Thyroid hormones are among the most prescribed medications to patients worldwide and are commonly used to treat hypothyroidism. Thyroxine is also indicated after total thyroidectomy for Graves' disease or a multinodular goitre. In this commentary, we discuss and provide guidance for family medicine and primary care clinicians on how to navigate thyroid hormone replacement in patients after total thyroidectomy for cancer.

Objective: This study aims to investigate the trends in otology, rhinology, and head and neck (H&N) operations over the past decade in England. These trends will allow for predictive modelling to forecast the demand over the coming years to aid workforce and resource planning in ENT. Methods: Hospital Episode Statistics data were extracted between April 2012 and April 2023. A total of 121 otology, 114 rhinology, and 122 H&N procedure codes were included. Correlation and linear regression analyses were conducted to examine trends and produce a forecast model for the volume of operations. Results: A gradual upward trend in the volume of operations was observed in rhinology, with a positive correlation coefficient (R = 0.74). In contrast, otology (R = -0.67) and H&N (R= -0.75) showed negative trends, indicating a moderate decline in operational volumes over time. The COVID-19 pandemic significantly disrupted operating activity in rhinology and otology. To address the backlog and reach the pre-pandemic forecasted levels within the next five years, surgical capacity must increase by an additional 33,807 rhinology 25,486 otology, and 10,300 head procedures per year in England. Conclusions: This analysis highlights a need for prioritization and expansion of the ENT workforce and resources to manage the current backlog and anticipated increase in demand over the next five years.

Background: Head and neck carcinoma of unknown primary (CUP) represents a challenging diagnostic process when standard work-up fails to identify the primary tumour site. The aim of this systematic review and meta-analysis was to evaluate the diagnostic utility and complication profile of transoral robotic surgery (TORS) tongue base mucosectomy (TBM) in the management of CUP. Patients and methods: An electronic database search was performed in the EMBASE, MEDLINE, PubMed and Cochrane databases. A meta-analysis of proportions was performed to obtain an estimate of the overall proportion for the detection and complication rates. Results: Nine studies representing 235 patients with CUP who had TORS TBM were included in the final analysis. The overall pooled tumour detection rate was 66.2% [95% confidence interval (CI) 56.1-75.8]. The incidence of tumour detection in human papilloma virus (HPV)-positive cases (81.5%, 95% CI 60.8-96.4) was significantly higher than HPV-negative cases (2.3%, 95% CI 0.00-45.7). Weighted overall complication rate was 11.4% (95% CI 7.2-16.2). The majority were grade I or II (80%) according to the Clavien-Dindo classification. Conclusions: This meta-analysis suggests TORS to be safe and effective in localising the primary tumour site in patients with CUP. While the current data supports the use of TORS in patients who are HPV positive, larger numbers of HPV-negative cases are required to determine the true diagnostic effect with TORS before any valid conclusions can be inferred in this particular subgroup. Further research should focus on high quality prospective trials with stringent methodological work-up to minimise heterogeneity and allow for more accurate statistical analysis.

Objective: Abscess tonsillectomy is performed during an active episode of quinsy. Apprehensions regarding an elevated bleeding risk have hindered its widespread acceptance. This study aims to assess the prevalence of post-tonsillectomy bleeding (PTB) associated with abscess tonsillectomy. Data sources: A search was performed on August 27, 2023 in Medline, Embase, PubMed, Cochrane CENTRAL, and Web of Science databases. Review methods: The systematic review was conducted in adherence to the PRISMA guidelines. Pooled PTB rate was determined using a meta-analysis of proportions. The JBI tool was used to assess the quality of the included studies. Results: Of the 525 search records, 18 studies met the eligibility criteria for final analysis. These comprised of retrospective single-center analyses. The pooled prevalence of PTB was 6.65% (95% C.I. 4.01-9.81), and the return-to-theatre rate was 2.35% (95% C.I. 1.48-3.37). There was no difference in PTB rate between unilateral and bilateral tonsillectomy. However, the bipolar technique was associated with a higher PTB rate compared to cold steel dissection. The overall quality of the body of evidence was moderate. Conclusion: Our study highlights the complications associated with abscess tonsillectomy. These findings contribute valuable insights into this potential treatment option for quinsy.

The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Endorsed by 39 societies and professional bodies, these consensus practice recommendations aim to decrease inconsistency of practice, reduce uncertainty in care, and provide reassurance for clinicians worldwide for head and neck surgical oncology in the context of the COVID-19 pandemic and in the setting of acute severe resource constraint and high risk of infection to patients and staff.

Introduction Fine needle aspiration cytology (FNAC) forms part of the routine workup for suspicious thyroid nodules. Whilst cytological analysis is less precise than histological assessment, it is quick and easy to perform and may avoid the need for invasive and potentially risky surgery. Methods This retrospective study spanned a 10-year period comparing preoperative FNAC with postoperative histology results to establish the accuracy of diagnosis and malignancy rates within our population. These results were then compared to the published figures in the literature. Results The histological reports of 659 consecutive cases of thyroid surgery between 2006 and 2015 were retrieved from our hospital database. Among the 471 patients (71.5%) who underwent preoperative FNAC, the postoperative histology was reported as benign in 352 (74.7%) and malignant in 119 cases (25.3%). Papillary thyroid cancer (PTC) was the commonest histological diagnosis. Thy1 grade was reported in 165 (30%) cases, with 19.4% having a final histological diagnosis of malignancy. In the Thy2 group, 85.3% of patients had a benign final histological diagnosis, while 14.7% had malignancy (false-negative results). Malignancy was found in 89% of Thy4 and 100% of Thy5 group patients. Conclusions Rates of malignancy varied considerably from those in the published literature. Each centre should be able to quote a local malignancy rate during patient counselling. It is also prudent for all units performing thyroid diagnostics to investigate the factors that might lead to inaccuracies in reporting.

Introduction: Iatrogenic facial nerve palsy is distressing to the patient and clinician. The deformity is aesthetically displeasing, and can be functionality problematic for oral competence, dental lip trauma and speech. Furthermore such injuries have litigation implications. Marginal mandibular nerve (MMN) palsy causes an obvious asymmetrical smile. MMN is at particular risk during procedures such as rhytidoplasties, mandibular fracture, tumour resection and neck dissections. Cited causes for the high incidence are large anatomical variations, unreliable landmarks, an exposed neural course and tumour grade or nodal involvement dictating requisite nerve sacrifice. An alternative cause for post-operative asymmetry is damage to the cervical branch of the facial nerve or platysmal dysfunction due to its division. The later tends to have a transient course and recovers. Distinction between MMN palsy and palsy of the cervical branch of the facial nerve or platysma division should therefore be made. In 1979 Ellenbogen differentiated between MMN palsy and "Pseudo-paralysis of the mandibular branch of the facial nerve". Despite this, there is paucity in the literature & confusion amongst clinicians in distinguishing between these palsies, and there is little regarding these post-operative sequelae and neck dissections. Method: This article reflects on the surgical anatomy of the MMN and cervical nerve in relation to danger zones during lymphadenectomy. The authors review the anatomy of the smile. Finally, case studies are utilised to evaluate the differences between MMN palsy and its pseudo-palsy to allow clinical differentiation. Conclusion: Here we present a simple method for clinical differentiation between these two prognostically different injuries, allowing appropriate reassurance, ongoing therapy & management.