Publications by authors named "Neil S Tolley"

25 Publications

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Differentiated Thyroid Cancer: A Health Economic Review.

Cancers (Basel) 2021 May 7;13(9). Epub 2021 May 7.

Department of Endocrine & Thyroid Surgery, Hammersmith Hospital, London W12 0HS, UK.

The incidence of differentiated thyroid cancer (DTC) is rising, mainly because of an increased detection of asymptomatic thyroid nodularity revealed by the liberal use of thyroid ultrasound. This review aims to reflect on the health economic considerations associated with the increasing diagnosis and treatment of DTC. Overdiagnosis and the resulting overtreatment have led to more surgical procedures, increasing health care and patients' costs, and a large pool of community-dwelling thyroid cancer follow-up patients. Additionally, the cost of thyroid surgery seems to increase year on year even when inflation is taken into account. The increased healthcare costs and spending have placed significant pressure to identify potential factors associated with these increased costs. Some truly ground-breaking work in health economics has been undertaken, but more cost-effectiveness studies and micro-cost analyses are required to evaluate expenses and guide future solutions.
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http://dx.doi.org/10.3390/cancers13092253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8125846PMC
May 2021

Viral Infectivity in Patients Undergoing Tracheotomy With COVID-19: A Preliminary Study.

Otolaryngol Head Neck Surg 2021 Mar 23:1945998211004255. Epub 2021 Mar 23.

Imperial College London, London, UK.

Objective: To establish the presence of live virus and its association with polymerase chain reaction (PCR) positivity and antibody status in patients with COVID-19 undergoing tracheotomy.

Study Design: Prospective observational study.

Setting: Single institution across 3 hospital sites during the first wave of the COVID-19 pandemic.

Methods: Patients who were intubated for respiratory wean tracheotomy underwent SARS-CoV-2 PCR nasal, throat, and endotracheal tube swabs at the time of the procedure. These were assessed via quantitative real-time reverse transcription PCR. The tracheal tissue excised during the tracheotomy was cultured for SARS-CoV-2 with Vero E6 and Caco2 cells. Serum was assessed for antibody titers against SARS-CoV-2 via neutralization assays.

Results: Thirty-seven patients were included in this study. The mean number of days intubated prior to undergoing surgical tracheotomy was 27.8. At the time of the surgical tracheotomy, PCR swab testing yielded 8 positive results, but none of the 35 individuals who underwent tissue culture were positive for SARS-CoV-2. All 18 patients who had serum sampling demonstrated neutralization antibodies, with a minimum titer of 1:80.

Conclusion: In our series, irrespective of positive PCR swab, the likelihood of infectivity during tracheotomy remains low given negative tracheal tissue cultures. While our results do not undermine national and international guidance on tracheotomy after day 10 of intubation, given the length of time to procedure in our data, infectivity at 10 days cannot be excluded. We do however suggest that a preoperative negative PCR swab not be a prerequisite and that antibody titer levels may serve as a useful adjunct for assessment of infectivity.
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http://dx.doi.org/10.1177/01945998211004255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8008096PMC
March 2021

Cochlear Implant Reliability: Reporting of Device Failures.

Indian J Otolaryngol Head Neck Surg 2020 Sep 7;72(3):326-328. Epub 2020 Mar 7.

Dept of Otolaryngology, Head and Neck Surgery, St Mary's Hospital, London, UK.

The aim of this study was to investigate the adequacy of the reporting of cochlear implant device failures. Data from a parallel study involving over 6300 children [1] was used to calculate the instantaneous failure rate for explantations. We found that this is comparable to what manufacturers term 'Cumulative Failure Percentage' (CFP). This finding raises concerns about the information provided by manufacturers on the reliability of their implants.
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http://dx.doi.org/10.1007/s12070-020-01826-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7374248PMC
September 2020

Cochlear Implant Reliability: On the Reporting of Rates of Revision Surgery.

