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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.

Antrochoanal polyps (ACPs) are benign lesions that originate from the mucosa of the maxillary sinus, and extend into the nasal cavity to reach the choana and nasopharynx. The treatment of ACPs is surgical, with a number of different surgical techniques having been described. We describe the first case series of ACPs from the UK and the endoscopic surgical technique that we have employed. A retrospective case note review of patients with ACPs managed under the care of the senior author was conducted. Demographic and clinical data for all patients were reviewed. The main outcome parameter measured was any sign of recurrence. A total of 29 consecutive patients were included for analysis from a 5-year study period, with 19 males and 10 females, and a mean age of 37.4 ± 13.6 years. Four patients within our group were referred to us with recurrent ACPs for revision surgery. All patients underwent surgery via the same endoscopic technique. The mean follow-up period was 14.7 ± 16.9 months, with an average follow-up of 22.5 months for the four revision cases. There were no recurrences in any of our patients. We describe the first reported series of endoscopic sinus surgery for antrochoanal polyps in the UK, and the largest worldwide series described for endoscopic management of ACPs in adults. We have had no recurrent cases, with a mean follow-up period of 14.7 months.

Nasal vestibular stenosis can result in a challenging cosmetic deformity, for which a variety of techniques have been described, including scar excision and replacement with local flaps, composite or cartilage grafts, with or without stents. We describe the Z-plasty technique to widen the alar base and assess patient satisfaction from the surgery. A retrospective review of patients who underwent Z-plasty to the alar subunit for nasal vestibular stenosis over a 4-year period was conducted. Demographic data and patient satisfaction were evaluated using pre- and postoperative visual analog scores and Rhinoplasty Outcome Evaluation questionnaires. Eight patients underwent the procedure, and all confirmed significant improvement in their esthetic outcome. We describe our Z-plasty technique to the alar base and review patient satisfaction.

Invasive rhino-orbito-cerebral mucormycosis, a rare opportunistic fungal infection which can rapidly lead to death is strongly associated with diabetic ketoacidosis.

Despite its rarity, extramedullary plasmacytoma should be considered in the differential diagnosis of a base of tongue mass.

Silent sinus syndrome (SSS) is a rare and interesting clinical condition that is associated with spontaneous, painless, unilateral enophthalmos and hypoglobus resulting from downward bowing of the orbital floor, in the absence of any symptomatic sinonasal disease. It generally affects younger patients between the third and fifth decades of life. The pathogenesis of silent sinus syndrome is based on chronic maxillary sinus obstruction, related to occlusion of the maxillary infundibulum which results in a hypoventilated sinus and negative pressures. Endoscopic sinus surgery to create a wide maxillary antrostomy with or without orbital floor reconstruction is considered the gold standard treatment of choice.

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.

Nasal examination should be obligatory in any patient who is being considered for lacrimal surgery. Preoperative assessment should include nasal endoscopy to allow evaluation of any concurrent intranasal pathology or anatomical variations. Furthermore, lacrimal surgery itself is now widely practiced via an endoscopic approach and therefore ophthalmologists performing lacrimal surgery should familiarize themselves with the use of nasal endoscopes.

We report the successful expression of recombinant human ceruloplasmin which was made possible by inclusion of splicing signals in the expression vector. Ceruloplasmin cDNA expressed from the vector pNUT in baby hamster kidney cells gave protein yields of 0.03 mg/l which increased to 15 mg/l with splicing signals present. The defect in expression from the intronless cDNA is due to complete retention of ceruloplasmin mRNA in cell nuclei. The block to cytoplasmic export is alleviated by splicing signals, allowing full expression of the mRNA.

