Lateral rectus muscle palsy secondary to sphenoid sinusitis

Isolated sphenoid sinus disease is a rare, often misdiagnosed condition of the paranasal sinus. If left untreated, it can lead to complications involving pituitary gland, cavernous sinus, neurological and vascular structures nearby. Early recognition and treatment are critical to prevent the progression of the disease. We present a case of a 60-year-old woman with a history of severe left-sided headache, facial pain, diplopia and left lateral rectus palsy. She was initially referred to ophthalmology and rheumatology for possible giant cell arteritis. Magnetic resonance imaging revealed opacification in left sphenoid sinus with cavernous sinus/superior orbital fissure involvement consistent with left sphenoid sinusitis. She was then referred to the ear, nose and throat department and had endoscopic transnasal sphenoidotomy in theatre. Culture results showed Haemophilus influenza and fungal pseudohyphae. She recovered three months later after a course of antibiotics and antifungals. The onset of isolated sphenoid sinus disease is often insidious and the diagnosis of this condition remains a challenge. Magnetic resonance imaging and computed tomography remain the best diagnostic tools to recognise and manage this condition.

Outcomes of 756 patients with differentiated thyroid cancer and excellent response to treatment: An evidence-based paradigm for long-term surveillance strategies

BACKGROUND

The 2014 British Thyroid Association thyroid cancer guidelines recommend lifelong follow-up of all thyroid cancer patients. This is probably unnecessary, particularly for differentiated thyroid cancer (DTC) patients with an excellent response to treatment and places significant demand on health service resources.

DESIGN

Single centre retrospective cohort analysis of patients diagnosed and treated at the Leeds Cancer Centre between 2001 and 2014.

PATIENTS

A total of 756 patients were dynamically risk-stratified (DRS) as having 'excellent response to treatment' after total thyroidectomy and radioiodineremnant ablation (RRA) for DTC.

RESULTS

Median follow-up was 11.2 (range: 6.5-18.5) years. Radiological recurrence occurred in 15/756 (2.0%) patients and was always preceded by a raised thyroglobulin or thyroglobulin antibody level. The vast majority of tumour recurrences (13/15, 85%) were identifiable within 5 years of diagnostic surgery. Patients classified as having high-risk disease as per American Thyroid Association (ATA) guidelines had an almost threefold higher recurrence rate (2/34 [5.9%] vs. 13/722 [1.8%]) than those with ATA low-risk or intermediate-risk disease. Tumour histology subtype was a significant contributing factor, with Hürthle cell cancer having a worse prognosis than papillary thyroid cancer (PTC) (5/68 [7.4%] vs. 9/582 [1.5%]; relative risk: 4.76 [95% confidence interval: 1.64-13.8]).

CONCLUSIONS

The recurrence rate of DRS patients with excellent response to treatment is low. It is reasonable to consider discharge of ATA low-risk or intermediate-risk patients with PTC who remain disease-free after 5 years of secondary care follow-up. Lifelong follow-up, however, currently remains the standard for subgroups at greater risk.

The Role of Chemokines in Thyroid Carcinoma

The global incidence of thyroid cancer is increasing, and metastatic spread to the lymph nodes is common in papillary thyroid carcinoma. The metastatic course of thyroid carcinoma is an intricate process involving invasion, angiogenesis, cell trafficking, extravasation, organ specific homing, and growth. A key aspect in this process involves a multitude of interactions between chemokines and their receptors. Chemokines are a group of small proteins, which act to elicit normal physiologic and immune responses principally through recruitment of specific cell populations to the site of infection or malignancy. Thyroid cancer cells, like other tumors, possess the ability to corrupt the chemokine system to their advantage by altering cell movement into the tumor microenvironment and affecting all aspects of thyroid cancer progression.

Deep lobe parotid pleomorphic adenoma presenting as obstructive sleep apnoea

We present a rare case of obstructive sleep apnoea (OSA) secondary to a deep lobe parotid pleomorphic adenoma and discuss its management, including the need for a thorough examination and multidisciplinary approach. Only a few cases of pleomorphic adenoma of the deep lobe of the parotid gland causing OSA have been reported. Our case is not only extremely rare but also highlights that key diagnoses maybe missed if a thorough assessment is not performed.

Severe obstructive sleep apnoea due to adenotonsillar hypertrophy after liver transplantation

Epstein-Barr virus-related adenotonsillar hypertrophy is a precursor to post-transplantation lymphoproliferative disorder. We report a case of a 4-year-old child with severe obstructive sleep apnoea, who had liver transplantation at the age of 7 months. She had gross lymphoid hypertrophy in the oropharynx and supraglottis. We performed an adenotonsillectomy and aryepiglottoplasty which improved her symptoms. We emphasise the importance to consider the diagnosis of post-transplantation lymphoproliferative disorder in post-transplantation immunosuppressed patients who present with adenotonsillar hypertrophy.

Obstructive sleep apnoea and snoring - is examination necessary?

This article outlines two cases of snoring and obstructive sleep apnoea (OSA) secondary to parapharyngeal space tumours. Both patients were referred to a specialist sleep clinic where oropharyngeal masses were seen and biopsied. Both underwent surgery and this was curative of both their snoring and their OSA. Parapharyngeal space tumours are an extremely rare cause of OSA and snoring. However, all patients with OSA and snoring should have a full head and neck examination before referral; in rare cases this could enable early detection of a parapharyngeal space tumour.