Total thyroidectomy for safe and definitive management of Graves' disease.

BACKGROUND: The role of total thyroidectomy in the management of patients with Graves' disease remains controversial. However, there is increasing evidence to support the role of the procedure as a safe and definitive treatment for Graves' disease. METHOD: Patients were identified from a prospective thyroid database of the multidisciplinary thyroid clinic at Hull Royal Infirmary. All case notes were independently reviewed to confirm the data held on the database. RESULTS: Over a 7-year period, the senior author has performed 206 total thyroidectomies for Graves' disease. The incidence of temporary recurrent laryngeal nerve palsy and hypoparathyroidism was 3.4 per cent and 24 per cent respectively. There was one case of permanent unilateral recurrent laryngeal nerve palsy, and 3.9 per cent of patients developed permanent hypoparathyroidism. There has been no relapse of thyrotoxicosis. CONCLUSION: In the context of a multidisciplinary thyroid clinic, total thyroidectomy should be offered as a safe and effective first-line treatment option for Graves' disease.

Thyroid cancer review 3: management of medullary and undifferentiated thyroid cancer.

This is the last of the three review articles dealing with thyroid cancer. Over 90% of thyroid cancer is of the differentiated type associated with a very good 10-year disease-free survival rate. In contrast, the rare forms of thyroid cancer which comprise medullary thyroid cancer arising from parafollicluar C cells, Hurthle cell carcinoma, anaplastic carcinoma, thyroid lymphoma and squamous cell carcinoma are typically associated with a poorer survival rate. Management is based upon small retrospective cohort studies.

Thyroidectomy does not cause globus pattern symptoms.

Post-thyroidectomy patients often complain of globus pharyngeus type symptoms. One of the organic pathologies recognized as causing globus pattern symptoms is goitre. We conducted a prospective questionnaire-based study in the thyroid clinic at Hull Royal Infirmary to examine the relationship between goitre, thyroidectomy and globus pattern symptoms by using the Glasgow-Edinburgh Throat Scale. A questionnaire-based study in which 41 consecutive patients due to undergo thyroidectomy prospectively completed the questionnaire pre-operatively and 12 months post-operatively. A subset of 25 randomly selected patients also completed the questionnaire three months post-operatively. Globus symptoms were not worsened by thyroidectomy at three or 12 months. Indeed two of the questioned parameters were significantly improved at three months, and six at one year (p < 0.023). In conclusion, thyroidectomy does not exacerbate globus pharyngeus symptoms. Indeed, in the absence of other clinical causes, when a patient has a World Health Organization (WHO) 2 goitre or greater, thyroidectomy may improve them.

Defining the criteria for radioresistant laryngeal cancer.

Survival rates for head and neck cancer are comparatively poor, typically 40% at 5 years. Radiotherapy is one of the most common modalities used to cure early-stage cancers. It has the advantage in that it preserves anatomical structure and function. However, treatment failures do occur necessitating salvage surgery if a cure is to be achieved. A universally accepted definition of radioresistant cancer does not exist. Second primaries and occult metastasis are common in head and neck cancer, and can be confused with true radioresistant tumours. We suggest a strict definition for radioresistant laryngeal cancer and characterize 66 radioresistant tumours stage matched to 66 radiosensitive tumours. It was not possible to differentiate the radioresistant group from the radiosensitive groups using tumour differentiation. By using an agreed set of criteria defining radioresistant head and neck tumours, researchers will be better able to investigate molecular and cellular markers of radioresistance.

Computerised tomography vs. pathological staging of laryngeal cancer: a 6-year completed audit cycle.

The aim of this audit was to examine the accuracy of computerised tomography (CT) staging of advanced laryngeal tumours. CT staging was evaluated against the T staging of laryngeal tumours as determined by pathological examination. Data from 38 patients, between 1996 and 2000 with laryngeal squamous cell cancer that fulfilled the audit criteria, were collected and compared. Subjects had to have a pre-operative CT scan of the larynx and a total laryngectomy specimen for pathological staging. The audit demonstrated that 45% of the patients were over staged and 10% were under staged using CT criteria as compared to pathological staging. Fourteen patients had been erroneously up staged to T4 on the basis of laryngeal cartilage invasion as judged by the radiological sign of cartilage sclerosis. While this radiological sign is used as a marker of neoplastic invasion in the literature, it was found to have a low sensitivity of 62% and low specificity of 42% in this study. Arytenoid cartilage sclerosis in isolation was no longer used as a radiological sign of neoplastic cartilage invasion. Following the change in practice, the CT staging of laryngeal cancer was re-evaluated in a second audit cycle. Correct CT staging of the tumour improved from 45 to 71%. Arytenoid cartilage sclerosis is no longer used as a sole CT criterion for predicting neoplastic cartilage invasion at our institution.

Neoplastic invasion of laryngeal cartilage: the significance of cartilage sclerosis on computed tomography images.

Cartilage sclerosis has been cited as a sensitive and a specific sign of neoplastic cartilage invasion, on cross-sectional computed tomography (CT) images of the larynx. We retrospectively reviewed 36 consecutive patients, who underwent a total laryngectomy for squamous cell carcinoma of the larynx. Preoperative CT images were compared with formal histological sections of the larynx in order to assess cartilage invasion by tumour. Isolated asymmetrical cartilage sclerosis was found to have a sensitivity of 62% and a specificity of 42% for predicting neoplastic cartilage invasion when compared with histopathological sections of the tumour. In this study we found that cartilage sclerosis was not a useful early radiological sign of neoplastic cartilage invasion when taken in isolation.

Radioresistant laryngeal cancer: beyond the TNM stage.

Early stage squamous cell carcinoma of the larynx can be effectively cured by radiotherapy. Unfortunately treatment failures do occur and at present cannot be predicted by the clinician. This article reviews the potential molecular and cellular markers that may help to predict radioresistance in early stage laryngeal cancer.

Carotid artery invasion by squamous cell carcinoma of the upper aerodigestive tract: the predictive value of CT imaging.

Carotid artery invasion by squamous cell carcinoma of the upper aerodigestive tract is a poor prognostic indicator and a relative indicator of tumour inoperability. A number of imaging modalities are available for detecting such invasion, but, because of its availability, computerised tomography (CT) is the usual modality. We have analysed the CT scans of 196 patients referred to the department with an upper aerodigestive tract squamous cell carcinoma. Comparing the scans with the operative findings indicates that CT scans significantly overestimate carotid artery invasion.

Delayed oesophageal perforation following endoscopic stapling of a pharyngeal pouch.

Endoscopic stapling of pharyngeal pouches is gaining popularity and is said to be a quick procedure with minimal morbidity and mortality. So far, there have been few reported cases of any severe complications following this procedure. However, complications as with other treatment modalities can occur. A case of mediastinitis due to delayed oesophageal perforation following the stapling procedure is presented.

Jugular thrombosis following tonsillectomy.

An unusual case of internal jugular thrombosis following routine tonsillectomy is presented. Guidelines for the clinical management of this case, with anticoagulants, do not exist.