Data from other countries indicate that chronic fatigue syndrome (also known as myalgic encephalomyelitis or myalgic encephalopathy) (CFS/ME) is relatively common (affecting at least 0.2-0.4% of the population), although good epidemiological data for the United Kingdom are lacking. Many different potential aetiologies for CFS/ME have been investigated, including neurological, endocrine, immunological, genetic, psychiatric, and infectious, but the aetiology cannot yet be fully explained. CFS/ME can cause prolonged illness and disability and substantially affect patients and their families. Although most patients have mild or moderate symptoms, some have severe CFS/ME and are housebound or even unable to move from their bed. Uncertainties about diagnosis and management may exacerbate the impact of symptoms, and patients often encounter delays in diagnosis and difficulty accessing information, support, and potentially helpful therapies.1 This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on diagnosing and managing this condition.2

NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available (as with CFS/ME), a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*). 

### General principles

https://www.bmj.com/content/bmj/335/7617/446.full.pdf

Diagnosis and management of chronic fatigue syndrome or myalgic encephalomyelitis (or encephalopathy): summary of NICE guidance

In human solid cancer, lymph node status is the most important indicator for clinical outcome. Recent developments in the sentinel lymph node concept and technology have resulted in a more precise way of examining micrometastasis in the sentinel lymph node and the role of lymphovascular system in the facilitation of cancer metastasis. Different patens of metastasis are described with respect to different types of solid cancer. Expect perhaps for papillary carcinoma and sarcoma, the overwhelming evidence is that solid cancer progresses in an orderly progression from the primary site to the regional lymph node or the sentinel lymph node in the majority of cases with subsequent dissemination to the systemic sites. The basic mechanisms of cancer metastasis through the lymphovascular system form the basis of rational therapy against cancer. Beyond the clinical patterns of metastasis, it is imperative to understand the biology of metastasis and to characterize patterns of metastasis perhaps due to heterogeneous clones based on their molecular signatures.

Clinical patterns of metastasis.

In spite of its rich vasculature, the thyroid gland is rarely the site of metastatic disease. The incidence of such metastases differs depending on the type of the analyzed material. In clinical papers, the incidence is low and, according to various sources, amounts to 2–3% of all malignant tumors of the thyroid. Most commonly, the primary tumor is located in the breast, bronchi, gastrointestinal system, (the colon, esophagus, or stomach) and kidneys. Usually, metastatic thyroid disease is identified upon autopsy, and only sporadic cases are encountered in clinical material. The authors present their experience in treating metastatic disease involving the thyroid gland based on the analysis of their clinical material consisting of patients operated on in a single center. Seventeen patients presented with metastatic tumors of the thyroid. The material was further analyzed retrospectively. The group included four men and 13 women, with the male to female ratio of 1:4.25. The age of the patients ranged from 46 to 76 years, with the mean age amounting to 62±9.78 years. Eleven patients were diagnosed based on fine needle aspiration biopsy (FNAB). In 13 patients, the primary lesion was a clear cell carcinoma of the kidney, in one breast cancer, in another one uterine carcinoma. In two patients, no primary focus location was established. All the patients were treated surgically. Twelve patients were consistently followed up after the surgery. Of this group, seven are still alive, including five individuals with metastases of renal carcinomas, but without recurrent disease. Five patients died due to disseminated neoplastic disease. No data are available on three patients. The mean follow-up time after thyroid surgery was 3.9 years. The longest followed-up survival time was 11 years. The most commonly clinically detected and treated surgically metastatic lesion of the thyroid gland is clear cell cancer of the kidney. In cases of renal cancer metastases to the thyroid gland, a total thyroidectomy seems to be warranted, although it does not affect the survival time.

Metastases to the thyroid gland: seventeen cases operated on in a single clinical center

