I was recently asked to write an article for INNEG which is medicolegal agency that I work with. I have written a short article on the problems with recurrent ear discharge (otorrhoea) and some of the diagnoses that we worry can be missed when this is not treated or investigated adequately. Article below or click the link on the image above.
The majority of children will have at least one and often more ear problems during childhood. This may take the form of an ear infection following a poolside holiday, glue ear causing deafness and requiring grommet insertion and in less common cases children may end up having episodes of repeated ear infections or otorrhoea. Most childhood ear infections are due to acute otitis media whereby the bugs that cause general winter-time coughs and colds ‘set up shop’ in the middle ear and cause the typical pain, fever and irritability followed by discharge of pus through a hole in the eardrum and often almost instantaneous relief from the symptoms.
A recent clinical negligence case that I was instructed to provide an expert opinion on involved a 7 year old girl who had been seen by her GP on several occasions with a discharging ear. On each of these occasions, the girl was prescribed antibiotic drops and appeared to make a good recovery. She was, however, referred to the local audiology department due to Mum’s concern about hearing loss. A subsequent examination identified glue ear for which he was referred to the local ear, nose and throat department to discuss further management options. For a variety of reasons, the girl was seen again in the audiology department and GP practice but did not see an ENT doctor until approximately 18 months later. At that time, she was noted to have some wax in her left ear and a moderate hearing loss on that side. She was listed to come in for grommets and adenoidectomy in order to ventilate the middle ear and drain out the offending fluid but at the time of surgery she was noted to have some polypoidal tissue arising from the superior (attic) region of the ear. This was biopsied and the results of the biopsy and a subsequent CT scan led to the diagnosis of cholesteatoma for which she underwent a modified radical mastoidectomy operation which left her with a long term conductive hearing loss in the left ear.
Cholesteatoma is collection of keratinous debris that collects in a retraction pocket of the tympanic membrane. It can be filled with keratin and appear quite dry or can be associated with active bacterial infection leading to profuse malodorous discharge. Cholesteatomas are potentially dangerous because of their potential to incite resorption of bone leading to intra-temporal or intra-cranial complications such as meningitis and brain abscesses in very rare cases. As well as the serious complications, cholesteatomas, when left untreated, can cause persistent, offensive otorrhoea (ear discharge) which most people find troublesome. The aim of surgery is to remove the cholesteatoma disease and render the ear safe, clean and dry.
The NICE guidelines on glue ear outline the presentation of glue ear with a history of repeated ear infections or earache, recurrent upper respiratory tract infections or frequent nasal obstruction and hearing difficulty. The claimant in this case suffered from all of these symptoms and although it may have seemed appropriate that she had been diagnosed with glue ear, there is an overlap in the presentation and symptoms of glue ear and cholesteatoma. The claimant in this case had predominantly unilateral ie left sided ear discharge. Otorrhoea can be seen in glue ear but is less common than the hearing loss that is seen. Persistent and unilateral discharge should have prompted the search for another cause. In addition the hearing loss that was diagnosed was moderate to severe whereas the typical level of hearing loss in glue ear is mild. A misinterpretation of the claimant’s symptoms as being due to glue ear led to a delay in the diagnosis of the underlying cholesteatoma and a delay in the appropriate, curative surgery.
Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery. 7th Edition 2008
NICE Clinical Guideline CG60
TikTok is a social network for sharing user-generated videos, mostly of people lip-synching to popular songs. Like most people aged over 20 I had only heard of it through my kids but it seems to have exploded in popularity over the COVID-19 lockdown. It allows sharing of 15s or 60s videos and whereas lots of them are fun and challenge based, it struck me that 60s was the perfect length of time to share short patient explanation videos. I'll try and keep them as factual, serious and gimmick free as possible but please have a look, see what you think, comment if you like but don't challenge me to a TikTok dance video challenge, it wouldn't be pretty!
My links are here to vids - and also on the 'T' sharing button on the social media buttons on the footer page below
I have been working with Claire, Emma and Helen - the fantastic team at Facilitate Expert Solutions for about 18 months. Claire also runs a Barrister Practice Management Company and brings her skills from the world of law to medicolegal expert practice. The team run my diary, invoice, bill and reconcile and are generally life-savers. I was recently asked to write a piece for the quarterly newsletter and have put pen to paper on some of my thoughts about the use of Social Media in medicolegal practice. I have attached the pdf of the newsletter below.
Please do consider getting on touch with Claire and the team if you are looking for a top notch, first rate practice management solution https://facilitateexpertsolutions.co.uk/
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Informative video by my Wythenshawe colleague Professor Ashley Woodcock in the cough clinic.
Why do we cough? What are thre reasons and what can we do to reduce it?
This is a really common condition. You probably remember having sore throats and infections as a child and being told that ‘your glands are up’. We all have about 100 lymph glands in the neck that are usually the size of a pea and increase and decrease in size if and when we have infections. Any lumps in the neck that come up and stay up, however, and any lumps that are bigger than 1cm in size definitely need looking at. I run a neck lump clinic at Wythenshawe Hospital on Wednesday mornings with my x-ray doctor colleagues and we do a one-stop clinic where we can see you, have a look in your mouth and nose and also put a small (4mm) camera in the nose to have a look at the back of the throat and voice box (bit of an odd feeling but doesn’t really hurt). We can get an ultrasound scan on the same day and if this does not look normal we can do a needle test to get an idea as to what the lump is.
