Intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery has gained widespread acceptance as an adjunct to the gold standard of visual nerve identification. Despite the increasing use of IONM, review of the literature and clinical experience confirms there is little uniformity in application of and results from nerve monitoring across different centers. We provide a review of the literature and cumulative experience of the multidisciplinary International Neural Monitoring Study Group with IONM spanning nearly 15 years. The study group focused its initial work on formulation of standards in IONM as it relates to important areas: 1) standards of equipment setup/endotracheal tube placement and 2) standards of loss of signal evaluation/intraoperative problemsolving algorithm. The use of standardized methods and reporting will provide greater uniformity in application of IONM. In addition, this report clarifies the limitations of IONM and helps identify areas where additional research is necessary. This guideline is, at its forefront, quality driven; it is intended to improve the quality of neural monitoring, to translate the best available evidence into clinical practice to promote best practices. We hope this work will minimize inappropriate variations in monitoring rather than to dictate practice options.

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To review the clinical presentation, histopathological features, and optimal treatment of chronic granulomatous mastitis, the authors conducted a retrospective study of 25 women admitted to a teaching hospital in Malaysia between January 1998 and December 2000 who met the required histologic criteria. The primary outcome measures were morbidity and recurrence of the disease. Thirteen patients presented with a breast mass clinically mimicking breast cancer, and 12 patients had breast induration and abscess formation. In addition, 8 of these patients had recurrent breast disease. Clinical and imaging diagnosis has often been difficult and inconclusive, so histopathology remains the optimal diagnostic tool. Of interest, 50% of patients experience recurrences, and long-term follow-up is therefore necessary. The authors concluded that, because chronic granulomatous mastitis is a rare benign breast condition that may be misdiagnosed as breast carcinoma, complete resection should be accomplished whenever possible. Steroid therapy may be an adjuvant for optimal treatment. Awareness among surgeons and pathologists should also be emphasized to avoid unnecessary misdiagnosis and treatment.

Breast cancer is the most common cancer among Malaysian women. There is a marked geographical difference in the worldwide incidence of breast cancer, with a higher incidence in developed countries compared to developing countries. From 1998 to 2001, new cases of breast cancer presenting to the breast clinics at Hospital Kuala Lumpur and University Malaya Medical Centre, Malaysia, were reviewed; the race, age and stage at presentation were analysed. Of 774 cases seen in Hospital Kuala Lumpur, only 5.2% (40/774) were impalpable breast cancers diagnosed on mammography. The prevalent age group was 40 to 49 years, and the median age was 50 years. The average size of the tumour was 5.4 cm in diameter. Malay women appear to have larger tumours and a later stage at presentation than other ethnic groups; 50% to 60% were in late stages (Stages 3 and 4). During the same period, 752 new cases of breast cancer were seen in the University Malaya Medical Centre. The average tumour size was 4.2 cm, and 30% to 40% were in late stages. The age incidence was similar. The delay in presentation of breast cancer was attributed to a strong belief in traditional medicine, the negative perception of the disease, poverty and poor education, coupled with fear and denial. A prospective, population-based study is required to determine the demographic pattern of breast cancer and the factors delaying presentation. These findings will have important implications in future programmes to promote the early detection of breast cancer, as well as in understanding geographical as well as racial variations in the incidence of breast cancer.

Although various methods of localizing the RLN have been described, surgeons should be aware of the variations and have a thorough knowledge of normal anatomy in order to achieve a high standard of care. This will ensure the integrity and safety of the RLN in thyroid surgery. The anatomical variation may be minor in degree, but is of great importance as it may affect the outcome of the surgery and the patient's quality of life.

Breast cancer is the most common cancer among Malaysian women. Nonetheless, in Malaysia there is a marked geographical difference in the incidence of breast cancer with advanced stage of presentation. The breast clinic in Kuala Lumpur Hospital diagnosed approximately 150 to 200 new cases of breast cancer a year. This number, however, represents only 12.0% to 15.0% of all breast disease seen annually in Kuala Lumpur Hospital. Between 1998 and 2001, of a total of 774 cases of newly diagnosed breast cancer in Kuala Lumpur Hospital, only 5.0% (40/774) were impalpable breast cancers. The peak age group for the three major ethnic distributions (Malay, Chinese, and Indian) ranged from 40 to 49 years. The mean tumor size at presentation was 5.4 cm (range: 1-20 cm), and the advanced stage of breast cancer is observed to be highest among the Malay ethnic group. Although it appears that the incidence of breast cancer in Malaysia is lower than in the developed countries, the difference may be attributable to the difficulty in getting accurate statistics and to underreporting of cases. Nonetheless, from the available data, it is clear that breast cancer continues to be the most common cancer among Malaysian women. The strongly negative social-cultural perception of the disease, made worse by the geographical isolation of many rural areas, accounts for the delayed diagnosis and the often advanced stage of disease at presentation. A prospective population-based study is called for to verify the demographic patterns of breast cancer, particular in Malaysia and other developing countries. The findings of such a study may have implications for future breast screening programs and for facilitating the understanding of differing risks of breast cancer among women around the world.

The diagnosis of primary thyroid lymphoma should be considered when dealing with rapidly growing goitres. The role of FNAC in diagnosing thyroid lymphoma is limited but it is still useful in the initial work-up. Nevertheless, surgical intervention is often required to establish the diagnosis and relieve critical airway compression. A combination of chemotherapy and irradiation is the mainstay of management.

The outcome of the present study demonstrated a substantial increased incidence of sore throat after thyroid surgery under GA. Postoperative sore throat following thyroid surgery under GA may be caused by multiple contributing factors. Nonetheless effort and care should be taken during endotracheal intubation and surgery to reduce this unpleasant complaint arising mainly from pharyngeal irritation or trauma.