Through our assessments we aim to find out as much as we can about the individual, this helps us to identify a communication aid and mounting solution (if appropriate) that is tailored to the person’s needs and wishes. Our assessments are friendly and we aim to gather the majority of information through informal discussion.

The assessment process usually follows a four or five step process.

• Assessment appointment – an opportunity to get to know the individual and try out devices and software
• Loan Period – the individual can borrow appropriate equipment to try out in the home/school environment.
• Review appointment – A decision is made as to whether the equipment is suitable or not
• Mounting appointment – if needed equipment can be mounted to wheelchairs or to provide access to the device whilst in bed or in a chair.
• Provision of equipment – if a device has been successfully identified and the individual meets the service specification criteria, we may be able to provide the equipment on long term loan

Assessments are carried out by an interdisciplinary team of experienced Speech and Language Therapists, Occupational Therapists Educational Specialists and Assistant Practitioners.

Assessments are carried out by a multi-disciplinary team of experienced Speech and Language Therapists, Occupational Therapists, Educational Specialists and Assistant Practitioners.

Emergency appointments are offered for people with Motor Neurone Disease (MND) who need to be seen as a priority, at short notice. AAC WEST schedules on average two emergency assessments a month, and they are scheduled for people with MND who meet the following criteria:

• Are deteriorating rapidly
• Are no longer able to rely on their speech
• Hand function has deteriorated to the extent that they would find it difficult to use communication equipment that is accessed by touch e.g. tablets, Lightwriters.
Referrals are made by the local Speech and Language Therapist, after which a series of 3 appointments will be made:
• An initial appointment where AAC WEST will assess the person and prescribe equipment that will be left for a trial period at that appointment
• A review appointment that will take place 4-6 weeks later
• A second review appointment that will be scheduled 6 weeks after the first review appointment. This appointment may not always be needed if everything is agreed to be working well at the first review.

The person with MND, the local SLT, other key professionals and people in the person’s life should attend.  The appointments are usually run by an AAC WEST Occupational Therapist and Assistant Practitioner.

During the initial appointment the person will be assessed with different devices and access methods depending on their needs.  As far as possible, equipment will be left for the person with MND to trial at the end of the initial appointment.

An initial assessment usually lasts between two to three hours. Review appointments usually last between one to two hours. Mounting appointments can take up to three hours.

We are aware that these appointments are lengthy and therefore we make sure that there are regular breaks and refreshments offered. In some cases we may split a session over two appointments if appropriate.

The person should be accompanied to the appointment by their local speech and language therapists. They are also encouraged to invite other people who are directly involved in their care, or play an important part in their life, such as family members, teachers, carers or occupational therapists.

Our appointments for adults mostly take place within the patient's own home, nursing home or hospice. Children are usually seen at their school or in their home.

We do also carry out appointments at the Bristol Centre for Enablement. Local therapists and support staff should attend all appointments.

Covid update: As a result of Covid-19, we have introduced offering some appointments as Attend Anywhere video consultations (Attend Anywhere). When a face to face appointment is required, we will take steps to minimise the risk of Covid-19 transmission, e.g. minimising people attending, wearing PPE, social distancing, decontaminating equipment etc. You may have a combination of face to face appointments and video consultations.

Through our assessments we aim to find out as much as we can about the individual, this helps us to identify a communication aid that is tailored to the person’s needs and wishes. Our assessments are friendly and we aim to gather the majority of information through informal discussion.

These discussions may focus on some of the following aspects:

• Communication skills – expressive skills, literacy skills, symbol recognition
• Physical abilities
• Sensory skills
• Cognitive abilities
• Previous experience of technology
• Where the person wants to communicate
• Where communication breaks down
• How an aid might be useful to individual Support networks
• Lifestyle and interests

These discussions and information from the referral form allow the therapist to identify devices and software which may suit the individual’s needs. The individual is then able to try out these devices and software within the session. If there is a particular device that fits the person’s requirements, a loan period will be agreed. If mounting is needed a mounting assessment will take place.

The loan period allows the person to try out the device in all areas of their lives. Goals will be set for the loan period in order to establish the positive and negative aspects of the device and its suitability. Devices are initially loaned for 4-6 weeks. We offer support during this period.

This may include:

• Programming the device with individualised vocabulary/photos
• Trouble shooting
• Training in how to use the device and program the software
• Training for the people supporting the person with the communication aid
• Practice sessions offered via video consultation or face-to-face if required.

Following this loan period, a review appointment will take place to discuss the outcome of the loan period and the goals set. We ask for feedback from the individual and their carers, therapists or teachers.

The outcome of this discussion could lead to one of the following:

• Another loan period using the same equipment to help explore it further
• A loan period may be organised for a different piece of equipment
• Supply of equipment for long term use.
• The person may decide that device or software offered does not suit their needs and would therefore be discharged.

When appropriate, mounting assessments are offered to allow devices to be attached to wheelchairs, or to be available whilst in bed or sitting in a chair. These sessions are offered as part of a communication aid assessment.

Through discussion with the individual and their carers and a detailed risk assessment, our experienced therapists take into account a number of different factors that may influence how or where a device might be mounted, for example:

• Device e.g. size and weight
• Type of wheelchair used
• Where the device will be used
• How the wheelchair will be transported
• How the wheelchair is propelled
• An individual’s weight, height, posture etc.

Appropriate mounting equipment will then be shown and demonstrated. Like a communication aid loan the individual can then trial the mounting equipment at home for a loan period of 4-6 weeks. At the end of this period the equipment is reviewed. In conjunction with the therapists, individual and their carers a decision is then made about the appropriate mounting solution. If the mounting assessment is running alongside a communication aid assessment, the success of the mount is taken into account when reviewing the device and vice versa.

