HPV overtakes smoking as the leading cause of oropharyngeal cancer in Ireland: experience of a head and neck surgery tertiary referral centre.

BACKGROUND: Worldwide, the incidence of oropharyngeal squamous cell carcinoma (OPSCC) caused by human papillomavirus (HPV), a sexually transmitted virus, is increasing. This increase has yet to be demonstrated in an Irish cohort. AIMS: To evaluate the number of OPSCC presentations locally, to stratify cases by HPV status and to estimate if any changes in the patient population had occurred over a 10-year period. METHODS: A STROBE-compliant, retrospective evaluation of patients with OPSCC at St James's Hospital between 2012 and 2022 was performed. Patients with non-SCC histology, undocumented HPV status and residual or recurrent tumours were excluded. RESULTS: We included 294 patients with a mean age of 60.4 years (95% CI 59.2-61.5 years) and 175 (59.5%) patients had HPV+ OPSCC. The number of new OPSCC diagnoses increased from 115 patients (39.1%) between 2012 and 2016 to 179 patients (60.9%) between 2017 and 2021. This was associated with an increased proportion of HPV-linked OPSCC (50.4% 2012-2016 vs. 65.4% 2017-2021, p = 0.011). Over time, more patients had a functionally limiting comorbidity (p = 0.011). The mean age of HPV+ OPSCC cases increased by 3.6 years (p = 0.019). Patients with HPV+ OPSCC had greater 2-year OS (83.9% vs. 54.9%; p < 0.001) and 2-year DFS (73.5% vs. 45.6%; p < 0.001). The 2-year OS and DFS did not change over time for HPV+ or HPV- patients. CONCLUSIONS: In our institution, the number of patients with OPSCC is increasing due to an escalation in cases associated with HPV. Population-level interventions such as vaccination programs may alter the current increase in the incidence of these tumours.

Anaplastic thyroid cancer:Improved understanding of what remains a deadly disease.

BACKGROUND: Anaplastic thyroid cancer (ATC) is a rare, undifferentiated form of thyroid cancer accounting for less that 2 % of thyroid cancers. Here we provide an overview of the contemporary understanding of ATC as well as discussing in detail any pertinent updates in the molecular understanding and treatment of this disease with reference to the 2021 American Thyroid Association (ATA) guidelines. METHODS: A review of the literature regarding the understanding, management and prognosis of ATC was undertaken using both Pubmed and Cochrane databases along with local institutional experience. Studies published in the last 5 years were prioritised for inclusion. RESULTS: Between 80 and 90 % of patients will have disease that has spread beyond the thyroid gland at presentation. Despite the use of aggressive, multimodal, conventional treatment strategies encompassing surgery and chemoradiotherapy, the median overall survival has remained between 3 and 6 months. Our understanding has evolved regarding the key oncogenic mutations involved in the development of ATC. These include BRAF, RAS, PI3K, PTEN, TP53 and TERT mutations. There is growing evidence that novel targeted therapies against these mutations may improve outcomes in this disease which has led to FDA approval of dabrafenib/trametinib combined BRAF/Mek inhibition. CONCLUSIONS: The prognosis of ATC remains dismal. Recent development and approval of targeted therapies offers hope of improved oncologic outcomes with further data eagerly awaited surrounding the impact of these targeted therapies.

The role of surgery for anaplastic thyroid carcinoma in the era of targeted therapeutics: A scoping review.

Background: Questions exist regarding patient selection for surgery in anaplastic thyroid carcinoma (ATC), particularly with the advent of neoadjuvant-targeted therapeutics. The present scoping review sought to evaluate what extent of surgical resection should be performed in ATC. Methods: A scoping review was carried out in accordance with Joanna Briggs Institute and the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) protocols. Included studies were required to provide clear description of the surgery performed for ATC. Results: The final search identified 6901 articles. Ultimately only 15 articles including 1484 patients met inclusion criteria. A total of 765 patients (51.5%) underwent attempted curative intent surgery. The approach to resection of adjacent tissues varied between studies. Eight studies considered laryngeal ± pharyngeal resection (8/15, 53.3%), eight studies (53.3%) considered tracheal resection and again eight studies (53.3%) considered esophageal resection. More extensive resections increased morbidity without improving overall survival (OS) (<9 months in the 12 studies using a combination of surgery and chemoradiotherapy). In the three studies utilizing targeted therapy in addition to surgery, OS was notably improved while surgical resection following neoadjuvant therapy was less extensive. Conclusions: There is no clear agreement in the literature regarding the limits of surgical resection in locoregionally advanced ATC. A definition of surgically resectable disease will be required to guide surgical decision making in ATC, particularly with the potential to reduce tumor burden using neoadjuvant targeted treatment in suitable patients. Level of evidence: III.