I am really glad to reassure the majority of patients that we see that their neck lumps are benign and nothing to worry about but some people do have lumps that need further treatment. I commonly see thyroid lumps that can be benign and left alone as well as thyroid cancers that do need surgery to remove. We sometimes see lumps that arise from the saliva glands and again most of these can be left alone. We also see some lumps that are cancers that have spread from other parts of the head and neck and need further treatment, sometimes with more extensive surgery or radiotherapy.
Further posts to follow about these conditions in detail but the most important take home is that if you notice a lump in your neck get your GP to refer you to ENT on the two week wait pathway where you will be seen urgently
Bond Solon - Meetings between experts Course
Part of the medicolegal process is the discussion between experts. The role of the expert in medicolegal cases is to provide expert advice to the Court. The expert for a claimant should not try to prove negligence or error and likewise the expert for the defendant should not aim to disprove it. Nevertheless, there are times when experts will disagree and this workshop outlined the CPR rules on discussions between experts as well as highlighting some salient practical tips.
It is an honour to have been invited to be the ENT speciality representative for the Spire Cheshire MAC. The MAC exisits to provide advice to the Hospital Director on matters relating to the safe, efficient and ethical medical use of the hospital as well as being instrumental in providing quality assurance on all aspects of healthcare. I look forward to participating in this group in the following years. #patientsafety #quality
This article is from the Journal of the American Medical Association and is an excellent overview of post-op thyroglobulin monitoring
JAMA Patient Page
March 26, 2019Thyroglobulin for Monitoring for Thyroid Cancer Recurrence
Alan N. Peiris, MD, PhD, FRCP(Lond)1,2; Dillon Medlock, BS2; Meredith Gavin, BS2
Author Affiliations Article Information
JAMA. 2019;321(12):1228. doi:10.1001/jama.2019.0803
Some thyroid cancers can come back after removal, so monitoring for recurrence is important.
The thyroid gland is located in the lower front part of the neck above the breastbone and regulates metabolism through production of thyroid hormones (T3 and T4). Thyroid cancer is a malignant tumor of the thyroid gland. Papillary and follicular thyroid cancers are the most common types, and are known as differentiated thyroid cancers because they process iodine similarly to normal thyroid tissue. Surgery is the initial treatment for papillary or follicular thyroid cancers.
After initial treatment, long-term monitoring is needed to check for recurrence of the cancer. This is done by repeat ultrasound examinations of the neck, radioactive scanning, and measuring thyroglobulin levels in the blood.
Thyroglobulin is a protein made by the follicular cells of the thyroid gland. It is used by the thyroid gland to produce T3 and T4. The normal value for thyroglobulin is 3 to 40 nanograms per milliliter in a healthy patient. If a patient’s thyroglobulin level is found to be increasing after all of the thyroid gland has been removed, the patient may have a recurrence of a differentiated thyroid cancer. Very high levels of thyroglobulin may suggest metastatic or recurrent disease. About one-fourth of patients who have thyroid cancer have antibodies to thyroglobulin. Antibodies should be checked along with thyroglobulin because if they are present, they could interfere with measurement of thyroglobulin. Thyroglobulin levels after a lobectomy (removal of half of the thyroid gland) should correlate with the size of the thyroid gland remaining after surgery. Falsely high values of thyroglobulin can occur after a partial thyroidectomy because the remaining thyroid gland can increase in size. Following thyroid gland removal, radioactive iodine ablation (destruction) of residual thyroid tissue maybe done to reduce chance of recurrence and to make monitoring of thyroglobulin more reliable.
How Is Thyroglobulin Measured?
Thyroglobulin is measured using enzyme-linked immunosorbent assay (ELISA). The accuracy of the test depends on how strong the binding is between thyroglobulin and the antibody used. If a thyroglobulin value seems abnormal, the ELISA test should be done again to ensure the results are accurate. There are other tests for thyroglobulin; the results of tests depend on which type of test was done. When comparing test results, it is important that tests were the same type and done in the same laboratory.
Thyroglobulin levels should be measured every 3 to 6 months for 2 years after thyroidectomy and every 6 to 12 months after that. Depending on an individual patient’s circumstances, the amount of testing may differ. If thyroglobulin levels are increasing, the cancer may have returned. When a thyroglobulin level is increased, testing should be done more frequently. When levels are decreasing, the cancer is probably receding. When there is a cancer recurrence, thyroglobulin levels can be suppressed at the same time that levels of thyroglobulin antibodies increase.
For More Information
The JAMA Patient Page is a public service of JAMA. The information and recommendations appearing on this page are appropriate in most instances, but they are not a substitute for medical diagnosis. For specific information concerning your personal medical condition, JAMA suggests that you consult your physician. This page may be photocopied noncommercially by physicians and other health care professionals to share with patients. To purchase bulk reprints, call 312/464-0776.
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Conflict of Interest Disclosures: None reported.
Sources: American Thyroid Association
Holsinger FC, Ramaswamy U, Cabanillas ME, et al. Measuring the extent of total thyroidectomy for differentiated thyroid carcinoma using radioactive iodine imaging. JAMA Otolaryngol Head Neck Surg. 2014;140(5):410-415. doi:10.1001/jamaoto.2014.264
This week I was down in London to attend the Royal Marsden update in the management of Thyroid Cancer. This was hosted by Dr Kate Newbold and was excellent.
There were talks on the role of biomarkers in the diagnosis and potential prognosis of thyroid cancer and discussions about the role of as well as the management of potential side effects of tyrosine kinase inhibitors. These new drugs block the growth of certain cancer cells and in thyroid cancer that is no longer responding to radio-iodine treatment they have become a game-changer.
The day ended with a panel discussion on the management of difficult cases. All in all an excellent course and now back to put it all into practice.