Risk of CA in MNG

I was asked this by a friend who has a progressively enlarging non-toxic goitre and a CT scan that showed a huge multinodular goitre with tracheal compression: do I need surgery and why? Should the whole thyroid be removed or can some be spared?

My quick answer was YES you need surgery, and a total thyroidectomy, both because of the risk of occult carcinoma. An FNAC can easily miss malignant foci, MNGs have a risk of malignant change, imaging has no reliable sign of malignancy, and compression heralds worse complications (with or without op).

But what's the risk exactly, and what does evidence say about how much of thyroid to remove? This is what the evidence says:

1)In a review of 317 patients operated for multinodular goiter, the incidence of occult micro-carcinoma was 3.3% (Wahl RA, Goretzki P, Meybier H, Nitschke J, Linder M, Roher HD. Coexistence of hyperthyroidism and thyroid cancer. World J Surg 1982; 6: 385-390)
2) Another review of 98 total thyroidectomies done for MNGs revealed an incidence of 10 cases (10.2 percent) occult carcinomas - seven patients were diagnosed with papillary carcinoma, two with the follicular variant of papillary and one with follicular carcinoma.
http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijs/vol17n1/goiter.xml
2) Total thryoidectomy may avoid need for reoperation in case of incidental thyroid
cancer; a study of 218 patients with euthyroid multinodular goiter and no suspicion for malignancy were randomized to total or near-total thyroidectomy (remnant tissue < 1 g) vs. bilateral subtotal thyroidectomy (remnant tissue> 5g); no significant differences in rates of temporary unilateral vocal cord dysfunction (0.9% vs. 0.9%), hypoparathyroidism (1.8% vs.0.9%) or finding of papillary cancer (9.2% vs. 7.3%) (Arch Surg 2004 Feb;139(2):179 in JAMA 2004 May 5;291(17):2058)

So, with a risk of somewhere between 3-10% occult carcinoma (papillary still being the commonest) and near-total also mean could-miss; I think it's still right to say MNGs should be treated with total thyroidectomies unless surgically difficult; upon which post-operative suppressive thyroxine may be an option.

Proud flesh

 

One rarely sees proud flesh outside of the diabetic foot these days, what more in the neck. This patient had a badly infected tracheostomy and was taken of it for a couple of weeks for Pseudomonas infestation. This is the result of a wound desperately trying to fill the gaps with granulation tissue while never being able to epithelialise.

What I had to do was to excise the entire granulating mass with a cuff of skin, all the way down to the strap muscles before redoing the tracheostomy. Wound care is going to be very important for this not to happen again.

Microflap excision

These vocal cords belong to a middle-aged chronic smoker who has suffered from a hoarse voice for close to a year. His wife has been my patient for many years and she decided to bring him to see me. As you can see there is intense leukoplakia on both vocal cords. A CT scan revealed no framework infiltration or extension into the pre-epiglottic space. I had tried several biopsies using a flexible scope but tissue was inadequate.


I put him under for a proper microflap excision today. Seen here is the epithelium and subepithelial layers raised, revealing the vocal ligament and gelatinous lamina propria covering it. One advantage of doing this is that I can directly inspect for deep infiltration and also examine the ventricle and subglottic space (which were free growth).


As the free edge of the vocal cord was not spared by this exophytic lesion, it didn't seem logical to confine my excision to the dorsal surface only. After all, voice-sparing was no longer my concern. More important was to get a good representative specimen. The dilemma/temptation was to get some tissue from the opposite vocal cord but thankfully caution prevailed. Last thing I need is an adhesion anteriorly and ruin his voice forever.

Should the lesion be non-invasive, I can still go in again to do the other side. If it's malignant then some radical modality will be offered. That's the plan.

GERD in the News

A new study, published in the journal "Digestion", determined the diagnostic and therapeutic response of the Reflux Disease Questionnaire (RDQ) using the symptom association probability as reference. The symptom association probability objectively determines with a Fisher exact test whether symptoms are due to reflux events taking all symptom episodes and reflux events into account. In addition, the RDQ's construct validity and its relationship to quality of life were ascertained.



