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    Pathogenesis Most thyroid lumps are benign but 5% are malignant and it is important to distinguish this sinister minority. Benign thyroid lumps may include thyroid adenoma, thyroiditis, thyroid cysts and hyperplastic nodules.[1] Pathogenesis Most thyroid nodules are adenomatous. Most are multiple and that is usually shown on ultrasound, scintigraphy and at surgery. The nodules are usually non-functioning (cold at scintigraphy), although a few may be hyper-functioning toxic adenomas (hot on scintigrams). They may also be a hyper-functioning adenoma in a multinodular goitre. When solid, the nodules are poorly encapsulated, not well defined and merge into the surrounding tissue. Cystic adenomatous nodules are haemorrhagic, with irregular internal walls and particulate fluid content. Intratumoral calcification is occasionally seen. Follicular adenomas are the most common and arise from follicular epithelium. They are usually single, well-encapsulated lesions. On ultrasound, adenomas may be hyperechoic or hypoechoic solid nodules with a regular hypoechoic area surrounding ring called the halo sign. Rarely, a parathyroid adenoma has an ectopic intrathyroid location. Whether solitary adenomas transform into follicular carcinoma is uncertain. Follicular adenomas are further classified according to their cellular architecture and relative amounts of cellularity and colloid into fetal (microfollicular), colloid (macrofollicular), embryonal (atypical) and Hürthle (oxyphil) cell types. Epidemiology About 40% of the general adult population have a single nodule or multiple ones. They are more common in women. Most nodules are benign. In most series, 8-65% of patients with clinically normal thyroid glands had one or more grossly visible nodules, whereas the incidence of malignancy was 2-4%.[2] Presentation Most patients with thyroid nodules are asymptomatic and most nodules are found on clinical examination or self-palpation. A single dominant or solitary nodule is more likely to represent carcinoma (malignancy incidence 2.7-30%) than a single nodule within a multinodular gland (malignancy incidence 1.4 to 10%).[3] Thyroid lumps are often asymptomatic and are noticed by family members or seen in the mirror. They may sometimes cause pain and (rarely) present with features of compression of the trachea. Ask about previous radiation. Signs Ask the patient to drink some water and note the thyroid move as they swallow. Note enlargement or asymmetry. Stand behind a seated patient and use the second and third fingers of both hands to examine the gland as they swallow again. Note lumps, asymmetry, size and tenderness. Check for regional lymphadenopathy. Examination findings that increase the concern for malignancy include:[25049 : Evaluation of a thyroid nodule. remove]  Nodules larger than 4 cm in size. Firmness to palpation. Fixation of the nodule to adjacent tissues. Cervical lymphadenopathy. Vocal fold immobility. Differential diagnosis Non-toxic goitre - non-functioning nodules. Toxic nodular goitre - functioning nodules. Graves' disease - diffuse overactive thyroid gland. Hashimoto's disease - autoimmune destruction of the gland. Solitary thyroid nodule - 15-25% are cysts and can be aspirated. Thyroid cancer. Medullary cell carcinoma. Thyroid lymphoma - usually non-Hodgkin's. De Quervain's thyroiditis - neck pain, fever and lethargy soon after an upper respiratory infection or a viral illness. Acute suppurative thyroiditis - results from bacterial or fungal infection causing abscess. Investigations TFTs will show most patients to be euthyroid - refer those which are abnormal for endocrine opinion.[1] Ultrasound is useful to detect and characterise most thyroid nodules.[3]It can show cystic lesions 2 mm wide and solid lesions 3 mm wide. Ultrasound examination is far more sensitive than clinical examination and only 4-7% of nodules detected by ultrasound are clinically palpable. Fine-needle aspiration (FNA) gives tissue for cytology. It is performed under ultrasound guidance (for maximum accuracy).[4]It is safe, inexpensive and provides direct information. The false negative rate varies with the experience of the person performing the procedure. However, the false negative rate for cancer can vary from 1-6% (owing to wrong diagnosis or sampling errors) even when the operator is experienced and the sample is sufficient for diagnosis. These errors occur more commonly in nodules smaller than 1 cm or larger than 4 cm. Radionuclide isotope scanning looks at iodine uptake by the thyroid and has a limited role in the diagnosis of thyroid cancer. The British Thyroid Association (BTA) does not support its routine use - it is 'usually non-diagnostic of cancer'.[1]The American Thyroid Association recommends its use only in specific situations.