Indian J Otolaryngol Head Neck Surg 2020 Jun 1;72(2):257-266. Epub 2020 Apr 1.

Department of Otolaryngology, Head and Neck Surgery, St Mary's Hospital, London, UK.

The aim of this study was to determine the magnitude of the risks associated with cochlear implantation. Results from a pool of thirty clinical studies involving cochlear implantation in over 6300 children were obtained from an internet search. The relevant data were transformed to a common time base (patient time) to allow an evaluation of events following implantation. The main outcome measure was cumulative survival probability for all-cause revision surgery. Over 10 years this was estimated to be 0.71. Thus, at 10 years post-implantation close to 30% of children with unilateral implants will have undergone revision surgery. This figure is considerably greater than that commonly reported for overall revision rates and illustrates the importance of interpreting results with respect to the relevant time frame. When non and low-use is incorporated into the analysis the above figure rises to about 37% of children affected. The findings raise concerns about the information provided to both individuals and regulatory bodies regarding the risks associated with cochlear implantation. The consequences for bilateral implantation are apparent. Our recommendations are i) a full disclosure to parents and children of the true magnitude of the risks and ii) for a body with significant expertise in reliability and systems engineering, and no conflicts of interest, to play a major role in the regulatory management of this service.
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http://dx.doi.org/10.1007/s12070-020-01795-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276475PMC
June 2020

Novel Energy Devices in Head and Neck Robotic Surgery - A Narrative Review.

Robot Surg 2020 23;7:25-39. Epub 2020 Apr 23.

Faculty of Medicine, Imperial College London, London, UK.

The advent of trans-oral robotic surgery (TORS) has facilitated removal of tumors previously deemed unresectable, by providing access to the deep structures of the head and neck. Despite this, the wider dissemination of TORS has been restricted due to issues with line of access, as the da Vinci robot was never designed with head and neck surgery in mind. Flexible instruments and novel energy delivery devices offer great potential in overcoming some of the existing challenges surrounding TORS. This review aimed to summarize the existing literature surrounding energy delivery in TORS and highlight areas of future innovation. MEDLINE was searched for studies relating to energy delivery in TORS in November 2019. The existing literature surrounding monopolar and bipolar electrocautery, LASER (CO, Tm:YAG and blue LASER), Ligasure and Harmonic was reviewed. Additionally, the latest iteration of the da Vinci; the SP, and the FLEX robot were evaluated as novel methods of energy delivery in TORS. Overall, these novel energy devices and robotic systems are predicted to further improve energy delivery to the head and neck. The use of flexible LASER in particular is well substantiated in the literature. This has the potential to achieve treatment de-escalation, based on the excellent outcomes demonstrated for disease-free margins and post-operative morbidity.
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http://dx.doi.org/10.2147/RSRR.S247455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7187864PMC
April 2020

Assessing Changes in Airflow and Energy Loss in a Progressive Tracheal Compression Before and After Surgical Correction.

Ann Biomed Eng 2020 Feb 2;48(2):822-833. Epub 2019 Dec 2.

Department of Bioengineering, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK.

The energy needed to drive airflow through the trachea normally constitutes a minor component of the work of breathing. However, with progressive tracheal compression, patient subjective symptoms can include severe breathing difficulties. Many patients suffer multiple respiratory co-morbidities and so it is important to assess compression effects when evaluating the need for surgery. This work describes the use of computational prediction to determine airflow resistance in compressed tracheal geometries reconstructed from a series of CT scans. Using energy flux analysis, the regions that contribute the most to airway resistance during inhalation are identified. The principal such region is where flow emerging from the zone of maximum constriction undergoes breakup and turbulent mixing. Secondary regions are also found below the tongue base and around the glottis, with overall airway resistance scaling nearly quadratically with flow rate. Since the anatomical extent of the imaged airway varied between scans-as commonly occurs with clinical data and when assessing reported differences between research studies-the effect of sub-glottic inflow truncation is considered. Analysis shows truncation alters the location of jet breakup and weakly influences the pattern of pressure recovery. Tests also show that placing a simple artificial glottis in the inflow to a truncated model can replicate patterns of energy loss in more extensive models, suggesting a means to assess sensitivity to domain truncation in tracheal airflow simulations.
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http://dx.doi.org/10.1007/s10439-019-02410-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6949211PMC
February 2020

