The involvement of the preauricular node is the typical lymphadenopathy of conjunctival infectious conditions. It is true that typical bacterial conjunctivitis does not usually present with lymphadenopathy. They have a more rapid and self-resolving course and do not awaken the lymphoid response as adenoviruses typically do. Or some more atypical bacteria that produce chronic conjunctivitis, such as Chlamydia, or much more infrequent bacteria such as those responsible for Parinaud's oculoglandular syndrome (Bartonella henselae, Francisella tularensis, Sporothrix schenckii, etc). Adenopathy being very typical of adenoviral conjunctivitis, this option is the easiest to rule out. Considering that chlamydiae arouse the lymphoid response in a similar way to adenoviruses (they also produce conjunctival follicles, for example), this would be the second easiest option to rule out. Perhaps the difficult thing is to rule out oculoglandular syndrome of Parinaud, because it is a very rare disease. If we do not realize that it is an infectious disease, we could hesitate. In any case, allergic conjunctivitis is not an infectious problem. So it is not going to have adenopathy. Even if we doubt with some of the previous options (especially with Parinaud), if we stay with the basic concepts (allergic conjunctivitis does not present with lymphadenopathies) we can be right. Option 2 is the correct one.

The involvement of the preauricular node is the typical lymphadenopathy of conjunctival infectious conditions. It is true that typical bacterial conjunctivitis does not usually present with lymphadenopathy. They have a more rapid and self-resolving course and do not awaken the lymphoid response as adenoviruses typically do. Or some more atypical bacteria that produce chronic conjunctivitis, such as Chlamydia, or much more infrequent bacteria such as those responsible for Parinaud's oculoglandular syndrome (Bartonella henselae, Francisella tularensis, Sporothrix schenckii, etc). Adenopathy being very typical of adenoviral conjunctivitis, this option is the easiest to rule out. Considering that chlamydiae arouse the lymphoid response in a similar way to adenoviruses (they also produce conjunctival follicles, for example), this would be the second easiest option to rule out. Perhaps the difficult thing is to rule out oculoglandular syndrome of Parinaud, because it is a very rare disease. If we do not realize that it is an infectious disease, we could hesitate. In any case, allergic conjunctivitis is not an infectious problem. So it is not going to have adenopathy. Even if we doubt with some of the previous options (especially with Parinaud), if we stay with the basic concepts (allergic conjunctivitis does not present with lymphadenopathies) we can be right. [HIDDEN]

A 36-year-old male consults for conjunctival hyperemia and foreign body sensation. Which of the following pathologies does NOT correspond to the above mentioned examination?

[Trachoma in patients with allergic conjunctivitis].

The aim of this paper was to identify a possible association between allergic conjunctivitis and Chlamydia trachomatis infection. A prospective study was carried out in 104 eyes of 52 patients with diagnosis of vernal conjunctivitis and atopic keratoconjunctivitis. Conjunctival cytology was performed in all the 52 patients, once it can evidence eosinophils presence and inclusions corpuscles in the conjunctival scraping smear, as well as the direct immunofluorescence that is the choice exam for Chlamydia trachomatis infection confirmation. All procedures were approved by the Institutional Review Board Ethics Committee. Of the 52 patients, 41 (78.8%) presented vernal conjunctivitis and 11 (21.2%) atopic keratoconjunctivitis. Forty-one patients (78.8%) were male and 11 (21.2%) female. The ages varied from 3 to 19 years, with an average of 9.8 years. Regarding racial distribution, 16 (30.8%) patients were caucasian, 14 (26.9%) were black and 22 (42.3%) were brown. Regarding systemic allergic diseases, it was observed that 25 (48.1%) patients presented asthma, 20 (38.5%) allergic rhinitis and 5 (9.6%) atopic dermatitis. The main symptoms complained by the patients were coryza (59.6%), ocular itching (98.1%), burning (61.5%), tearing (65.3%) and photophobia (61.5%). The main clinical signs were: ocular hyperemia (100%), bilaterality (100%), superior tarsal papilla (92.3%) and mucous secretion (82.7%). The cytology of the conjunctival scrapings found eosinophil in 86.5% of the cases. Only seven patients did not present eosinophils in the conjunctival scrapings. Three patients (5.8%) presented positive immunofluorescence for Chlamydia, evidencing an association between allergic conjunctivitis and trachoma. It is important to determine the simultaneous coexistence of Chlamydia trachomatis and allergic conjunctivitis, due to the possibility to change the visual prognostic and of symptoms potentiation in case of double attack. Therefore, it is necessary to perform direct immunofluorescence for the correct diagnosis in patients with allergic conjunctivitis.

Chlamydial conjunctivitis in neonates and adults. History, clinical findings and follow-up.

This study presents data from 73 neonatal and 60 adult patients with chlamydial conjunctivitis who were studied by culture, enzyme-linked immunosorbent assay (ELISA) and immunofluorescence (IF) tests. All patients had visited three or more doctors before the diagnosis was established. Fourteen of the adults had consulted an ophthalmological emergency unit complaining of a foreign body sensation in the eye. The symptoms started monocularly in all 133 cases, however, the fellow eye was affected after 2-7 days in 54 of the neonates and in 5-30 days in 20 of the adult patients. The duration of symptoms before the etiological diagnosis was established was 5-198 days (mean 24 and median 15 days) in the neonates and 7-120 (mean 29 and median 22 days) in the adults. The conjunctivitis was mild, moderate and severe in 7, 72 and 48 of the neonatal eyes, when the etiological diagnosis was established. The corresponding figures for severity of conjunctivitis in the adult group were 9, 57 and 14. Nasopharyngeal colonization occurred in 56 (77%) of the children and in 35 (58%) of the adults. In the adults, only two males complained of symptoms of genital infection. In 46 (77%) adults one or more of the chlamydial diagnostic tests performed on genital samples was positive for Chlamydia trachomatis. Forty-five of the neonates were treated with erythromycin 40-50 mg per kg body weight divided in four daily doses for 14 days, while 35 of the adults were given 250 mg x 4 x 14 of erythromycin.(ABSTRACT TRUNCATED AT 250 WORDS)

[Keratoconjunctivitis sicca during folicular conjunctivitis in adult patients with Chlamydia pneumoniae etiology (summarizing twelve years study)].

Following the previous study observing keratoconjunctivitis sicca (KCS) after treated follicular conjunctivitis of chlamydial etiology from the years 1999-2002, at this time the authors would like to point out the possible connection between KCS appearance and Chlamydia pneumoniae infection. In the Department of Ophthalmology, during the period of 12 months (in the years 2009 - 2010), there were treated 11 adult patients (6 women and 5 men) in the age of 28 - 81 years (median, 50 years) with follicular conjunctivitis lasting on average 2.5 years and caused by Chlamydia pneumoniae, and simultaneously were diagnosed the symptoms of KCS, out of the total number of 37 examined patients with similar clinical findings. The diagnosis of chlamydial infection in clinical symptoms of follicular conjunctivitis and simultaneous signs of KCS was established partly according to the serologic positivity of chlamydial genus (anti-LPS) and/or species (anti-Ch. pneumoniae and anti-Ch. trachomatis) IgG, IgM, and IgA antibodies together with simultaneous anti-cHSP60 IgG positivity, further using conjunctival prints examined by means of indirect immunofluorescence method using specific monoclonal antibodies; in conjunctival smears and peripheral leucocytes was tested also the presence of Chlamydia pneumoniae DNA. The main subjective complaints of the patients were burning sensation, sticking, or foreign-body sensation; the itching and lacrimation were less common. Among clinical signs dominated the hyperemia and the edema of the lower fornix; the tortuosity of the vessels and the follicles were not always present. The KCS diagnosis was confirmed by Bengal rose staining. In 10 patients, the positive IgA and/or IgM anti-Ch. pneumoniae antibodies were detected. Simultaneously, the positive anti-cHSP60 IgG were confirmed, out of them medium- and high-positive findings were in 7 patients, and anti-LSP antibodies IgA and/or IgM in 8 of them. Positive smears were found in 6 patients. In 2 persons of this group of treated patients, the general serologic findings were not significant, but the Chlamydia pneumoniae infection was confirmed by Chlamydia pneumoniae DNA positivity in peripheral leucocytes; in these 2 patients, the symptoms lasted for one half of the year. As the side findings were the confirmations of active Chlamydia trachomatis infection in other 4 patients of the whole group. The patients with Chlamydia pneumoniae infection were treated systemically by macrolide antibiotic azithromycine for 12 days. After the treatment, above all else the clinical signs of conjunctival inflammation disappeared, but remained KCS symptoms, which were disappearing only slowly. The optimal supporting therapies were lubricant drops with different concentration of sodium hyaluronide without preservatives. Control microbiological examinations during 6 months after the treatment termination confirmed negative smears findings, but the antibody levels were not decreased significantly. This study confirmed the possible connection between the KCS and Chlamydia pneumoniae infection in simultaneous clinical signs of follicular conjunctivitis. Along with that the study pointed out the necessity of simultaneous evaluating of the microbial findings and clinical symptoms to consider the systemic antibiotic treatment.

Adult inclusion conjunctivitis diagnosed by polymerase chain reaction and Giemsa stain.

