https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/cen.12515

Guidelines for the management of thyroid cancer

Melanomas on sun-exposed skin are heterogeneous tumours, which can be subtyped on the basis of their cumulative levels of exposure to ultraviolet (UV) radiation. A melanocytic neoplasm can also be staged by how far it has progressed, ranging from a benign neoplasm, such as a naevus, to a malignant neoplasm, such as a metastatic melanoma. Each subtype of melanoma can evolve through distinct evolutionary trajectories, passing through (or sometimes skipping over) various stages of transformation. This Review delineates several of the more common progression trajectories that occur in the patient setting and proposes models for tumour evolution that integrate genetic, histopathological, clinical and biological insights from the melanoma literature.

From melanocytes to melanomas

Objective:To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.Background:Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in th

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

Objective This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia. Purpose The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology-head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology. Action Statements The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include, but are not limited to, recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia. Disclaimer This clinical practice guideline is not intended as an exhaustive source of guidance for managing dysphonia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem. Differences from Prior Guideline (1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia.

https://journals.sagepub.com/doi/pdf/10.1177/0194599817751030

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update).

Objectives/Hypothesis
Existing intraoperative neuromonitoring (IONM) formats stimulate the recurrent laryngeal nerve (RLN) intermittently, exposing it to risk for injury in between stimulations. We report electrophysiologic parameters of continuous vagal monitoring, utilizing a novel real-time IONM format, and relate these parameters to intraoperative surgical maneuvers that delineate nascent adverse but reversible electrophysiologic parameters to prevent nerve injury. These results are correlated with postoperative vocal cord functional outcome.

Study Design
Prospective multicenter tertiary study.

Method
Evoked vagal nerve waveform amplitude and latency changes during 102 thyroidectomies were recorded. Adverse electrophysiologic response was categorized into 1-concordant amplitude reduction and latency increase events (combined events) and 2-loss of signal (LOS). Surgical maneuvers were modified when adverse electrophysiologic findings were noted. All patients underwent preoperative and postoperative laryngoscopy; intraoperative electrophysiologic findings were correlated with postoperative laryngeal function.

Results
Continuous vagal monitoring did not result in stimulation-evoked nerve injury or intraoperative adverse cardiac, pulmonary, or gastrointestinal effects. Both intraoperative combined events and LOS were associated with development of vocal cord paralysis (VCP) (P = 0.001 and P >0.001 respectively). Combined events had a positive predictive value (PPV) of 33%, negative predictive value (NPV) of 97%, and were reversible in 73%. LOS had a PPV of 83%, NPV of 98%, and was reversible in only 17%. Milder combined events and isolated amplitude or latency changes were not associated with VCP.

Conclusions
Continuous vagal monitoring is safe and provides real-time RLN evaluation during surgical maneuvers. Combined events and LOS, both easily identifiable intraoperatively, are related to the development of VCP. A combined event represents a largely reversible electrophysiologic change when the associated surgical maneuver is aborted. If allowed to continue, it can advance to LOS (which typically is significantly less reversible) and to postoperative VCP. Continuous vagal monitoring has utility in identifying real-time adverse concordant amplitude and latency changes (combined events), which can prompt modification of the associated surgical maneuver and may prevent RLN paralysis during thyroidectomy.

Level of Evidence
4. Laryngoscope, 124:1498–1505, 2014

Continuous vagal IONM prevents recurrent laryngeal nerve paralysis by revealing initial EMG changes of impending neuropraxic injury: a prospective, multicenter study

ObjectiveThyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esop...

https://journals.sagepub.com/doi/pdf/10.1177/0194599813487301

Clinical Practice Guideline: Improving Voice Outcomes after Thyroid Surgery

Benign metastasizing pleomorphic adenoma.

Sudden Hearing Loss in Sickle Cell Disease: A Case Report

BACKGROUND: After undergoing tonsillectomy and adenoidectomy (T&A), children may experience significant pain. Clonidine, an alpha2 agonist, exhibits significant analgesic properties. The current investigation sought to determine whether intramuscular (I.M.) clonidine would decrease pain in paediatric patients undergoing T&A. METHODS: Thirty-nine children undergoing elective T&A were studied. Following inhalational anaesthetic induction, fentanyl (2 microg x kg(-1)) was given intravenously, acetaminophen (paracetamol) (30 mg.kg-1) was given rectally and the children then randomly received an i.m. injection of either normal saline or clonidine (2 microg x kg(-1)). Perioperative analgesic requirements in the postanaesthesia care unit and at home following hospital discharge were evaluated. RESULTS: There were no significant demographic, analgesic consumption, haemodynamic or pain score differences between the groups. CONCLUSIONS: We do not recommend adding i.m. clonidine (2 microg x kg(-1)) to the analgesic regimen of children undergoing tonsillectomy and adenoidectomy.

Analgesia for paediatric tonsillectomy and adenoidectomy with intramuscular clonidine.

From the Department of Otolaryngology, Harvard Medical School, Children's Hospital. Presented at the 1992ASPO Meeting, Palm Springs, Calif., April 15, 1992. Received for publication Feb. 5, 1993;revision received June 28, 1993; accepted July 7, 1993. Reprint requests: Laurie A. Ohlms, MD, Department of Otolaryngology, 300 Longwood Ave., Boston, MA 02115. OtoLARYNOOL HEAD NECK SURG 1993;109:1070-3. Copyright @ 1993by the ~erican Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/93/$1.00 + .10 23/4/49888 Sclerosing osteomyelitis of the mandible

Jerry M. Schreibstein

Papers

Clinical Practice Guideline: Improving Voice Outcomes after Thyroid Surgery

Benign metastasizing pleomorphic adenoma.

Sudden Hearing Loss in Sickle Cell Disease: A Case Report

Analgesia for paediatric tonsillectomy and adenoidectomy with intramuscular clonidine.

Sclerosing osteomyelitis of the mandible.