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Vagus Nerve Stimulation (VNS) paired with rehabilitation delivered by the Vivistim® Paired VNS™ System was approved by the FDA in 2021 to improve motor deficits in chronic ischemic stroke survivors with moderate to severe arm and hand impairment. Vagus nerve stimulators have previously been implanted in over 125,000 patients for treatment-resistant epilepsy and the surgical procedure is generally well-tolerated and safe. In this report, we describe the Vivistim implantation procedure, perioperative management, and complications for chronic stroke survivors enrolled in the pivotal trial.The pivotal, multisite, randomized, triple-blind, sham-controlled trial (VNS-REHAB) enrolled 108 participants. All participants were implanted with the VNS device in an outpatient procedure. Thrombolytic agents were temporarily discontinued during the perioperative period. Participants were discharged within 48 hrs and started rehabilitation therapy approximately 10 days after the Procedure.The rate of surgery-related adverse events was lower than previously reported for VNS implantation for epilepsy and depression. One participant had vocal cord paresis that eventually resolved. There were no serious adverse events related to device stimulation. Over 90% of participants were taking antiplatelet drugs (APD) or anticoagulants and no adverse events or serious adverse events were reported as a result of withholding these medications during the perioperative period.This study is the largest, randomized, controlled trial in which a VNS device was implanted in chronic stroke survivors. Results support the use of the Vivistim System in chronic stroke survivors, with a safety profile similar to VNS implantations for epilepsy and depression.

Objectives The aim of this study was to assess the current post-tonsillectomy haemorrhage and return to theatre rates in Scotland. Design National cross-sectional study. Participants and setting Tonsillectomy outcomes data were collated for all NHS patients undergoing tonsillectomy in Scotland between 1998-2002 and 2013-2017. Main outcome measures Using Information Services Division (ISD) Scotland retrospective data, 30-day re-admission and 30-day return to theatre rates allowed an assessment of post-tonsillectomy haemorrhage rates. Data were validated through comparison with an audit conducted in NHS Greater Glasgow & Clyde between 2015 and 2016. Results Tonsillectomy was performed in 27 819 patients between 1998 and 2002, and 23 184 patients between 2013 and 2017. 30-day re-admission rates increased considerably between the 1998-2002 and 2013-2017 cohorts, from 4.7% to 12.1% in paediatric patients, and 9.8%-19.9% in adult patients. Similarly, 30-day "return to theatre rates" increased between the two cohorts, from 1.2% to 1.7% in paediatric patients, and 3.6%-4.9% in adult patients. Re-admission and return to theatre rates were similar across Health Boards for both adult and paediatric tonsillectomies in each cohort. Conclusions Current 30-day re-admission and return to theatre rates are significantly higher than the majority of reported series to date. The rising rate of tonsillectomy haemorrhage between cohorts is likely to be multifactorial, possibly reflecting an underestimation of previous rates and the changing profile of the tonsillectomy patient. A detailed audit of current practice is needed to investigate these tonsillectomy outcomes, which are similar across all Health Boards in Scotland. Of most significance are the implications for accurate patient consent and non-elective ENT service provision.

Introduction Flexible nasendoscopy (FNE) is the principal assessment method for vocal cord movement. Because the procedure is inherently subjective it may not be possible for clinicians to grade the degree of vocal cord movement reliably. The aim of this study was to assess the accuracy and consistency of grading vocal cord movement as viewed via FNE. Methods Thirty FNE videos, without sound or clinical information, were assessed by six consultant head and neck surgeons. The surgeons were asked to assess and grade right and left vocal cord movement independently, based on a five-category scale. This process was repeated three times on separate occasions. Agreement and reliability were assessed. Results Mean overall observed inter-rater agreement was 67.7% (sd 1.9) with the five-category scale, increasing to 91.4% (sd 1.9) when a three-category scale was derived. Mean overall observed intra-rater agreement was 78.3% (sd 9.7) for five categories, increasing to 93.1% (sd 3.3) for three categories. Discriminating vocal cord motion was less reliable using the five-category scale (k = 0.52) than with the three-category scale (k = 0.68). Conclusions This study demonstrates quantitatively that it is challenging to accurately and consistently grade subtle differences in vocal cord movement, as proven by the reduced agreement and reliability when using a five-point scale instead of a three-point scale. The study highlights the need for an objective measure to help in the assessment of vocal cord movement.