Neck lymph node status is the most important factor for prognosis in head and neck squamous cell carcinoma. Sentinel node detection reliably predicts the lymph node status in melanoma and breast cancer patients. This study evaluates the predictive value of sentinel node detection in 50 patients suffering from pharyngeal and laryngeal carcinomas with a N0 neck as assessed by ultrasound imaging. Following 99m-Technetium nanocolloid injection in the perimeter of the tumour intraoperative sentinel node detection was performed during lymph node dissection. Postoperatively the histological results of the sentinel nodes were compared with the excised neck dissection specimen. Identification of sentinel nodes was successful in all 50 patients with a sensitivity of 89%. In eight cases the sentinel node showed nodal disease (pN1). In 41 patients the sentinel node was tumour negative reflecting the correct neck lymph node status (pN0). We observed one false-negative result. In this case the sentinel node was free of tumour, whereas a neighbouring lymph node contained a lymph node metastasis (pN1). Although we have shown, that skipping of nodal basins can occur, this technique still reliably identifies the sentinel nodes of patients with squamous cell carcinoma of the pharynx and larynx. Future studies must show, if sentinel node detection is suitable to limit the extent of lymph node dissection in clinically N0 necks of patients suffering from pharyngeal and laryngeal squamous cell carcinoma.

Sentinel node detection in N0 cancer of the pharynx and larynx

One of the most difficult aspects in rhinoplasty is resolving and preventing functional compromise of the nasal valve area reliably. The nasal valves are crucial for the individual breathing competence of the nose. Structural and functional elements contribute to this complex system: the nasolabial angle, the configuration and stability of the alae, the function of the internal nasal valve, the anterior septum symmetrically separating the bilateral airways and giving structural and functional support to the alar cartilage complex and to their junction with the upper lateral cartilages, the scroll area. Subsequently, the open angle between septum and sidewalls is important for sufficient airflow as well as the position and function of the head of the turbinates. The clinical examination of these elements is described. Surgical techniques are more or less well known and demonstrated with patient examples and drawings: anterior septoplasty, reconstruction of tip and dorsum support by septal extension grafts and septal replacement, tip suspension and lateral crural sliding technique, spreader grafts and suture techniques, splay grafts, alar batten grafts, lateral crural extension grafts, and lateral alar suspension. The numerous literature is reviewed.

Nasal valves--importance and surgical procedures.

Numerous diseases that require surgical treatment often occur in the thyroid, one of the most important organs in the neck. An example of such pathologies are benign and malignant neoplasms. It is still not well known, however, if certain secondary malignant neoplasms may also arise there. While this pathology is relatively frequent, and often asymptomatic, the incidence of secondary lesions observed clinically in the thyroid is much lower than that found in series based on necroscopy. The thyroid may be involved by metastatic spreading of systemic malignant neoplasms (of the kidney, breasts, lung, colon, rectum, etc.) or by direct extension of laryngeal, hypopharyngeal or esophageal cancer, the latter being more frequent. In this paper the Authors report their experience with regard to the incidence of tumorous involvement of the thyroid in 23 patients (22 of which were males between the ages of 48 and 69--average age, 65) under observation for laryngeal cancer from 1986 to 1990. All the patients had an epidermoid carcinoma of the larynx that, due to its location and size, required a hemithyroidectomy or an isthmectomy associated with laryngectomy (20 total laryngectomies with hemithyroidectomies and 3 subtotal laryngectomies with isthmectomy). Upon pathologic examination, 7 thyroid specimens (30%) revealed tumorous involvement of the thyroid and in those cases of males who had undergone total laryngectomy with hemithyroidectomy, thyroid involvement was found. In 5 cases, tumorous involvement was immediately evident upon microscopic examination (1 case of solitary tumor metastasis and 4 of direct extension).(ABSTRACT TRUNCATED AT 250 WORDS)

Thyroid gland involvement in cancer of the larynx

Tympanometry with 220 Hz probe tone mainly measures compliance related components of the middle ear. Only higher frequency probe tones provide information on mass related components. In order to study the behavior of the mass related components in endolymphatic hydrops, the Authors tested 15 Meniere's disease patients and 10 healthy subjects using multifrequency tympanometry. In both groups tympanometry with 220 and 678 Hz probe tone was employed to evaluate resonance frequency. The presence of a "camel hump" ([symbol: see text]) pattern obtained with the 678 Hz probe tone test indicated an elastic tympano-ossicular system (low point of middle ear resonance); the presence of an inverted "V" ([symbol: see text]) pattern showed a more rigid system (high point of middle ear resonance). In Meniere's disease carriers multifrequency tympanometry revealed 21 ears (70%) with a resonance frequency higher and 6 (20%) lower than 678 Hz. Three patterns (10%) were not classifiable. In the healthy group resonance frequency resulted lower than 678 Hz in 23 ears (57.5%); in 13 ears higher (32.5%). Four patterns (10%) were not classifiable. In Meniere's disease carriers the tympanometric patterns found with 678 Hz probe tone indicated the presence of a more rigid tympano-ossicular system.