'Juvenile' nasal angiofibroma presenting in adulthood.

Juvenile nasopharyngeal angiofibromas (JNAs) are rare hyper vascular, benign tumours typically demonstrating a locally aggressive growth pattern. The cardinal presenting symptoms are unilateral nasal obstruction and recurrent, spontaneous epistaxis. Cases outside the adolescent male population are exceedingly rare and present a diagnostic challenge. We present the case of a man in his 30s referred to our tertiary skull base centre, presenting with left nasal obstruction. Examination showed left nasopharyngeal fullness without a discrete mass. Cross-sectional imaging detailed a 2.5×2.1×1.3 cm mass localised to his left sphenoid sinus with bony erosion. Due to the suspicion of malignancy, multidisciplinary consensus was to perform a diagnostic excisional biopsy and this revealed a JNA. He remains clinically well and asymptomatic following surgery. This case highlights the potential for subtle symptomatology in the presentation of these tumours and the challenge in diagnosing a JNA outside the adolescent male population.

Training in Endoscopic Ear Surgery: A Scoping Review.

OBJECTIVE: Despite the increasing popularity of Endoscopic Ear Surgery (EES), there is a lack of evidence to guide trainees as they introduce EES into practice. This review aims to evaluate training in EES including the optimal introductory procedures, methods of training, the learning curve, and the determination of competency in EES. In addition, this review seeks to identify any areas falling within these themes requiring further clarification. DATA SOURCES: A database search of Pubmed, Embase and the Cochrane Library was conducted in June 2022. Original articles, systematic reviews, and meta-analyses reporting on training in EES, introduction into practice, learning curves, and competency assessment were included. REVIEW METHODS: A scoping review was carried out in accordance with the Joanna Briggs Institute guidelines and reported according to PRISMA guidelines for scoping reviews. A qualitative assessment of results grouped thematically was performed. RESULTS: Twenty-eight studies met the inclusion criteria, with 24 rating as "fair" or "good" on quality assessment. Surgical simulation was the most frequently described method of training as utilized in 11 studies. The most suggested introductory procedure was tympanoplasty which was advocated for in five studies. Heterogeneity existed in the outcomes and methodologies used to measure EES learning curves, with an overreliance on surgical times. No robust definition of competency in EES procedures exists at present. CONCLUSIONS: Surgical simulation appears to be a beneficial training methodology for EES. However, there is a marked lack of objective data to describe the optimal introductory procedures or assessment of competency in EES. Laryngoscope, 133:3269-3278, 2023.

Frailty as a predictor of adverse outcomes in head and neck reconstruction: A systematic review.

BACKGROUND: Frailty has been shown to adversely impact outcomes in a number of surgical disciplines. In head and neck reconstructive surgery, frailty may represent a significant risk factor in predicting post-operative outcomes due to the common characteristics of the patient population undergoing these procedures. OBJECTIVES: To summarize the available evidence about frailty as a predictor of post-operative complications, length of hospital stay and quality of life in patients undergoing head and neck reconstructive surgery. STUDY DESIGN: Systematic Review. METHODS: The study protocol was registered with PROSPERO, registration CRD42022302899. Methodology was in keeping with the PRISMA Guidelines for Systematic Reviews. MEDLINE, SCOPUS, EMBASE, Web of Science and CENTRAL were the databases searched. Qualitative synthesis of the included studies was carried out, and quality assessment was performed. RESULTS: Nine studies that reported data on 10,457 patients undergoing reconstruction of the head and neck were included in the review. A number of different tools were used to assess frailty, with the modified frailty index being the most frequently used. In total, 8 studies reported increased rates of complications in patients with increased levels of frailty, irrespective of the frailty tool used, with varied levels of statistical significance across the studies. CONCLUSION: An association is observed between increased rates of perioperative complications and increased levels of frailty in patients undergoing head and neck reconstruction. Frailty tools may represent a useful method to risk stratify patients undergoing reconstructive head and neck surgery.