The MEN1 gene is positioned on the long arm of chromosome 11 (11q13) and results in the production of menin. A classical tumour suppressor gene; the spectrum of reported germline MEN1 mutations occur throughout the gene with no strong genotype/phenotype relationship. Mosaicism is extremely rare, a recent report citing only 2 mosaic cases by next generation sequencing1. We describe a 43-year-old female with MEN1 mosaicism associated with parathyroid adenoma and probable gastrinoma. Our patient initially presented with nephrolithiasis and nephrocalcinosis alongside biochemistry of primary hyperparathyroidism. Imaging confirmed a right lower pole parathyroid adenoma and the lesion was removed, pathology confirming the diagnosis (July 2018). Post operatively she remained hypercalcaemic. Repeat imaging suggested a further right sided culprit lesion. One year previously (August 2017) she was admitted with a perforated duodenal ulcer within the first part of the duodenum (D1), ascribed to ibuprofen use, requiring surgical repair. Whilst awaiting repeat parathyroid surgery she represented with a further duodenal ulcer and perforation (February 2019) this time in the second part of the duodenum(D2). A second parathyroidectomy was performed and genetic investigations were instigated, given the presence of classical MEN1 phenotype. Again, pathology was consistent with a parathyroid adenoma (March 2019). DNA was extracted for next generation sequencing which revealed mosaicism with a c.124 G>A variant detected in the MEN1 gene at a level of approximately 15%. Further investigations have shown normal serum prolactin and pituitary and pancreatic MRI imaging. With no other family members testing positive (parents and 2/3 children) this mutation appears to be a de novo index case. Adjusted Calcium is normal 2.53 mmol/L (2.2-2.6 mmol/L) but serum Chromogranin A is elevated (2620 µg/L (ref range The c.124 G>A variant predicts an amino acid substitution p.(Gly42Ser) in menin structure, an amino acid change previously associated with MEN12. Given the paucity of MEN1 mosaicism reported within the literature with the presence of the two cell lines and only 15% mosaicism close monitoring will be crucial to determine the genotype/phenotype relationship in our patient. 1 Choppin et al 2019 Eur J Endocrinol 1; 180(2):L1-L3 2 Itoh et al 2017 Clin Pediatr Endocrinol 26;25-28

To assess the accuracy of initial combined cytological accuracy and radiological staging of patients suspected of having thyroid malignancy with their final histopathology. Retrospective case series in a tertiary referral centre for head and neck malignancy. All patients with malignant thyroid cytology and cytology suspicious for malignancy, between the dates of June 2010 and July 2014, were included. The pre-operative staging was compared against the final histological staging. Demographics and outcomes for each patient were recorded. Sixty-five patients were recorded in this group. 20 (30.7 %) were male. The mean age at presentation was 51 years (SD 16.8 years). 39 (60 %) patients were aged over 45 years. Fine needle aspiration cytology (FNAC) was performed in all patients and was Thy 4 in 40 (62 %) and Thy 5 in 25 (38 %). Following surgery or subsequent biopsy, FNAC was found to be accurate in 38/40 (Thy 4) and 25/25 (Thy 5) cases in diagnosing malignancy, with Thy 4 yielding 95 % malignancy and Thy 5 % 100 %. Fifty-eight patients underwent a surgical procedure for thyroid cancer. Two further patients had a diagnostic hemi-thyroidectomy for later proven benign disease. Five patients due to medical co morbidities, inoperable disease or refusal of surgery were managed non-surgically. In the surgical group 16 patients underwent a diagnostic hemi-thyroidectomy and 11 of these required a completion thyroidectomy. Forty-six patients underwent total thyroidectomy. Forty-six patients underwent a neck dissection: 27 prophylactic central compartment neck dissections and 19 planned therapeutic neck dissections were performed. Radiological staging correctly predicted final pathological TNM staging in 25 (43 %) patients. 27 (47 %) patients had radiological staging which under staged their final histological staging and 6 (10 %) patients had scans that over staged their cancer. Of those that were under staged, 15 (56 %) had their nodal disease under staged (following prophylactic central neck dissection). Radiological staging comprised ultrasound (n = 58) and CT scanning (n = 45/58 pre-operatively). Pre-operative staging in thyroid cancer should include cytology, ultrasound and CT scanning. Unless low-risk papillary thyroid cancer is suspected pre-operatively, patients with Thy 4 cytology can be given the offer of a total thyroidectomy as surgical management.