Adult inclusion conjunctivitis, caused by <iChlamydia trachomatis</i, is easily underdiagnosed with nonspecific ocular manifestation. Combined scrape cytology and molecular testing may be a useful strategy for its early diagnosis. A 24-year-old healthy male complained of blurred vision, foreign body sensation, and watery discharge in his right eye for four weeks. His visual acuity was 20/20 bilaterally at his first visit. Allergic conjunctivitis was the first impression, and topical treatment with corticosteroid and anti-histamine was prescribed. However, he returned five days later without symptom improvement, and his right eye vision declined to 20/40. Subepithelial corneal infiltration of his right eye was observed. According to his personal history, his girlfriend was diagnosed with sexually transmitted chlamydial infection and genital gonorrhea. Under the suspicion of sexually transmitted adult inclusion conjunctivitis, we collected his conjunctival lavage to both real-time polymerase chain reaction, which proved chlamydial infection, and Giemsa stain, which demonstrated typical basophilic intracytoplasmic inclusions. To diagnose adult inclusion conjunctivitis, we can use real-time polymerase chain reaction or Giemsa stain to help us obtain a quick and correct diagnosis.

[The secret of red eyes].

"Red eye" is a sign and the same time a symptom frequently met in the ophthalmological practice. The "red eye" is not always the clinical manifestation of a common conjunctivitis. We will present a case report of a patient who accused conjunctival hyperemia, lacrimation, foreign--body sensation; she was also describing recurrent conjunctivitis for the past year. After an detailed ophthalmologic examination and interdisciplinary consultations. She was diagnosed with Basedow Disease and paraselar meningioma with invasion in the pterigoid fossa. The authors are suggesting that there is an indirect left carotid - cavernous fistula.

Self-inflicted (factitious) conjunctivitis.

To describe the diagnosis and management of self-inflicted factitious conjunctivitis in conscripted soldiers. Prospective, noncomparative, consecutive case series. Seventeen conscripted soldiers. Soldiers with chronic conjunctivitis (>3 weeks) were referred by ophthalmologists, and cases of shorter duration were referred by primary-care physicians. All cases underwent thorough ophthalmic and systemic history and examination, as well as questioning regarding their military units, military duties, and social background. Exclusion criteria were any condition that may cause conjunctivitis. Inferior fornix specimen microscopy and culture and eye photography were performed in most cases. In cases suspected of self-inflicted conjunctivitis all medication, besides lubricant drops, was stopped. Underlying psychosocial problems were investigated and managed. Cases were followed for at least 3 months after resolution of the conjunctivitis, at which point the diagnosis was confirmed, and the case entered the analysis. Resolution of the conjunctivitis. Seventeen consecutive cases of self-inflicted conjunctivitis, 8 of long duration and 9 of short duration, were studied. All cases demonstrated inconsistent clinical findings. The ocular signs most suggestive of self-inflicted conjunctivitis were purulent discharge purposely left on the lashes and periorbital skin, discharge more severe than in conjunctival hyperemia, less conjunctival chemosis than in hyperemia, mainly inferior conjunctival involvement, and an uninvolved cornea. Five of the 8 chronic cases had significant underlying psychologic or social problems. Their conjunctivitis resolved only after their underlying problems were addressed. Two cases admitted introducing freshly scraped dental plaque into the lower conjunctival sac. In the remaining 15 the similarity of the clinical findings suggested that a similar method was used. In the context of a subject standing to gain by assuming the sick role and after exclusion of ocular pathology, self-inflicted conjunctivitis can be reliably diagnosed by noting the characteristic clinical profile. Effective management includes addressing the underlying psychologic and social problems.

Conjunctivitis -- History and Physical

While conjunctivitis often presents similarly, a thorough systematic history and physical exam can safely rule out any acute sight-threatening diagnoses and elucidate the likely cause of conjunctivitis. The classic findings of the 3 most common types of conjunctivitis are: Bacterial - Findings include conjunctival redness, having the sensation of a foreign body in the eye, morning matting of the eyes, white-yellow purulent or mucopurulent discharge, conjunctival papillae, and infrequently preauricular lymphadenopathy. [45] Viral - Findings include eye itching, watery discharge, tearing, a history of recent upper respiratory tract infection, inferior palpebral conjunctival follicles, and tender preauricular lymphadenopathy. [46] [47] Allergic: Findings include eye itching and burning, watery discharge, history of allergies/atopy, edematous eyelids, conjunctival papillae, and no preauricular lymphadenopathy. [48]

An Unusual Presentation of Retinal Detachment and Conjunctivitis: A Case Report.

Vision loss is an ophthalmologic emergency with broad differential requiring prompt medical attention. We describe a 55-year-old male presenting to the emergency department (ED) with unilateral, painless visual field deficit with ipsilateral conjunctivitis induced by a presumed foreign body. The patient described a foreign body sensation nine days prior to developing visual changes. In the ED, the patient was diagnosed with a retinal detachment using point-of-care ultrasonography, and emergent ophthalmologic consultation was obtained. Concurrent retinal detachment and conjunctivitis in a patient is extremely rare. Healthcare providers should be aware that foreign body-induced conjunctivitis could lead to retinal detachment.

InternalMed_Harrison

acUte HemorrHagic conjUnctivitis Patients with acute hemorrhagic conjunctivitis present with an acute onset of severe eye pain, blurred vision, photophobia, and watery discharge from the eye. Examination reveals edema, chemosis, and subconjunctival hemorrhage and often shows punctate keratitis and conjunctival follicles as well (Fig. 228-2). Preauricular adenopathy is often found. Epidemics and nosocomial spread have been associated with enterovirus 70 and coxsackievirus A24. Systemic symptoms, including headache and fever, develop in 20% of cases, and recovery is usually complete in 10 days. The sudden onset and short duration of the illness help to distinguish acute hemorrhagic conjunctivitis from other ocular infections, such as those due to adenovirus and Chlamydia trachomatis. Paralysis has been associated with some cases of acute hemorrhagic conjunctivitis due to enterovirus 70 during epidemics.

[Persistence of Chlamydia trachomatis in patients with chronic therapy refractory conjunctivitis].

We report three patients with recurrent Chlamydia-associated conjunctivitis. The clinical course of the Chlamydial infection was documented by positive conjunctival smears (direct immunofluorescence staining) and the evaluation of the IgA-titer in the sera (immunoperoxidase assay). The recovery of the ocular symptoms after therapy onset correlated well with the negative results of the conjunctival smears and the decrease in IgA level in the sera. The recurrence of the conjunctivitis was accompanied by an increase in the IgA titer in the sera of all three patients and the presence of Chlamydial elementary bodies in the conjunctival scrapings in two cases. Three patients showed immunologic pecularities: two had an allergic diathesis; the third patient developed Wegener disease 3 months after the onset of ocular inflammation. Inclusion bodies or Chlamydial DNA can persist in conjunctival cells. Anderson suggested that a recurrence of active Chlamydial infection may be induced by external causes, which lead to reconstitution of elementary bodies from the persisting DNA. The extraordinary immune situation of our patients might be one cause of the recurrent conjunctivitis.

Bacterial Conjunctivitis in Childhood: Etiology, Clinical Manifestations, Diagnosis, and Management.

Bacterial conjunctivitis is a common reason for children to be seen in pediatric practices. A correct diagnosis is important so that appropriate treatment can be instituted. To provide an update on the evaluation, diagnosis, and treatment of bacterial conjunctivitis in children. A PubMed search was completed in Clinical Queries using the key term "bacterial conjunctivitis". Patents were searched using the key term "bacterial conjunctivitis" from www.freepatentsonline.com and www.google.com/patents. In the neonatal period, bacterial conjunctivitis is rare and the most common cause of organism is Staphylococcus aureus, followed by Chlamydia trachomatis. In infants and older children, bacterial conjunctivitis is most often caused by Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Clinically, bacterial conjunctivitis is characterized by a purulent eye discharge, or sticky eyes on awakening, a foreign body sensation and conjunctival injection (pink eye). The diagnosis is made clinically. Cultures are unnecessary. Some authors suggest a watchful observation approach as most cases of bacterial conjunctivitis are self-limited. A Cochrane review suggests the use of antibiotic eye drops is associated with modestly improved rates of clinical and microbiological remission as compared to the use of placebo. Various investigators have also disclosed patents for the treatment of conjunctivitis. The present consensus supports the use of topical antibiotics for bacterial conjunctivitis. Topical antibiotics shorten the course of the disease, reduce discomfort, prevent person-to-person transmission and reduce the rate of reinfection.

Compared to iritis, patients with infective keratitis often complain of a foreign body sensation and trouble opening or keeping the eye open. These symptoms are consistent with corneal involvement and can present with other corneal disorders such as corneal ulcer, abrasion, or foreign body. [58] Foreign body and orbital trauma can result in hyphema, which can also result in acute and permanent vision loss.

Conjunctivitis

Bacterial Bacterial conjunctivitis causes the rapid onset of conjunctival redness, swelling of the eyelid, and a sticky discharge. Typically, symptoms develop first in one eye, but may spread to the other eye within 2–5 days. Conjunctivitis due to common pus-producing bacteria causes marked grittiness or irritation and a stringy, opaque, greyish or yellowish discharge that may cause the lids to stick together, especially after sleep. Severe crusting of the infected eye and the surrounding skin may also occur. The gritty or scratchy feeling is sometimes localized enough that patients may insist that they have a foreign body in the eye. Common bacteria responsible for nonacute bacterial conjunctivitis are Staphylococcus, Streptococcus, and Haemophilus species. Less commonly, Chlamydia spp. may be the cause.