International neuromonitoring study group guidelines 2018: Part II: Optimal recurrent laryngeal nerve management for invasive thyroid cancer-incorporation of surgical, laryngeal, and neural electrophysiologic data.

Laryngoscope 2018 10 6;128 Suppl 3:S18-S27. Epub 2018 Oct 6.

Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A.

The purpose of this publication was to inform surgeons as to the modern state-of-the-art evidence-based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real-time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision-making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal. Level of Evidence: 5 Laryngoscope, 128:S18-S27, 2018.
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http://dx.doi.org/10.1002/lary.27360DOI Listing
October 2018

International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal.

Laryngoscope 2018 10 5;128 Suppl 3:S1-S17. Epub 2018 Oct 5.

Mount Sinai Hospital, Department of Otolaryngology, Toronto, Ontario, Canada.

This publication offers modern, state-of-the-art International Neural Monitoring Study Group (INMSG) guidelines based on a detailed review of the recent monitoring literature. The guidelines outline evidence-based definitions of adverse electrophysiologic events, especially loss of signal, and their incorporation in surgical strategy. These recommendations are designed to reduce technique variations, enhance the quality of neural monitoring, and assist surgeons in the clinical decision-making process involved in surgical management of recurrent laryngeal nerve. The guidelines are published in conjunction with the INMSG Guidelines Part II, Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer-Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data. Laryngoscope, 128:S1-S17, 2018.
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http://dx.doi.org/10.1002/lary.27359DOI Listing
October 2018

AHNS Series: Do you know your guidelines? Optimizing outcomes in reoperative parathyroid surgery: Definitive multidisciplinary joint consensus guidelines of the American Head and Neck Society and the British Association of Endocrine and Thyroid Surgeons.

Head Neck 2018 08 2;40(8):1617-1629. Epub 2018 Aug 2.

Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard University, Boston, Massachusetts.

Background: Revision parathyroid is challenging due to possible diagnostic uncertainty as well as the technical challenges it can present.

Methods: A multidisciplinary panel of distinguished experts from the American Head and Neck Society (AHNS) Endocrine Section, the British Association of Endocrine and Thyroid Surgeons (BAETS), and other invited experts have reviewed this topic with the purpose of making recommendations based on current best evidence. The literature was also reviewed on May 12, 2017. PubMed (1946-2017), Cochrane SR (2005-2017), CT databases (1997-2017), and Web of Science (1945-2017) were searched with the following strategy: revision and reoperative parathyroidectomy to ensure completeness.

Results: Guideline recommendations were made in 3 domains: preoperative evaluation, surgical management, and alternatives to surgery. Eleven guideline recommendations are proposed.

Conclusion: Reoperative parathyroid surgery is best avoided if possible. Our literature search and subsequent recommendations found that these cases are best managed by experienced surgeons using precision preoperative localization, intraoperative parathyroid hormone (PTH), and the team approach.
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http://dx.doi.org/10.1002/hed.25023DOI Listing
August 2018

Laryngeal examination in thyroid and parathyroid surgery: An American Head and Neck Society consensus statement: AHNS Consensus Statement.

Head Neck 2016 06 11;38(6):811-9. Epub 2016 Mar 11.

Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.

