Preoperative investigations in thyroglossal duct cyst surgery: a 9-year experience and proposed practice guide.

INTRODUCTION: Thyroglossal duct cysts (TGDC) are the commonest midline developmental cyst and have a bimodal age distribution. They usually develop in an infrahyoid position. A National survey of TGDC practice among otolaryngologists in 2012 recommended preoperative investigation with ultrasound, with or without blood tests. METHODS: Retrospective analysis of preoperative investigation for clinically diagnosed TGDC surgeries between 2012 and 2020 in a single tertiary centre was undertaken. This was collated alongside postoperative outcomes (histology, recurrence, hypothyroidism). Comparison was made with the 2012 national survey. RESULTS: Ninety-five cases of thyroglossal duct surgery in children and adults were studied. Demographic data were comparable to the literature. Ultrasonography was the most commonly used preoperative investigation. Histology of 71% of excised cysts confirmed TGDC with another 8% reported as development cysts. The excision of the cyst with a cuff of strap muscles and middle portion of hyoid bone had the lowest recurrence rate, which was 4% overall in this study. There were no cases of ectopic thyroid tissue or postoperative hypothyroidism. DISCUSSION AND CONCLUSION: Nearly a decade of thyroglossal duct cyst excisions in a large-volume unit gave detail on actual preoperative practice and outcomes. Practice was found to be consistent overall with the 2012 recommendations although not standardised across all cases. From this experience, and a literature review, a visual guide on preoperative investigations for different age groups in the form of a flow chart is proposed to reduce risk of complications while avoiding unnecessary investigations.

Morbidity and Mortality Following Transoral Robotic Surgery, a Prospective Single Centre Study.

To review complications including mortality after transoral robotic surgery (TORS) for both benign and malignant pathologies. This is a prospective observational study. Postoperative haemorrhage (8.7%) was the most common complication and 2 (1.7%) mortality were seen in this study. Airway complications and tracheostomy (1.7%), aspiration pneumonia (1.7%), swallowing problems and nasogastric feeding (7%), intra-operative pharyngocutaneous fistula (0.9%) and transient nasal regurgitation (3.5%) were also seen. The more tissue is removed the more is the risk of complication. Complications were mainly seen in the first year of starting the service of TORS and it is a reflection of the learning curve. However, secondary haemorrhage did not follow any pattern in our series. The postoperative haemorrhage was more common in patients with T2 oropharyngeal carcinoma. The mortality was seen in 2 patients (1.7%) with T2 oropharyngeal carcinoma due to postoperative haemorrhage. Higher T stage of oropharyngeal squamous cell carcinoma (OPSCC) needs bigger resection with resultant increase in morbidity.

Two-week-wait referrals in otolaryngology in a tertiary centre: cross-sectional study of benign outcomes, with a systematic review.

OBJECTIVE: The two-week-wait referral is designed to improve early detection in cancer patients. This retrospective study analysed those ENT two-week-wait referrals to out-patient clinics in a tertiary head and neck oncology centre, from January to June 2018, which were not compliant with National Institute for Health and Care Excellence guidelines (2015 update). METHODS: Referral symptoms were statistically analysed against National Institute for Health and Care Excellence guidelines, with detailed analysis of reasons for non-compliance. In addition, a systematic review of similar previously published articles was conducted. RESULTS: There were 1107 patients referred through the two-week-wait pathway. Of these referrals, 52 per cent were compliant with National Institute for Health and Care Excellence 2015 guidelines. Six errors were identified for non-compliant referrals, most commonly inconsistencies in referral (e.g. globus sensation) and intermittent disease course (e.g. intermittent hoarseness). Of all patients referred, 93 per cent were diagnosed with benign conditions, with laryngopharyngeal reflux being the commonest. Twenty-two per cent of referred patients were discharged after the first visit. CONCLUSION: Two-week-wait referral is inappropriately overused. There are many non-compliant referrals, and most of the outcomes are benign.

Outcome of two-week head and neck cancer pathway for the otolaryngology department in a tertiary centre.