Allergic Conjunctivitis -- History and Physical -- Vernal Keratoconjunctivitis

Symptoms of VKC are usually most severe during the spring season and can include thick mucus discharge, pain, lacrimation, photophobia, and blurred vision. Patients often complain of a foreign body sensation in the eye, and increased blinking may be observed. Upon examination, corneal ulcers and infiltrates on the conjunctival can occasionally be detected. Giant papillae on the tarsal conjunctiva are universally seen during the examination. [24]

Japanese guideline for allergic conjunctival diseases.

The definition, classification, pathogenesis, test methods, clinical findings, criteria for diagnosis, and therapies of allergic conjunctival disease are summarized based on the Guidelines for Clinical Management of Allergic Conjunctival Disease (Second Edition) revised in 2010. Allergic conjunctival disease is defined as "a conjunctival inflammatory disease associated with a Type I allergy accompanied by some subjective or objective symptoms." Allergic conjunctival disease is classified into allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis, and giant papillary conjunctivitis. Representative subjective symptoms include ocular itching, hyperemia, and lacrimation, whereas objective symptoms include conjunctival hyperemia, swelling, folliculosis, and papillae. Patients with vernal keratoconjunctivitis, which is characterized by conjunctival proliferative changes called giant papilla accompanied by varying extents of corneal lesion, such as corneal erosion and shield ulcer, complain of foreign body sensation, ocular pain, and photophobia. In the diagnosis of allergic conjunctival diseases, it is required that type I allergic diathesis is present, along with subjective and objective symptoms accompanying allergic inflammation. The diagnosis is ensured by proving a type I allergic reaction in the conjunctiva. Given that the first-line drug for the treatment of allergic conjunctival disease is an antiallergic eye drop, a steroid eye drop will be selected in accordance with the severity. In the treatment of vernal keratoconjunctivitis, an immunosuppressive eye drop will be concomitantly used with the above mentioned drugs.

[Reddened eyes, what should be done?].

Not every patient who consults his physician because of reddening, pain, burning or itching sensation in an eye suffers from a bacterial or viral infection of the anterior eye segments. The sicca-syndrome mainly occurring in the elderly leads often to chronic reddening and a disturbing sensation of a foreign body in the eye. Allergic manifestations are often a cause for swelling and reddening of the conjunctiva. If next to reddening a rapidly progressing deterioration of vision develops, eventually accompanied by nausea and vomiting acute glaucoma has to be considered. In uveitis the patient mainly complains about sensations of dazzling, reduced visual acuity and pain, reddening of the conjunctiva may be variable. If in addition to acute hyperemia also a yellow-whitish infiltrate of the cornea is observed a bacterial ulcer of the cornea may be suspected. In this case an ophthalmologist has to be consulted without delay. Viral inflammations are often a diagnostic and therapeutic challenge. If reduced sensibility of the cornea is observed, herpetic infection should be considered.

[Evaluation of the efficacy and safety of lodoxamide in patients with allergic eye diseases].

To evaluate the effectiveness of lodoxamide in the therapy and prophylaxis of the ocular allergies. This prospective study included 64 patients divided in 2 groups. In the first group there were 47 symptomatic patients suffering from seasonal allergic conjunctivitis (n = 27), perennial allergic conjunctivitis (n = 16) and giant papillary conjunctivitis (n = 4). The symptomatic patients were examined upon arrival and every 2 weeks until the symptoms were reduced. During the period, lodoxamide drops were administered 4 times a day. In the second group there were 17 patients who had a history of seasonal ocular allergies during previous years but were still not symptomatic upon arrival. In the group of 17 patients who were very likely to develop ocular allergy but up to inclusion into the study had no ocular symptoms, 12 (70%) presented with allergic rhinitis while 5 (30%) had asthma. The symptoms intensity (itching, discomfort, foreign body sensation, pain, tearing) was graded on a 0-3 scale. The clinical signs (follicles, papillae, hyperemia, conjunctival edema, Trantas dots, stromal infiltrates) were detected on a slit lamp examination and graded on a 0-3 scale. In the group of 47 symptomatic patients 2-4 weeks after lodoxamide administration, 70-80% of symptomatic patients examined clinically had less or no follicles, 60-70% had reduced or no edema, the secretion was stopped or greatly reduced in 50-70% of patients. All of the patients reported reduced or no itching, 60% of patients reported less discomfort, photophobia and reduced tearing. In the asymptomatic group two weeks after the initiation of the prophylaxis 88% of patients were still with no ocular signs of allergy while 12% of patients had a conjunctival hyperemia and follicles. After 4 weeks of the prophylaxis 76% of patients patients were still asympthomatic while only 4 developed a mild form of allergic conjunctivitis (conjunctival hyperemia and papillae), but less severe than during previous episodes. Lodoxamide was effective in reduction of symptoms and clinical signs of the ocular allergies. The best results were obtained if the drug was administered as a prophylaxis or very early in the course of the disease.

Chlamydia trachomatis presenting as preseptal cellulitis in a 3-year-old girl.

Inclusion conjunctivitis usually presents with lid swelling, red eye, foreign body sensation, and a mucopurulent discharge in association with a follicular reaction involving the palpebral and bulbar conjunctiva and semilunar fold. Similar to epidemic keratoconjunctivitis, it may present with preauricular lymphadenopathy, superficial punctate keratitis, and subepithelial corneal infiltrates, which tend to be more peripheral. We present the case of preseptal cellulitis in a 3-year-old child, caused by nonconsensual sexual contact with chlamydia trachomatis.

Brimonidine/timolol

Adverse effects The most common adverse effects affecting 5 to 15% of the patients include allergic conjunctivitis, conjunctival folliculosis, conjunctival hyperemia, eye pruritus, ocular burning, and stinging. 1 to 5% of the patients in clinical trials experienced asthenia, blepharitis, corneal erosion, depression, epiphora, eye discharge, eye dryness, eye irritation, eye pain, eyelid edema, eyelid erythema, eyelid pruritus, foreign body sensation, headache, hypertension, oral dryness, somnolence, superficial punctate keratitis, and visual disturbance. Contraindications Contraindications of Combigan include the following: reactive airway disease including bronchial asthma, a history of bronchial asthma, severe chronic obstructive pulmonary disease, sinus bradycardia, secondary or third degree atrioventricular block, overt cardiac failure, cardiogenic shock, age less than 2 years, and hypersensitivity to any component of Combigan.

[Complaints following treatment of common acute eye diseases].

The aim of the study was to determine the duration of symptoms in patients treated in the emergency room at Glostrup Hospital for acute eye-trouble. Nine common diagnoses were selected for the study. All patients seen during a 2 1/2 month period were asked to complete a questionnaire one week after the consultation. Those who did not return the questionnaire, and cases where the diagnosis was changed by a doctor in the days following the consultation, were excluded. The final material comprised 422 patients. 28% did not have any complaints after the consultation. 50% were free of symptoms within 24 hours and 75% within 48 hours. 10% had symptoms for more than a week. Cases of infectious conjunctivitis and trauma to the eye (without intrabulbar lesion) had the highest risk of developing symptoms after the consultation. The lowest incidence of complaints was seen among patients in whom a foreign body was removed from the cornea or conjunctiva. The longest duration of symptoms was seen among patients with infectious conjunctivitis. Cases with a foreign body on the cornea or conjunctiva or trauma to the eye (without intrabulbar lesion) had a slightly longer duration of the symptoms when a corneal tear was present. Patients with photoelectric conjunctivitis and conjunctivitis caused by chemical products had the shortest durations of symptoms. Patients with pain should be treated with analgesic tablets as the pain-relief after application of local anaesthetics was brief. Only half of those who had a prescription for chloramphenicol used this for as long as it had been recommended. Compliance was better to ointment than to eye-drops.

[Chlamydia pneumoniae--the etiologic agent of follicular conjunctivitis followed by keratoconjunctivitis sicca in adult patients].

The authors refer to 21 adult patients at the age of 22 to 87 years, who have suffered from a chronic form of follicular conjunctivitis, found to be caused by Chlamydia pneumoniae as the etiological agent. The observation was made in the period from July 1999 to December 2002. Chl. pneumoniae was detected by a direct demonstration of the conjunctiva smears and by means of serological examination. The print preparations on glass were examined by the method of indirect immunofluorescence by means of specific monoclonal antibodies (Medac, Germany). The serological examination included detection of genus-specific IgG, IgA, IgM antibodies, respectively (Medac, Germany) and species-specific anti-Ch. pneumoniae IgG, IgA abd IgM antibodies, respectively (FOCUS Technologies, U.S.A.). The clinical picture included various long-term subjective complaints (within the range of several months to ten years), particularly a pathological secretion or increased lacrimation, cutting, burning or feeling of a foreign body in the eye. The objective examination revealed chronic changes characterized by a mild edema of bulbar conjunctiva with increased meandering in vessels of irregular caliber and edema in the lower transition plica with follicular structure crossing into the tarsal conjunctiva. In the fornix there was an apparent sticking aqueous or mucinous secretion. The therapy was indicated by the positive smears alone in four patients or positive IgA and/or IgM of genus- or species-specific antibodies in 12 patients. The therapy in the remaining five patients was recommended by the combination of suspect-positive smears in combination with positive genus- or species specific antibody reaction. The therapy made use of systemic administration of a macrolide antibiotic, azithromycin, for the period of 12 to 14 days in a single course of treatment. The pretreatment was always followed by control smears after two weeks and by serological examinations after three and six months. The serological findings remained virtually unchanged during that period of time in all patients under observation. In two of them only the species-specific antibodies anti-Ch. pneumoniae IgA antibodies disappeared six months after the therapy. The clinical findings disappeared slowly, particularly the follicular changes occurred after more than six months after the therapy ended. The subjective complaints, accompanied by a transient hyperemia of conjunctives in particular, remained after the therapy in nine patients older than 45 years, who were found to suffer from kieratoconjnunctivitis sicca. The ocular symptomatology was not accompanied by symptoms of autoimmune disease. The general treatment by antibiotics and the results supportive treatment succeeded in 67% of patients who were completely free of subjective complaints and the pathological process in conjunctives was inhibited.

