Management of life-threatening airway obstruction caused by benign thyroid disease.

INTRODUCTION: Goitre presenting with acute, life-threatening airway compromise is an uncommon indication for thyroid surgery. The management of this critical condition is controversial. AIMS: To investigate the incidence of life-threatening airway compromise in patients with benign goitre, to investigate the predisposing factors, and to outline an optimal management policy for such critical cases. METHODS: Retrospective review of the medical records of patients presenting with life-threatening, acute airway compromise secondary to benign thyroid disease, treated by the senior author (CT) between July 1994 and July 2005. RESULTS: Of a total of 505 thyroid surgery procedures over the 11-year period, five patients with benign thyroid disease had presented with life-threatening, acute airway compromise. Three of the five patients had been thyrotoxic and two of these had received an iodine load prior to airway compromise. Immediate endotracheal intubation for airway control followed by admission to the intensive care unit had been the presentation in two patients. An incidental diagnosis of tracheal compression had been made from the computed tomography (CT) scan in two patients who had non-resolved obstructive airway disease. Emergency thyroidectomy had been performed in all five patients. Significant tracheomalacia had been noted in four patients. Following thyroidectomy, two patients had required tracheostomy and one had required tracheal stenting. CONCLUSION: Chronic obstructive airways disease, substernal extension and long-standing goitre are considered as risk factors for developing acute, life-threatening airway compromise in the presence of benign thyroid disease. A recent iodine load may lead to airway compromise in thyrotoxic patients. A CT scan is indicated in cases of unresponsive chronic obstructive airways disease to rule out substernal extension of non-palpable goitres. Life-threatening airway compromise secondary to benign goitres is best treated by endotracheal intubation if conservative measures fail, followed by emergency thyroidectomy. Following surgery, close observation is mandatory to exclude airway compromise due to tracheomalacia and laryngeal oedema.

Bone anchored hearing aids: reality, failure and current status.

Bone Anchored Hearing Aids have both cosmetic and acoustic advantages over most conventional hearing aids and hence is a popular choice today. We report the first Irish group of patients who received a BAHA over a six year period of time and evaluated outcomes of these subjects using subjective assessment. The medical records of all patients who received a BAHA at the Mater and Children's University Hospital, Dublin, were reviewed. A questionnaire had been sent to the patients to obtain long-term subjective information. Twenty three patients were identified. The commonest indication for surgery was found to be the presence of a discharging mastoid cavity, followed by congenital ear malformations. Surgical procedures were carried out as a single stage in 16 patients. Questionnaires were sent to 19 patients; sixteen patients responded in total. BAHA has a beneficial outcome to the quality of life and has significantly reduced ear discharge. The one stage technique was found to have a lower complication rate.

Pearls and pitfalls in the management of branchial cyst.

INTRODUCTION: Although branchial cysts may present as asymptomatic swellings, about one-third present acutely due to inflammation. The use of fine-needle aspiration biopsy (FNAB) and computerized tomography (CT) is controversial. The treatment of inflamed cysts is also controversial. AIMS: To compare the findings of FNAB and CT between cases of branchial cysts presenting as an asymptomatic swelling, and those presenting acutely due to inflammation, and to examine the management of infected cysts. MATERIALS AND METHODS: Retrospective review of the medical records of 39 adult patients with histologically proven branchial cysts treated by the senior author (C.V.T.) between 1994 and 2003. RESULTS: Twenty-eight patients presented with an asymptomatic swelling. Eleven presented acutely with inflammation. A higher incidence of indeterminate fine needle aspirates and atypical CT features were found in the inflamed group. Initial treatment in the infected group consisted of intravenous antibiotics, followed by aspiration or surgical exploration in non-resolving cases. Interval excision after six weeks was performed in all inflamed cases without complication. CONCLUSIONS: FNAB is recommended in all cystic neck lumps to rule out malignancy, but may be inconclusive, especially in inflamed cysts. Inflamed cysts are best treated with intravenous antibiotics, with or without aspiration or incision and drainage, followed by interval excision.