Hesham Kaddour

Do Immediate Cytology and Specialist Radiologists Improve the Adequacy of Ultrasound-Guided Fine-Needle Aspiration Cytology?

Objective To assess whether a dedicated “1-stop” neck lump clinic has improved the percentage of adequate fine-needle aspiration cytology (FNAC) samples and reduced the need for repeat FNAC. Study Design Retrospective review. Setting District General Hospital in the United Kingdom. Subjects and Methods Patients attending for ultrasound-guided FNAC over a 6-month period from August 2012 to February 2013. Patients were placed in 4 groups: group 1, FNAC performed by any of the subspecialist radiologists with cytology support (n = 100); group 2, FNAC performed by general radiologists without cytology support (n = 112); group 3, FNAC performed by a particular subspecialist radiologist with cytology support (n = 61); and group 4, FNAC performed by the same subspecialist radiologist without cytology support (n = 125). Results There was a significantly higher rate of adequacy of FNAC in the presence of a subspecialist radiologist with immediate cytology (group 1) versus a general radiologist without cytology support (group 2; 87/100 vs 63/112, P = .0001), a significantly higher rate of adequacy of FNAC in the presence of cytology support with the same radiologist (group 3 vs group 4, 55/61 vs 97/125, P = .04), and a significantly higher rate of adequacy of FNAC in the presence of a subspecialist radiologist versus a general radiologist without cytology support (group 4 vs group 2, 97/125 vs 63/112, P = .0005). Conclusion Immediate cytology and the presence of a subspecialist radiologist increase the adequacy of FNAC. The adequacy rate of non–cytology-supported FNAC or nonsubspecialist FNAC is below the adequate rate expected from the literature or as recommended in national guidelines.

Endotracheal tube positioning during neck extension in thyroidectomy.

OBJECTIVE To evaluate the effect of body mass index and neck length on endotracheal tube movement during neck extension in thyroidectomy. METHODS A prospective study was conducted of 30 patients undergoing thyroidectomy during an 8-month period. Patient characteristics were recorded and endotracheal tube displacement was determined. RESULTS Mean body mass index was 27.8 kg/m2 (range, 17.5-34.7 kg/m2) and mean neck circumference was 43.2 cm (range, 28-56 cm). The mean (± standard deviation) upward displacement of the endotracheal tube during neck extension was 7.17 ± 5.87 mm. Patients with a larger body mass index had a significantly greater amount of tube displacement (R2 = 0.67, p < 0.0001), as did patients with a smaller neck length (R2 = 0.48, p < 0.0001). CONCLUSION Neck extension results in upward displacement of the endotracheal tube. The amount of displacement is significantly higher in patients with a larger body mass index or shorter neck length. This has particular relevance for nerve monitoring in thyroidectomy.

Paravertebral cervical chordoma – a case report

Chordomas constitute <5% of vertebral column tumours and a third of these arise in the upper cervical spine and tend to be clival – usually midline, with occasional eccentric extension. We report a case of cervical chordoma presenting as a lateral neck mass and discuss its origin, diagnosis and management.

Endoscopic-guided injection of botulinum toxin into the cricopharyngeus muscle: our experience.

OBJECTIVE To assess the efficacy of endoscopic-guided botulinum toxin injection into the cricopharyngeus muscle and evaluate the duration of its effects. METHODS A 3-year prospective study of 12 patients undergoing injection of botulinum toxin was conducted, with a telephone survey to assess dysphagia pre-operatively, and at 1, 3 and 6 months post-treatment, using the MD Anderson Dysphagia Inventory. RESULTS Median age was 66.2 years. Causes of cricopharyngeal dysphagia included idiopathic cricopharyngeal hypertrophy (67 per cent), previous cerebrovascular accident (17 per cent), cranial nerve palsy (8 per cent) and previous chemoradiotherapy to the neck (8 per cent). There were no complications. Two patients had repeat injections after six months. There was significant improvement in MD Anderson Dysphagia Inventory scores at one and three months versus pre-operative scores (73.1 ± 14.9 vs 46.9 ± 7.6, p = 0.0001, and 65.1 ± 11.5 vs 46.9 ± 7.6, p = 0.0001), but not at six months (51.0 ± 11.0 vs 46.9 ± 7.6, p = 0.14). CONCLUSION Endoscopic-guided injection of botulinum toxin into the cricopharyngeus muscle is a safe and effective method for treating cricopharyngeal muscle dysfunction, lasting up to six months.