Efficacy and safety of topical azelastine compared with topical mitomycin C in patients with allergic conjunctivitis.

To compare the efficacy and safety of topical azelastine with topical mitomycin C (MMC) in patients with allergic conjunctivitis. Sixty-three patients (29 male, 29 female; 34 in the age range of 6 to 65 years) with allergic conjunctivitis were enrolled in this study. The patients were randomly assigned to receive topical azelastine 0.02% (n = 31) or topical MMC (0.2 mg/10 mL) (n = 31) four times daily for 3 months. Follow-up examinations were done at 2 weeks to examine side effects of the medications and again at 4 weeks to assess the outcome of treatment. The eyes were examined for relief of symptoms, cure of signs, and the appearance of side effects with use of these drugs. The mean age of the patients in this study was 34.8 +/- 17.3 years. The age of patients in the MMC group was significantly higher than patients in the azelastine group (mean +/- SD, 25.2 +/- 13.5 years). More patients in the MMC group had relief of symptoms like redness [25 (80.7%) in the MMC group versus 19 (55.9%) in the azelastine group; p= 0.033], photophobia [11 (35.5%) in the MMC group versus six (17.7%) in the azelastine group; not significant], discharge [17 (54.8%) in the MMC group versus 11 (32.3%) in the azelastine group; not significant], and foreign body sensation [21 (67.7%) in the MMC group versus 16 (47.1%) in the azelastine group; not significant], while more patients in the azelastine group had relief of lacrimation [14 (41.2%) in the azelastine group versus 10 (32.3%) in the MMC group; not significant] and pain [12 (35.3%) in the azelastine group versus eight (25.8%) in the MMC group; not significant]. The MMC group also showed a greater decrease in follicles [31 (100.0%) in the MMC group versus six (17.7%) in the azelastine group; p= 0.0001] and papillae [29 (93.6%) in the MMC group versus four (11.8%) in the azelastine group; p= 0.0001]. Both drugs were found to be equally effective in relieving itching [18 (58.1%) in the MMC group versus 18 (52.9%) in the azelastine group; not significant]. In the MMC group, 27 (87.1%) patients had conjunctival hyperemia, 28 (90.3%) patients had episcleritis, and 29 (93.6%) patients had irritation. The use of topical azelastine did not cause any adverse event. Though this was a short-term study, we found topical MMC to be more effective than topical azelastine in the treatment of allergic conjunctivitis both in terms of relief of symptoms and resolution of signs. The use of topical MMC in low doses does not cause any significant adverse effect.

Neonatal conjunctivitis

If left untreated, neonatal conjunctivitis can cause blindness. Signs and symptoms Neonatal conjunctivitis by definition presents during the first month of life. Signs and symptoms include: Pain and tenderness in the eyeball Conjunctival discharge: purulent, mucoid or mucopurulent (depending on the cause) Conjunctival hyperaemia and chemosis, usually also with swelling of the eyelids Corneal involvement (rare) may occur in herpes simplex ophthalmia neonatorum Time of onset Chemical causes: Right after delivery Neisseria gonorrhoeae: Delivery of the baby until 5 days after birth (early onset) Chlamydia trachomatis: 5 days after birth to 2 weeks (late onset – C. trachomatis has a longer incubation period) Complications Untreated cases may develop corneal ulceration, which may perforate, resulting in corneal opacification and staphyloma formation. Cause

Rapidly evolving conjunctivitis due to Pasteurella multocida, occurring after direct inoculation with animal droplets in an immuno-compromised host.

The rare descriptions, in the literature, of ocular infections due to Pasteurella multocida include: endophtalmitis, keratitis and corneal ulcers, Parinaud's oculoglandular syndrome, and conjunctivitis. Here, we report a rare case of rapidly evolving conjunctivitis due to Pasteurella multocida, occurring after direct inoculation with animal droplets in an immuno-compromised host. A 69-year-old, Caucasian male was referred to our department with purulent conjunctivitis, occurring five days after chemotherapy for an angioimmunoblastic-T-cell-lymphoma, and thirty-three hours after being struck in his right eye by his sneezing Dachshund dog. Physical examination revealed purulent conjunctivitis of the right eye associated with inflammatory edema of both lids. Direct bacteriological examination of conjunctival secretions showed gram-negative bacilli and regular, grey non-hemolytic colonies appearing the next day on blood agar. The oxidase test was positive for these colonies. An antibiotherapy associating intravenous amoxicillin and amoxicillin/clavulanate was administered. The outcome was favorable in the next three days allowing discharge of the patient with amoxicillin (2 g tid per os). This case report may be of interest for infectious diseases, ophthalmology or oncology specialists, especially nowadays with chemotherapy being administered in day care centres, where unusual home pathogens can be encountered in health related infections. In this case, previous animal contact and conjunctival samples showing Enterobacteriaceae like colonies with positive oxidase test were two important clues which could help clinicians to make the diagnosis of Pasteurella conjunctivitis in every day practice.

[Ocular injuries related to Independence Day celebrations].

Each year, following Israel's Independence Day celebrations, patients are referred to the Soroka University Medical Center as a result of ocular injuries from items such as artificial snow spray, fireworks, plastic hammers and stick-lights (plastic tubes filled with fluorescent liquid). This study aims to describe and characterize the ocular injuries that are directly related to the use of these devices. The files of all patients who were referred to the Department of Ophthalmology in the Soroka University Medical Center, between the years 1998 and 2005, during the period of Israel's Independence Day, were screened. If a patient sustained an injury from a device used during the celebration, then data relating to the age, sex, injured eye, diagnosis, the device that caused the injury and treatment were collected. A total of 437 patients were included in this study; fifty-two patients had suffered an ocular injury directly due to a celebration device. The patients' mean age was 17.6 years; 61.5% of the patients were male. The three most common ocular injuries were corneal erosions, conjuctival erosions, and superficial punctate keratitis (38.5%, 28.9%, and 23.0%, respectively). Other injuries included corneal and conjuctival foreign bodies, traumatic iritis, elevated intraocular pressure, and subconjuctival hemorrhage. The devices responsible for most of the injuries were artificial snow spray and fireworks. Ocular injuries from stick-light liquid, plastic hammers, and balloon explosions were seen as well. Almost all patients (96.1%) required medical treatment. Patients injured by celebration devices accounted for 27.9% of all patients seen during this period in our Ophthalmology Department; after several years, the rate approached 40%. Strict enforcement of rules and legislation regarding the use of celebration devices must be upheld. The public's awareness of the harm that these devices can cause should be strengthened.

Tele-ophthalmology as an aid tool for primary care physicians in the IDF, during the Covid-19 lockdown.

To describe tele-ophthalmology consultations for primary-physicians in the IDF during the Covid-19 lockdown. Retrospective cross-sectional study. Medical records of tele-ophthalmology consultations from March to June 2020 were reviewed. The study included 245 cases in which an ophthalmologist was consulted. In 62.0% cell-phone camera photographs were used. The mean age was 21.5 ± 6.4 years. The most common diagnoses were acute-conjunctivitis (8.6%); conjunctival-hyperemia (non-specific diagnosis, 8.2%); scleritis/episcleritis (7.3%); chronic allergic-conjunctivitis (7.3%); chalazion (7.3%) hordeolum (6.5%); acute allergic-conjunctivitis (4.5%). 37.6% of patients received primary physician-based treatment, 24.9% of patients received specialist-based treatment. 13.1% were referred to the ER. The consult prevented ER referral for 39.2% and changed the physician's treatment plan in 70.6% of cases. Foreign-body sensation complaints were more likely treated by a primary-physician (p = 0.015). Cases with suspected foreign-body diagnosis were referred more to the ER (p < 0.001). For most cases of eyelid complaints and diagnoses, primary physician care was sufficient (p < 0.001). Conjunctival complaints and diagnoses received significantly more ophthalmologist-based treatment (p < 0.001). Corneal disorders were significantly referred more to the ER (p = 0.001). Despite of possible ethical and legal problems and clinical limitations of this instrument, Tele-ophthalmology using objective aids such as smartphone photography can be an efficient tool in aiding the primary-physician, especially for patients with low access to ophthalmologists, with major impact on patient management.

Parinaud's oculoglandular syndrome

Parinaud's oculoglandular syndrome is the combination of granulomatous conjunctivitis in one eye, and swollen lymph nodes in front of the ear on the same side. Most cases are caused by cat-scratch disease, although it is an unusual feature of this condition. Occasionally it may be caused by other infections. It should not be confused with the neurological syndrome caused by a lesion in the midbrain which is also known as Parinaud's syndrome. Both were named after the same person, Henri Parinaud. Causes Bartonella henselae Francisella tularensis herpes simplex virus type 1 Paracoccidioides brasiliensis Diagnosis References External links Infectious diseases Herpes simplex virus-associated diseases Syndromes caused by microbes

Corneal Foreign Body -- History and Physical

If present for greater than 24 hours, WBCs may migrate into the cornea/ anterior chamber as a sign of iritis. Gross hyphema, however, may indicate globe perforation. Other gross exam findings may show eyelid edema, as well as generalized or focal injection of the conjunctiva.