The study shows the RDQ to be a valid and reliable questionnaire with excellent construct validity and a good relationship to quality of life. The diagnostic value of the RDQ in primary care is limited, but combination with an additional proton pump inhibitor treatment course might improve the RDQ's ability to discriminate GORD patients according to their symptom association probability outcome.



Medical News Today





Heartburn could be a precursor to gastro-oesophageal reflux disease, British doctors warn and note that the diagnosis of the disease is a relatively new phenomenon.&nbsp; Statistics show that over a quarter of Britons have gastro-oesophageal reflux disease, also known as the GORD, and thousands of these are not getting the treatment they need. A noted general practitioner, Dr Rob Hicks, said that the GORD as a diagnosis was a relatively new phenomenon and that although most medical practitioners were aware of it, many patients could still be suffering in ignorance. "What we are trying to do is to raise awareness, because there are many people still suffering from heartburn two or three times a week. I would advise them to see their doctor," Hicks said.



MedIndia.com

Powered by ScribeFire.

Combined Approach to Paranasal Sinuses

Summary of article: Combined anterior-to-posterior and posterior-to-anterior approach to paranasal sinus surgery: an update. Schaefer SD, Li JC, Chan EK, Wu ZB, Branovan DI.Laryngoscope. 2006 Apr;116(4):509-13

This article first reviews the historical development of FESS, from Wigand's postero-anterior approach (expose posterior ethmoids, open face of spehnoid, and retrograde ethmoidectomy) to the antero-posterior approach of Messerklinger & Stammberger (anterior ethmoidectomy followed by antegrade dissection posteriorly, extent determined by disease.) Kennedy's FESS is built on these antecedent techniques with the aim of 'reestablishing sinus drainage & mucosal recovery through restoration of obstructing sinus ostium and removal of devitalised mucous membrane or bone.'

The obvious advantage and disadvantage of the P-A approach is that
1. it avoids the skull base
2. surgery is excessive in cases of limited disease

As for the A-P approach:
1. surgery is selective and limited to pathologic sinus
2. there is potential for penetrating the posterio-inferiorly sloping skull base

The author's (Schaeffer) CAPS (combined approach to paranasal sinuses) is introduced and discussed. It is claimed that CAPS aims to 'bring together the salient features of the AP and PA approaches while observing the concept of functional endoscopic sinus surgery' and is therefore a 'minimally invasive surgery.. seeking the least disruption of form and function of the paranasal sinuses'

Key tenets of the combined approach are :
1. It is a 'disease-and-anatomy-oriented surgical approach'
2. It's goal is to 'conserve sinus anatomy'
3. Surgical principles utilizes 'anatomic relationships'

(It is disease-oriented in that surgery is targeted to 'relieve medically irreversibly obstruction of sinus outflow tracts' and it is anatomy-oriented in that anterior and posterior ethmoid sinuses are approached separately, in view that they are 'embryologically distinct structures... separated by the basal lamella of the middle turbinate.')

The key surgical principles include:
1. Complete uncinectomy necessary for anterior ethmoidectomy and prevent recurrence
2. Identification of MSO necessary to find plane of lamina papyracea
3. Anterograde (AP) dissection of anterior ethmoid cells up to basal lamella, retrograde (PA) dissection of posterior ethmoid cells

The authors' experience indicates that CAPS can be performed under local or general anesthesia, as permitted or tolerated. In this review of 2,344 patients, 'the overall complication rate was 3.4%. The minor complication rate was 2.6% (6 of 2,344 patients), and the major complication rate was 0.8% (2 of 2,344 patients).' Evidence that underscores how this 'hybrid technique' succesfully combines 'the conservation goals of the AP approach and anatomic virtues of the PA approach to ethmoidectomy.'

PubMed link

Blame it all on GERD!