Objectives:1) Explore developments in endoscopic techniques and their application in the management of Sinonasal Inverted Papilloma (SNIP). 2) Describe 0% recurrence rates with aggressive endoscopic resection of complex SNIP.Methods:Retrospective single-center patient cohort analysis of twenty-one cases of SNIP treated by endoscopic resection at Charing Cross Hospital from December 2002 to September 2012. Pre-operative assessment included tomography or magnetic resonance imaging and biopsies. The origin and extent of the tumor determined the surgical strategy, and a combination of antrostomy, ethmoidectomy, sphenoidotomy, and endoscopic medial maxillectomy (EMM) with the assistance of angled instrumentation were performed. Sub-periosteal dissection followed by diamond burr drilling of the underlying bone were performed in all cases. All patients were followed up by regular endoscopic surveillance.Results:The study group consisted of 12 (57%) male and 9 (43%) female patients with a mean age of 59 years. El...

Objectives:Nasal vestibular stenosis results in significant functional impairment and cosmetic deformity. Various techniques can be used, including excision of the deformed segment and replacement with healthy tissue using local flaps, composite or cartilage grafts, with or without stents. W-plasty, Z-plasty, and double-cross plasty techniques have also been described. We aimed to evaluate the following outcome measures: 1) Describe our modified Z-plasty technique to widen the ala base. 2) Report patient satisfaction with respect to functional and cosmetic improvement.Methods:A retrospective study over a 4-year period was conducted on patients who underwent modified Z-plasty of the ala. This is performed under general anaesthetic, with infiltration of 2% lignocaine, and 1:80,000 adrenaline to the lateral alar margin and adjacent soft tissue, overlying the piriform aperture margin. A Z-plasty incision is made around the lateral ala and anterior nasal process of maxilla. The two triangular flaps are transpo...

Antrochoanal polyps (ACPs) are benign lesions that originate from the mucosa of the maxillary sinus, and extend into the nasal cavity to reach the choana and naso- pharynx. The treatment of ACPs is surgical, with a num- ber of different surgical techniques having been described. We describe the first case series of ACPs from the UK and the endoscopic surgical technique that we have employed. A retrospective case note review of patients with ACPs managed under the care of the senior author was con- ducted. Demographic and clinical data for all patients were reviewed. The main outcome parameter measured was any sign of recurrence. A total of 29 consecutive patients were included for analysis from a 5-year study period, with 19 males and 10 females, and a mean age of 37.4 ± 13.6 years. Four patients within our group were referred to us with recurrent ACPs for revision surgery. All patients under- went surgery via the same endoscopic technique. The mean follow-up period was 14.7 ± 16.9 months, with an average follow-up of 22.5 months for the four revision cases. There were no recurrences in any of our patients. We describe the first reported series of endoscopic sinus surgery for antro - choanal polyps in the UK, and the largest worldwide series described for endoscopic management of ACPs in adults. We have had no recurrent cases, with a mean follow-up period of 14.7 months.

The conventional treatment for patients with acute upper airway obstruction is tracheostomy, which is a safe, definitive procedure in most hands. Alternatively, a debulking procedure can be considered but this requires both surgical and anaesthetic skill and expertise. However, where possible, it provides a good alternative with the advantages of removing the cause of obstruction and yielding tissue for histopathological analysis, and avoiding the need for a tracheostomy, with its associated morbidity. We evaluated all patients who presented with acute upper airway obstruction and underwent endoscopic laser debulking surgery performed by the senior author, over a three and a half year period. We recorded patient demographic data, their underlying pathologies, complication rates associated with laser debulking surgery and the conversion to tracheostomy. Thirty patients were identified, including 19 males and 11 females, with a mean age of 57.10 ± 17.20 years (19–93 years). All patients underwent debulking procedures with carbon dioxide laser under general anaesthetic. All patients had their underlying diagnosis confirmed from their debulking surgery. Twelve patients were found to have benign pathology and 18 had malignant airway obstruction. There were no laser-associated complications. One patient required conversion to emergency tracheostomy, during their debulking surgery. Endoscopic laser assisted debulking surgery has successfully been used to establish a safe airway. It allows obtaining tissue specimens, to confirm the underlying diagnosis, thus avoiding the need for further biopsies under anaesthetic. For all malignant cases, patients were subsequently able to proceed to definitive treatment. It has obviated the need for emergency tracheostomy in almost all of the cases in our patient cohort.

