Journal of Laryngology and Otology

• Ultrasound scanning (USS) of the nodule or goitre is a crucial investigation in guiding the need for fine needle aspiration cytology (FNAC). (R)

• FNAC should be considered for all nodules with suspicious ultrasound features (U3–U5). If a nodule is smaller than 10 mm in diameter, USS guided FNAC is not recommended unless clinically suspicious lymph nodes on USS are also present. (R)

• Cytological analysis and categorisation should be reported according to the current British Thyroid Association Guidance. (R)

• Ultrasound scanning assessment of cervical nodes should be done in FNAC-proven cancer. (R)

• Magnetic resonance imaging (MRI) or computed tomography (CT) should be done in suspected cases of retrosternal extension, fixed tumours (local invasion with or without vocal cord paralysis) or when haemoptysis is reported. When CT with contrast is used pre-operatively, there should be a two-month delay between the use of iodinated contrast media and subsequent radioactive iodine (I¹³¹) therapy. (R)

• Fluoro-deoxy-glucose positron emission tomography imaging is not recommended for routine evaluation. (G)

• In patients with thyroid cancer, assessment of extrathyroidal extension and lymph node disease in the central and lateral neck compartments should be undertaken pre-operatively by USS and cross-sectional imaging (CT or MRI) if indicated. (R)

• For patients with Thy 3f or Thy 4 FNAC a diagnostic hemithyroidectomy is recommended. (R)

• Total thyroidectomy is recommended for patients with tumours greater than 4 cm in diameter or tumours of any size in association with any of the following characteristics: multifocal disease, bilateral disease, extrathyroidal spread (pT3 and pT4a), familial disease and those with clinically or radiologically involved nodes and/or distant metastases. (R)

• Subtotal thyroidectomy should not be used in the management of thyroid cancer. (G)

• Central compartment neck dissection is not routinely recommended for patients with papillary thyroid cancer without clinical or radiological evidence of lymph node involvement, provided they meet all of the following criteria: classical type papillary thyroid cancer, patient less than 45 years old, unifocal tumour, less than 4 cm, no extrathyroidal extension on ultrasound. (R)

• Patients with metastases in the lateral compartment should undergo therapeutic lateral and central compartment neck dissection. (R)

• Patients with follicular cancer with greater than 4 cm tumours should be treated with total thyroidectomy. (R)

• I¹³¹ ablation should be carried out only in centres with appropriate facilities. (R)

• Serum thyroglobulin (Tg) should be checked in all post-operative patients with differentiated thyroid cancer (DTC), but not sooner than six weeks after surgery. (R)

• Patients who have undergone total or near total thyroidectomy should be started on levothyroxine 2 µg per kg or liothyronine 20 mcg tds after surgery. (R)

• The majority of patients with a tumour more than 1 cm in diameter, who have undergone total or near-total thyroidectomy, should have I¹³¹ ablation. (R)

• A post-ablation scan should be performed 3–10 days after I¹³¹ ablation. (R)

• Post-therapy dynamic risk stratification at 9–12 months is used to guide further management. (G)

• Potentially resectable recurrent or persistent disease should be managed with surgery whenever possible. (R)

• Distant metastases and sites not amenable to surgery which are iodine avid should be treated with I¹³¹ therapy. (R)

• Long-term follow-up for patients with differentiated thyroid cancer (DTC) is recommended. (G)

• Follow-up should be based on clinical examination, serum Tg and thyroid-stimulating hormone assessments. (R)

• Patients with suspected medullary thyroid cancer (MTC) should be investigated with calcitonin and carcino-embryonic antigen levels (CEA), 24 hour catecholamine and nor metanephrine urine estimation (or plasma free nor metanephrine estimation), serum calcium and parathyroid hormone. (R)

• Relevant imaging studies are advisable to guide the extent of surgery. (R)

• RET (Proto-oncogene tyrosine-protein kinase receptor) proto-oncogene analysis should be performed after surgery. (R)

• All patients with known or suspected MTC should have serum calcitonin and biochemical screening for phaeochromocytoma pre-operatively. (R)

• All patients with proven MTC greater than 5 mm should undergo total thyroidectomy and central compartment neck dissection. (R)

• Patients with MTC with lateral nodal involvement should undergo selective neck dissection (IIa–Vb). (R)

