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By: N. Surus, M.A., M.D.
Deputy Director, Burrell College of Osteopathic Medicine at New Mexico State University
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While cytopatho logic interpretation has improved, a clear diag nosis for malignancy is not always achieved. Certainly, any evidence of thyroid can cer in the neck nodes is an indication for total thyroidectomy and appropri ate neck dissection. Remember, that absent any risk factors, there is a high degree of probabil ity that the nodule is benign. When multiple nodules are found, the thyroid is classifed as a multinodular 99 thyroid or goiter, and only the dominant or largest nodules are biopsied. Radionuclide thyroid scans have become less essential to the diagnostic workup of nodules with the development and refnement of ultrasound and fne-needle aspiration techniques. Forms of Thyroid Cancer Tere are two essential classifcations of thyroid cancer: well diferentiated and other. Papillary Carcinoma Approximately 80 percent of thyroid cancers are papillary histologically. Tese may have a follicular component, but any amount of papillary com ponent means the tumor will behave more like a papillary tumor. Tese tumors can be multifocal in the gland and ofen metastasize to neck lymph nodes. For unknown reasons, this disease follows a much more indolent course when discovered in people under age 40. How ever, while papillary carcinoma patients under 40 years of age ultimately live longer, they also experience a higher rate of recurrence. Historically, a total thyroid lobectomy and isthmectomy have been used to treat smaller papillary thyroid cancers (<1 cm). More recently, the trend has been toward total thyroidectomy in patients with nodules containing pap illary thyroid cancers. Newer evidence from a study by Mazzaferri and colleagues suggests that total thyroidectomy, when compared to subtotal, may signifcantly decrease the local recurrence rate (18% versus 7%), and ultimately the number of deaths (from 1. However, 100 there was no diference in the number of deaths between these two groups. As mentioned earlier, if cervical metastatic thyroid cancer is present, a modifed or selective neck dissection is indicated, depending on the location of the disease.
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Active sunscreen agents including avobenzone, benzophenones, octyl methoxycinnamate, oxybenzone, padimate O, and many others can cause irritation on the skin, creating patches of dryness, itching, rashlike breakouts, redness, and swelling. As safe and effective as titanium dioxide and zinc oxide are they can be occlusive, meaning they can block and clog pores. The issue for any ingredient that can cause breakouts is threefold: how occlusive it is (meaning blocking oil fow out of the pores), how irritating it is on the skin (perhaps caus ing rashlike breakouts), and how much the ingredient duplicates what the pore already produces, adding more fuel to the fre. One other issue with a sunscreen that uses only titanium dioxide and/or zinc oxide as the active ingredient is a cosmetic one, as these products tend to leave a white appearance and can feel somewhat heavy on the skin. Su n S c r e e n S F o r oi ly Sk i n the search for a sunscreen that is appropriate for oily skin can be a frustrating, lifelong pursuit. First, the types of ingredients that can be used to suspend sunscreen agents are not exactly the best for oily skin. Regardless of the claim on the label, there are risks that the base formulation can clog pores or feel slippery or greasy on the skin. Finally, given the wide variety in formulations, there is no way to quantify which ingredients are more problematic than others for causing problems. This is also an option for women who are just tired of wearing layers and layers of skin-care products and makeup. Fo r t h e lit tle on e S When choosing a sunscreen for your child it is always best to follow the advice of your pediatrician. It is very easy to be enticed to buy sunscreen products with pictures of cute babies on the label. However, despite these marketing tactics, products aimed at children and babies are not formulated any differently than products for adults.
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By comparison, this type of gentle cleanser was more effective than either soap or a benzoyl peroxide cleanser alone. Products designed to tackle acne often contain ingredients like harsh surfactants and overly abrasive scrub particles, as well as alcohol, menthol, peppermint, camphor, and eucalyptus, lemon, or grapefruit oils. Instead, they kill more skin cells than necessary, which can further clog pores, produce dry skin, cause irritation, and make skin redder. Skin-care products with irritating ingredients, such as facial masks, astringents, toners, and facial scrubs (which also contain waxes), are a big no-no. Bar soaps and bar cleansers are often recommended for acne, yet all of them contain ingredients that can clog pores. Soaps contain tallow, and bar cleansers contain other heavy, wax-based thickening agents that can clog pores. Shockingly, high-pH soaps and cleansers (those with a pH of 8 or higher) can actually increase the presence of bacteria in the pore! All this makes matters much worse inside the pore, again greatly increasing the risk of breakouts. Oversqueezing, picking, digging, scraping, or poking at pimples may be hard to resist, and you may think it speeds healing, but in fact it sets you up for more problems. Creating scabs and constantly reinjuring the lesion just increases the chances of scarring. Actu ally, hot compresses severely damage skin by burning it; the heat causes more redness and swelling; and the whole process can also rupture the pore, increasing the possibility of more breakouts. Use tepid water and a gentle, water-soluble cleanser on the face, and do not wipe off makeup. Wiping and rubbing will make the ir ritation worse, and can also make the skin sag and cause wrinkles. Hairspray, mousse, hair gel, and other styling products contain polymers (plastic-like, flm-forming ingredients) that can clog pores and cause pimples.
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Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The closure of defects created by incision, excision, or trauma may require intermediate or complex closure. Excision is defined as full-thickness (through the dermis) removal of a lesion including margins, and includes simple (non-layered) closure when performed. The excised diameter is the same whether the surgical defect is repaired in a linear fashion, or reconstructed (eg, with a skin graft). When frozen section pathology shows the margins of excision were not adequate, an additional excision may be necessary for complete tumor removal. Use only one code to report the additional excision and re-excision(s) based on the final widest excised diameter required for complete tumor removal at the same operative session. To report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600-11646, as appropriate. Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code. This includes local anesthesia and chemical or electrocauterization of wounds not closed. Single layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair. Necessary preparation includes creation of a defect for repairs (eg, excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions. Instructions for listing services at time of wound repair: Version 2019 Page 14 of 257 Physician Procedure Codes, Section 5 Surgery 1. The repaired wound(s) should be measured and recorded in centimeters, whether curved, angular or stellate. When multiple wounds are repaired, add together the lengths of those in the same classification (see above) and from all anatomic sites that are grouped together into the same code descriptor. For example, add together the lengths of intermediate repairs to the trunk and extremities. Do not add lengths of repairs from different groupings of anatomic sites (eg, face and extremities). Also, do not add together lengths of different classifications (eg, intermediate and complex repairs). Decontamination and/or debridement: Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure.
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