This American Head and Neck Society (AHNS) consensus statement discusses the techniques of laryngeal examination for patients undergoing thyroidectomy and parathyroidectomy. It is intended to help guide all clinicians who diagnose or manage adult patients with thyroid disease for whom surgery is indicated, contemplated, or has been performed. This consensus statement concludes that flexible transnasal laryngoscopy is the optimal laryngeal examination technique, with other techniques including laryngeal ultrasound and stroboscopy being useful in selected scenarios. © 2016 Wiley Periodicals, Inc. Head Neck 38: 811-819, 2016.
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http://dx.doi.org/10.1002/hed.24409DOI Listing
June 2016

Outcome of TORS to tongue base and epiglottis in patients with OSA intolerant of conventional treatment.

Sleep Breath 2016 May 15;20(2):739-47. Epub 2015 Dec 15.

Department of Otorhinolaryngology and Head & Neck Surgery, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London, W2 1NY, UK.

Purpose: Transoral robotic surgery (TORS) of the tongue base with or without epiglottoplasty represents a novel treatment for obstructive sleep apnea (OSA). The objective was to evaluate the clinical efficacy of TORS of the tongue base with or without epiglottoplasty in patients who had not tolerated or complied with conventional treatment (continuous positive airway pressure or oral appliance).

Methods: Four-year prospective case series. The primary outcome measure was the apnea-hypopnea index (AHI) in combination with the Epworth Sleepiness Score (ESS). Mean oxygen saturation levels (SaO2) before and after TORS on respective sleep studies were also recorded. Secondary outcome measures included operative time and complications. Patient reported outcome measures (PROMs) assessed included voice, swallow and quality of life.

Results: Fourteen patients underwent TORS for tongue base reduction with ten having additional wedge epiglottoplasty. A 64 % success rate was achieved with a normal post-operative sleep study in 36 % of cases at 6 months. There was a 51 % reduction in the mean AHI (36.3 ± 21.4 to 21.2 ± 24.6, p = 0.02) and a sustained reduction in the mean Epworth Sleepiness Score (p = 0.002). Mean SaO2 significantly increased after surgery compared to pre-operative values (92.9 ± 1.8 to 94.3 ± 2.5, p = 0.005). Quality of life showed a sustained improvement 3 months following surgery (p = 0.01). No major complications occurred.

Conclusions: TORS of the tongue base with or without epiglottoplasty represents a promising treatment option with minimal morbidity for selected patients with OSA. Long-term prospective comparative evaluation is necessary to validate the findings of this study.
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http://dx.doi.org/10.1007/s11325-015-1293-9DOI Listing
May 2016

Construct validity of cadaveric temporal bones for training and assessment in mastoidectomy.

Laryngoscope 2015 Oct 17;125(10):2376-81. Epub 2015 Apr 17.

Department of Surgery and Cancer, Imperial College London.

Objective: To determine the construct validity of cadaveric temporal bones in mastoidectomy training.

Study Design: A prospective observational study.

Methods: Trainees from the North London otolaryngology training program performed step-wise modified radical mastoidectomy on cadaveric temporal bones under faculty supervision. Performance was assessed using a validated mastoidectomy assessment tool. A longitudinal assessment of nine trainees was also carried out over two sessions separated by 12 months. The main outcomes measures were task-specific (TS) and global skills (GS).

Results: Twenty-six intermediate and eight novice trainees participated and were assessed by a minimum of two assessors each. Intermediate trainees performed significantly better than novices in TS and GS (P < 0.001). Performance correlated well with training level using Spearman rank correlation coefficient (r(s)) (TS r(s) 0.265 and GS r(s) 0.503). The number of otological procedures performed, and in particular mastoidectomies, correlated well with performance (TS r(s) 0.327 and GS r(s) 0.528). Longitudinal assessment showed significant improvement with iteration (TS P = 0.008 and GS P = 0.008). Attending otological courses also improved performance significantly (TS r(s) 0.345 and GS r(s) 0.469).

Conclusions: The cadaveric temporal bone demonstrated construct validity and can be used to detect progress in performance of otolaryngology trainees. This is a keystone in moving toward a competency-based training system.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1002/lary.25310DOI Listing
October 2015

Reliability and validity of procedure-based assessments in otolaryngology training.