The Rapid Diagnostic Clinic (RDC) was introduced to comply with NICE recommendations for improving head and neck cancer services (National Institute of Clinical Excellence 2004 Improving outcomes in head and neck cancer: the manual. NICE, London). It provides multi-modality specialist assessment for new referrals, with on-site sonography and cytology. We have critically appraised the efficacy of our RDC, with respect to its impact on patients’ timelines and outcomes. A retrospective audit of new referrals to the head and neck clinic during a 6-month period was conducted (pre-RDC period); areas in delay in patients reaching a definitive outcome were identified. Following implementation of the RDC, a second cycle, prospective audit was performed and its impact on timelines for patients’ journey and outcomes determined. One hundred and ninety-seven patients were seen during the pre-RDC period. The average time from referral to being seen was 11 days for 2-week wait (2WW) referrals and 34 days for other sources. During the RDC period, 299 patients were seen in total. The average waiting time was reduced to 9 days for 2WW referrals and 23 days for other referrals. During the RDC period, over one-third of patients utilised the provision of ultrasound ± FNAC, and consequently, the majority reached a definitive outcome (discharged or scheduled for surgery) following their first consultation. This was a significant improvement compared to the pre-RDC period, where the main outcome was referral for an investigation, with consequently longer waiting time for surgery. We report the first study to consider the effect of a ‘one-stop’ clinic on patients’ journey timelines and outcomes. Our study has shown that the RDC provides an efficient and effective system, which facilitates the patients’ pathway to a definitive management plan.

The goal of otoplasty is to achieve a normal antihelical fold with a scaphoconchal angle of about 90o, normally curved superior crus, and an adequate depth of the concha. After recession of the ear, neither the tail of the helix nor the antitragus should be abnormally prominent and the lobe should not bend forward. The vertical helical rim should be about 1.5 cm from the scalp, and the rim should have a curl. Thinning of the cartilage by drilling softens the cartilage spring and allows accurate shaping which can be held in a stable position by mattress sutures. It is a safe and controlled technique, and one can stop drilling when the desired result has been achieved. It is a middle path between cartilage-sparing and cartilage-cutting techniques and thus avoids the complications associated with both the techniques. The surgical technique using the diamond burr is described.

Objective: 1) Ascertain whether CT findings correlate with surgical need for access septoplasty during endoscopic sinus surgery. Evaluated due to risk of litigation from patients not consented for septoplasty who require it, despite having a “straight septum” on CT. 2) Establish whether site of septal deviation affects the requirement for septoplasty.Method: We retrospectively studied 129 endoscopic sinus surgery procedures. The preoperative CT report was recorded. Blinded to the report, 2 independent observers commented on evidence and site of septal deviation and predicted the need for access septoplasty. The operative notes were used to record the surgical outcome.Results: Septal deviation was reported by radiologists in 57 of the 129 patients (44%). Both observers agreed on septal deviation being present in 85 patients (66%). Thirteen of 87 patients who were predicted not to need access septoplasty underwent the procedure (15%). A confidence interval (CI) of 95% gives a range of 9%-24% for patients un...

Branchiootoic syndrome is part of the spectrum of brachiootorenal disorders. Brachiootorenal disorder is a rare autosomal dominant condition, characterized by malformations of the outer, middle, and inner ear, which are associated with branchial and renal anomalies. We describe a case of bilateral branchiootoic syndrome and discuss the anatomy of second branchial cleft fistulae and the surgical management of this uncommon condition. We report the case of a 6-year-old girl referred to our department with bilateral intermittently discharging neck swellings. Clinical examination revealed bilateral branchial fistulae and preauricular sinuses, on a background of a positive family history of branchial fistulae. A magnetic resonance imaging scan confirmed the diagnosis of bilateral second branchial cleft fistulae. In view of her symptoms, she underwent bilateral branchial fistula excision and tonsillectomy with an uneventful postoperative recovery.