Background and aims We aimed to analyse the safety and feasibility of day case hemithyroidectomy. Methods and results We reviewed all hemithyroidectomies led by two surgeons across two sites between 2010 and the end of 2013. Patients were divided into ‘planned inpatient’ or ‘planned day case’. Results Day of discharge, conversion to inpatient procedure, intraoperative and postoperative complications and postoperative presentations or readmission to hospital were analysed. Age, gender, American Society of Anaesthesiologists score and indication for surgery were also recorded. One-hundred and eighty hemithyroidectomy cases were analysed, 35 (19.5%) were planned as inpatient procedures. Of the remaining 145 (80.5%) planned day case: 106 (73.1%) were successfully discharged on the same day and 39 (26.9%) were not; 11 (7.6%) were converted to inpatient procedures perioperatively; 8 (5.5%) had additional procedures; 6 (4.1%) had wound infections; 7 (4.8%) presented to ER; 1 (0.7%) of which required readmission to hospital for a reason unrelated to the surgery. None had laryngeal nerve palsy, compressive haematoma or symptomatic hypocalcaemia. Conclusion This study showed that hemithyroidectomy by experienced surgeons can be performed safely as a day surgery. No ‘planned day case patients’ in this study developed laryngeal nerve palsy, compressive haematoma or symptomatic hypocalcaemia.

Background and aims Thyroglossal surgery is not common in Scotland with 0.013 procedures performed per 1000 population in 2010. There is a growing practice in surgery to consolidate service providers to ensure a minimum ‘case volume’, with the belief that this will raise standards and improve co-ordination of services. We investigated thyroglossal surgery to see if this had occurred. Methods and results Data on thyroglossal surgery performed in Scotland from 1981 to 2010 were obtained from the Information Services Division of NHS Scotland. This was analysed to investigate the number of procedures involving thyroglossal tissue, the surgical speciality of operating surgeon and the health board in which the procedure was performed. Whilst the number of thyroglossal operations has remained essentially static over the study period, there has been a steady trend of consolidation of the surgical speciality performing the procedure. In 1981, 58% of thyroglossal surgery was performed by general surgeons, 18% by paediatric surgeons and 15% by ENT surgeons nationally. In 2010, ENT surgeons are performing 81%. Conclusions Our data suggest that the provision of thyroglossal surgery is being consolidated in Scotland by speciality and that ENT surgeons are providing this service in the majority of cases.

Background: Salivary lumps are common and constitute 13.8% of all lumps assessed at the North Glasgow neck lump clinic. We present our management plan for these conditions. Method: Literature search using key words salivary lumps or glands or cancer or sialadenitis or sialalisthiasis in combination with diagnosis, management, investigation, treatment, intervention and surgery was performed in June 2009 using MEDLINE and Pubmed. Data from the North Glasgow neck lump clinic database are also presented. Results: Published literature on management of salivary lumps is level 2/3 evidence. Conclusion: The majority of salivary gland swellings can be adequately assessed with ultrasound and ultrasound guided FNA. The majority of patients with salivary gland tumours are likely to benefit from surgical excision. Due to the higher risk of malignancy in submandibular gland tumours surgical excision should be undertaken, unless there is significant co-morbidity.

Supplemental Digital Content is available in the text., Background and Purpose— Recent animal studies demonstrate that vagus nerve stimulation (VNS) paired with movement induces movement-specific plasticity in motor cortex and improves forelimb function after stroke. We conducted a randomized controlled clinical pilot study of VNS paired with rehabilitation on upper-limb function after ischemic stroke. Methods— Twenty-one participants with ischemic stroke >6 months before and moderate to severe upper-limb impairment were randomized to VNS plus rehabilitation or rehabilitation alone. Rehabilitation consisted of three 2-hour sessions per week for 6 weeks, each involving >400 movement trials. In the VNS group, movements were paired with 0.5-second VNS. The primary objective was to assess safety and feasibility. Secondary end points included change in upper-limb measures (including the Fugl–Meyer Assessment-Upper Extremity). Results— Nine participants were randomized to VNS plus rehabilitation and 11 to rehabilitation alone. There were no serious adverse device effects. One patient had transient vocal cord palsy and dysphagia after implantation. Five had minor adverse device effects including nausea and taste disturbance on the evening of therapy. In the intention-to-treat analysis, the change in Fugl–Meyer Assessment-Upper Extremity scores was not significantly different (between-group difference, 5.7 points; 95% confidence interval, −0.4 to 11.8). In the per-protocol analysis, there was a significant difference in change in Fugl–Meyer Assessment-Upper Extremity score (between-group difference, 6.5 points; 95% confidence interval, 0.4 to 12.6). Conclusions— This study suggests that VNS paired with rehabilitation is feasible and has not raised safety concerns. Additional studies of VNS in adults with chronic stroke will now be performed. Clinical Trial Registration— URL: https://www.clinicaltrials.gov. Unique identifier: NCT01669161.

