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Perforated Ear Drum

The eardrum, otherwise known as the tympanic membrane, separates the ear canal from the middle ear. A perforated eardrum occurs when the eardrum ruptures, leaving an opening between the middle and outer ear. This can be problematic.

Causes

A ruptured eardrum commonly results from injury or trauma, or following a chronic infection. Very loud and sudden noises (i.e., explosion or gunshot) can cause the eardrum to perforate. This is often associated with an acute, sudden onset of pain.

Another possible cause of eardrum perforations is from a chronic ear infection, such as otitis media. Otitis media is a fluid build up in the middle ear cavity. The middle ear is usually filled with air, and with an accumulation of fluid or pus, pressure is increased on the eardrum. If the pressure against the eardrum is too great, it may perforate. Chronic otitis media may also weaken the eardrum over time and leave it more vulnerable to rupture. Children are more likely to suffer from a perforated eardrum due to chronic infection.

The use of cotton buds to clean your ears may also pierce the eardrum if pushed in too far, causing it to rupture. This is why eardrops are a much safer option when cleaning your ears.

It is also possible for the eardrum to rupture during a flight. The pressure in the cabin of an aircraft changes at different altitudes. If the pressure outside the ear and the pressure inside the middle ear are not even, pressure build-up may cause the eardrum to rupture. This is called barotrauma. Young children are more sensitive to barotrauma because the tube between the middle ear and the throat (Eustachian tube), which helps to equalise the pressure between the middle ear and environment, has not fully developed.

Flying with a cold may also block the Eustachian tube, leading to a build-up of pressure in the middle ear, which increases the risk of rupturing the eardrum whilst flying.

Symptoms

In some instances, there are no symptoms of a perforated eardrum. When present, common symptoms of a perforated eardrum include:

  • Pain
  • Hearing loss
  • Discharge
  • Ringing in the ear
  • Dizziness or vertigo

Treatment

In some cases, the eardrum will heal itself within a few weeks. However, during this time it is important to protect your ear. The most effective way to protect your ear is to avoid swimming and other activities where water can enter your ear. The water may cause damage and increases susceptibility to infection. It is therefore important to protect your ear in the shower as well. Covering the opening to your ear with a piece of cotton or something similar can help to stop water from getting in.

Antibiotics may also be prescribed, especially if the perforation was caused by an infection. The antibiotics will also help to prevent further infections of the ear whilst it is healing.

In other cases, treatment is required to repair the ruptured ear drum. In some patients, a patch may be placed over the site of the tear. The patch encourages the tissue of the membrane to grow and heal the site. In other cases, surgery may be necessary to repair the perforation. This type of surgery is called a tympanoplasty, and it involves using a tissue graft from another site in the body and placing it over the perforation. Tympanoplasty will also correct any problems in the middle ear at the same time. Surgery is generally reserved for cases that do not heal by themselves after promoting healing by keeping the ear dry, and attempting other treatments, such as antibiotic therapy.

Complications

If the membrane does not heal and remains untreated, several complications may arise from a perforated eardrum. An untreated perforated eardrum may lead to hearing loss over time, as one of the main functions of the eardrum is to transfer sound waves to the three tiny bones in the middle ear that allow us to perceive sounds.

Another important complication of an untreated perforated eardrum is infection. The ear drum acts as a barrier, preventing bacteria in the outer ear from entering the middle ear and causing otitis media. However, otitis media is not exclusively caused by a perforated ear drum – there are other possible causes. In order to minimise the risk of developing these complications, it is important to keep your ear dry and follow treatment instructions carefully.

For more information

If you have questions or concerns about ear surgery contact your local doctor, who will arrange for you to see an Ear Nose Throat Specialist.

Click here for more information about perforated ear drum.

The post Perforated Ear Drum Problem appeared first on ENT Clinic Sydney.

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About earaches

Earaches typically result from viral or bacterial ear infections, and commonly occur in children between 6 months and 2 years old. At this age, it can be difficult for your child to communicate their problems to you verbally. This is why it is important to be aware of the telltale signs that your child is suffering an earache.