'Heavner et al., in two animal studies, have demonstrated that exposure of the eustachean tube to simulated gastric content in rodents creates eustachean tube dysfunction. Velepic et al., in two separate studies, have demonstrated a strong correlation of otitis media and GERD. Using a 24-h double pH probe, they found that approximately 60% of the patients had pathologic GERD. In a 2002 study, Tasker et al. demonstrated that middle-ear effusions taken from 54 children contained pepsin/pepsinogen at concentrations up to 1000-fold greater than those in serum 83% of the time. These data suggest that the reflux of gastric juices could be a major cause for otitis media with effusion in children. The link between otitis media with effusion and pharyngeal reflux was further strengthened in a 2004 study by Keles et al. This dual-probe pH study demonstrated that 48% of the children with chronic otitis media effusion had GERD and 64% of the children had pharyngeal reflux. This study suggests that pharyngeal reflux may play an important role in the causes of chronic otitis media with effusion and also that standard single-channel pH probes evaluating for gastroesphageal reflux frequently will miss pharyngeal reflux.'

Should we blame everything on GERD? The above discussion, excerpted from 'SPECIAL COMMENTARY: Should otolaryngologists perform pH probe studies?' by Craig W. Senders in Current Opinion in Otolaryngology & Head and Neck Surgery 2006, 14:38–40 seems to say so.

In the past decade or so, more and more 'mysterious' diseases of ENT are finding its origin in acid. From globus pharyngicus, recurrent tonsillitis, chronic pharyngitis to sinusitis. Now, good old 'glue ear' has a new culprit to blame. And which otolaryngologist hasn't been wondering along those lines? It seems in the fragmented world of subspecialised medicine, diseases are pulling us back together!

Heavner SB, Hardy SM, White DR, et al. Function of the eustachian tube
after weekly exposure to pepsin/hydrochloric acid. Otolaryngol Head Neck
Surg 2001; 125:123–129.
Velepic M, Rozmanic V, Velepic M, Bonifacic M. Gastroesophageal reflux, allergy
and chronic tubotympanal disorders in children. Int J Pediatr Otorhinolaryngol
2000 Oct 16; 55 (3):187–190
Velepic MM, Velepic MS, Starcevic R, et al. Gastroesophageal reflux and sequelae
of chronic tubotympanal disorders in children. Acta Otolaryngol 2004
Oct; 124 (8):914–917
Tasker A, Dettmar PW, Panetti M, et al. Is gastric reflux a cause of otitis
media with effusion in children? Laryngoscope 2002 Nov; 112 (11):1930–
1934
Keles B, Ozturk K, Gunel E, et al. Pharyngeal reflux in children with chronic
otitis media with effusion. Acta Otolaryngol 2004 Dec; 124 (10):1178–
1181

HIgh frequency hearing loss from low frequency noise

It has long been believed that the spectrum of hearing loss closely matches that of the presenting noise. An antiquated study by Mill et al showed that this is not always true.

Human subjects were exposed to an octave-band noise for 24 hours. Temporary threshold shifts increased for the first eight hours of exposure and then were asymptotic. While threshold shifts were largest at about one-half octave above the center frequency of the noise, a second maximum was observed at higher test frequencies. The exact frequency of this second maximum decreased from 7.0 kHz, for a noise centered at 2.0 kHz, to 5.5 kHz for a noise centered at 0.5 kHz. This result could be caused by the travelling wave pattern along the cochlear partition or to the production of distortion products.

PubMed

Effects of gastroesophageal reflux disease in laryngeal carcinoma

GERD as a contributory factor to laryngeal carcinoma is much appreciated in the ORL community, but just how strong is it as a risk? Should it be aggresively investigated and treated if the risk is high?

An Italian retrospective investigates the association with 36 consecutive non-smoking and non-drinking patients with histologically confirmed SCC of the larynx vs a control, a group of 125 lifetime non-smoking and non-drinking cancer-free subjects. Patients with laryngeal cancer had a higher prevalence of gastroesophageal reflux disease than the control subjects (P < 0.0001).