[5] CT scans and MRI scans are valuable to detect local and mediastinal spread and regional lymph nodes. Referral[1] Patients with thyroid nodules who may be managed in primary care: Patients with a history of a nodule or goitre which has not changed for several years and who have no other worrying features (ie adult patient, no history of neck irradiation, no family history of thyroid cancer, no palpable cervical lymphadenopathy, no stridor or voice change). Patients with a non-palpable asymptomatic nodule <1 cm in diameter discovered incidentally on neck ultrasound/CT/MRI scanning without other worrying features. Patients who should be referred non-urgently: Patients with nodules who have abnormal TFTs. These patients should be referred to an endocrinologist because thyroid cancer is very rare in this group. Patients with a history of sudden onset of pain in a thyroid lump (likely to have bled into a benign thyroid cyst). Symptoms needing urgent referral (two-week rule): Unexplained hoarseness or voice changes associated with a goitre. Thyroid nodule in a child. Palpable cervical lymphadenopathy (usually deep cervical or supraclavicular region). A rapidly enlarging, painless thyroid mass over a period of weeks (a rare presentation of thyroid cancer and usually associated with anaplastic thyroid cancer or thyroid lymphoma). Symptoms needing immediate (same day) referral: Stridor associated with a thyroid mass. Management Solitary thyroid nodules which are malignant, suspicious, or indeterminate on FNA require removal (see the separate Thyroid Cancer article). Most benign thyroid nodules do not require any specific intervention, unless there are local compressive symptoms from significant enlargement, such as dysphagia, choking, shortness of breath, hoarseness, or pain, in which case thyroidectomy should be performed. Other indications for surgery in benign nodules include the presence of a single toxic nodule, or a toxic multinodular goitre. Aspiration is the treatment of choice for thyroid cysts but the recurrence rate is high.[6] Associated hyperthyroidism needs to be treated in the usual way. Complications Both surgery and alcohol injection can cause recurrent laryngeal nerve palsy, which should occur in fewer than 5% of procedures.[1]The primary disease can cause nerve damage in both benign and malignant conditions. Prognosis After exclusion of malignancy, prognosis for thyroid disease is excellent
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    Earwax and Care Patient Health Information r o Good intentions to keep ears clean may weaken the ability to hear. The ear is a delicate and intricate body part, including the skin of the ear canal and the eardrum. Therefore, special care should be given to this part of the body. Start by discontinuing the habit of inserting cotton-tipped applicators or other objects into the ear canals. WHY DOES THE BODY PRODUCE EARWAX? Cerumen or earwax is healthy in normal amounts and serves as a self-cleaning agent with protective, lubricating, and antibacterial properties. The absence of earwax may result in dry, itchy ears. Self-cleaning means there is a slow and orderly movement of earwax and dead skin cells from the eardrum to the ear opening. Old earwax is constantly being transported, assisted by chewing and jaw motion, from the ear canal to the ear opening where, most of the time, it dries, flakes, and falls out. Earwax is not formed in the deep part of the ear canal near the eardrum. It is only formed in the outer one-third of the ear canal. So, when a patient has wax blockage against the eardrum, it is often because he has been probing the ear with such things as cotton-tipped applicators, bobby pins, or twisted napkin corners. These objects only push the wax in deeper. WHEN SHOULD THE EARS BE CLEANED? Under ideal circumstances, the ear canals should never have to be cleaned. However, that isn’t always the case. The ears should be cleaned when enough earwax accumulates to cause symptoms or to prevent a needed assessment of the ear by your doctor. This condition is call cerumen impaction, and may cause one or more of the following symptoms: Earache, fullness in the ear, or a sensation the ear is plugged Partial hearing loss, which may be progressive Tinnitus, ringing, or noises in the ear Itching, odor, or discharge Coughing WHAT IS THE RECOMMENDED METHOD OF EAR CLEANING? To clean the ears, wash the external ear with a cloth, but do not insert anything into the ear canal. Most cases of ear wax blockage respond to home treatments used to soften wax. Patients can try placing a few drops of mineral oil, baby oil, glycerin, or commercial drops in the ear. Detergent drops such as hydrogen peroxide or carbamide peroxide (available in most pharmacies) may also aid in the removal of wax. Irrigation or ear syringing is commonly used for cleaning and can be performed by a physician or at home using a commercially available irrigation kit. Common solutions used for syringing include water and saline, which should be warmed to body temperature to prevent dizziness. Ear syringing is most effective when water, saline, or wax dissolving drops are put in the ear canal 15 to 30 minutes before treatment. Caution is advised to avoid having your ears irrigated if you have diabetes, a hole in the eardrum (perforation), tube in the eardrum, skin problems such as eczema in the ear canal or a weakened immune system. Manual removal of earwax is also effective. This is most often performed by an otolaryngologist using suction or special miniature instruments, and a microscope to magnify the ear canal. Manual removal is preferred if your ear canal is narrow, the eardrum has a perforation or tube, other methods have failed, or if you have skin problems affecting the ear canal, diabetes or a weakened immune system. WHY SHOULDN'T COTTON SWABS BE USED TO CLEAN EARWAX? Wax blockage is one of