Clinical decision making in paediatric otitis media: A pilot quality improvement study.

OBJECTIVES: This study aimed to improve local management of paediatric otitis media using the 2022 American-Academy of Otolaryngology Head and Neck Surgery (AAO-HNS) Clinical Practice Guideline for Tympanostomy Tubes in Children. METHODS: A SQUIRE 2.0 compliant quality improvement study was carried out within the outpatient department of our otolaryngology tertiary referral centre. Local outpatient management of paediatric otitis media was compared to the AAO-HNS guidelines, specifically focussing on the decision to offer tympanostomy tubes. Following initial audit of practice, an educational session was performed within the otolaryngology department and local practice was subsequently re-evaluated. RESULTS: Overall, 88 children were included (46 pre-intervention and 42 post-intervention) with a mean age of 7.6 years (range 1-12 years). Sixty-four (72.7%) children presented with suspected otitis media with effusion. The remainder presented with recurrent or persistent acute otitis media (24/88, 27.3%). Twenty-six children were offered tympanostomy tubes (29.5%). Initial evaluation of practice identified that the decision to offer tympanostomy tubes was guideline appropriate in 76.1% of children (35/46). This significantly improved following an educational session (40/42, 95.2%, p = 0.02). The reasons for non-guideline compliance included: otitis media with effusion <3 months, no evidence of middle ear fluid and patients meeting criteria for tympanostomy tube insertion not being offered. CONCLUSIONS: A focussed educational intervention may improve local adherence to guidelines in the management of paediatric otitis media. Continued re-evaluation of local practice is essential in order to ensure children are managed in accordance with the guidelines.

Assessing Clinical Acumen in Predicting Acute Appendicitis in Emergency Surgery: A Prospective Study.

BACKGROUND: Clinical acumen and experience are critical in the diagnosis of the commonest surgical emergency, acute appendicitis. However, there is an increasing focus on haematological and radiological parameters in reaching the diagnosis of appendicitis, which can negate the importance of clinical findings. The aim was to assess the accuracy of each grade of the surgical team in diagnosing acute appendicitis using clinical acuity alone and compare them to each other as well as validated predictive scores. METHODS: A prospective single-centre study was performed over a six-month period (Dec 2020-May 2021). All patients presenting to the emergency department with right iliac fossa pain were included. RESULTS: A total of 180 patients were included of whom 35% were male. Mean age was 36.2 years (range 16-91). 51.1% had a final diagnosis of appendicitis, of which 91.3% were managed surgically and 8.7% were treated conservatively with antibiotics. Consultants were correct in their prediction of appendicitis in 84.6% of cases (females-83.4%, males-86.6%). Registrars accurately predicted appendicitis in 82.2% of patients (females-80.3%, males-85.7%), whilst house officers (SHOs) and interns were right in 73.8% (females-69.2%, males-82.5%) and 72.7% (females-66.6%, males-83.9%) of cases, respectively. In patients with a histological or radiological diagnosis of appendicitis, the mean Acute Inflammatory Response Score and Acute Appendicitis Score were 7.0 (high risk ≥ 9) and 12.5 (high risk ≥ 16), respectively. Clinicians had superior diagnostic accuracy when compared with both the clinical scores used. CONCLUSION: Seniority was associated with improved diagnostic accuracy in clinically predicting acute appendicitis. This study showed that the clinical judgement of experienced surgeons is more reliable than clinical scores in the diagnosis of appendicitis.

Endoscopic Versus Microscopic Type-1 Tympanoplasty: A Meta-Analysis of Randomized Trials.

