Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Difficult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery.

Haematoma after thyroid surgery can lead to airway obstruction and death. We therefore developed guidelines to improve the safety of peri-operative care of patients undergoing thyroid surgery. We conducted a systematic review to inform recommendations, with expert consensus used in the absence of high-quality evidence, and a Delphi study was used to ratify recommendations. We highlight the importance of multidisciplinary team management and make recommendations in key areas including: monitoring; recognition; post-thyroid surgery emergency box; management of suspected haematoma following thyroid surgery; cognitive aids; post-haematoma evacuation care; day-case thyroid surgery; training; consent and pre-operative communication; postoperative communication; and institutional policies. The guidelines support a multidisciplinary approach to the management of suspected haematoma following thyroid surgery through oxygenation and evaluation; haematoma evacuation; and tracheal intubation. They have been produced with materials to support implementation. While these guidelines are specific to thyroid surgery, the principles may apply to other forms of neck surgery. These guidelines and recommendations provided are the first in this area and it is hoped they will support multidisciplinary team working, improving care and outcomes for patients having thyroid surgery.

Utilisation of a smartphone-enabled video otoscope to train novices in otological examination and procedural skills.

OBJECTIVE: The ai/m of this study was to compare the self-reported confidence of novices in using a smartphone-enabled video otoscope, a microscope and loupes for ear examination and external ear canal procedures. METHOD: Medical students (n = 29) undertook a pre-study questionnaire to ascertain their knowledge of techniques for otoscopy and aural microsuction. Participants underwent teaching on ear anatomy, examination and procedural techniques using a microscope, loupes and smartphone-enabled video otoscopes. Confidence and preference using each modality was rated using a Likert-like questionnaire. RESULTS: After teaching, all modalities demonstrated a significant increase in confidence in ear examination (p < 0.0001). Confidence in using the smartphone-enabled otoscope post-teaching was highest (p = 0.015). Overall, the smartphone-enabled video otoscope was the preferred method in all other parameters assessed including learning anatomy or pathology (51.72 per cent) and learning microsuction (65.51 per cent). CONCLUSION: Smartphone-enabled video otoscopes provide an alternative approach to ear examination and aural microsuction that can be undertaken outside of a traditional clinical setting and can be used by novices.

Rare case of venous tumour thrombus from acinic cell carcinoma of the parotid gland.

Head and neck tumour thrombus is a rare pathology and at present there are no reported cases of tumour thrombus secondary to acinic cell carcinoma of the parotid gland. We report a case of an 81-year-old man with an acinic cell carcinoma of the left parotid and an intravenous tumour thrombus extending from the retromandibular vein into the internal jugular vein. This case also highlights the importance of radiological imaging in the management of tumour thrombus.

Endoscopic electrocautery and fibrin obliteration of an acutely complicated pyriform fossa sinus tract in a septuagenarian.

BACKGROUND: Pyriform fossa sinus tracts classically present with neck abscess, recurrent infections and suppurative thyroiditis in children; acute presentation in a geriatric patient is rare. METHODS: Case report and Medline literature review. CASE REPORT: A 79-year-old female presented with a left-sided neck mass and severe odynophagia of 3 days' duration. Magnetic resonance imaging revealed a large-volume, loculated fluid collection extending throughout the deep spaces of the neck on the left, within and around the thyroid gland capsule. There was radiological evidence of internal jugular vein thrombophlebitis. Abscess incision and drainage, and endoscopic evaluation, were performed. A deeply penetrating sinus was seen in the left pyriform apex, the entrance of which was circumferentially cauterised and the lumen obliterated with fibrin glue. Following post-operative intravenous antibiotics, the patient made a complete recovery. CONCLUSION: This paper describes the first use of fibrin glue to obliterate a pyriform fossa sinus tract in an adult.

Encountering a high jugular bulb during ear surgery.

Encounters with jugular bulb abnormalities during ear surgery are a rare but recognised problem. A high riding jugular bulb is present in 10%-15% of patients and its variable position within the temporal bone can lead to problems as brisk venous haemorrhage can result if the bulb is inadvertently opened. The case of a 52-year-old woman with a central tympanic membrane perforation who underwent elective endaural myringoplasty and experienced brisk bleeding on raising the tympanomeatal flap is presented.

Safety trial of Floseal(®) haemostatic agent in head and neck surgery.

INTRODUCTION: Floseal(®) can be of value in reducing blood loss and haematoma rates. The manufacturer's warnings include allergic reaction, poor wound healing and intravascular thrombosis. We aimed to determine whether Floseal(®) is safe to use in various head and neck surgery procedures. METHODS: A prospective trial was conducted using Floseal(®) in 42 various consecutive head and neck surgery procedures. Adverse incidents were used as the main outcome measure, including allergic reaction, wound breakdown, wound infection and thrombosis. Secondary outcome measures included haematoma formation, hospital stay, drain times and output. RESULTS: No adverse incidents were recorded in the trial period. Two patients developed haematomas and required surgical exploration where a bleeding vessel was identified and dealt with. CONCLUSIONS: Floseal(®) is safe to be used in head and neck surgery with no adverse effects. A larger number and a control group are required to ascertain its value in reducing blood loss, haematoma formation, drain usage and hospital stay.

