The Management of Locally Invasive Primary Thyroid Paraganglioma: A Case Report and Review of the Literature

Paragangliomas (PG) are very rare neuroendocrine tumours, arising from neural crest derived paraganglia of the autonomic nervous system. Primary thyroid paraganglioma (PTPG) is a rare site of PG and only 45 cases have been previously reported. The preoperative diagnosis of PTPGs presents a challenge as the clinical, cytological and histological features overlap with more common primary thyroid cancers. A 55 year old male was found to have significant enlargement of the left lobe of his thyroid. Following lobectomy, the thyroid lobe showed unencapsulated tumour which was positive for synaptophysin, CD56 and S100 (sustentacular cells). Post-operative imaging demonstrated incomplete resection. There was no post-operative radiotherapy and monitoring was by 6-12 monthly MRI. 48 months after his surgery he is alive and well with no evidence of disease progression. The diagnosis of PTPG was only made postoperatively, and although rare should be considered in the differential diagnosis of a hypervascular thyroid nodule.

Sudden cardiac death in adults with congenitally corrected transposition of the great arteries

Background

Congenitally corrected transposition of the great arteries (ccTGA) is a rare congenital heart disease. There have been only few reports of sudden cardiac death (SCD) in patients with ccTGA and reasonable ventricular function.

Methods

A retrospective review of the medical records of all patients attending our adult congenital heart centre, with known ccTGA.

Results

From a database of over 3500 adult patients with congenital heart disease, we identified 39 (∼1%) with ccTGA and ‘two-ventricle’ circulations. 65% were male. The mean age at diagnosis was 12.4±11.4 years and the mean age at last time of review was 34.3±11.3 years. 24 patients (56%) had a history of surgical intervention. 8 (19%) had had pacemaker implantation and 2 had had a defibrillator implanted for non-sustained ventricular tachycardia (NSVT). In 544 years of patient follow-up, there had been five cases of SCD in our population; 1 death per 109 patient-years. Two of these patients had had previously documented supraventricular or NSVT. However, they were all classified as New York Heart Association (NYHA) class I or II, and systemic (right) ventricular function had been recorded as normal, mildly or mildly–moderately impaired, at most recent follow-up.

Conclusions

Our experience suggests the need for improved risk stratification and/or surveillance for malignant arrhythmia in adults with ccTGA, even in those with reasonable functional class on ventricular function.

Level 5 Lymphadenopathy Warrants Heightened Suspicion for Clinically Significant Pathology

We conclude that patients presenting with level 5 lymphadenopathy should be investigated with heightened clinical vigilance. Our results suggest that up to 80 % will harbour clinically significant pathology requiring further medical treatment, three quarters of which will be malignancy. We report an observational study of histological outcomes of level 5 lymph node biopsies from a regional histopathology department across 5 years. 184 subjects were identified as having a biopsy of a lymph node from the level 5 region within the study period. One hundred and fifty six cases (84.8 %) had clinically significant pathology on final histology requiring further medical treatment. Lymphoma accounted for the highest number of cases (n = 72, 39.1 %), followed by metastatic carcinoma (n = 65, 35.3 %) and granulomatous change (n = 17, 9.2 %). Gender and laterality were not shown to be independent predictors of pathology significance (p > 0.05).

Sino nasal assessment questionnaire, a patient focused, rhinosinusitis specific outcome measure

It is becoming increasingly important for clinicians to be able to demonstrate the effectiveness of their interventions. We have developed a rhinosinusitis--specific outcome measure (SNAQ-11) that avoids the shortcomings of the existing tools. This paper compares its use with the widely used Sinonasal Outcome Test (SNOT-20). We carried out a prospective study that involved forty patients undergoing endoscopic sinus surgery. Their SNAQ-11 and SNOT-20 scores were compared pre and post operatively. We also recorded individual symptom scores pre and post operatively in order to study the impact of surgery. The study shows a larger change in the postoperative SNAQ score compared to that in SNOT-20 (21% c.f. 11%) Although the pre and post-op changes in SNOT-20 are significant at the p = 0.005 level, the changes in the SNAQ-11 are highly significant at the p = 0.0001 level. Furthermore we have statistically confirmed that the change seen with SNAQ-11 is larger in relation to the variation in change as compared with SNOT-20 (-1.08 c.f. -0.59). Our results show that SNAQ-11 is a valid and highly relevant rhinosinusitis outcome tool. The results also confirm that Endoscopic Sinus Surgery seems especially effective at addressing nasal obstruction, congestion and facial pain/pressure, fair at anterior nasal discharge, sneezing, hyposmia and sleep disturbance and poor for post nasal drip, cough and earache.

Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999

Tinnitus is a common experience with up to one third of the adult population experiencing it at some time in their life. Less than 1% of the adult population have tinnitus of sufficient severity to affect their quality of life seriously (although up to 8% may seek medical advice about it). Much of the severity of tinnitus relates to the individuals' psychological response to the abnormal tinnitus signal. The prevalence of tinnitus increases in association with high frequency hearing loss. There is, unfortunately, no diagnostic test that either confirms the presence of tinnitus or its severity. Currently there is no satisfactory severity grading system. A five-point severity grading scheme is therefore proposed and the entry criteria detailed. The five severity points are: slight, mild, moderate, severe and catastrophic. Categorization as 'severe' or 'catastrophic' should be, by epidemiological definition, very rare. General guidance, theory and evidential support are contained within.