Laryngoscope 2015 Jun 27;125(6):1328-35. Epub 2014 Oct 27.

Department of Surgery and Cancer, Imperial College, London, United Kingdom.

Objectives/hypothesis: To investigate the reliability and construct validity of procedure-based assessment (PBA) in assessing performance and progress in otolaryngology training.

Study Design: Retrospective database analysis using a national electronic database.

Methods: We analyzed PBAs of otolaryngology trainees in North London from core trainees (CTs) to specialty trainees (STs). The tool contains six multi-item domains: consent, planning, preparation, exposure/closure, technique, and postoperative care, rated as "satisfactory" or "development required," in addition to an overall performance rating (pS) of 1 to 4. Individual domain score, overall calculated score (cS), and number of "development-required" items were calculated for each PBA. Receiver operating characteristic analysis helped determine sensitivity and specificity.

Results: There were 3,152 otolaryngology PBAs from 46 otolaryngology trainees analyzed. PBA reliability was high (Cronbach's α 0.899), and sensitivity approached 99%. cS correlated positively with pS and level in training (rs : +0.681 and +0.324, respectively). ST had higher cS and pS than CT (93% ± 0.6 and 3.2 ± 0.03 vs. 71% ± 3.1 and 2.3 ± 0.08, respectively; P < .001). cS and pS increased from CT1 to ST8 showing construct validity (rs : +0.348 and +0.354, respectively; P < .001). The technical skill domain had the highest utilization (98% of PBAs) and was the best predictor of cS and pS (rs : +0.96 and +0.66, respectively).

Conclusions: PBA is reliable and valid for assessing otolaryngology trainees' performance and progress at all levels. It is highly sensitive in identifying competent trainees. The tool is used in a formative and feedback capacity. The technical domain is the best predictor and should be given close attention.

Level Of Evidence: NA.
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http://dx.doi.org/10.1002/lary.24983DOI Listing
June 2015

Construct validity of the ovine model in endoscopic sinus surgery training.

Laryngoscope 2015 Mar 8;125(3):539-43. Epub 2014 Sep 8.

Department of Surgery and Cancer , Imperial College, London; Department of Otolaryngology , St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.

Objectives/hypothesis: To demonstrate construct validity of the ovine model as a tool for training in endoscopic sinus surgery (ESS).

Study Design: Prospective, cross-sectional evaluation study.

Methods: Over 18 consecutive months, trainees and experts were evaluated in their ability to perform a range of tasks (based on previous face validation and descriptive studies conducted by the same group) relating to ESS on the sheep-head model. Anonymized randomized video recordings of the above were assessed by two independent and blinded assessors. A validated assessment tool utilizing a five-point Likert scale was employed. Construct validity was calculated by comparing scores across training levels and experts using mean and interquartile range of global and task-specific scores. Subgroup analysis of the intermediate group ascertained previous experience. Nonparametric descriptive statistics were used, and analysis was carried out using SPSS version 21 (IBM, Armonk, NY).

Results: Reliability of the assessment tool was confirmed. The model discriminated well between different levels of expertise in global and task-specific scores. A positive correlation was noted between year in training and both global and task-specific scores (P < .001). Experience of the intermediate group was variable, and the number of ESS procedures performed under supervision had the highest impact on performance.

Conclusions: This study describes an alternative model for ESS training and assessment. It is also the first to demonstrate construct validity of the sheep-head model for ESS training.
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http://dx.doi.org/10.1002/lary.24927DOI Listing
March 2015

Feasibility of a synthetic temporal bone for training in mastoidectomy: face, content, and concurrent validity.

Otol Neurotol 2014 Dec;35(10):1813-8

*Imperial College, †St Mary's Hospital, Imperial College Healthcare NHS Trust; ‡St Bartholomews and The Royal London Hospitals; and §Whipps Cross University Hospital, Barts Health, London, United Kingdom.