OBJECTIVES: Totally endoscopic ear surgery is becoming increasingly utilized in otologic practice. Although the well-established microscope-assisted tympanoplasty remains the most common technique to repair a tympanic membrane defect, the merits of endoscopic approaches have been well-documented. This systematic review and meta-analysis compares the outcomes of endoscopic to microscopic tympanoplasty incorporating only randomized trials. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A comprehensive search of PubMed/MEDLINE, Scopus, Cochrane Library, and EMBASE was conducted. All randomized studies comparing endoscopic to microscopic tympanoplasty were collected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Quality assessment was carried out utilizing the Risk of Bias 2. RESULTS: The initial search identified 1711 studies, of which 9 met the inclusion criteria comprising of 540 patients (microscopic tympanoplasty 51.5%; endoscopic tympanoplasty 49.5%). The mean age was 32.5 years with a similar number of males (50.1%) and females (49.9%). Both endoscopic and microscopic groups had comparable outcomes with regards to graft success rate (RD 0.00; 95% confidence interval [CI], -0.04 to. 0.05; p = 0.87) and hearing improvement (MD 0.57 dB; 95% CI, -1.23 to 2.36; p = 0.54). A significantly shorter operative time was noted in the endoscopic group (MD, -24.73 min; 95% CI, -38.56 to -10.89; p = 0.0005). CONCLUSION: Our results, assimilating level 1 evidence, demonstrates that endoscopic and microscopic-assisted type-1 tympanoplasty have similar outcomes in both graft success and hearing improvement, with endoscopic approaches yielding a shorter operative time. LEVEL OF EVIDENCE: 1 Laryngoscope, 133:1550-1557, 2023.

Trans-canal tragal cartilage myringoplasty; a comparative analysis of endoscopic and microscopic approaches.

BACKGROUND: The advent of Endoscopic Ear Surgery (EES) has allowed otologists an improved view of the surgical field compared with conventional Microscopic Ear Surgery (MES). EES presents different challenges for surgeons and a learning curve is necessary. AIMS: The purpose of this study was to compare the efficacy of EES and MES for trans-canal tragal cartilage myringoplasty, an entry level EES. METHODS: We retrospectively analysed patients who underwent push through trans-canal tragal cartilage myringoplasty in our institution over 5 years (2016-2020). Exclusion criteria were: patients with prior ear surgery, non-tragal cartilage tympanic membrane graft, additional procedure at time of surgery and patients with insufficient follow up. EES and MES groups were compared using outcomes such as graft success rate, changes in pure tone audiometry (PTA), operative time and complications. RESULTS: Seventy-four patients met inclusion criteria (MES = 38, EES = 36). Mean age of included patients was 29.3 years with no significant demographic differences between groups. Graft success rate at 12 months was higher among the EES group versus MES (94.4% v 86.8%, p = 0.43). Mean operative time was reduced in the EES group (47.3 min v 53.8 min, p = 0.04). Hearing outcomes did not differ significantly between groups. No major operative complications occurred in either group. CONCLUSIONS: Outcomes were marginally better in the cohort who underwent EES. This supports that EES offers an otologic choice to complement established practice for trans-canal myringoplasty and may be used to facilitate introduction to EES for trainees and otologists wishing to learn this technique.

Hypocalcaemia following thyroidectomy among patients who have previously undergone bariatric surgery: systematic review and meta-analysis.

BACKGROUND: Hypocalcaemia is a common complication after thyroidectomy. Bariatric surgery is associated with significant changes in calcium metabolism. Some studies have identified bariatric surgery as a risk factor for hypocalcaemia after thyroidectomy. This systematic review and meta-analysis assessed whether a history of bariatric surgery was associated with an increased risk of hypocalcaemia after thyroidectomy. METHODS: This prospectively registered systematic review (PROSPERO; CRD42021295423) was performed in accordance with PRISMA guidelines. Meta-analysis was undertaken using the Mantel-Haenszel method, with outcomes reported as ORs with 95 per cent confidence intervals. RESULTS: Twenty studies were included in the qualitative synthesis. Five studies incorporating 19 547 patients met the inclusion criteria for meta-analysis, of whom 196 (1.0 per cent) had a history of bariatric surgery. Patients with a history of bariatric surgery were more likely to develop hypocalcaemia after thyroidectomy (30.6 versus 13.0 per cent; OR 3.90, 95 per cent c.i. 1.50 to 10.12; P = 0.005). Among those with a history of bariatric surgery, patients who underwent a bypass procedure were more likely to develop hypocalcaemia after thyroidectomy than those who had a restrictive procedure (38 versus 23 per cent; OR 2.12, 1.14 to 3.97; P = 0.020). CONCLUSION: Patients with a history of bariatric surgery have a significantly greater risk of hypocalcaemia after thyroidectomy, with a heightened risk among those who have had a bypass procedure. Surgeons performing thyroid surgery should be aware of the increased risk of hypocalcaemia after thyroidectomy among these patients.