Partial resection of the middle turbinate at functional endoscopic sinus surgery

The middle turbinate is often carefully preserved at Functional Endoscopic Sinus Surgery (FESS). However there is no clear understanding of its importance and its presence may prevent good access to the middle meatus to the detriment of the surgical result. In addition its bulk may cause symptoms of nasal obstruction and prevent paranasal sinus drainage. Adhesions and stenosis have been reported at the middle meatus following its preservation. We undertook a prospective study of 50 consecutive patients all of whom underwent resection of the anterior half of the middle turbinate at the time of Functional Endoscopic Sinus Surgery. The patients were asked to complete a symptom score sheet before and ten weeks after surgery. The parameters considered were nasal obstruction, nasal congestion, discharge, facial pain and headache. Non parametric analysis of the results indicated a significant improvement in all patient symptom scores and no postoperative complications were noted. We conclude that partial resection of the middle turbinate is a useful modification of accepted endoscopic sinus surgery techniques.

Establishing a new ENT-head and neck clinic

We report our experience of the first fourteen months of a new head and neck surgical clinic established at a district general hospital. The structure of the clinic together with analysis of the patient case mix and referral patterns are considered. The perceived benefits include rapid patient access to specialist management, the development of subspecialty skills and excellent training opportunities for trainee registrars.

Extracapsular haemorrhage from a parathyroid adenoma presenting as a massive cervical haematoma

Spontaneous massive haemorrhage from a parathyroid adenoma is rare. It can cause extensive cervical ecchymosis as well as compression of structures within the neck. We present a case, discuss the diagnostic features and review the literature.

Clinical photographs as teaching aids: how reliable are they?

A study to investigate the value and reliability of clinical photographs as teaching aids was undertaken. Twenty colour photographs were taken using the StarMed video-otoscopic system. The pictures, which were a mixture of normal and abnormal ears, were shown to 21 experienced otolaryngologists from the UK and Canada. These clinicians were asked to identify the abnormality if any. The median score for correctly identified pictures was 15 (range 12-18). This score was identical for both the UK and Canadian subgroups. Although the abnormalities were consistently well recognized with an average correct identification rate of 90 per cent (range 67-100 per cent), the 'normals' were recognized significantly less well at only 41 per cent (range 5-71 per cent) (chi-squared = 110.6; 1 df; p < 0.001). This result is probably due to failure of the camera to capture the huge variation and subtleties in the range of normal, and the clinicians' natural inclination to identify pathology, when in doubt. We would conclude that as long as this failing is recognized, clinical photographs, and specifically those from the video-otoscope, represent a useful and reliable teaching tool.

An evaluation of the penetration of cefuroxime axetil into human paranasal sinus tissue

Nineteen patients presenting for sinus surgery were studied to evaluate the percentage penetration from serum to paranasal sinus tissue of a single orally administered dose of cefuroxime axetil. The methods and results are presented. Cefuroxime penetrates well into human sinus mucosa following oral administration and the concentrations obtained exceed minimum inhibitory concentrations of cefuroxime for the most common pathogens in sinusitis.

Emergency laryngectomy

From 1974 to 1990, 31 patients underwent emergency laryngectomy for airway obstruction due to laryngeal carcinoma, in an effort to avoid the complication of stomal recurrence. This group of patients had a greater proportion of multiregional tumours (35 per cent vs 13 per cent) than a comparison group of elective laryngectomies. In other respects the two groups were similar. Early post-operative mortality (6.5 per cent vs 3 per cent), stomal recurrence rates (4.2 per cent vs 4.8 per cent) and survival (53 per cent vs 55 per cent) were not significantly different between the emergency laryngectomy group and the comparison group undergoing elective laryngectomy.

Recurrence in juvenile angiofibroma

A potential for recurrence of juvenile angiofibroma exists after all treatment modalities, both surgical and medical but the methods of defining recurrence and failure to cure varies considerably from series to series. To evaluate factors which might influence successful treatment, a series of 33 patients have been reviewed retrospectively. All patients were treated by simple or extended lateral rhinotomy as a primary or secondary procedure. The final long-term disease control rate was 97% but during the treatment period the overall symptomatic recurrence rate was 50%. However, amongst those treated primarily the recurrence rate was 34%. Of the factors examined, the strongest predictor of recurrence was preoperative embolisation. This group exhibited both early and multiple recurrence when compared with the non-embolised group and the possible reasons for this are examined.

Multiple synchronous carcinoma of the aero-digestive tract

Multiple carcinoma of the upper aerodigestive tract is an increasingly recognized problem, and a concept of 'field cancerization' has been proposed to explain this phenomena. The initial assessment of a patient with an isolated aerodigestive carcinoma must be extensive so as not to miss any synchronous lesions, and may include radiography and endoscopy. Treatment cannot be standardised but must be tailored to suit individual problems and because of the high incidence of metachronous tumours, follow-up must be both thorough and 'lifelong'. A case of three primary synchronous squamous carcinomas of the upper aerodigestive tract is presented. The relevant literature is reviewed.