Asthmatic smokers have poor symptom control and accelerated decline in lung function. A reduced ratio of matrix metalloproteinase (MMP)-9/tissue inhibitors of metalloproteinases (TIMPs) in nonsmokers with asthma has been implicated in airway remodelling. We tested the hypothesis that sputum MMP-9 activity/TIMPs ratios are reduced in smokers compared with never-smokers with asthma and are associated with reduced lung function and altered computed tomography (CT) measures of airway wall dimensions.Lung function, airway dimensions by CT, and induced sputum concentrations (and activity) of MMP-9 and TIMP-1 and -2 were measured in 81 asthmatics and 43 healthy subjects (smokers and never-smokers). Respiratory epithelial MMP9 and TIMP mRNA was quantified in 31 severe asthmatics and 32 healthy controls.Sputum MMP-9 activity/TIMP-1 and TIMP-2 ratios, and nasal epithelial MMP9/TIMP1 and MMP9/TIMP2 expression ratios were reduced in smokers with asthma compared with never-smokers with asthma. Low sputum ratios in asthmatic smokers were associated with reduced post-bronchodilator forced expiratory volume in 1 s (FEV1), FEV1/forced vital capacity ratio and segmental airway lumen area.The association of a low sputum MMP-9 activity/TIMP-1 ratio with persistent airflow obstruction and reduced CT airway lumen area in smokers with asthma may indicate that an imbalance of MMP-9 and TIMPs contributes to structural changes to the airways in this group.

Keypoints • Caudal septal deformities if uncorrected can lead to poor functional and cosmetic outcomes. • Adequate fixation of the septum to the maxillary spine is paramount in correcting these deformities. • We describe a simple technique for securing the caudal septum to the maxillary spine that stabilises it in all three planes.

KEYPOINTS: Endoscopic ligation of the sphenopalatine artery (ESPAL) has recently become the treatment of choice for refractory epistaxis. This paper reviews the background, indications and potential complications of ESPAL. The main focus of this article is an online video tutorial on the anatomy and surgical technique of ESPAL. Web links lead to video clips of operative steps and therefore this paper should be read in front of a computer with access to the Internet. To study the techniques the links detailed below should be followed. (For computers running RealPlayer software the .wmv extension in each of these links should be replaced with the .rm extension.) * Incision, http://nhsgg.org.uk/content/streams/Figure3.wmv * Flap elevation, http://nhsgg.org.uk/content/streams/Figure4.wmv * Pedicle location, http://www.nhsgg.org.uk/content/streams/Figure5.wmv * Clip application, http://www.nhsgg.org.uk/content/streams/Figure6.wmv.

Background Matrix-metalloproteinase (MMP)-9 has been implicated in the pathogenesis of COPD, although its link to disease severity is unclear. The purpose of the study was to examine the relationship between disease severity assessed by lung function and computed tomography (CT) and sputum MMP-9 expression, concentration and activity in patients with COPD. Findings In 53 COPD subjects, smokers and ex-smokers; 46 healthy controls, smokers and never smokers, we measured sputum MMP-9 concentrations (ELISA) and enzyme activity (FRET), sputum MMP-9 mRNA expression, spirometry, diffusing capacity for carbon monoxide (DLco) and CT assessment of emphysema (% low attenuation areas below-950 Hounsfield units). Sputum MMP-9 concentrations and mRNA expression in COPD subjects were significantly greater than in healthy never-smokers (p = 0.007 and p = 0.001 respectively) and similar to those in healthy smokers. Disease severity when assessed by the extent of emphysema measured by CT, but not by spirometry or DLco values, was directly associated with sputum MMP-9 concentrations [r = 0.442 (0.171, 0.634), p = 0.020], and MMP-9 activity [r = 0.447 (0.219, 0.643), p = 0.010]. In moderate to severe COPD, increased MMP-9 mRNA expression levels were associated with reduced post-bronchodilator FEV1 [r = −0.530 (−0.686, -0.327), p 1/FVC ratio [r = −0.551 (−0.701, -0.354), p Conclusions Sputum MMP-9 concentrations in COPD are directly associated with the extent of emphysema measured by CT and MMP-9 expression levels are inversely associated with DLco. These findings support a role for MMP-9 in the pathogenesis of COPD.