Low calcium levels are a common complication after surgical removal of the thyroid gland. Patients who have had weight loss surgery (bariatric surgery) have altered calcium metabolism and are prone to low calcium levels. This study assessed whether previous weight loss surgery increased the risk of low calcium levels after thyroid surgery. A search was made of previously published studies assessing the relationship between previous weight loss surgery and low calcium levels after thyroid surgery. Studies have shown that previous weight loss surgery makes patients more than three times more likely to have low calcium levels after thyroid surgery. Management of low calcium in these patients is more challenging than in patients who have not had weight loss surgery. Surgeons performing thyroid surgery need to be aware of whether a patient has previously had weight loss surgery as they have an increased risk of low calcium after thyroid surgery.

Intra-operative nerve monitoring and recurrent laryngeal nerve injury during thyroid surgery: a network meta-analysis of prospective studies.

PURPOSE: Recurrent laryngeal nerve (RLN) injury is a feared complication of thyroid surgery occurring in 1-5% of cases. The present approaches to RLN preservation include RLN visualization with no nerve monitoring (No-NM), intermittent intra-operative nerve monitoring (I-IONM) and continuous intra-operative nerve monitoring (C-IONM). There is ambiguity as to which of these strategies should be the preferred method of RLN preservation. METHODS: A systematic review of the PubMed, Embase and the Cochrane Collaboration databases was undertaken with network meta-analysis (NMA) performed according to the PRISMA and Cochrane Collaboration guidelines. A Bayesian NMA was conducted using R packages netmeta with outcomes expressed as odds ratios (ORs) with 95% credible intervals (CrI). Only prospective studies were included. RESULTS: Eighteen studies met inclusion criteria, including 22,080 patients and 40,642 nerves at risk (NAR). Overall, 23,364 NARs (57.5%) underwent I-IONM, 17,176 (42.3%) No-NM and 98 (0.2%) underwent C-IONM. There were no significant differences between groups regarding the incidence of permanent RLN injury following thyroid surgery (I-IONM vs.No-NM, OR 0.84, 95% CrI 0.55-1.19; C-IONM vs. No-NM, OR 0.44, 95% CrI 0.02-5.00). Pooled analysis showed that IONM (I-IONM or C-IONM) demonstrated a protective effect versus No-NM in reducing the incidence of transient RLN injury (OR 0.75, 95% CI 0.59-0.97, p = 0.03). CONCLUSIONS: IONM strategies did not significantly reduce the incidence of permanent RLN injury following thyroid surgery. However, the small number of C-IONM NARs limits conclusions that may be drawn. Further well-designed prospective studies will be required to definitively assess the utility of C-IONM.

"Age is just a number"; frailty as a marker of peri-operative risk in head and neck surgery: Systematic review and meta-analysis.

BACKGROUND: Frailty refers to a patient's reduced capacity to withstand stressors due to a reduction in physiologic reserves. We assessed the impact of frailty on outcomes following head and neck surgery. METHODS: We performed a systematic review in accordance with the PRISMA guidelines. Meta-analysis was performed using the Mantel-Haenszel method. RESULTS: Fourteen studies incorporating 182 059 patients were included in qualitative synthesis with 15 953 (8.8%) of patients deemed as frail. Meta-analysis incorporating nine studies demonstrated that frailty is associated with an increased 30 day postoperative morbidity (OR 2.74; 95% CI 1.98-3.80; p < 0.01) and meta-analysis with six studies suggested increased 30-day mortality (OR 2.94; 95% CI 2.62-3.31; p < 0.01). Preliminary meta-analyses between two and five studies suggested that frail patients had reduced overall survival and were more likely to be discharged to a nonhome location or readmitted within 30 days. CONCLUSIONS: Frailty appears to be associated with poor short-term outcomes following head and neck surgery and may improve understanding of an individual patient's peri-operative risk.

Radiomic Detection of Malignancy within Thyroid Nodules Using Ultrasonography-A Systematic Review and Meta-Analysis.