Objective: To investigate the face, content, and concurrent validity of the synthetic Pettigrew temporal bone (PTB) for mastoidectomy training as compared with cadaveric temporal bone (CTB).

Study Design: A prospective evaluation study.

Methods: Participants were invited to perform a step-by-step modified radical mastoidectomy using both bones and complete a 22-item, 5-point Likert scale questionnaire. The questionnaire is divided into 4 domains: face validity (FV), global content (GC), task-specific content (TSC), and curriculum recommendation (CR).

Results: Thirty-six experts and 89 trainees completed all tasks, 63 using CTB and 62 using PTB. The PTB median FV was 4 (IQR: 4-5), GC of 4 (IQR: 4-5), TSC of 4 (IQR: 3-4), and CR of 4 (IQR: 4-5). The CTB was rated significantly higher than PTB by both groups in all domains; CTB FV: 5 (IQR: 4-5), GC: 5 (IQR: 4-5), TSC: 5 (IQR: 4-5), and CR: 5 (IQR: 5-5), p < 0.001 for each. Trainees rated PTB significantly higher than experts in all domains. There was no statistically significant difference between experts and trainees in rating the CTB in all domains. PTB gives similar haptic feedback to CTB, allows the use of suction and irrigation, has the important landmarks painted for identification, and contains articulating ossicles. The facial nerve anatomy was found to be inaccurate around the region of the second genu.

Conclusion: Participants found PTB to be valid for teaching some, yet not all, aspects of mastoid surgery, and experts agreed that it could improve global transferrable otologic skills. It is essential that the facial nerve anatomy is addressed before recommending this model.
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http://dx.doi.org/10.1097/MAO.0000000000000511DOI Listing
December 2014

Tonsillitis.

BMJ Clin Evid 2014 Jul 22;2014. Epub 2014 Jul 22.

Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.

Introduction: The definition of severe recurrent throat infections is arbitrary, but recent criteria have defined severe tonsillitis as: five or more episodes of true tonsillitis a year; symptoms for at least 1 year; and episodes that are disabling and prevent normal functioning. Diagnosis of acute tonsillitis is clinical, and it can be difficult to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis, but more accurate tests take longer to deliver results. Bacteria are cultured from few people with tonsillitis. Other causes include infectious mononucleosis from Epstein-Barr virus infection, cytomegalovirus, toxoplasmosis, HIV, hepatitis A, and rubella.

Methods And Outcomes: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of tonsillectomy in children and adults with acute recurrent or chronic throat infections? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results: We found 15 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: cold-steel tonsillectomy and diathermy tonsillectomy.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106232PMC
July 2014

Nasal inspiratory flow: at rest and sniffing.

Int Forum Allergy Rhinol 2011 Mar-Apr;1(2):128-35

Department of Otolaryngology, St Mary's Hospital, Imperial College Healthcare Trust, London, UK.

Background: This study quantifies the time-varying flow rate during inspiration at rest and in sniffing, both predecongestion and postdecongestion. It aims to provide a better understanding of nasal airflow mechanics, for application to the physiological modeling of nasal respiration and to therapeutic drug delivery.

Methods: The temporal profiles of nasal inspiration were measured at high fidelity in 14 healthy individuals using simultaneous bilateral hot-wire anemometry. Peak nasal inspiratory flow (PNIF) rate, acoustic rhinometry (AR), and the sinonasal outcome test (SNOT) provided complementary clinical measurements. The impact of decongestion was also investigated.

Results: In the initial phase of inspiration, a rapid rise in flow rate was observed. Flow first exceeded 150 mL/second in either passage within a median time of approximately 120 ms for inspiration at rest and approximately 60 ms in sniffing (∼20 ms in the fastest sniffs). The mean sustained flow rate attained and the overall period of each measured inspiratory profile were analyzed. AR showed a significant change in nasal volume with decongestion, although these change were not manifest in the temporal profiles of inspiratory flow (barring a weak effect associated with the most vigorous sniffs).