If your child seems restless, repeatedly touches their ears, tries to cover them, and/or is sensitive to having her ears touched by others, chances are that they have an earache. Children’s Eustachian tubes are more horizontal than adults’ making them more prone to blockage and infection.

With or without the aid of surgically implanted ear grommets, most children grow out of periodic ear infections by age 2-4. If ear infections become chronic at any time in late infancy through toddlerhood and early childhood, an ear, nose, throat doctor may recommend ear grommets. Earaches are incredibly painful, and it can be difficult to watch your child go through them.

Go to the ENT Specialist

This is not like a cold or cough; you should not wait to see if it goes away. Ear infections can be caused by a viral or bacterial infection. Either way, it is time to make an appointment with your child’s ear, nose, and throat doctor as soon as possible.

By examining your child’s ears, the doctor will be able to tell whether it is a bacterial or viral infection. For a bacterial infection, antibiotics will be prescribed. Unfortunately, viral infections have to just run their course, but the doctor should prescribe some eardrops to help drain fluid from the middle ear and relieve pressure and pain. Draining this fluid should also help hasten your child’s recovery.

Care at Home

Ear infections are not contagious, so you will not have to worry about keeping your child home from daycare or school. However, these infections are very painful, and your child will need to rest to get healthy again.

Cloudy Fluids or Pus

If at any point you see cloudy fluids or pus draining from your child’s ear, call the doctor as soon as possible. These signs could mean that the infection is getting worse or even that your child’s eardrum has ruptured due to infection.

Fortunately, a ruptured eardrum is not as dire as it might sound. You will want to seek medical attention to assess if antibiotics need to be prescribed or if any other treatment is necessary.

In most cases, a ruptured eardrum will heal on its own within about 3 months, after the underlying infection is managed. Just be sure to follow all of the doctor’s instructions, administer all medication that the doctor prescribes, and don’t use any medications without consulting with your child’s doctor first.

In general, ear infections are an unpleasant fact of life, and most children get them. If you follow the doctor’s instructions, you and your child will get through this difficult time.

If you have questions or concerns about ear surgery contact your local doctor, who will arrange for you to see an Ear Nose Throat Specialist.

References

The post Children’s Earaches: What to do appeared first on ENT Clinic Sydney.

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By Ashleigh Elkins

Thyroidectomy is a commonly performed surgical procedure which involves the removal of the thyroid gland. Historically, thyroidectomy has been performed as an open procedure with an incision in the anterior neck, which is usually longer than 6 centimetres.

The open procedure provides the surgeon with good visualisation and exposure of the thyroid gland and surrounding structures, such as the recurrent laryngeal nerve and the parathyroid glands.[1] Open thyroidectomy carries a low complication rate and is regarded as a safe procedure.[2] A disadvantage of open thyroidectomy is scar formation post-operatively. The incision is made in the lower, anterior neck. This area is not typically covered by clothing and is visible to others, and patients may be dissatisfied with the scarring.[1] The incision is typically made into one of the creases into the lower neck, and with good post-operative wound care and taping, the wound usually settles sufficiently to blend in with the creases of the skin. Open thyroidectomy also requires more dissection of neck tissues, which can contribute to post-operative pain.

Minimally Invasive Techniques

In order to improve cosmetic outcomes post-surgery, post-operative pain and duration of hospital stay, minimally invasive thyroidectomy techniques have been developed. These procedures typically utilise endoscopy or video assistance and involve smaller incisions than the open procedure.[2,3] Some endoscopic techniques involve making no incisions into the neck. Instead, the thyroid is approached via incisions made into the axilla, chest or breast. This ensures that the post-operative scars are less visible than those made in the neck. However, a disadvantage of these approaches is that they involve a substantial degree of tissue resection in sites distant from the thyroid gland. Although they may achieve superior cosmetic outcomes, they may not be minimally invasive from a tissue resection point of view.[1]