Sphenoid mucocele: a rare cause of ocular dysfunction

### Learning Point for Clinicians Sphenoid mucoceles are rare and usually an incidental finding. However, headache and visual symptoms including oculomotor nerve palsy and reduced visual acuity can be due to these benign but expansile lesions. Surgical endoscopic decompression is recommended. Sphenoid mucoceles are rare clinical conditions, usually presenting with headache but can rarely result in visual defect, diplopia and ptosis.1,2 We present a series of three cases and discuss their diagnosis, management and outcome. ### Case 1 A 66-year-old man presented with a 9-day history of pain over the right maxilla. He was initially treated as sinusitis with simple analgesia and a course of antibiotics. However, he re-presented with diplopia, severe right periorbital pain, headache, vomiting and photophobia. On examination, his pupils were equal and reactive to light with normal visual fields and fundi. His acuity 6/6 on the left but 6/24 on …

Endotracheal Tube Displacement during Neck Extension in Thyroid Surgery

Objectives: Evaluate how much the endotracheal tube moves on neck extension in patients undergoing elective thyroid surgery and whether this is affected by body mass index (BMI) or neck length. Methods: Prospective study of 20 patients undergoing thyroidectomy during a 4-month period in 2013-2014. Patient demographics, BMI, collar size, sterno-mental distance, and sterno-cricoid distance were recorded. The electromyography endotracheal tubes used in thyroid surgery were marked at 1 cm, and the distance was noted in the neutral and extended (30° as tolerated) neck positions. Results: The mean age of patients was 46.4 years (range 26-68 years). There were 18 female and 2 male patients. The mean BMI was 28.2 (range, 20.1-32.6) and mean sterno-mental distance was 15.2 cm (range, 9.8-20.4 cm). The mean upward displacement of the endotracheal tube during neck extension was 22.2 ± 7.6 mm. Patients with a larger BMI (>25) had a significantly smaller amount of tube displacement than patients with a smaller BMI (<25; 17.1 ± 7.3 mm vs 24.5 ± 8.1 mm, P = .02) and patients with a smaller neck length (sterno-mental <12 cm) had a significantly smaller amount of tube displacement than those with a larger neck length (sterno-mental distance >12 cm; 18.2 ± 6.9 mm vs 24.6 ± 7.1 mm, P = .04). Conclusions: Neck extension results in upward displacement of the endotracheal tube. The amount of displacement is significantly lower in patients with a larger BMI or shorter neck length, possibly due to the limitation of neck extension in these patients. This has particular relevance for thyroidectomy patients in whom accurate positioning of the tube is essential for nerve monitoring.

Does Immediate Cytology Improve the Adequacy of Ultrasound-Guided FNAC?

Objectives: Assess whether a dedicated “one stop” neck lump clinic has helped to improve the percentage of adequate fine-needle aspiration cytology (FNAC) samples and reduce the need for repeat FNAC. Methods: Retrospective review of patients attending for ultrasound-guided FNAC over a 6-month period from August 2012 to February 2013. Patients were placed within 2 groups (Group 1: FNAC performed by any of the subspecialist radiologists with cytology support (n = 100) and Group 2: FNAC performed by general radiologists without cytology support (n = 112)). In order to test for intra-observer agreement, 2 further groups were added (Group 3: FNAC performed by particular subspecialist radiologist with cytology support (n = 61) and Group 4: FNAC performed by the same subspecialist radiologist without cytology support (n = 125). Results: Seventy-four percent of neck lumps originated from the thyroid, 13% from the salivary glands, and 4% from lymph nodes. Adequacy rates of FNAC in Group 1 were 87% as compared with 56% in Group 2. Adequacy rates of FNAC in Group 3 were 90% as compared with 78% in Group 4. Thus, the presence of immediate cytology and a subspecialist radiologist increased FNAC adequacy by 31%. The presence of cytology support increased adequacy by 12% and presence of a subspecialist radiologist increased adequacy by 22%. Conclusions: Immediate cytology and the presence of a subspecialist radiologist increase the adequacy of FNAC. The adequacy rate of noncytology supported FNAC or nonsubspecialist FNAC is below the adequate rate expected from the literature or as recommended in national guidelines.