Conclusion: Novel methods were applied to investigate the temporal profiles of nasal inspiration. Characteristic features of the profile were identified and found to be significantly different between inspiration at rest and sniffing. Decongestion was found to have little effect on the temporal profiles for the flow regimes studied.
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http://dx.doi.org/10.1002/alr.20021DOI Listing
May 2012

A multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cN0 papillary thyroid cancer.

Surgery 2011 Dec;150(6):1048-57

University of Sydney Endocrine Surgical Unit, Sydney, Australia.

Background: The role of routine central lymph node dissection (CLND) for papillary thyroid cancer (PTC) remains controversial. The aim of this study was to evaluate the impact of routine CLND after total thyroidectomy (TTx) in the management of patients with PTC who were clinically node negative at presentation with emphasis on stimulated thyroglobulin (Tg) levels and reoperation rates.

Methods: This retrospective, multicenter, cohort study used pooled data from 3 international Endocrine Surgery units in Australia, the United States, and England. All study participants had PTC >1 cm without preoperative evidence of lymph node disease (cN0). Group A patients had TTx alone and group B had TTx with the addition of CLND.

Results: There were 606 patients included in the study. Group A had 347 patients and group B 259 patients. Stimulated Tg values were lower in group B before initial radioiodine ablation (15.0 vs 6.6 ng/mL; P = .025). There was a trend toward a lower Tg at final follow-up in group B (1.9 vs 7.2 ng/mL; P = .11). The rate of reoperation in the central compartment was lower in group B (1.5 vs 6.1%; P = .004). The number of CLND procedures required to prevent 1 central compartment reoperation was calculated at 20.

Conclusion: The addition of routine CLND in cN0 papillary thyroid carcinoma is associated with lower postoperative Tg levels and reduces the need for reoperation in the central compartment.
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http://dx.doi.org/10.1016/j.surg.2011.09.003DOI Listing
December 2011

Physical and computational modeling of ventilation of the maxillary sinus.

Otolaryngol Head Neck Surg 2011 Jul;145(1):165-70

Department of Otolaryngology, St Mary's Hospital, Imperial College Healthcare Trust, London, UK.

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http://dx.doi.org/10.1177/0194599811401202DOI Listing
July 2011

Systematic review and meta-analysis of the adverse effects of thyroidectomy combined with central neck dissection as compared with thyroidectomy alone.

Laryngoscope 2009 Jun;119(6):1135-9

Department of ENT and Thyroid Surgery, St. Mary's Hospital, Imperial College Hospitals NHS Trust, London, UK.

Objectives/hypothesis: Meta-analysis to assess the increased morbidity of performing a central neck dissection with thyroidectomy to thyroidectomy alone.

Study Design: Systematic review and meta-analysis.

Methods: Published articles were searched for using PubMed. Suitability was assessed by using predefined inclusion/exclusion criteria. Meta-analysis on the data was performed using the Mantel-Haenszel method and a risk difference calculated.

Results: Five studies with a total of 1,132 patients were included. For every 7.7 central neck dissections performed with thyroidectomy, there was one extra case of temporary hypocalcemia when compared to thyroidectomy alone. There was no significant increased risk of permanent hypocalcemia or temporary or permanent vocal cord palsy when a central neck dissection was performed in addition to a thyroidectomy.

Conclusions: The benefits of prophylactic central neck dissection in differentiated thyroid carcinoma may be debated but there is no increased permanent morbidity by performing the procedure at the same time as thyroidectomy. Laryngoscope, 2009.
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http://dx.doi.org/10.1002/lary.20236DOI Listing
June 2009

Tonsillitis.

BMJ Clin Evid 2009 Oct 26;2009. Epub 2009 Oct 26.

Department of Otolaryngology, St Mary's Hospital, London, UK.