Conjunctivitis -- History and Physical

The ocular exam should focus on visual acuity, extraocular motility, visual fields, discharge type, shape, size and response of pupil, the presence of proptosis, corneal opacity, foreign body assessment, tonometry, and eyelid swelling.

Conjunctival and bulbar sporotrichosis as Parinaud's oculoglandular syndrome acquired by blood inoculation.

Parinaud's oculoglandular syndrome (POS) is a clinical condition characterized by granulomatous conjunctivitis associated with homolateral neck pain and anterior preauricular lymphadenopathy. Several reports of this condition occurred and some bacterial etiological agents were identified. However, fungal infections have also been associated, especially sporotrichosis. A 40-year-old female patient complained about a "little ball" in the lower eyelid of the left eye. On ocular examination, visual acuity and fundoscopy were normal. The biomicroscopy revealed a granulomatous lesion in the lower eyelid of the left eye associated with yellowish discharge. The patient returned the next day, reporting worsening of the condition accompanied by low fever, malaise, preauricular and submandibular lymphadenomegaly. The examination showed the evolution of conjunctival edema and various conjunctival granulomas in the lower and upper tarsus of the left eye, a clinical picture compatible with POS. In the investigation of the clinical history, the patient remembered an episode of contact with blood of cats. During the investigation, we discarded differential diagnoses such as tuberculosis, toxoplasmosis, CMV, herpes virus and <iBartonella</i. Serology was positive for <iSporothrix</i. Treatment with itraconazole 100 mg once daily was started. By the eighth week, the conjunctival granulomas had disappeared, and the medication was discontinued after 90 days of treatment, after about 2 weeks of total remission. According to the literature, there are no cases of primarily ocular manifestation of blood sporotrichosis transmission. However, in the report, the form of transmission of the disease occurred by inoculation by direct contact with the blood of contaminated cats.

Acute haemorrhagic conjunctivitis: an epidemic in August/September 2003.

To clinically analyze 400 cases of red eye attending Nepal Eye Hospital in August/ September 2003 and to study the aetiology of the disease on the clinical basis with available laboratory resources. It is a prospective study of 400 cases of acute conjunctivitis visiting Nepal Eye Hospital during the epidemic of acute haemorrhagic conjunctivitis in August/September 2003. 30.5% presented in the age group of 20-29 years. Males presented predominantly (73.3%). Maximum number of patients presented at two days of onset of symptoms. All 400 cases had red eye, 89.8% had pain, 86.3% had foreign body sensation and 87.5% had discharge. Bilateral involvement was seen in 73.5% and unilateral involvement in 26.5%, 4.3 % of the total cases had corneal involvement and 20% of the cases had associated fever and preauricular lymphadenopathy. Based on clinical presentation and the report of available laboratory results, picorna virus was found to be responsible for this epidemic of acute haemorrhagic conjunctivitis.

Conjunctivitis -- Differential Diagnosis -- Non-Emergent Diagnoses

Pterygium and episcleritis are typically associated with localized redness, which differs from the diffuse redness in conjunctivitis. Blepharitis, contact overuse, and dry eyes are similar in presentation to allergic conjunctivitis. These conditions commonly present with a foreign body sensation, itching, or burning. History of contact use, lack of blinking, and allergies/atopy are important in differentiating contact lens overwear, dry eyes, and allergic conjunctivitis, respectively. Crusting of the eyelids, marked erythema, and edema of the eyelid margins are most consistent with blepharitis. Lastly, a subconjunctival hemorrhage is due to bleeding of conjunctival vessels and appears as blood in the subconjunctival space rather than the typical injection or vessel dilation seen in conjunctivitis. [46] [57] [60]


I think the correct answer is 3 answers 2,4 and 5 are clearly false. The doubt is between 1 and 2. The statement of 1 is correct in cases of follicular carcinoma without capsular invasion a total thyroidectomy can be performed. But if there are data of poor prognosis and the possibility of metastases - as in this case - it is best to complete the thyroidectomy and perform a radioactive iodine scan to rule out metastases or treat them if they are present.

I think [HIDDEN] answers [HIDDEN]. The doubt is [HIDDEN]. The statement of 1 is correct in cases of follicular carcinoma without capsular invasion a total thyroidectomy can be performed. But if there are data of poor prognosis and the possibility of metastases - as in this case - it is best to complete the thyroidectomy and perform a radioactive iodine scan to rule out metastases or treat them if they are present.

Ten days after performing a hemithyroidectomy on a patient with a 1.5 cm thyroid nodule you receive the following anatomopathologic report: "very cellular follicular pattern without capsular invasion and infiltrating adjacent blood vessels and nerves". Point out the correct answer:

As there is no capsular invasion, no further surgery is necessary.

Follicular pattern is an indication for prophylactic cervical lymph node emptying.

This is a follicular carcinoma and requires completion of thyroidectomy.

The report allows us to rule out with total certainty a papillary carcinoma in the remaining thyroid.

Measurement of plasma calcitonin will allow us to distinguish between papillary and follicular carcinoma.

Selective treatment of differentiated thyroid carcinoma.

Over a period of 20 years 84 papillary and 82 follicular carcinomas operated on by one surgeon and examined by one pathologist were documented prospectively, treated selectively, and followed for 1 to 20 years (median 7 years). Tumors with a low risk of recurrence or incurable disease-i.e., papillary carcinoma pT1-3 N0 M0 (n = 56) and minimally invasive follicular carcinoma (n = 37)-were treated by a limited-radicality hemithyroidectomy or total thyroidectomy without radioiodine in 79 of the 93 cases (85%). No unfavorable course was observed, and only one curable recurrence (1.3%) developed contralaterally after hemithyroidectomy for papillary cancer. Of the remaining 73 patients, including 100% of those with nodal involvement, 65 (89%) underwent total thyroidectomy with radioiodine. Total thyroidectomy was achieved in 34% of the cases by completion thyroidectomy, based on definitive histologic examination. No instance of a serious, potentially incurable recurrence and no tumor-related death was observed in patients with a papillary TNM stage I+II or with a minimally invasive follicular carcinoma. Five of the patients (6%) with papillary carcinoma, all with TNM stage III or IV, and seven of the patients (8.5%) with follicular carcinoma, all grossly invasive and pT3 or pT4, had tumor-related deaths following total thyroidectomy in all and with remnant ablation in 10 cases. A potentially curable node recurrence occurred in two patients 1 and 10 years, respectively, after primary treatment. Permanent hypoparathyroidism (n = 4) (2.4%) and permanent recurrent laryngeal nerve palsy (n = 2) (1.2%) were observed only in patients with a grossly invasive follicular carcinoma and concomitant benign recurrent goiter. We conclude that (1) hemithyroidectomy or total thyroidectomy without radioiodine is adequate for papillary carcinoma pT1-3 N0 and minimally invasive follicular carcinoma; (2) there were no nodal recurrences in tumors recognized as node-negative; and (3) extracapsular excision of one or both lobes can be carried out technically with low morbidity. The study confirms the prognostic value of age-related TNM classification for papillary carcinoma; classification of follicular thyroid carcinoma as minimally invasive or grossly invasive proved to be useful.

[The lymph node dissection in thyroid carcinoma].

Rule and indications of lymph node dissection (LD) in thyroid carcinoma is still under debate because of the biological variety of different histological types and the difficulty to have an accurate preoperative diagnosis of metastatic lymph nodes; moreover prognostic factors of metastatic lymph nodes are still unclear. The AA. have separately analyzed different thyroid carcinomas and different clinical situations requiring thyroid LD. Metastatic lymph nodes from differentiated carcinomas, including papillary and follicular type, range from 12 to 90% and apparently do not worsen the prognosis. Level II-VI LD is indicated in presence of metastatic lymph nodes or macroscopic nodal recurrence after a previous LD. No prognostic advantages have been demonstrated when LD is performed without clinical or instrumental evidence of metastatic disease, including suspected recurrence characterised only by plasma Thyreoglobulin increased values. Lymph node metastases from medullary carcinoma range from 25 to 63%. Level II-VI LD is indicated if node metastases are present, whereas prophylactic LD, confined to level VI, is always recommended. Controversies still remain about: 1) LD extension whether it is prophylactic (level VI vs. II- VI) or in case of nodal involvement (levels II- VI monolateral or bilateral), 2) LD indications in case of an increased plasma Calcitonin levels during the follow-up after total thyroidectomy, without clinical or instrumental evidence of nodes involvement. Anaplastic carcinoma represents 5% of all thyroid carcinomas; it is the most aggressive type with an early tendency to invade surrounding organs and to give metastases; prognosis is very poor. LD is indicated only for a palliation in cases with compression syndromes.

Completion thyroidectomy: a critical appraisal.

