy via an endoscopic approach is now widely favored and considered to result in comparable outcomes to similar surgery via an external approach. Such surgery is usually done jointly between ophthalmologists and otolaryngologists. If endoscopic surgery is to be considered, patients should have a complete preoperative assessment to facilitate surgical planning. Clearly, patients with lacrimal obstruction require a comprehensive ophthalmologic assessment to confirm the diagnosis. However, in addition nasal examination should be considered obligatory in such patients, for evaluation of any concurrent intranasal pathology or anatomical variations, and therefore ophthalmologists practicing lacrimal surgery should familiarize themselves with the use of the nasal endoscopes. Examination with a nasal speculum and headlight provides only a limited view of the anterior nasal passages, and therefore rigid nasal endoscopy should be performed as part of the standard preoperative assessment.

Antrochoanal polyps (ACP) are benign, large, inflammatory polyps which originate from within the maxillary sinus and extend through the natural or accessory ostia, into the nasal cavity, with extension into the choana. They are relatively uncommon, accounting for just 3 – 6% of all nasal polyps, although they are much more frequently encountered in children, affecting upto 35% of the paediatric population 1. Even among adults, they usually present at a younger age, as compared with usual nasal polyps with a mean age at diagnosis of 27 and 50 years respectively 2. This article is protected by copyright. All rights reserved.

The metastatic spread of infraclavicular malignancies to the nasal cavity is rare. We describe the case of a 58-year-old man who presented with a 4-month history of right-sided rhinorrhoea, maxillary hypoesthesia, hyposmia and hypogeusia. Clinical examination revealed an irregular mass within the right nasal cavity. Immunohistochemical analyses of biopsies were consistent with small cell carcinoma of indeterminate origin. A positron emission tomography scan demonstrated extensive mediastinal lymphadenopathy with collapse-consolidation of the right lung's middle lobe and no other sites of metastasis. Following discussion at the lung multidisciplinary team meeting, a diagnosis of metastatic small cell lung cancer (SCLC) was made; the patient was staged with N3, M1b disease and palliative chemo-radiotherapy was started. To the best of our knowledge, this report represents the first documented case of a solitary nasal cavity metastasis arising from a SCLC.