Evolution of transoral endoscopic thyroidectomy vestibular approach according to the IDEAL framework.

BACKGROUND: The IDEAL Framework is a scheme for safe implementation and assessment of surgical innovation. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new innovation in thyroid surgery that eliminates the need for a cervical incision. Despite considerable interest and adoption worldwide, significant scepticism remains regarding the outcomes and cost-effectiveness for healthcare systems. The aim of this narrative review was to appraise the available literature and examine whether TOETVA has progressed in line with the IDEAL Framework. METHODS: A literature review of PubMed with a focus on historical and landmark studies was undertaken to classify the evidence according to the different stages of the IDEAL Framework. RESULTS: Several different transoral approaches were developed by a small of number of surgeon-innovators on animals and cadavers, and subsequently in first-in-human studies. The trivestibular approach emerged as the safest technique, with further refinements of this technique culminating in TOETVA. The basic steps and indications for this technique have been standardized and it is now being replicated by early adopters in many centres worldwide. The development of TOETVA has closely aligned with the IDEAL Framework, and is currently at stage 2B (Exploration). CONCLUSION: There is need for multi-institutional collaborations and international registry studies to plan high-quality randomized trials comparing TOETVA with other remote-access approaches and collect long-term follow-up data. In countries where TOETVA has yet to be adopted, the IDEAL Framework will be a useful roadmap for government regulators and professional societies to evaluate, regulate, and provide best practice recommendations for the adoption of this technique.

#10-Year Challenge: Local anaesthetic for post-tonsillectomy pain: Update meta-analysis.

INTRODUCTION: Adequate management of post-tonsillectomy pain is an important consideration in postoperative management after tonsillectomy. A 2008 meta-analysis showed that the use of local anaesthetic either by infiltration or topical application reduced postoperative pain. OBJECTIVES: To review the current evidence for the use of local anaesthetic as a means of reducing post-tonsillectomy pain and compare current evidence to the previous meta-analysis 10 years ago. METHOD: Systematic literature searches of MEDLINE [*"ANESTHETICS, LOCAL"/ AND *TONSILLECTOMY/], EMBASE [*"LOCAL ANESTHETIC AGENT"/ AND *TONSILLECTOMY/] and PubMed [(Tonsillectomy).ti,ab AND (Local Anaesthetic).ti,ab OR (Local Anesthetic).ti,ab]. A meta-analysis of randomised control trials assessing the use of local anaesthetic agents for post-tonsillectomy pain. RESULTS: Twenty-three studies were included in the meta-analysis. Overall, local anaesthetic, applied topically or infiltrated, significantly reduces pain scores compared with controls at 4-6 hours [-0.65 (95% CI: -0.77; -0.53)]; 24 hours [-0.50 (95% CI: -0.66, -0.35)]; and 5-7 days [-0.78 (95% CI: -0.90, -0.65)] (standardised mean differences). CONCLUSION: Current studies suggest that use of peri-operative local anaesthetic during tonsillectomy does improve postoperative pain outcomes. The limitations of the analysis are as follows: all studies are small, and a multi-centred larger trial is recommended to guarantee statistical reliability. There was no description of significant adverse side effects from local anaesthetic use.

Recurrent laryngeal nerve palsy in benign thyroid disease: can surgery make a difference?

The association between a pre-operative recurrent laryngeal nerve (RLN) palsy and thyroid disease is usually suggestive of locally advanced malignant thyroid disease by invasion of the nerve. However, the risk of benign thyroid disease causing paralysis to the nerve is extremely rare and has been scarcely reported. The aims of this paper are to analyse the experience of patients presenting with RLN palsy and benign multinodular goitre (MNG), evaluate the mechanisms of pathogenesis and determine if thyroid surgery may be of benefit for these patients. A retrospective review was conducted of five patients presenting to the Otorhinolaryngology Head and Neck Surgery Department at Guy's and St Thomas' NHS Foundation Trust Hospital between 2000 and 2009. All patients were evaluated with fibre-optic laryngoscopy, ultrasound-guided fine needle aspiration cytology and computerised tomography. All patients underwent total or completion thyroidectomy and a handheld nerve stimulator (Xomed-Medtronics Vari-Stim III(®)) was used at the end of the procedure to check the integrity of the RLN. Post-operatively all patients were followed up for at least 12 months with fibre-optic laryngoscopy. Five females with an age range between 32 and 81 years presented with RLN palsy and benign MNG. All patients underwent total or completion thyroidectomies with preservation of the affected nerves. Two patients recovered the function of the nerves. All patients were confirmed to have benign multinodular goitres on histological analysis. RLN palsy in the presence of benign disease is rare. Patients should be carefully evaluated to confirm the palsy and exclude malignant disease prior to surgery. Surgery should be undertaken to remove the MNG, confirm the diagnosis and preserve the affected nerve. There is a significant chance that some of these patients will recover the function of the nerve.

Increasing incidence of differentiated thyroid cancer in South East England: 1987-2006.