As there are no cavities in the neck, the amount of space available for the surgeon to work within is limited. Hence, endoscopic thyroid surgery requires the creation of a working space within the neck, which can be achieved by carbon dioxide insufflation, where carbon dioxide is blown into the neck to create a working space. This is a technique commonly used in endoscopic abdominal surgery. Potential complications include elevated blood levels of carbon dioxide and subcutaneous emphysema.[3]  Another technique which has been devised to increase the working space within the neck is known as anterior skin lifting, in which the skin is pulled upwards and away from the body.[3]

Incision Lengths

In minimally invasive video assisted thyroidectomy, an incision is made into the neck that is approximately 2 centimetres in length. This incision is made either to one side of the thyroid gland, or slightly above the sternal notch. In comparison, traditional open thyroidectomy is performed through an incision into the base of the neck, which is generally around 6cm to 10cm in length, depending on the size of the neck and the thyroid gland.[1]

However, depending on the underlying pathology and size of the thyroid gland to be removed, open thyroidectomy may be possible through a smaller incision.[4] The length of incisions made into the chest, axilla and breast vary. These are usually small incisions and due to their position, are usually covered by clothing.[3] For patients undergoing a hemithyroidectomy procedure, which removes one lobe of the thyroid gland, the neck incision is usually smaller, at around 4cm to 5cm.

Who is Eligible for Minimally Invasive Thyroid Surgery?

One of the issues with minimally invasive thyroid surgery is that not all patients are eligible for the procedure. Generally speaking, patients are considered to be eligible for minimally invasive thyroid surgery if they have small thyroid nodules (that is, the largest diameter of the nodule is less than 30mm), the volume of the thyroid gland is less than 20mL (this is usually determined by ultrasound), if they have not had any previous neck surgery or radiation treatments to the neck, and if the patient does not have thyroiditis.[5] Patients with malignancies are generally treated with an open thyroidectomy procedure. Patients who are best suited to undergoing minimally invasive thyroid surgery have small nodules which are located within normal sized or slightly enlarged thyroid glands.

Reported Outcomes of Minimally Invasive Thyroid Surgery

Open thyroidectomy is a safe procedure with a low complication rate and results in good patient outcomes. The main issue with the open procedure is that sometimes patients are not satisfied with the appearance of the scar. Minimally invasive thyroid surgery was developed to reduce the size of the neck scar. The results of minimally invasive thyroid surgery have been promising in patients who have been carefully selected and are appropriate candidates for the minimally invasive surgery. Patients who have been selected for the minimally invasive surgery, but are not suitable for the procedure (usually because their thyroid gland is too large), will have their operation converted to an open procedure to ensure the best results are obtained.

Patients undergoing the minimally invasive procedure are generally observed overnight in hospital in case of complications. This is also standard for many patients who undergo the open procedure. Complication rates, including post-operative bleeding, recurrent laryngeal nerve palsy, and hypocalcaemia following minimally invasive thyroid are comparable to the open procedure. Minimally invasive techniques may be associated with a better cosmetic outcome and less pain post-surgery.

Advantages of Minimally Invasive Thyroid Surgery

Minimally invasive thyroid surgery is generally performed in young, fit women who have few skin creases in the neck, who meet the above selection criteria. This is because the minimally invasive technique produces a smaller, less visible scar than the open procedure.

Disadvantages of Minimally Invasive Thyroid Surgery

One of the main limitations of minimally invasive thyroid surgery is that it is only suitable for a small number of patients with specific indications that meet the selection criteria. The procedure is also more technically demanding and has a longer operative time than traditional open thyroidectomy. Another disadvantage is that there is a learning curve associated with the procedure. It is also difficult for surgeons to gain experience with the technique. This is because the procedure is only suitable for a small number of patients, and the open technique is therefore more routinely performed.

If you have questions about thyroid nodules or thyroid surgery contact your local doctor, who will arrange for you to visit a thyroid surgeon.

References

[1] Timon C, Rafferty M. Minimally invasive video-assisted thyroidectomy (MIVAT): technique, advantages and disadvantages. Operative Techniques in Otolaryngology (2008) 19, 8-14.