the most common causes of hearing loss. This is often caused by attempts to clean the ear with cotton swabs. Most cleaning attempts merely push the wax deeper into the ear canal, causing a blockage. The outer ear is the funnel-like part of the ear that can be seen on the side of the head, plus the ear canal (the hole which leads down to the eardrum). The ear canal is shaped somewhat like an hourglass narrowing part way down. The skin of the outer part of the canal has special glands that produce earwax. This wax is supposed to trap dust and dirt particles to keep them from reaching the eardrum. Usually the wax accumulates a bit, dries out, and then comes out of the ear, carrying dirt and dust with it. Or it may slowly migrate to the outside where it can be wiped off. ARE EAR CANDLES AN OPTION FOR REMOVING WAX BUILD UP? No, ear candles are not a safe option of wax removal as they may result in serious injury. Since users are instructed to insert the 10- to 15-inch-long, cone-shaped, hollow candles, typically made of wax-impregnated cloth, into the ear canal and light the exposed end, some of the most common injuries are burns, obstruction of the ear canal with wax of the candle, or perforation of the membrane that separates the ear canal and the middle ear. The U.S. Food and Drug Administration (FDA) became concerned about the safety issues with ear candles after receiving reports of patient injury caused by the ear candling procedure. There are no controlled studies or other scientific evidence that support the safety and effectiveness of these devices for any of the purported claims or intended uses as contained in the labeling. Based on the growing concern associated with the manufacture, marketing, and use of ear candles, the FDA has undertaken several successful regulatory actions, including product seizures and injunctions, since 1996. These actions were based, in part, upon violations of the Food, Drug, and Cosmetic Act that pose an imminent danger to health. WHEN SHOULD A DOCTOR BE CONSULTED? If the home treatments discussed in this leaflet are not satisfactory or if wax has accumulated so much that it blocks the ear canal (and hearing), a physician may prescribe eardrops designed to soften wax, or she may wash or vacuum it out. Occasionally, an otolaryngologist (ear, nose, and throat specialist) may need to remove the wax under microscopic visualization. If there is a possibility of a perforation in the eardrum, consult a physician prior to trying any over-the-counter remedies. Putting eardrops or other products in the ear with the presence of an eardrum perforation may cause pain or an infection. Certainly, washing water through such a hole could start an infection. WHAT CAN I DO TO PREVENT EXCESSIVE EARWAX? There are no proven ways to prevent cerumen impaction, but not inserting cotton-tipped swabs or other objects in the ear canal is strongly advised.  If you are prone to repeated wax impaction or use hearing aids, consider seeing your doctor every 6 to 12 months for a checkup and routine preventive cleaning.
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    Presbycusis is the most common type of Sensorineural Hearing Loss caused by the natural aging of the auditory system. It occurs gradually and initially affects the ability to hear higher pitched (higher frequency) sounds. Over time, it can result in individuals being unable to clearly hear sounds at progressively lower frequencies. People with Presbycusis often notice that speech is loud enough, but not clear – as if the talker is mumbling. Symptoms Having Presbycusis can result in higher-pitched sounds of speech, such as /s/ and /th/, sounding unclear and indistinct to the listener. This can lead to confusions (e.g. not being about to tell the difference between the words soot and foot), which can impact on an individual’s ability to understand conversations, particularly in noisy situations. This can make communication in bars, cafés, clubs and restaurants extremely difficult if not impossible. It’s estimated that 30-40% of people over the age of 65 have some from of it. Causes of Presbycusis Unlike Noise-induced Hearing Loss, Presbycusis is the cumulative result of the normal aging process on your ears. However, Noise-Induced Hearing Loss can compound the effects of Presbycusis, which can result in the onset of hearing loss earlier in life. There are many factors that can cause it but most commonly it’s the loss of nerve hair cells in the Cochlea – the organ that senses sound – caused by repeated daily exposure to noise over a lifetime. Pre-existing health conditions and use of some medicines can also contribute to the hearing loss associated with Presbycusis. Treatments There are many ways Presbycusis can be treated and managed. If you think you have it, make an appointment to see a hearing health professional, such as an audiologist or audiometricist, who can test your hearing and work out if you have a hearing loss. From your hearing test results, an audiologist will then know the specifics of your hearing loss such as which ear is most affected and at what frequencies. The audiologist will use this information to determine what kind of treatment is required to manage your hearing loss, including if you would benefit from a hearing device such as Hearing Aids.
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