Completion thyroidectomy can most accurately be described as reexploration of the neck to remove the contralateral thyroid lobe. This procedure has commonly been performed when the histopathologic condition of the ipsilateral thyroid lobe reveals papillary or follicular carcinoma of the thyroid. Because of a definitely increased risk of complications with completion thyroidectomy, avoiding its routine use is important. The purpose of this paper is to define the specific indications for completion thyroidectomy. Over the past 9 years, we have performed 400 thyroidectomies; the patients ranged in age from 18 to 88 years. Although we have routinely used preoperative needle biopsy and intraoperative frozen section, decisions regarding the extent of thyroidectomy have been based on the gross findings at operation, taking into consideration such prognostic factors as patient age, tumor grade and size, the presence of extracapsular spread or distant metastasis, and associated risk factors. The minimal procedure for solitary thyroid nodule has been lobectomy with isthmusectomy. If the contralateral lobe is grossly normal, lobectomy with isthmusectomy has also been the maximal operation in most of patients. Very few specific indications exist for removal of the opposite lobe. Only three patients underwent completion thyroidectomy. All three patients had aggressive follicular carcinoma requiring radioactive iodine ablation, and all were referred after the initial surgery. We have not performed completion thyroidectomy on any of the patients on whom we initially operated. The most common indication considered for completion thyroidectomy is a frozen section diagnosis of a benign follicular adenoma that is subsequently changed on permanent pathologic condition to follicular carcinoma based on the presence of capsular and/or vascular invasion. However, if minimal invasion has occurred, no difference exists in survival related to the extent of the thyroidectomy. Local recurrence in the contralateral lobe occurs in less than 10% of the time. Because completion thyroidectomy carries more risks, it should be avoided in most patients when possible. The definitive decision should be made during the initial operation based on gross findings, prognostic factors, and frozen section, and this plan should only be changed to mandate completion thyroidectomy in select circumstances.

Thyroidectomy

Hemithyroidectomy — Entire isthmus is removed along with 1 lobe. Done in benign diseases of only 1 lobe. Subtotal thyroidectomy — Removal of majority of both lobes leaving behind 4-5 grams (equivalent to the size of a normal thyroid gland) of thyroid tissue on one or both sides—this used to be the most common operation for multinodular goitre. Partial thyroidectomy —Removal of gland in front of trachea after mobilization. Done in nontoxic MNG. Its role is controversial. Near total thyroidectomy — Both lobes are removed except for a small amount of thyroid tissue (on one or both sides) in the vicinity of the recurrent laryngeal nerve entry point and the superior parathyroid gland. Total thyroidectomy — Entire gland is removed. Done in cases of papillary or follicular carcinoma of thyroid, medullary carcinoma of thyroid. This is now also the most common operation for multinodular goitre.

[Indication and extent of cervical lymph node dissection in differentiated thyroid carcinoma].

Indication and extent of lymph node dissection in differentiated thyroid carcinoma are still subject to controversy. The overall favourable prognosis, low study numbers and the different biological features of papillary and follicular carcinoma lead to few evidence-based recommendations and a low level of evidence. The different therapeutic and operative strategies are illustrated on the principles of evidence-based medicine. A literature search was carried out in Medline and EMBase using the keywords differentiated/papillary/follicular thyroid carcinoma, lymphadenectomy, lymph node dissection. PTC: Eleven retrospective studies outline the effect of prophylactic vs. no lymph node dissection on tumour relapse rate and long-term survival. Six of these studies combine PTC and FTC. A minor evidence-based recommendation for prophylactic cervico-central lymph node dissection in PTC can be given (evidence level 3). Lymph node dissections involving the cervico-lateral compartment can be recommended in the case of clinically pathological findings at the lymph nodes (evidence level 3). A prophylactic mediastinal lymph node dissection is not indicated (evidence level 4), a therapeutic mediastinal LAD cannot be recommended because of higher morbidity and mortality (evidence level 3). FTC: 3 retrospective studies outline the effect of prophylactic lymph node dissection on tumour relapse rate and long-term survival. Based on these, a recommendation for prophylactic cervico-central systematic lymph node dissection can be given for invasive follicular carcinoma (evidence level 3). There is no indication for prophylactic cervico-lateral or mediastinal lymph node dissection (evidence level 3). The following recommendations can be given in differentiated thyroid carcinoma: In the case of clinically pathological findings in cervical lymph nodes, a systematic lymph node dissection of the lateral and central compartment is indicated (evidence level 3). Prophylactic cervico-central lymph node dissection is recommended for PTC larger than 10 mm in diameter and invasive FTC, a cervico-lateral or mediastinal prophylactic lymph node dissection is not indicated (evidence level 3). In papillary microcarcinoma and minimally invasive follicular carcinoma, a prophylactic lymph node dissection is not indicated (evidence level 3).

Follicular thyroid cancer

Diagnosis It is difficult to correctly diagnose follicular neoplasms (FNs) on fine-needle aspiration cytology (FNAC) because it shares many cytological features with other mimicking lesions. Classification It is impossible to distinguish between follicular adenoma and carcinoma on cytological grounds. If fine needle aspiration cytology (FNAC) suggests follicular neoplasm, thyroid lobectomy should be performed to establish the histopathological diagnosis. Features sine qua non for the diagnosis of follicular carcinoma are capsular invasion and vascular invasion by tumor cells. Still, focuses of the capsular invasion should be carefully evaluated and discriminated from the capsular rupture due to FNA penetration resulting in WHAFFT (worrisome histologic alterations following FNA of thyroid). Follicular carcinoma tends to metastasize to lung and bone via the bloodstream. Papillary thyroid carcinoma commonly metastasizes to cervical lymph nodes.

Follicular Adenoma -- Evaluation

FNA is performed to provide a cytological examination of the nodule, and it remains the mainstay for assessing these lesions, although it may not provide a diagnosis in all cases. [7] The success rate of FNA is improved when the procedure is done under ultrasound guidance. The cytopathological findings are reported using one of the three major international nomenclatures: the British Thyroid Association and Royal College of Pathologists (Thy), the Italian Consensus (TIR) and the Bethesda System for Reporting Thyroid Cytopathology [40] [28] . Thyroid nodule fine-needle aspiration (FNA) washout may be examined for calcitonin in the preoperative evaluation in patients with elevated serum calcitonin (20–100 pg/mL). In patients with follicular adenoma the cytological sample has abundant follicular epithelial cells organized in sheets with crowding and overlapping of cells, microfollicle formation with scant or absent colloid. Some patients have follicular cells with abnormal architecture with atypia that is more significant than usually seen with benign lesions but not sufficient enough to call it a neoplasm. According to the Bethesda classification system, these patients are characterized as having "atypia of undetermined significance" or "follicular lesion of undetermined significance". Molecular assessment of indeterminate cytology can be helpful [28] . A final diagnosis of follicular adenoma is made only after ruling out capsular and vessel invasion by standard nodulectomy or thyroidectomy with subsequent histological examination. Frozen section should not be requested in clinically benign nodules but is a common practice in cases of suspect papillary thyroid carcinoma hence its evaluation intraoperatively can guide in performing lymphadenectomy.

Follicular thyroid cancer

Hurthle cell variant Hurthle cell thyroid cancer is often considered a variant of follicular cell carcinoma. Hurthle cell forms are more likely than follicular carcinomas to be bilateral and multifocal and to metastasize to lymph nodes. Like follicular carcinoma, unilateral hemithyroidectomy is performed for non-invasive disease, and total thyroidectomy for invasive disease. Diagnosis It is difficult to correctly diagnose follicular neoplasms (FNs) on fine-needle aspiration cytology (FNAC) because it shares many cytological features with other mimicking lesions.

Surgery_Schwartz

patients will have benign adenomas. Total thyroidectomy is recommended by some surgeons in older patients with follicular lesions >4 cm because of the higher risk of cancer in this setting (50%) and certainly should be performed in patients with atypia on FNA, a family history of thyroid cancer, or a history of radiation exposure. Intraoperative frozen-section examination usually is not helpful, but it should be performed when there is evidence of capsular or vascular invasion or when adjacent lymphadenopa-thy is present. Total thyroidectomy should be performed when thyroid cancer is diagnosed. There is debate among experts about whether patients with minimally invasive follicular can-cers should undergo completion thyroidectomy because the prognosis is so good in these patients. A diagnosis of frankly invasive carcinoma or follicular carcinoma with angioinvasion, with or without capsular invasion, necessitates completion of total thyroidectomy primarily so that 131I can be used to

Thyroid cancer

The follicular and papillary types together can be classified as "differentiated thyroid cancer". These types have a more favorable prognosis than the medullary and undifferentiated types. Papillary microcarcinoma is a subset of papillary thyroid cancer defined as a nodule measuring less than or equal to 1 cm. 43% of all thyroid cancers and 50% of new cases of papillary thyroid carcinoma are papillary microcarcinoma. Management strategies for incidental papillary microcarcinoma on ultrasound (and confirmed on FNAB) range from total thyroidectomy with radioactive iodine ablation to lobectomy or observation alone. Harach et al. suggest using the term "occult papillary tumor" to avoid giving patients distress over having cancer. Woolner et al. first arbitrarily coined the term "occult papillary carcinoma", in 1960, to describe papillary carcinomas ≤ 1.5 cm in diameter.

Carcinoma of the thyroid with description of a new scanning technic.

A statistical analysis of 193 patients with thyroid carcinoma encountered at Vanderbilt University Hospital from 1925 to 1974 is reported, from which the following conclusions are drawn: (1) Papillary thyroid carcinoma is an extremely favorable lesion that when grossly limited to one thyroid lobe can usually be managed successfully by ipsolateral total lobectomy. (2) Cervical lymph node enlargement in patients with papillary carcinoma requires lymph node dissection. When feasible, the spinal accessory nerve should be preserved. (3) Failure to cure papillary and follicular thyroid carcinoma is influenced by advanced age, inadequate local extirpation, and unresectability of the carcinoma. (4) Prophylactic lymph node dissection is rarely indicated in the treatment of follicular carcinoma. A new isotope scanning procedure, developed at Vanderbilt University Hospital, promises to be helpful in preoperatively differentiating benign  from malignant solitary thyroid nodules.