• Patients with MTC with central node metastases should undergo ipsilateral prophylactic lateral node dissection. (R)

• Prophylactic thyroidectomy should be offered to RET-positive family members. (R)

• All patients with proven MTC should have genetic screening. (R)

• Radiotherapy may be useful in controlling local symptoms in patients with inoperable disease. (R)

• Chemotherapy with tyrosine kinase inhibitors may help in controlling local symptoms. (R)

• For individuals with anaplastic thyroid carcinoma, initial assessment should focus on identifying the small proportion of patients with localised disease and good performance status, which may benefit from surgical resection and other adjuvant therapies. (G)

• The surgical intent should be gross tumour resection and not merely an attempt at debulking. (G)

• Royal College of Pathologists minimum datasets for NMSC should be adhered to in order to improve patient care and help work-force planning in pathology departments. (G)

• Tumour depth is of critical importance in identifying high-risk cutaneous squamous cell carcinoma (cSCC), and should be reported in all cases. (R)

• Appropriate imaging to determine the extent of primary NMSC is indicated when peri-neural involvement or bony invasion is suspected. (R)

• In the clinically N0 neck, radiological imaging is not beneficial, and a policy of watchful waiting and patient education can be adopted. (R)

• Patients with high-risk NMSC should be treated by members of a skin cancer multidisciplinary team (MDT) in secondary care. (G)

• Non-infiltrative basal cell carcinoma (BCC) <2 cm in size should be excised with a margin of 4–5 mm. Smaller margins (2–3 mm) may be taken in sites where reconstructive options are limited, when reconstruction should be delayed. (R)

• Where there is a high risk of recurrence, delayed reconstruction or Mohs micrographic surgery should be used. (R)

• Surgical excision of low-risk cSCC with a margin of 4 mm or greater is the treatment of choice. (R)

• High-risk cSCC should be excised with a margin of 6 mm or greater. (R).

• Mohs micrographic surgery has a role in some high-risk cSCC cases following MDT discussion. (R)

• Delayed reconstruction should be used in high-risk cSCC. (G)

• Intra-operative conventional frozen section in cSCC is not recommended. (G)

• Radiotherapy (RT) is an effective therapy for primary BCC and cSCC. (R)

• Re-excision should be carried out for incompletely excised high-risk BCC or where there is deep margin involvement. (R)

• Incompletely excised high-risk cSCC should be re-excised. (R)

• Further surgery should involve confirmed marginal clearance before reconstruction. (R)

• P+ N0 disease: Resection should include involved parotid tissue, combined with levels I–III neck dissection, to include the external jugular node. (R)

• P+ N+ disease: Resection should include level V if that level is clinically or radiologically involved. (R)

• Adjuvant RT should include level V if not dissected. (R)

• P0 N+ disease: Anterior neck disease should be managed with levels I–IV neck dissection to include the external jugular node. (R)

• P0 N+ posterior echelon nodal disease (i.e. occipital or post-auricular) should undergo dissection of levels II–V, with sparing of level I. (R)

• Consider treatment of the ipsilateral parotid if the primary site is the anterior scalp, temple or forehead. (R)

• All patients should receive education in self-examination and skin cancer prevention measures. (G)

• Patients who have had a single completely excised BCC or low-risk cSCC can be discharged after a single post-operative visit. (G)

• Patients with an excised high-risk cSCC should be reviewed three to six monthly for two years, with further annual review depending upon clinical risk. (G)

• Those with recurrent or multiple BCCs should be offered annual review. (G)

• Surgery remains the mainstay of management for oral cavity tumours. (R)

• Tumour resection should be performed with a clinical clearance of 1 cm vital structures permitting. (R)

• Elective neck treatment should be offered for all oral cavity tumours. (R)

• Adjuvant radiochemotherapy in the presence of advanced neck disease or positive margins improves control rates. (R)

• Early stage lip cancer can be treated equally well by surgery or radiation therapy. (R)

Hearing loss can present at birth or be acquired as a result of illness, middle-ear disease, injury, age, overuse of certain medications, and/or induced by exposure to damaging noise levels. There are serious short-term consequences for people living with hearing impairment, including the effects on language acquisition, education, employment and overall wellbeing. There are also complex long-term implications.