BACKGROUND: The two-week-wait head and neck cancer referral pathway was introduced by the Department of Health, and refined through National Institute for Health and Care Excellence guidelines which were updated in 2015. METHODS: A retrospective study was conducted of two-week-wait referrals to out-patient ENT from January to June 2018. The analysis included demographics, referral symptoms according to National Institute for Health and Care Excellence 2015 guidelines, cancer pick-up rates and positive predictive values. RESULTS: A total of 1107 patients were referred for suspected head and neck cancer over six months, with 6 per cent diagnosed with cancer. Neck lump, persistent hoarseness and throat pain were the most common presenting symptoms. Neck lump had the highest positive predictive value, followed by oral swelling. Oral bleeding and persistent unilateral sore throat showed significant positive predictive values. Investigation for metastatic head and neck cancer of an unknown primary or the involvement of other multidisciplinary teams could hinder the achievement of a 62-day treatment target. CONCLUSION: The cancer pick-up rate from two-week-wait referrals is only 1.5 times higher than routine referrals. The 'red flag' symptoms given in the 2015 National Institute for Health and Care Excellence update would benefit from further review.

Magnetic resonance imaging for vestibular schwannoma: cost-effective protocol for referrals.

OBJECTIVE: Vestibular schwannoma is the most common neoplasm in the cerebellopontine angle, and fast spin-echo T2-weighted magnetic resonance imaging is the most sensitive test for diagnosing it. This study evaluated the financial and time costs of unnecessary magnetic resonance imaging referrals before and after the application of a magnetic resonance imaging protocol. METHOD: A full audit cycle was used for the assessment. The first cycle in January 2012 was retrospective and evaluated the financial impact of current selection criteria for magnetic resonance imaging referral against standard guidelines. The second cycle in January 2014 was prospective after implementation of the protocol. RESULTS: There were 46 and 112 patients who had magnetic resonance imaging during first and second cycle, respectively. Of the referrals for magnetic resonance imaging, 65 per cent versus 81 per cent of the referrals were appropriate in the first and second cycles, respectively. The relative risk was reduced from 0.5 to 0.2. The waiting times for magnetic resonance imaging scans improved. CONCLUSION: Selection criteria for magnetic resonance imaging referral are important in reducing waiting times for scans, patient anxiety and conserving trust resources.

[Pott's puffy tumour: innovative technique in calvarial reconstruction].

BACKGROUND: Pott's puffy tumour is a rare complication of sinusitis. This osteomyelitis can affect the outer and inner tables of the frontal sinus. The treatment of Pott's puffy tumour combines medical and surgical approaches. Surgical approaches have traditionally been open, but endoscopic techniques have been adopted recently in select cases. The bony defect from debridement can be left alone, or closed with autografts or allografts. OBJECTIVE: To describe a technique for the reconstruction of a large skull vault after the debridement of extensive osteomyelitis of the anterior cranial vault. METHODS: Modified distraction osteogenesis is used in the cranial vault, to induce new bone formation. This is customarily used to lengthen long bones. The advantages of this technique include avoiding autologous grafts or alloplastic cranioplasty in the infected surgical bed, and allowing primary closure. RESULTS: Early post-operative imaging results have been encouraging, with no reported complications. CONCLUSION: Modified distraction osteogenesis is a novel technique in the primary reconstruction of calvarial bone.

Pooled analysis of the evidence for open cavity, combined approach and reconstruction of the mastoid cavity in primary cholesteatoma surgery.

BACKGROUND: Cholesteatoma is keratinising epithelium within the middle-ear cleft or mastoid. This disease destroys the peripheral organs of balance and hearing, with possible intracranial sequelae. The management of cholesteatoma is surgical and the primary aim is to remove the disease and prevent recurrence. Secondary aims are to obtain a non-discharging, hearing ear. Cholesteatoma surgery falls into two broad categories: open cavity surgery and combined approach surgery. A third surgical category is reconstruction of an open mastoid cavity after open surgery. This study performed a pooled analysis of the worldwide literature to compare the rates of cholesteatoma not being cured (i.e. recidivism), ear discharge and hearing change among open cavity, combined approach and reconstruction mastoid surgery for primary cholesteatoma. METHODS: A literature search for all types of cholesteatoma surgery in the PubMed, Google Scholar and Medline databases and in published conference proceedings was undertaken. RESULTS: There was no level 1 evidence for the best method of primary cholesteatoma surgery. The highest evidence level found (level 2; 5366 patients) shows no difference in hearing change or discharge rate between open and combined approach surgery; however, these methods fail to cure the cholesteatomas in 16.0 per cent and 29.4 per cent of cases, respectively. In a total of 640 patients, reconstruction and/or repair mastoid surgery using a variety of non-comparable techniques had a failure rate of between 5.3 per cent and 20 per cent. CONCLUSION: The available evidence suggests that reconstruction of the posterior canal wall and/or obliteration of the mastoid may be the best surgical treatment alternative. This technique appears to provide the lowest recidivism rate combined with a low post-operative ear discharge rate.