[2] Rafferty M, Timon C. Minimal incision thyroidectomy. Operative Techniques in Otolaryngology (2008) 19, 2-7.

[3] Shimizu K. Minimally invasive thyroid surgery. Best Practice & Research Clinical Endocrinology and Metabolism (2001); 15(2):123-137.

[4] Rafferty M, Miller I, Timon C. Minimal incision for open thyroidectomy. Otolaryngology Head and Neck Surgery (2006); 135(2): 295-298.

[5] Miccoli P, Berti P, Raffaelli M, Conte M, Materazzi G, Galleri D. Minimally invasive video-assisted thyroidectomy. The American Journal of Surgery (2001); 181:567-570.

The post Minimally Invasive Thyroid Surgery appeared first on Thyroid Clinic Sydney.

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Thyroid dysfunction has thought to possibly contribute to memory disorders, such as Alzheimer’s disease and other types of dementia. Consequently, in patients who are experiencing memory problems, thyroid function tests are commonly ordered. A recent study aimed to see if elderly patients with hypothyroidism were more likely to suffer from mild cognitive impairment than elderly euthyroid individuals (those with normal thyroid function). Mild cognitive impairment is described as a state between normal age-related memory loss and dementia. It usually has minimal, if any, functional impact for the patient. Other studies on the topic have yielded conflicting results.

This study assessed cognitive function by face to face interviews and with detailed neurological and psychological tests. These tests looked at how well people performed in different areas of cognition, including memory, language, visuospatial, attention and executive function. In terms of thyroid function, patients were classified as either euthyroid, clinically hypothyroid or as having subclinical hypothyroidism. Clinical hypothyroidism was determined from medical records. Patients were deemed to have subclinical hypothyroidism if they had a thyroid stimulating hormone level of less than 10mIU/L, a free T4 level of 1.01 to 1.79ng/dL and were not on thyroxine therapy.

From the results of the cognitive testing, 316 of the 1904 participants in the study were found to have mild cognitive impairment, and the remaining 1588 patients were deemed to have normal cognitive function. Mild cognitive impairment was found in 16.3% of euthyroid participants, 17.2% of clinically hypothyroid patients and 17.7% of those with subclinical hypothyroidism. However, after the authors of this study accounted for other factors which were likely to influence the results (age, education, other medical conditions etc.), there was no significant influence of clinical or subclinical hypothyroidism on mild cognitive impairment.

A limitation of this study is that in the patients found to have mild cognitive impairment, there is no indication as to whether the hypothyroidism started before the onset of cognitive impairment or vice-versa. Additionally, the way the study was designed means that a cause-and-effect relationship cannot be determined.

Given the mixed results in other studies, more research is needed to determine the influence of hypothyroidism on cognitive function.

Reference

www.archneur.jamanetwork.com

Hypothyroidism and risk of mild cognitive impairment in elderly persons: A population-based study. JAMA Neurology; 71(2):201-207. Parsaik AK, et al. (2014).

The post Is there a link between Hypothyroidism and Mild Cognitive Impairment in the Elderly appeared first on Thyroid Clinic Sydney.

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By Ashleigh Elkins

There are many different tests that can be used to help confirm the diagnosis of a thyroid problem. Based on taking a history and performing a physical examination, if your doctor suspects you have a problem with your thyroid gland, he or she will most likely order one or more tests to help confirm or rule out the diagnosis of a thyroid disorder.

Common tests include blood tests to check the thyroid function, fine needle aspiration biopsy to evaluate lumps and nodules, and scans to obtain imaging of the thyroid gland.

Thyroid Function Tests

Thyroid function tests are a very common investigation performed when a thyroid problem is suspected. Thyroid function tests require a blood test. They are also used to monitor the effectiveness of treatment. Thyroid function tests assess the levels of thyroid stimulating hormone (TSH) and the two thyroid hormones – thyroxine (T4) and v (T3). These tests can be used to determine if the thyroid has a normal level of activity (euthyroid), if the thyroid is underactive (hypothyroid) or if the thyroid is over-active (hyperthyroid). The table below shows the results for the different states of thyroid activity:

Thyroid State TSH Free T4 Free T3
Euthyroid Normal Normal Normal
Hyperthyroid Decreased Increased Increased
Hypothyroid Increased Decreased Decreased

Due to Medicare restrictions in Australia, TSH needs to be tested alone first. If the TSH is found to be abnormal, then levels of thyroid hormone can be tested. This restriction does not apply to people who have already been diagnosed with a thyroid problem.