Background: Despite investigation, 95% of thyroid nodules are ultimately benign. Radiomics is a field that uses radiological features to inform individualized patient care. We aimed to evaluate the diagnostic utility of radiomics in classifying undetermined thyroid nodules into benign and malignant using ultrasonography (US). Methods: A diagnostic test accuracy systematic review and meta-analysis was performed in accordance with PRISMA guidelines. Sensitivity, specificity, and area under curve (AUC) delineating benign and malignant lesions were recorded. Results: Seventy-five studies including 26,373 patients and 46,175 thyroid nodules met inclusion criteria. Males accounted for 24.6% of patients, while 75.4% of patients were female. Radiomics provided a pooled sensitivity of 0.87 (95% CI: 0.86−0.87) and a pooled specificity of 0.84 (95% CI: 0.84−0.85) for characterizing benign and malignant lesions. Using convolutional neural network (CNN) methods, pooled sensitivity was 0.85 (95% CI: 0.84−0.86) and pooled specificity was 0.82 (95% CI: 0.82−0.83); significantly lower than studies using non-CNN: sensitivity 0.90 (95% CI: 0.89−0.90) and specificity 0.88 (95% CI: 0.87−0.89) (p < 0.05). The diagnostic ability of radiologists and radiomics were comparable for both sensitivity (OR 0.98) and specificity (OR 0.95). Conclusions: Radiomic analysis using US provides a reproducible, reliable evaluation of undetermined thyroid nodules when compared to current best practice.

Sentinel lymph node biopsy in patients with ductal carcinoma in situ: systematic review and meta-analysis.

BACKGROUND: Axillary lymph node status remains the most powerful prognostic indicator in invasive breast cancer. Ductal carcinoma in situ (DCIS) is a non-invasive disease and does not spread to axillary lymph nodes. The presence of an invasive component to DCIS mandates nodal evaluation through sentinel lymph node biopsy (SLNB). Quantification of the necessity of upfront SLNB for DCIS requires investigation. The aim was to establish the likelihood of having a positive SLNB (SLNB+) for DCIS and to establish parameters predictive of SLNB+. METHODS: A systematic review was performed as per the PRISMA guidelines. Prospective studies only were included. Characteristics predictive of SLNB+ were expressed as dichotomous variables and pooled as odds ratios (o.r.) and associated 95 per cent confidence intervals (c.i.) using the Mantel-Haenszel method. RESULTS: Overall, 16 studies including 4388 patients were included (mean patient age 54.8 (range 24 to 92) years). Of these, 72.5 per cent of patients underwent SLNB (3156 of 4356 patients) and 4.9 per cent had SLNB+ (153 of 3153 patients). The likelihood of having SLNB+ for DCIS was less than 1 per cent (o.r. <0.01, 95 per cent c.i. 0.00 to 0.01; P < 0.001, I2 = 93 per cent). Palpable DCIS (o.r. 2.01, 95 per cent c.i. 0.64 to 6.24; P = 0.230, I2 = 0 per cent), tumour necrosis (o.r. 3.84, 95 per cent c.i. 0.85 to 17.44; P = 0.080, I2 = 83 per cent), and grade 3 DCIS (o.r. 1.34, 95 per cent c.i. 0.80 to 2.23; P = 0.270, I2 = 0 per cent) all trended towards significance in predicting SLNB+. CONCLUSION: While aggressive clinicopathological parameters may guide SLNB for patients with DCIS, the absolute and relative risk of SLNB+ for DCIS is less than 5 per cent and 1 per cent, respectively. Well-designed randomized controlled trials are required to establish fully the necessity of SLNB for patients diagnosed with DCIS. REGISTRATION NUMBER: CRD42021284194 (https://www.crd.york.ac.uk/prospero/).

Intraoperative recurrent laryngeal nerve monitoring versus visualisation alone - A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Intraoperative nerve monitoring (IONM) is perceived to reduce recurrent laryngeal nerve injury (RLNI) compared to RLN visualisation alone (VA). We performed a meta-analysis of randomized controlled trials (RCTs) to establish the value of using IONM instead of RLN VA for patients undergoing thyroidectomy. METHODS: A meta-analysis of RCTs was performed as per PRISMA guidelines. RLNI rates were expressed as dichotomous variables and pooled as odds ratios (OR) and associated 95% confidence intervals (CI) using the Mantel-Haenszel method. RESULTS: Eight RCTs with 2521 patients with 4977 nerves at risk were included. Overall, 49.8% of RLNs underwent IONM (2480/4978) and 50.2% underwent VA (2497/4978). Overall RLNI rates were higher for VA (VA: 3.2% (80/2497) vs. IONM: 2.3% (58/2480), OR: 0.72, 95% CI: 0.51-1.02, P = 0.060, I2 = 9%). Permanent RLNI rates were slightly higher for VA (VA: 0.6%, (12/2497) vs. IONM: 0.5%, (12/2480), OR: 0.76, 95% CI: 0.36-1.59, P = 0.470, I2 = 0%). CONCLUSION: When compared to VA alone, using IONM failed to significantly reduce RLNI rates during thyroid surgery.