Impact of oxygen concentration and laser power on occurrence of intraluminal fires during shared-airway surgery: an investigation.

OBJECTIVES: Airway fires pose a risk during laser microlaryngoscopy, and neurosurgical cotton patties, used to prevent tissue injury from stray laser beams, are a potential ignition source. Using a configuration approximating clinical practice, we experimentally assessed the relative impact of changing different 'fire triad' components on the occurrence of airway fires, in order to better inform patient care. METHODS: The relative effects of wet vs dry neurosurgical patties, oxygen concentration and laser power setting on the patty ignition time were studied in a cadaveric porcine model. Data were analysed using t-test and two-way analysis of variance. RESULTS: Dry patties ignited after 2.3 +/- 1.2 seconds (average +/- standard deviation) of continuous 5 W laser fire at 50 per cent oxygen concentration, compared with 63.9 +/- 27.8 seconds for wet patties under the same laser and oxygen settings (p < 0.0001). There was a statistically significant reduction in the time to patty ignition when laser power settings were increased from 5 to 7.5 W, but no further reductions occurred when the power was further increased to 10 W (p < 0.05; Tukey test for multiple comparisons; two-way analysis of variance). There was no significant reduction in the time to ignition between oxygen concentrations of 50 and 75 per cent, but the time to ignition fell significantly when the oxygen concentration was further increased to 100 per cent. CONCLUSION: We suggest that surgical patties should always be soaked and should be used for relatively short periods, in order to prevent drying. If at all possible clinically, prolonged laser use at high power settings and ventilation with 100 per cent oxygen should be avoided.

How we do it: Changes in thyroid and salivary gland surgery since 1989: who's doing it and what are they doing?

Keypoints * The aim of this study was to identify changes in the provision of parotid, submandibular and thyroid gland surgery between surgical specialties since 1989, as well as changes in surgical practice. * Data from the Department of Health's Hospital Episode Statistics (HES) was extracted from 1989/1990 and 2003/2004 records by operation and surgical specialty in England. * The data reveals a considerable decline in the amount of parotid and submandibular surgery performed by General surgeons; with the majority of this surgery currently being performed by ENT surgeons, and to a lesser extent, Oral and Maxillo-Facial surgeons. * Thyroid surgery has undergone less radical change, with General surgeons continuing to perform the majority of cases; however, an increasing proportion is now provided by ENT surgeons. * There also seems to be changes in the types of thyroid operation being performed; with large increases in total thyroidectomy and reductions in subtotal thyroidectomies.

Patterns of regional head and neck lymph node metastasis in primary conjunctival malignant melanoma.

OBJECTIVE: To correlate patterns of regional lymph node metastasis with the site of origin in primary conjunctival malignant melanoma. DESIGN: Retrospective analysis (1990-2003) of clinical data. SETTING: Two London tertiary referral centres. PARTICIPANTS: 12 patients presenting with regional metastases after failed local treatment for conjunctival malignant melanoma. RESULTS: 6 cases predominantly involving the temporal conjunctiva metastasised to the pre-auricular lymph nodes. Two cases predominantly involving the nasal conjunctiva metastasised to the submandibular nodes. Of the two cases with purely multifocal disease, one metastasised to the pre-auricular nodes and another to both submandibular and parotid nodes. One primary conjunctival malignant melanoma had its origin in temporal conjunctiva but metastasised to submandibular nodes, and another case originating from nasal conjunctiva metastasised to pre-auricular nodes. CONCLUSIONS: Temporal conjunctival melanotic lesions tend to metastasise clinically to pre-auricular lymph nodes and nasal conjunctival melanotic lesions metastasise to the submandibular lymph nodes. Patterns appear consistent with laboratory-based anatomically mapped lymphatic drainage basins of the conjunctiva.

Upper neck spinal accessory nerve identification during neck dissection.

Iatrogenic injury to the spinal accessory nerve (SAN) during neck dissection may result in significant and avoidable morbidity in the form of 'shoulder syndrome'. The authors describe a simple method, based on the anatomy of the sternocleidomastoid muscle (SCM), which allows consistent and rapid identification of the SAN in the upper neck during dissection, thereby facilitating its preservation.

How we do it: transnasal fibreoptic oesophagoscopy.