PubMed

New centre for deafness research

'A new centre is to open in London in the new year, bringing together the previously disparate fields of research into deafness and communication.

The Deafness, Cognition and Language Research Centre (DCAL) will be based at University College London and will be funded by a 4.5m grant from the Economic and Social Research Council (ESRC), it was announced yesterday.

The aim of the centre is to create "a world-class hub of excellence" that will connect research into neuroscience and linguistics to issues affecting deaf individuals in their communities. It will also seek to challenge the perceptions of deafness and study sign language and communication techniques. All the centre's researchers will be expected to become fluent in British Sign Language.'

EducationGuardian.co.uk

Medical management of middle ear disease in children less than 2 years of age with sensorineural hearing loss

'Pneumatic otoscopy should be used to diagnose middle ear effusion. Clearance of OME may be prolonged in children with craniofacial abnormalities. Antibiotics provide a small short-term increase in the resolution of OME and may be warranted in children with coexisting SNHL and OME for 4 to 6 weeks. If OME persists for 8 to 12 weeks, bilateral myringotomy and tube placement (BM&T) with short-term tubes will improve hearing and help resolve OME. AOM in children less than 2 years of age should be treated with a 10-day course of antibiotics. Prophylactic antibiotics may be useful in avoiding tube placement in children less than 2 years of age with recurrent AOM. BM&T with short-term tubes are recommended if recurrent AOM persists. Pneumococcal vaccination can decrease episodes of AOM by 6 to 7%.'

Above are the recommendations based on a meta-analytic study by Westerberg BD, et al. in J Otolaryngol. 2005 Aug;34 Suppl 2:S64-9.

Wherefrom the infection?

A 55yr-old man had craniectomy and drainage for a huge intracranial temporal lobe abscess and an ipsilateral extracranial temporal abscess as seen in this CT scan. He was referred to ENT for clearance of a possible foci of infection from the mastoid or middle ear which would seem to be the case from the 2nd image presented here. A large area of erosion is seen in the mastoid, communicating with the middle fossa as well as the temporal space.







The history, however, was not quite so convincing. He had no history of chronic ear discharge, and was not diabetic. The only lead was one experience of external ear infection 3 months ago after he traumatised his ear canal by overenthusiastic cleaning. Examination would show an external canal filled with pus, a sagging posterosuperior meatal wall, a soft and fluctuant postauricular region and a discharging sinus.



























I proceeded to perform a mastoid exploration/cortical mastoidectomy but to my surprise found only a sclerotic mastoid and no foci of disease at all. Drilling was carried all the way down to the bony defect where dura is clearly seen. No pus, granulation, or cholesteatomas found.

So where was the foci of infection? How did an abscess of such magnitude, with such extensive destruction of bone come about? We are hoping a HRCT will give us more clues. Could this be a skull base osteomyelitis secondary to otitis externa?

Genetic Differences Determine Taste Perception

By Daniel DeNoon
WebMD Medical News
Scientists looked at a specific taste receptor for a bitter substance known as PTC. Small changes in the genes made big differences in the receptor's ability to recognize the bitter chemical. This helps explain why some people can't taste PTC at all while others find it terribly bitter - and still others find it bitter in varying degrees.
Read the full article

Interview: Genes and Deafness

Host Jennifer Ludden discusses the new research breakthrough on hearing loss with Dr. James Battey, who directs the National Institute on Deafness and Other Communication Disorders at the National Institutes of Health. Dr. Battey explains what research remains to be done, before gene therapy can be tested on humans.

Listen to the interview by Jennifer Ludden

Gene Therapy for Deafness

By Roger Highfield
American scientists have found that the transplant of a specific gene permits the growth of new hair cells in the inner ear.. The technique, which one day could help millions of people worldwide, was described yesterday by Dr Yehoash Raphael of the Kresge Hearing Research Institute, University of Michigan, in the journal Nature Medicine.
Read the FULL ARTICLE

Cure for sensorineural deafness?

Researchers in the US have for the first time restored hearing in deaf mammals - a feat that represents a major step toward treating people with acquired hearing loss.