Thyroid Autoantibodies

Thyroid autoantibodies are another type of blood test that can be ordered in the investigation of thyroid problems. This test is used to rule in or rule out an autoimmune disease as the cause of thyroid problems. There are three main autoantibodies that can be tested for:

  1. Thyroid peroxidase antibodies (TPO); these are antibodies towards thyroid peroxidase, an enzyme that is needed in the process of producing T3 and T4. TPO antibodies are positive in most patients with Hashimoto’s thyroiditis and in most patients with Graves’ disease. TPO antibodies may also be elevated in patients with other autoimmune diseases, such as rheumatoid arthritis.
  2. Thyroglobulin antibodies; these antibodies are markers of autoimmune thyroid diseases. They are positive in almost all patients with Hashimoto’s thyroiditis and are positive in most people with Graves’ disease
  3. TSH receptor autoantibodies; these are antibodies that bind to the TSH receptor and cause it to activate. TSH receptor autoantibodies are positive in the majority of people with Graves’ disease.

Other Thyroid Blood Tests

There are a few other blood tests that may be ordered to investigate suspected thyroid disease. Calcitonin is a hormone made by the C cells of the thyroid and is released when levels of blood calcium are high. Calcitonin levels may be ordered in the investigation of people with thyroid nodules or suspected medullary thyroid cancer. Blood levels of calcitonin may be elevated in medullary thyroid cancer, and may be used in monitoring following treatment for medullary thyroid cancer. In addition, another blood test called carcinoembryonic antigen, or CEA, is also used in addition to calcitonin for monitoring and follow up after treatment of medullary thyroid cancer. CEA is also used for monitoring following treatment of other types of tumours, such as colorectal cancers.

Fine Needle Aspiration Biopsy

Fine needle aspiration biopsy is most commonly used in the investigation of thyroid nodules. The procedure involves inserting a needle into the nodule in order to remove a sample of cells which can then be analysed under a microscope to assist in diagnosis. There are usually several samples taken from different parts of the nodule to ensure that the samples that are taken are representative of the cells and tissues within the nodule. This test helps to determine whether or not the nodule requires surgical removal or further monitoring.

Fine needle aspiration can also be used to help evaluate thyroid cysts. This involves inserting a needle into the cyst and draining the fluid within the cyst. The fluid that is collected can be evaluated in the lab to see if there are any suspicious changes.

Fine needle aspiration biopsy is used to guide the treatment and management of patients with thyroid nodules. Thyroid fine needle aspiration cytology results are classified according to the Bethesda classification system which is a six-category system used to guide management of thyroid nodules.

The six categories of this system are:

  1. Unsatisfactory sample/Non-diagnostic
  2. Benign
  3. Atypia of undetermined significance
  4. Follicular neoplasm/suspicious for follicular neoplasm
  5. Suspicious for malignancy
  6. Malignant

Fine needle aspiration cytology cannot help to differentiate between benign and malignant follicular neoplasms. Ultrasound guidance can be used to visualise the nodule when performing the fine needle biopsy to make sure that the samples are being taken from within the nodule and not the surrounding thyroid tissue.

Nodules that are removed surgically undergo histopathological analysis to provide a definitive diagnosis.

Thyroid Imaging

Thyroid Ultrasound

Ultrasound is a safe, accurate, non-invasive, inexpensive and readily available imaging modality that can be used to assess the thyroid gland. Ultrasound is usually the first type of imaging ordered for the investigation of thyroid problems. Ultrasound uses sound waves transmitted through a hand-held transducer probe. A gel is placed over the neck which helps to transmit the ultrasound waves from the probe. There is no radiation used in an ultrasound. Thyroid ultrasounds are particularly useful for imaging thyroid cysts, nodules, goitre (enlargement of the thyroid gland) and suspected tumours. Ultrasounds can also be used to assess the blood flow in the thyroid. Ultrasound can also be used to guide fine needle aspiration biopsy of nodules or growths in the thyroid.