Follicular thyroid cancer

Initial treatment If follicular cells are found on cytological testing, it is common to carry out hemithyroidectomy to distinguish between follicular adenoma and follicular carcinoma on histopathological examination, proceeding to completion thyroidectomy and postoperative radioiodine ablation where carcinoma is confirmed. This way total thyroidectomy is not carried out unnecessarily. Thyroidectomy is invariably followed by radioiodine treatment at levels from 50 to 200 millicuries following two weeks of a low iodine diet (LID). Occasionally treatment must be repeated if annual scans indicate remaining cancerous tissue. Some physicians favor administering the maximum safe dose (calculated based on a number of factors), while others favor administering smaller doses, which may still be effective in ablating all thyroid tissue. I-131 is used for ablation of the thyroid tissue. Minimally invasive thyroidectomy has been used in recent years in cases where the nodules are small.

Medullary thyroid cancer

Prognosis Depending on source, the overall 5-year survival rate for medullary thyroid cancer is 80%, 83% or 86%, and the 10-year survival rate is 75%. By overall cancer staging into stages I to IV, the 5-year survival rate is 100% at stage I, 98% at stage II, 81% at stage III and 28% at stage IV. The prognosis of MTC is poorer than that of follicular and papillary thyroid cancer when it has metastasized (spread) beyond the thyroid gland. The prognostic value of measuring calcitonin and carcinoembryonic antigen (CEA) concentrations in the blood was studied in 65 MTC patients who had abnormal calcitonin levels after surgery (total thyroidectomy and lymph node dissection). The prognosis correlated with the rate at which the postoperative calcitonin concentration doubles, termed the calcitonin doubling time (CDT), rather than the pre- or postoperative absolute calcitonin level:

Lymph node dissection in papillary or follicular thyroid carcinoma.

Prospective randomized studies aimed at evaluating the different therapeutic protocols for the treatment of papillary or follicular carcinoma are lacking at the moment. Although total thyroidectomy is widely accepted, indication to locoregional lymphadenectomy is strongly debated. Fifty-four patients with papillary or follicular thyroid carcinoma (45 papillary and 9 follicular) underwent functional evaluation of the gland before intervention, FNAB included Surgical management was carried out as follows: 41 total thyroidectomy, 6 lobectomy with further totalization in 5, 6 total thyroidectomy plus central compartment lymphadenectomy and 1 left laterocervical lymphadenectomy (papillary carcinoma, treated elsewhere through total thyroidectomy plus central and right laterocervical lymphadenectomy). All operated patients were submitted to whole body scintigraphy and treated thereafter by radiometabolic therapy and chronic hormone suppressive therapy. Fifty-one patients are currently alive, 3 died from non-related causes; surgical complications included 1 permanent impairment of inferior laryngeal nerve function and 1 case of hypoparathyroidism. The follow-up was from 1 to 139 months. The optimal treatment of lymph node metastases, especially for papillary carcinomas, has not yet been defined. Two trends are evident concerning lymphadenectomy: the first one suggests routine lymphadenectomy, the second supports lymphadenectomy by necessity. In follicular carcinoma lymphadenectomy is recommended only in the presence of clinical evidence of lymph node involvement. Occult differentiated carcinoma does not require any further treatment of lymph nodes. Considering the high efficacy of radiometabolic treatment after total thyroidectomy combined with chronic TSH inhibition through L-tyrosine administration, lymphadenectomy is suggested only by necessity.

History Patients in the distant past with this lesion would have been regarded as showing signs of having a benign lesion, a follicular adenoma. However, over time and with additional evaluation and molecular testing, these lesions came to be regarded as showing features of a papillary thyroid carcinoma because of their papillary carcinoma type nuclei. Thus, the "follicular variant" of a tumor that normally shows a papillary architecture and papillary nuclear features was named. Over the years, those cases that do not show invasion of either the capsule of the tumor or the vessels in the capsule, have been shown to behave in an indolent fashion, with only rare reported cases of metastatic disease.

Over a multiyear time frame, an international consensus project was undertaken to re-define the pathological criteria for the encapsulated follicular variant of papillary thyroid carcinoma. Based on a rigorous review of the literature and a multicentre review of many cases with long-term follow-up (a minimum of 10 years) together with molecular analysis of some tumors, this working group has determined that tumors previously classified as the encapsulated follicular variant of papillary carcinoma—without any evidence of capsular or vascular invasion, provided that the entire periphery of the tumor (capsule if encapsulated or periphery if well circumscribed) has been sampled—can be reclassified as noninvasive follicular thyroid neoplasms with papillary-like nuclear features. There are several major inclusion and exclusion criteria.

Thyroid cancer

Thyroid cancer can spread directly, via lymphatics or blood. Direct spread occurs through infiltration of the surrounding tissues. The tumor infiltrates into infrahyoid muscles, trachea, oesophagus, recurrent laryngeal nerve, carotid sheath, etc. The tumor then becomes fixed. Anaplastic carcinoma spreads mostly by direct spread, while papillary carcinoma spreads so the least. Lymphatic spread is most common in papillary carcinoma. Cervical lymph nodes become palpable in papillary carcinoma even when the primary tumor is unpalpable. Deep cervical nodes, pretracheal, prelaryngeal, and paratracheal groups of lymph nodes are often affected. The lymph node affected is usually the same side as that of the location of the tumor. Blood spread is also possible in thyroid cancers, especially in follicular and anaplastic carcinoma. The tumor emboli do angioinvasion of lungs; end of long bones, skull, and vertebrae are affected. Pulsating metastases occur because of their increased vascularity.

Follicular thyroid cancer

Follicular carcinoma tends to metastasize to lung and bone via the bloodstream. Papillary thyroid carcinoma commonly metastasizes to cervical lymph nodes. HMGA2 has been proposed as a marker to identify malignant tumors. Treatment Treatment is usually surgical, followed by radioiodine.

Thyroid adenoma

Careful pathological examination may be necessary to distinguish a thyroid adenoma from a minimally invasive follicular thyroid carcinoma. Management Most patients with thyroid adenoma can be managed by watchful waiting (without surgical excision) with regular monitoring. However, some patients still choose surgery after being fully informed of the risks. Regular monitoring mainly consists of watching for changes in nodule size and symptoms, and repeat ultrasonography or needle aspiration biopsy if the nodule grows. For patients with benign thyroid adenomata, thyroid lobectomy and isthmusectomy is a sufficient surgical treatment. This procedure is also adequate for patients with minimally invasive thyroid cancer. When histological examination shows no signs of malignancy, then no further intervention is required. These patients should continue to have their thyroid hormone status regularly checked. References External links Thyroid cancer

Papillary thyroid cancer

The so-called lateral aberrant thyroid is usually a lymph node metastasis from a papillary thyroid carcinoma. Papillary microcarcinoma is a subset of papillary thyroid cancer defined as measuring less than or equal to 1 cm. The highest incidence of papillary thyroid microcarcinoma in an autopsy series was reported by Harach et al. in 1985, who found 36 of 101 consecutive autopsies to have an incidental microcarcinoma. Michael Pakdaman et al. report the highest incidence in a retrospective surgical series at 49.9 percent of 860 cases. Management strategies for incidental papillary microcarcinoma on ultrasound (and confirmed on FNAB) range from total thyroidectomy with radioactive iodine ablation to observation alone. Harach et al. suggest using the term "occult papillary tumor" to avoid giving patients distress over having cancer. It was Woolner et al. who first arbitrarily coined the term "occult papillary carcinoma" in 1960, to describe papillary carcinomas ≤ 1.5 cm in diameter.

Abbreviations: NIFTP: Noninvasive follicular thyroid neoplasm with papillary-like nuclear features EFVPTC: Encapsulated follicular variant of papillary thyroid carcinoma. PTC: Papillary thyroid carcinoma. The new classification will be included in the World Health Organization's new Classification of Endocrine Organ Tumours, due out in 2017. Imaging findings Clinical evaluation is usually done with ultrasound studies, which will usually show a solid, well demarcated mass, often showing limited shadowing (hypoechoic). Depending on the specific character on ultrasound and other clinical findings, a fine needle aspiration is often performed.

Computed tomography of the thyroid

Thyroid cancers Epidemiology Primary thyroid carcinomas include papillary, follicular, medullary, and anaplastic carcinomas. Lymphoma and metastasis of other primary malignancies to the thyroid gland represent a minority of thyroid carcinomas. Differentiated thyroid carcinomas (DTCs) originate from follicular epithelial cells and encompass PTCs and follicular thyroid carcinomas, including the Hurthle cell variant of follicular carcinoma. DTCs have an excellent prognosis and fortunately represent the majority of thyroid carcinomas. PTCs and follicular thyroid carcinomas represent 88 % and 8 %, respectively, of all thyroid malignancies. Medullary thyroid carcinoma arises from neuroendocrine C-cells and has a good prognosis. Anaplastic carcinoma is an aggressive undifferentiated tumour that usually affects the elderly and tends to have a worse prognosis. Role of imaging

Surgery_Schwartz

capsule without extension into the parenchyma and/or invasion into smallto medium-sized vessels (venous caliber) in or immediately out-side the capsule, but not within the tumor. On the other hand, widely invasive tumors demonstrate evidence of large vessel invasion and/or broad areas of tumor invasion through the cap-sule. They may, in fact, be unencapsulated. It is important to note that there is a wide variation of opinion among clinicians and pathologists with respect to the above definitions. Tumor infiltration and invasion, as well as tumor thrombus within the middle thyroid or jugular veins, may be apparent at operation.Surgical Treatment and Prognosis. Patients diagnosed by FNAB as having a follicular lesion should undergo thyroid lobectomy because at least 70% to 80% of these patients will have benign adenomas. Total thyroidectomy is recommended by some surgeons in older patients with follicular lesions >4 cm because of the higher risk of cancer in this setting (50%) and

Thyroglobulin

A subsequent elevation of the thyroglobulin level is an indication of recurrence of papillary or follicular thyroid carcinoma. In other words, a rise in thyroglobulin levels in the blood may be a sign that thyroid cancer cells are growing and/or the cancer is spreading. Hence, thyroglobulin levels in the blood are mainly used as a tumor marker for certain kinds of thyroid cancer (particularly papillary or follicular thyroid cancer). Thyroglobulin is not produced by medullary or anaplastic thyroid carcinoma. Thyroglobulin levels are tested via a simple blood test. Tests are often ordered after thyroid cancer treatment.