There has been a worldwide increase in the incidence of thyroid cancer (TC). Documenting these recent trends is of immense value to cancer control measures, monitoring policies, improving clinical outcomes, resource allocation and stimulating research. Hence this study aimed to analyse the changes in incidence, staging and morphologic types of TC in South East England (1987-2006) by means of a retrospective, descriptive epidemiological study using anonymized data obtained from the Thames Cancer Registry (TCR) of all patients registered with TC in the period 1987-2006. Ethical approval was obtained from the Kent Research Ethics Committee. 4,880 anonymized datasets using the ICD-10 code for thyroid cancer (C73) were analyzed using SPSS v.17. TC was commoner amongst females 3,560 (73%) than males 1,320 (27%) with a 2.7:1 ratio. Mean age at diagnosis was 53 years (Range 5-99) years. An increasing incidence trend was observed in early stage disease (p < 0.001), in young adults aged ≤ 49 years (p < 0.001) and in well-differentiated TC (papillary p < 0.001 and follicular p = 0.03). The results showed that TC is commoner in females than males in SE England with a 2.7:1 ratio. The results also indicate that TC incidence has increased in SE England over the 20 years studied, with the greatest increase occurring in early stage disease, in females, young adults and well-differentiated types (papillary and follicular). This may be due to widespread usage of ultrasound with detection of incidental nodules. Further studies are required to explain the trend.

Systematic review of middle ear implants: do they improve hearing as much as conventional hearing AIDS?

OBJECTIVE: A systematic review to determine whether middle ear implants (MEIs) improve hearing as much as hearing aids. DATA SOURCES: Databases included MEDLINE, EMBASE, DARE, and Cochrane searched with no language restrictions from 1950 or the start date of each database. STUDY SELECTION: Initial search found 644 articles, of which 17 met the inclusion criteria of MEI in adults with a sensorineural hearing loss, where hearing outcomes and patient-reported outcome measures (PROMs) compared MEI with conventional hearing aids (CHAs). DATA EXTRACTION: Study quality assessment included whether ethical approval was gained, the study was prospective, eligibility criteria specified, a power calculation made and appropriate controls, outcome measures, and analysis performed. Middle ear implant outcome analysis included residual hearing, complications, and comparison to CHA in terms of functional gain, speech perception in quiet and in noise, and validated PROM questionnaires. DATA SYNTHESIS: Because of heterogeneity of outcome measures, comparisons were made by structured review. CONCLUSION: The quality of studies was moderate to poor with short follow-up. The evidence supports the use of MEI because, overall, they do not decrease residual hearing, result in a functional gain in hearing comparable to CHA, and may improve perception of speech in noise and sound quality. We recommend the publication of long-term results comparing MEI with CHA, reporting a minimum of functional gain, speech perception in quiet and in noise, complications, and a validated PROM to guide the engineering of the new generation of MEI in the future.

Left supraclavicular spindle cell lipoma.

Background. Spindle cell lipoma (SCL) is a benign lipomatous tumour, typically occurring in the posterior neck, shoulder or upper back of elderly males. They compose of fat, CD34 positive spindle cells, and ropey collagen on a myxoid matrix. This case highlights a rare presentation of SCL and the need for pre-operative diagnosis. Case Report. A 63-year-old gentleman presented with a pre-existing left supraclavicular mass that had recently increased in size. FNA and CT Scans were performed and results discussed in the mutidisciplinary team meeting. Excisional biopsy was recommended. Radiology. CT neck showed a left supraclavicular mass of fatty density with fine internal septations. A low-grade liposarcoma could not be excluded. Histopathology. FNA was indeterminate. Histology of specimen showed bland spindle cells with no evidence of malignancy. Immuno-histochemistry showed SCL with CD34 positivity and negative staining on CDK4 and p16. Management. Excision biopsy of the mass was performed which was technically difficult as the mass invaginated around the brachial plexus. The patient recovered well post-operatively with no neurological deficits. Conclusion. Spindle cell lipoma is a rare benign tumour and a pre-operative diagnosis based on the clinical context, imaging and immuno-histochemistry is crucial to management.

Endoscopic management of inverted papilloma of the sphenoid sinus.

We present the case of a rare sinonasal tumour originating in a rare location in close proximity to vital structures. We describe how the patient was managed, including detailed description of how the mass was removed.A 54-year-old man presented with a long history of nasal blockage, recently complicated by severe headaches and a left VIth nerve palsy. CT scan showed complete opacification of the left sphenoid sinus.Symptoms improved following administration of steroids and nasal decongestants. Histology from endoscopic debulking of the mass confirmed the presence of inverted papilloma. Fine-cut CT showed the course of the carotid artery and optic nerve, closely related to the tumour, allowing for complete removal during a second endoscopic procedure. Five years following the procedure, the patient remains symptom free.With appropriate imaging, isolated sphenoid sinus tumours can be removed endoscopically even when in close relation to vital structures.