KEYPOINTS: Transnasal fibreoptic oesophagoscopy (TFO) allows the upper aerodigestive tract, from the nasal vestibule to the gastric cardia to be examined in the outpatients department without sedation. This permits patients with symptoms of upper aerodigestive pathology to be investigated at the initial consultation without the need for inpatient endoscopy or swallow studies. The technique is easily learned, and is statistically comparable with standard flexible nasoendoscopy in respect of procedural pain and discomfort. It is highly cost-efficient, paying for itself within 1 year, and thereafter leading to cost savings of over 80%. Its role can be expanded to encompass investigating patients with potentially malignant disease processes, as well as outpatients "panendoscopy" and biopsy, and a number of therapeutic interventions.

Celon radiofrequency thermo-ablative palatoplasty for snoring - a pilot study.

A prospective non-randomized study was designed to investigate the effects of Celon radio-frequency thermo-ablation (RFTA) of the soft palate in patients with snoring/mild obstructive sleep apnoea. Ten patients, fulfilling various inclusion/exclusion criteria, underwent single operator sub-mucosal RFTA palatoplasty as an office procedure. Two separate procedures six weeks apart involved each patient receiving six distinct sub-mucosal lesions on each visit. Questionnaires including visual analogue scales (VAS) were used to evaluate post-operative pain and subjective snoring (scored by patient/partner). Polysomnography (PSG) was performed pre-operation and three months following the second procedure. Using non-parametric statistical analysis, a significant reduction in VAS snoring was noted from initial levels to those scored at six and 16 weeks in nine of 10 patients (p = 0.013 and p = 0.007 respectively). (Five of these nine showed a greater than 50 per cent reduction in score). Objectively, six of 10 patients had a reduction in the apnoea-hypopnea Index between the two PSGs, (four of these six showed a greater than 50 per cent reduction) however, this was not statistically significant. Subjective assessment of the PSG snoring signal by the senior author showed eight of 10 patients had either a reduced or much reduced signal at four months. VAS pain confirmed both procedures are well tolerated with minimal analgesia requirements. Minor complaints of transient mild palatal swelling, dry throat, catarrh and referred otalgia were noted and one patient developed mucosal ulceration following both procedures that healed within three weeks. Swallowing and speech were unaffected. These results confirm similar findings using the Somnus Unit, although the Celon device provides additional advantages including inherent safety in a bipolar electrode tip, auto-stop energy application and reduced procedure time.

Epistaxis as a rare presenting feature of glomus tympanicum.

Glomus tumours are the most common primary neoplasms of the middle ear, typically benign and slowly progressive. Pulsatile tinnitus and ipsilateral hearing loss are the most common symptoms at presentation by far; otalgia, aural fullness and otorrhoea being less frequent. A case of primary glomus tympanicum presenting with recurrent epistaxis, previously unreported in the literature, is described and associated imaging presented.

Making your mark again in surgery.

Accurate, durable pre-operative skin marking that withstands the necessary vigorous surgical skin preparation on the theatre table minimises confusion and the risk of mistakes occurring perioperatively, as well as assisting the surgeon with the technicalities of required skin incisions. Felt-tipped marker pens vary widely in achieving these objectives. A selection of markers, including a number used by junior surgical staff on the wards, was investigated.

Expression patterns of the bone morphogenetic protein genes Bmp-4 and Bmp-2 in the developing chick face suggest a role in outgrowth of the primordia.

Bone morphogenetic proteins BMP-4 and BMP-2 are closely-related members of the transforming growth factor-beta superfamily that have been implicated in signalling in a number of developmental systems. To determine whether they could be involved in the epithelial-mesenchymal interactions that control face development, we mapped the distribution of Bmp-4 and Bmp-2 gene transcripts in the developing chick facial primordia. At stages when primordia were becoming established, Bmp-4 transcripts were present in specific regions of epithelium in all facial primordia, but were undetectable in the mesenchyme. Bmp-4 transcripts appeared subsequently in specific regions of mesenchyme at the distal tips of the primordia. This mesenchymal expression first appeared in the frontonasal mass and then, in turn, in the lateral nasal processes, the maxillary primordia and the mandibular primordia. There was a complex relationship between domains of epithelial and mesenchymal Bmp-4 expression, and at many sites there was an inverse correlation between epithelial and mesenchymal Bmp-4 expression. Bmp-2 transcripts were found in the epithelium and mesenchyme of the maxillary and mandibular primordia at early stages in facial development. Bmp-2 transcripts appeared in the frontonasal mass and lateral nasal processes at later stages, with epithelial expression preceding mesenchymal expression. In general, mesenchymal Bmp-2 expression was associated with overlying epithelial Bmp-2 expression. The domains of Bmp-4 expression overlapped with those of Bmp-2, but detailed examination showed that there was no precise correlation between the expression patterns of the two genes. Indeed, in some places the Bmp-4 and Bmp-2 expression domains were complementary. The expression of the Bmp-4 and Bmp-2 genes in the epithelium and distal mesenchyme of the facial primordia suggests that BMP-4 and BMP-2 may be involved in the epithelial-mesenchymal interactions that control outgrowth of these primordia.