[Multifrequency tympanometry in Meniere's disease: preliminary results].

Warthin's tumor is the second most common salivary gland tumor preceded only by pleomorphic adenoma. In most cases it involves the parotid gland and can, at times, be bilateral. It can also arise in ectopic salivary tissue in the latero-cervical and para-parotid lymph nodes. This neoplasm consists of two histologic components: one epithelial, the other lymphoid. Malignant transformation involving each of these tissues has been reported. However, few cases give clear-cut examples of the epithelial malignant change. Therefore, primary malignant transformation of Warthin's tumor is extremely rare. This event appears related to the initial time of tumor onset and/or past radiotherapy for other malignant cervico-facial lesions. The authors report a case of epidermoid carcinoma arising on an ectopic Warthin's tumor in a 57-year-old male. Physical examination revealed a recent, smooth tumor mass on the left, located near the laryngeal thyroid cartilage. Fine needle aspiration cytology was suspicious of a malignant epithelial neoplasm. Functional latero-cervical dissection, modified by excision of the digastric and sternohyoid muscles plus a 2 x 2 cm section of the overlying skin, was performed in this case. Histology and immunocytochemical tests on the surgical specimen revealed a 14 cytokeratin-positive, malignant epidermoid neoplasm arising from the adjacent 14 cytokeratin-negative, oncocytic epithelium. This relationship may rule out metastasis and may, therefore, be a case of Warthin's tumor associated with an epidermoid carcinoma or a case of branchial cyst.

[Carcinoma in ectopic Warthin's tumor: a case study and review of the literature].

The thyroid gland harbours many diseases which require a surgical treatment; the gland may also be involved by some secondary malignant neoplasms. Such type of involvement by laryngeal and hypopharyngeal cancers is more often due to direct extension rather than metastases. In this paper the Authors report their experience of tumoral involvement of the thyroid gland in 35 patients with laryngeal or hypopharyngeal cancer observed from 1986 to 1990. All patients had an epidermoid carcinoma of the larynx or hypopharynx that required an hemithyroidectomy (always plus isthmectomy) or an isthmectomy associated to laryngectomy. On pathologic examination 5 thyroid specimens revealed tumoral involvement in patients with laryngeal neoplasms: 1 case of solitary metastasis and 4 cases of direct extension. In patients with hypopharyngeal lesions, on the contrary, the gland was, in all cases, undamaged. For this very interesting and uncommon finding the Authors agree with Harrison's proposal suggesting total thyroidectomy is necessary in case of subglottic lesions while in all the other laryngeal and hypopharyngeal lesions the homolateral lobe of the thyroid gland and the isthmus should be removed with the specimen also performing a frozen section examination of the contralateral lobe. In this study tumoral involvement of the thyroid gland appeared to be a very important negative prognostic factor and was higher in the subglottic and anterior commissure lesions.

[Thyroid gland and carcinoma of the hypopharyngeal-laryngeal region].

Head and neck malignant tumors show a high tendency to spread to cervical lymph nodes. Therefore, surgical approach to these neoplasms is primary tumor exeresis associated with functional or radical neck dissection, unilaterally or bilaterally at the same time, in relation to T site and N stage. In this paper the validity of such approaches is evaluated by correlating clinical and histopathologic N involvement in 168 patients with head and neck malignancies, observed in a 5-year period (1986-1990), and submitted to radical (65 pts.) and functional (198 pts.) neck dissection. The histopathologic findings showed 31 patients (14.7%) with N0+ (false negatives). The incidence of occult latero-cervical metastases confirms the importance of elective functional neck dissections in N0 patients with head and neck malignant tumors even though the risk of performing many unnecessary surgical procedures may be considerable (180 cases out of 211 in the Authors experience). Rare false positives (overall 4 cases) did not represent a significant clinical problem while N3 showed massive neoplastic invasion with extracapsular spread.

Bianchedi M

Papers

Thyroid gland involvement in cancer of the larynx

[Multifrequency tympanometry in Meniere's disease: preliminary results].

[Carcinoma in ectopic Warthin's tumor: a case study and review of the literature].

[Thyroid gland and carcinoma of the hypopharyngeal-laryngeal region].

The surgical treatment of laterocervical adenopathies due to malignant cervicofacial tumors