There are several ultrasound features which suggest that a thyroid nodule is likely to be benign. These include:

  • Sharp, well-defined borders around the entire nodule
  • Fluid within the nodule is indicative of the nodule being a cyst
  • Numerous nodules throughout the thyroid; this generally indicates a benign multinodular goitre
  • Minimal or no blood flow through the nodule indicates that the nodule is likely to be a cyst

Thyroid Scan/Thyroid Isotope Scans

An isotope scan of the thyroid is used to determine thyroid function because the scan measures how much of a substance similar to iodine is taken up by the gland. The thyroid uses iodine to produce thyroid hormones, so the thyroid normally absorbs iodine. For the scan, technetium (Tc- 99m) pertechnetate is injected. This is a substance that behaves similarly to iodine. Radioactive iodine has been used in the past, but technetium pertechnetate is now preferred because there is less radiation exposure and it is more cost-effective than radioactive iodine. After about 20 minutes, a scan is performed to identify the pattern of uptake in the thyroid.

This type of thyroid scan is particularly useful in helping to determine if the thyroid is over-active, such as in conditions like Graves’ disease, subacute thyroiditis and toxic multinodular goitre. All three conditions have different patterns of uptake:

Graves’ disease

  • Diffuse increased uptake

Subacute Thyroiditis

  • Low iodine uptake

Toxic Multinodular Goitre

  • Patchy uptake; areas of increased uptake and areas of decreased uptake

Thyroid isotope scans are helpful in the investigation of thyroid nodules. Thyroid nodules are generally classified as cold, warm or hot. A cold nodule does not take up any pertechnetate and is non-functioning, a warm nodule is functioning normally, and a hot nodule takes up more pertechnetate than the surrounding thyroid tissue and is said to be hyper-functioning. Isotope scans are particularly helpful for investigating patients with low levels of TSH. If a patient has low TSH and the isotope scan identifies a hot nodule, it is likely that the nodule is benign. Overall, the majority of thyroid nodules scanned are cold nodules, approximately 80%. However, only about 20% of cold nodules are found to be malignant after further investigation.

Thyroid CT Scan

Computed tomography, or CT scans can also be used to investigate suspected thyroid pathologies. It is not as good as ultrasound for identifying pathology within the thyroid gland itself, but CT is useful for investigating lymph nodes in the neck, chest and thyroid region. It is also used in the investigation of goitre to determine if the goitre has extended behind the sternum and into the mediastinum (retrosternal extension). CT may also be used if thyroid cancer is suspected to see if the tumour has spread to other surrounding organs. CT scans use x-rays to create cross-sectional images of the thyroid and surrounding structures. In some cases, a contrast medium may be injected to help define anatomical structures more clearly. A limitation of CT scans is that there is radiation exposure associated with the scan, unlike MRI and ultrasound.

Thyroid MRI Scan

Another type of investigation which may be ordered to investigate problems with the thyroid is a magnetic resonance imaging (or MRI) scan. Just like a CT scan, MRI is also not as good as ultrasound for detecting pathology within the thyroid gland itself. MRI scans might be ordered to assess surrounding lymph nodes and other neck and chest structures. It is useful to help determine if a suspected thyroid cancer has spread to surrounding organs. MRI can also be used to evaluate retrosternal goitre extension. MRI is also helpful to determine the size and shape of the thyroid. MRI may be recommended instead of a CT scan because there is no radiation exposure associated with an MRI, and an MRI scan of the thyroid does not usually require the administration of a contrast medium. CT and MRI are similar in terms of evaluating lymph nodes and spread to the surrounding tissues.

The post Diagnostic Tests for the Thyroid Gland appeared first on Thyroid Clinic Sydney.

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