By inserting a corrective gene with a virus, the team at the University of Michigan Medical School induced the formation of cochlear hair cells - the key intermediaries in converting sound waves into electrical impulses - in the ears of artificially deafened adult guinea pigs, according to the Los Angeles Times.

Read the FULL ARTICLE

Just when you taught it was safe!

from REDNOVA
'The prevalence of asthma has increased worldwide. The reasons for this rise remain unclear. Various studies have reported an association between acetaminophen, a widely used analgesic, and diagnosed asthma. In a prospective cohort study, the rate of newly diagnosed asthma was 63% higher among frequent acetaminophen users than nonusers in multivariate analyses. Studies of patients with asthma suggest that acetaminophen challenge can precipitate a decline in FEV^sub 1^ > 15% among sensitive individuals. Plausible mechanisms to explain this association include depletion of pulmonary glutathione and oxidative stress. This article reviews the existing literature and evaluates the epidemiologic and pathophysiologic evidence underlying a possible link between acetaminophen and asthma. (CHEST 2005; 127:604-612)'

-- An excellent article reviewing the association between acetaminophen and atopic diseases. Could it also be related to allergic rhinitis? Just when you taught some drugs were safe... Ed.

read the FULL ARTICLE

Men 20-29 most at risk for sleep apnea

by GLOBES Correspondent
'According to a new study, men in their 20s are most at risk for sleep apnea, and need to be screened the most. The study, carried out by the Technion-Israel Institute of Technology, showed that men aged 20 to 29 with severe sleep apnea have 10 times the risk of dying from heart related ailments than their non-sleep apnea peers in the general population, and a much higher risk than older men with sleep apnea.

The Technion study, which appears in the March 2005 European Respiratory Journal, was based on the largest population of sleep apnea patients (nearly 15,000 men) ever to be studied. All were recorded in the Technion sleep clinics in Israel from 1991 through 2000. The researchers compared the risk of dying for men with severe sleep apnea -- having at least 50 breathing stops per hour -- with the general population.'
read the FULL ARTICLE

An aberration in a natural pattern

by Joan Skelton
'With so many other grieving parents, I weep at this variance. I am 25 years older than he is. I should be dying, not him.

He had actively been in the medical system for three months with golf-ball size lymph nodes, head, face and neck pain, blocked ears, difficulty swallowing, weight loss and fatigue. His treatment was a stent in his ear, then the recommendation of two weeks of bed rest because of "exhaustion" and "viruses," finally antibiotics for "sinusitis" and Percocet. Percocet! Then, a CT scan showed the possibility of a tumour.

At least four health professionals made grievous mistakes in the care of my son. Were they irresponsible? Negligent? Incompetent? Unlikely. Undoubtedly, they are over-worked, tired, stressed out, scratching to maintain a semblance of sanity in a system that would suck out their soul, if they let it. Such is our Canadian health-care system.'

- A grim but not uncommon story to remind us of the 'failures' of the health care system. If only to keep us alert. YY

read the FULL ARTICLE

Brain gene for Presbycusis

from Health India
A new study conducted by researchers at University of Rochester Medical Center suggests that a "feedback" problem in the brain diminishes our ability to hear.
"Traditionally, scientists studying hearing problems started looking at the ear. But we are finding patients with normal ears who still have trouble understanding a conversation. There are many people who have good inner ears who just don't hear well. That's because their brains are aging." lead researcher, Robert D. Frisina was quoted as saying.
Read the FULL ARTICLE

Saliva Testing for Head and Neck Cancer?

by Robert Preidt
'New discoveries in proteomics -- the study of proteins found in saliva and elsewhere throughout the body -- is bringing saliva testing within spitting distance of other much-used screens, such as blood or urine testing, the experts said.
Saliva and other oral fluids contain many of the same proteins and other molecules found in blood and urine that can reveal the presence of diseases, including head and neck cancers, the researchers noted.'
Read the FULL ARICLE at Forbes Health