Fine-needle aspiration and intraoperative consultation in thyroid pathology: when and how?

Fine-needle aspiration (FNA) and frozen section evaluation are traditional components of the management of thyroid lesions. Their role and usefulness are dictated by some basic facts about thyroid pathology: (a) nodules are very common; (b ) they are benign in the majority of cases; and (c) the diagnosis of malignancy is primarily based on cytologic features in the case of papillary carcinoma, and on the presence of invasion of the tumor capsule or of blood vessels in the case of follicular carcinoma. The common occurrence of benign thyroid nodules mandates a cost-effective effective method for preoperative screening. Since, as already stated, the diagnosis of papillary thyroid carcinoma (by far the most common thyroid malignancy) is based on the identification of characteristic cytologic features, FNA has easily emerged in the past 30 years as the most accurate and cost-effective tool-indeed a true cornerstone-for the preoperative management of thyroid nodules. Standardized terminology to report cytologic diagnoses is highly recommended and is being implemented worldwide. Conversely, the importance of intraoperative frozen section diagnosis has been constantly decreasing over the past years, as a direct consequence of the widespread application of FNA. It may, however, be very useful in cases that are suspicious for papillary carcinoma on FNA and in selected cases with an indeterminate cytologic diagnosis.

Exclusion criteria 1) Any invasion. 2) The presence of any other papillary thyroid carcinoma variant (examples would include tall cell, columnar cell, cribriform morular, diffuse sclerosing, etc.). 3) True papillary structures (a fibrovascular core surrounded by neoplastic cells). While originally limited to <1%, newer data suggests no papillary structures should be allowed. 4) Psammoma bodies. These are calcified remnants of papillary structures, and thus if a psammoma body is present anywhere within the tumor (in the correct location), then a NIFTP cannot be diagnosed. 5) Tumor necrosis: If there is true tumor necrosis not associated with a fine needle aspiration. 6) Increased mitoses: If there are ≥3 mitoses per 10 high-power fields, then this category cannot be used.

Additional Tissue Sampling Trials Did Not Change Our Thyroid Practice.

This study aimed to determine whether additional tissue sampling of encapsulated thyroid nodules would increase the frequency of follicular thyroid carcinoma (FTC) diagnoses. We examined thyroid tissue specimens from 86 patients suspected of FTC (84.9% female; mean age, 49.0 ± 17.8 years). The number of tissue blocks created for pathological assessments ranged from 3 to 20 (mean, 9.1 ± 4.1); the numbers in the previous method recommended by the Japanese General Rules for the Description of Thyroid Cancer and additional blocks ranged from 1 to 12 (mean, 6.0 ± 2.8) and from 1 to 8 (mean, 3.1 ± 2.0), respectively. The additional blocks were subsequently examined to determine whether any diagnoses changed from those based on the previous method. Five patients were diagnosed with FTC using the previous method; however, additional tissue blocks led to the diagnosis of FTC in 6 patients, as 1 diagnosis was revised from follicular adenoma to FTC. It has been reported that increasing the number of tissue blocks used for pathological assessments can increase the frequency of FTC diagnoses; however, this was not clinically significant in thyroid carcinoma, which requires completion thyroidectomy and radioactive iodine treatment. It resulted in no benefits to the patient because all minimally invasive FTCs, follicular tumors of uncertain malignant potential (FT-UMP), and follicular adenomas are treated with lobectomy alone in Japan. Additional tissue sampling only had a slight impact on our thyroid practice; therefore, we decided to cease it.

[Surgical treatment of differentiated thyroid carcinoma].

This paper reports the results and experiences of 95 cases with differentiated thyroid carcinoma managed by surgical treatment. Eighty-two patients were followed up with an average time of 6.2 years, the longest was fifteen years and six months, 96% of patients were survival over 5 years. The factors influencing prognosis are as follows: 1. Age: Elder predicts worse prognosis. 2. Papillary is better then follicular. 3. The stage of thyroid carcinoma: Bigger mass, tumor cells spreading out of thyroid capsule with invasion of adjacent tissues and regional lymph nodes, and intravascular tumor cell embolus almost always shows higher recurrence and mortality. 4. Simple tumor removal before admission gives no reasonable cure, but increasing risk of spreading as showed in our cases. Therefore, we emphasize that thyroid carcinoma should be treated primarily with radical operation. By our experience thyroid carcinoma should be treated with lobectomy for affected site, excision of isthmus, and contralateral subtotal thyroidectomy. Because of the low grade malignancy in differentiated thyroid carcinoma, modified neck dissection is the surgical procedure of choice. Patients undergoing such surgical procedure as stated above can be prevented from sequelae.

The value of frozen section examinations in determining the extent of thyroid surgery in patients with indeterminate fine-needle aspiration cytology.

To determine the usefulness of intraoperative frozen section (FS) examinations in establishing the diagnosis of thyroid cancer in patients undergoing thyroidectomy for nodules with indeterminate cytological features and to determine the cost-effectiveness of FS examinations in this situation. Retrospective medical record review. The results of fine-needle aspiration biopsies (FNABs), FS examinations, and final pathologic examinations are compared. A cost-effectiveness analysis of routine FS examinations compared with the cost of additional surgical procedures is performed. A private surgical practice in a medical school-affiliated teaching hospital. The records of all 480 patients undergoing thyroidectomy between January 1, 1998, and September 30, 2000, were reviewed. All 199 patients with a dominant thyroid nodule and FNAB results either highly suggestive of papillary cancer or indeterminate were studied. Of the patients with FNAB results highly suggestive of papillary cancer, 95% had cancer according to the final pathologic examination results. The diagnosis of cancer was made by FS examination results in 67% of these patients. Of the remaining 178 patients whose FNAB result was indeterminate, 64 (36%) had thyroid cancer. Malignancy was diagnosed by FS examination results in 30 (47%) of these patients. If FS examinations had not been performed, these 30 patients would have required a second operation to complete a total thyroidectomy. The cost savings of routine FS examinations in patients with indeterminate FNAB results is 1298 US dollars per patient. The routine performance of FS examinations in patients with thyroid nodules with indeterminate cytological features is a cost-effective way of avoiding a second surgical procedure if a total thyroidectomy is indicated. In patients with FNAB results highly suggestive of papillary cancer, FS examinations are not useful. In these patients, the definitive operation can be based on the results of the FNAB.

Papillary thyroid cancer

Treatment Surgery remains the mainstay of treatment for papillary thyroid cancer. The Revised 2009 American Thyroid Association guidelines for papillary thyroid cancer state that the initial procedure should be near-total or total thyroidectomy. Thyroid lobectomy alone may be sufficient treatment for small (<1 cm), low-risk, unifocal, intrathyroidal papillary carcinomas in the absence of prior head and neck irradiation or radiologically or clinically involved cervical nodal metastasis. Minimal disease (diameter up to 1.0 centimeters) - hemithyroidectomy (or unilateral lobectomy) and isthmectomy may be sufficient. There is some discussion whether this is still preferable over total thyroidectomy for this group of patients.

Papillary thyroid cancer

Papillary thyroid carcinomas are also discovered when a hard nodule is found in multinodular goiter, when enlarged cervical lymph nodes are detected, or when there are unidentified metastatic lesions elsewhere in the body. Expanding lesions found in the thyroid gland, especially if they are painful, should be examined as they may indicate the presence of papillary thyroid carcinoma. Other clinical signs that could indicate papillary thyroid are fixation to the trachea, a firm neck mass, damage to recurrent laryngeal or cervical sympathetic nerves. Five percent of the population can have thyroid nodules, and the majority will be benign. Appropriate workup includes an ultrasound of the neck, followed by lab studies. Patients will usually meet with both an endocrinologist and a surgeon (head and neck surgeon or endocrine surgeon).

Thyroid Adenoma -- Evaluation

Fine needle aspiration (FNA) has ultimately been used in evaluating a thyroid nodule with suspicious radiology features, especially in patients with a high risk of malignancy. It should be mentioned that fine-needle aspiration may not provide a definite diagnosis in all cases. In patients with thyroid adenoma, the cytological sample has organized follicular epithelial cells. On the other hand, aspiration can show follicular cells with abnormal architecture and atypia. These patients are characterized as having atypia of undetermined significance. [26] A benign thyroid adenoma is confirmed only after ruling out capsular and vessel invasion in the final histological examination done by pathologists after a partial or total thyroidectomy operation. Genetic testing has also helped a lot in predicting the risk of thyroid cancer, and it has frequently been used in the final decision-making of proceeding to surgical intervention of removing a thyroid nodule versus not. [27]