Introduction: The definition of severe recurrent throat infections is arbitrary, but recent criteria have defined severe tonsillitis as: five or more episodes of true tonsillitis a year; symptoms for at least 1 year; and episodes that are disabling and prevent normal functioning. Diagnosis of acute tonsillitis is clinical, and it can be difficult to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis, but more accurate tests take longer to deliver results. Bacteria are cultured from few people with tonsillitis. Other causes include infectious mononucleosis from Epstein-Barr virus infection, cytomegalovirus, toxoplasmosis, HIV, hepatitis A, and rubella.

Methods And Outcomes: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of tonsillectomy in children and adults with acute recurrent or chronic throat infections? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results: We found 10 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions: In this systematic review we present information relating to the effectiveness and safety of the following interventions: cold-steel tonsillectomy and diathermy tonsillectomy.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907808PMC
October 2009

A new classification system for retrosternal goitre based on a systematic review of its complications and management.

Int J Surg 2008 Feb 16;6(1):71-6. Epub 2007 Feb 16.

Department of Otolaryngology and Head and Neck Surgery, St. Mary's Hospital, Praed Street, London W2 1NR, UK.

Introduction: There is no standard definition for thyroid glands extending below the thoracic inlet, and there are no clear guidelines for pre-operatively identifying those patients that may require an intrathoracic approach. We therefore reviewed the current literature in order to establish the current practices regarding the management of retrosternal goitres (RSGs), and propose a classification system to aid pre-operative planning for this important group of patients.

Materials And Methods: A PubMed Medline search was conducted using the search terms 'retrosternal', 'substernal', 'intrathoracic', 'mediastinal', 'goitre' and 'goiter', resulting in 626 hits. Exclusion criteria reduced the number of papers to the 34 used for this review.

Results: A total of 34 papers totaling 2426 patients were included. Eighty-four percent of patients operated on for RSG were achieved via a cervical approach, with the remainder also requiring manubriotomy (3.1%), full sternotomy (6.6%) or thoracotomy (4%). Tracheomalacia occurred in 1% of patients and Superior Vena Cava syndrome (SVC) in 3.2%. There was a clear and highly significant association between the extent and definition of RSG and reported complications, as well as the approach used, with the incidence of tracheomalacia, SVC and need for intrathoracic approach increasing more than 10-fold in cases of RSG reaching the aortic arch.

Discussion: There is a clear need to establish a common standard in the definition and description of the extent of RSG. Using our findings, we propose a new, simple, 3-grade classification system of RSGs, based on their relation with the aortic arch and the right atrium.
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http://dx.doi.org/10.1016/j.ijsu.2007.02.003DOI Listing
February 2008

Recurrent throat infections (tonsillitis).

BMJ Clin Evid 2007 Jun 1;2007. Epub 2007 Jun 1.

Department of Otolaryngology, St Mary's Hospital, London, UK.

Introduction: Diagnosis of acute tonsillitis is clinical, and it can be difficult to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis, but more accurate tests take longer to deliver results. Bacteria are cultured from few people with tonsillitis. Other causes include infectious mononucleosis from Epstein-Barr virus infection, cytomegalovirus, toxoplasmosis, HIV, hepatitis A, and rubella.

Methods And Outcomes: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of tonsillectomy in children and adults with acute recurrent or chronic throat infections? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2006 (BMJ Clinical evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results: We found nine systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions: In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, cold steel tonsillectomy, diathermy tonsillectomy.
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June 2007

Tissue engineering and ENT surgery.

J Laryngol Otol 2002 Mar;116(3):165-9

Tissue Engineering Centre, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK.

Tissue engineering is the development of biological substitutes for the repair and regeneration of damaged tissues. We explain the principles of this emerging field of biotechology. The present and potential applications of tissue engineering technologies in ENT surgery are then reviewed.
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http://dx.doi.org/10.1258/0022215021910339DOI Listing
March 2002
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