Value of the 21-gene expression assay in predicting locoregional recurrence rates in estrogen receptor-positive breast cancer: a systematic review and network meta-analysis.

PURPOSE: The Oncotype DX© 21-gene Recurrence Score (RS) estimates the risk of distant disease recurrence in early-stage estrogen receptor-positive, human epidermal growth factor receptor-2-negative (ER+/HER2- ) breast cancer. Using RS to estimate risk of locoregional recurrence (LRR) is less conclusive. We aimed to perform network meta-analysis (NMA) evaluating the RS in estimating LRR in ER+/HER2- breast cancer. METHODS: A NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny. RESULTS: 16 studies with 21,037 patients were included (mean age: 55.1 years (range: 22-96)). The mean RS was 17.1 and mean follow-up was 66.4 months. Using traditional RS cut-offs, 49.7% of patients had RS < 18 (3944/7935), 33.8% had RS 18-30 (2680/7935), and 16.5% had RS > 30 (1311/7935). Patients with RS 18-30 (risk ratio (RR): 1.76, 95% confidence interval (CI): 1.32-2.37) and RS > 30 (RR: 3.45, 95% CI: 2.63-4.53) were significantly more likely to experience LRR than those with RS < 18. Using TAILORx cut-offs, 16.2% of patients had RS < 11 (1974/12,208), 65.8% had RS 11-25 (8036/12,208), and 18.0% with RS > 30 (2198/12,208). LRR rates were similar for patients with RS 11-25 (RR: 1.120, 95% CI: 0.520-2.410); however, those with RS > 25 had an increased risk of LRR (RR: 2.490, 95% CI: 0.680-9.390) compared to those with RS < 11. There was a stepwise increase in LRR rates when applying traditional and TAILORx cut-offs (both P < 0.050). CONCLUSION: RS testing accurately estimates LRR risk for patients being treated for early-stage ER+/HER2- breast cancer. Future prospective, randomized studies may validate the predictive value of RS in estimating LRR.

Giant Nonfunctioning Parathyroid Cyst: A Case Report and Review of the Literature.

Parathyroid cysts are a rare clinical entity that may arise in the neck or mediastinum. They are more common in women and generally present in the fourth and fifth decades of life. Diagnosis of parathyroid cysts is challenging, and despite thorough radiological and cytological investigation, they are often mistaken for thyroid pathology. Definitive diagnosis is often only confirmed following complete surgical resection and histopathological analysis. We present the case of a woman who was referred to our outpatient clinic with a left-sided neck mass and associated compressive symptoms. Initial examination and investigation appeared consistent with a large thyroid nodule. Following surgical resection, the lesion was found to be a parathyroid cyst. Subsequently, we review the available literature on parathyroid cysts with particular emphasis on the diagnostic challenge they pose to clinicians.

Instrumentation failure during microlaryngoscopy.

Equipment failure can be a cause of morbidity during surgical procedures. We present two cases where a broken surgical instrument, a heart-shaped curved micro-grasper, colloquially termed 'sweetheart' micro-forceps, compromised patient safety during microlaryngoscopy. We discuss the importance of thorough safety protocols and communication between team members to mitigate this risk. Microinstruments used during microlaryngoscopy are at risk of failure or breakage due to their small size. Surgeons must be alert to the risk of equipment failure during surgery as a potential cause of patient morbidity. In our patient, loss of the broken instrument in the respiratory tract could have resulted in iatrogenic aspiration, respiratory infection and would have necessitated rigid bronchoscopy for removal. Instruments and equipment must checked and communicated by the surgical team before and after use to prevent potential patient morbidity.