The outcome of these discussions could include:

• Another loan period using the same equipment to help explore it further
• A loan period may be organised for a different piece of mounting equipment
• Supply of mounting equipment for long term use.
• The person may decide that the mounting solution offered does not suit their needs and would therefore be discharged.

If an appropriate mounting solution is found, the mounts are then fitted by the therapist. Training is given on how the mounts can be attached and removed and how they should be stored.

They are 4 little glands in your neck, next to the thyroid gland. Each is usually the size of a grain of rice. 

Their only job is to control levels of calcium in our body. Calcium is an important substance that we need for our nerves and muscles to work properly and for our bones to remain strong. Parathyroid glands secrete a substance called Parathyroid hormone which controls the amount of calcium in our blood. If our blood levels are low the hormone is released to increase blood calcium levels. It does this by increasing the absorption of calcium from the food we eat and taking calcium from our bones. 

In some people one or all four glands start over working and producing too much parathyroid hormone. We don’t know why this happens. The effect of too much parathyroid hormone in the body is to increase calcium levels in the blood by increasing absorption of calcium from the food you eat and releasing it from the stores in your bones.  This is called primary hyperparathyroidism.

In the majority of patients, this is a problem with one gland over working (80% of people), which is called a parathyroid adenoma, but in the other 20% it is due to all four glands over working, which is a process called hyperplasia. This is a benign process ie. not cancerous.

Very, very rarely, primary hyperparathyroidism can be caused by a cancer in one of the parathyroid glands.

This is a disease often seen in patients with kidney failure. As your kidneys don’t work well, you excrete too much calcium in your urine. As a result your parathyroid glands are constantly stimulated to produce more parathyroid hormone.

This situation arises when patients have had long standing secondary hyperparathyroidism. After a while, the glands continue to produce high levels of hormone, even though the stimulus of low blood calcium no longer exists. This is usually seen in patients who have had a successful kidney transplant, and so have normal blood calcium levels again, but the glands have not learnt to switch off again.

The symptoms are related to having a high level of calcium in your blood but are often thought of as just some of the signs of aging in older patients.

Nerves

Calcium is need for nerves to work properly so high levels can cause:

• Confusion
• Forgetfulness
• Depression

Muscles

Calcium is needed for muscles to work properly so high levels can cause:

• Weakness
• Overwhelming tiredness

Bones

Calcium is needed to keep bones strong so high levels can cause:

• osteoporosis (thin, weak bones)
• fractures (broken bones, often with very little force)
• bone pain

Others

There are a range of other symptoms associated with high calciums:

• excessive thirst
• needing to pass water more frequently
• kidney stones
• pancreatitis (inflammation of your pancreas gland)
• stomach ulcers and acid reflux

If your endocrinologist or GP thinks that you have over active parathyroid glands they may refer you to us for further investigation and treatment.

The diagnosis of hyperparathyroidism is made on blood tests to measure the level of hormone and calcium in your blood. In order to confirm the diagnosis we may need to test your levels of Vitamin D and perform a test on your urine also.

You may also have to undergo other tests such as a DEXA scan to diagnose osteoporosis or other conditions that your high calcium may have caused.

After you are referred to us we will arrange for two scans which will help us decide on whether this is a one gland or a four gland problem

MIBI scan

This scan involves the injection of a substance that is taken up by the parathyroid glands. It takes a couple of hours to perform.

USS scan

This is a scan, like the one that pregnant women undergo but of the neck. It is painless and quick.

We aim to perform both of these scans on the same day.

CT scan

Although the parathyroid scans are usually in the neck, they can occasionally be found in your chest and sometimes we have to do other scans to locate them before we consider an operation.

The only treatment of hyperparathyroidism is an operation. However, if your disease is very mild or you are not fit to undergo a general anaesthetic the risks of surgery may outweigh any benefits and surgery may not be the best option for you. When we meet you in the outpatients department we will ask you about your symptoms and medical history and will review your scans and blood test. We will then discuss with you the best options for you.  

Before you undergo surgery you will need to have the following:

1. Meeting with a surgeon to discuss your case and make a decision about surgery
2. Pre-operative assessment to check that you are fit to undergo an operation. This will include taking a full medical history from you, listening to your heart and lungs and measuring your blood pressure.
3. A check of your vocal cords. One of the potential complications of surgery on your parathyroid glands is injury to the nerves to your voice box/vocal cords. Therefore, everyone has to undergo a small telescope test up the nose to look down at the vocal cords and check that they are working properly. This takes just a few minutes, and is pain free. 

cTo undergo this operation you must first be put to sleep completely, ie. a general anaesthetic. We then make a small incision at the lower part of the front of your neck and search for your parathyroid gland/glands. We will be guided by the USS and MIBI scans as to which glands we will look at and which we will remove. This will have been discussed with you prior to surgery.  At the end of the operation we will stitch up your skin with dissolvable stitches so there will be nothing to be removed. We will inject local anaesthetic before you wake up to make you as comfortable as possible.

Possible complications

These can be divided those associated with the actual operation and those with receiving a general anaesthetic.

Surgical:

1. Infection – this is a fairly quick healing and clean part of the body so infections are not common. However, if your wound becomes red, sore or mucky after you return home then you should contact your GP who can decide if it is infected or not.
2. Bleeding – the worst bleeding most patients get is a bit of bruising which resolves with time. Bleeding that requires another operation can happen but is rare. If it does happen, it is usually apparent before you are discharged
3. Scar
4. Stiff neck – this is fairly common, but usually temporary.
5. Nerve injury -there is a nerve that supplies your voice box that runs very near the parathyroid glands. This can be injured during the operation, giving you a hoarse voice. This is a temporary problem in 1 in 100 operations and permanent very rarely (1 in 1000 case). Most patients wake up with a sore throat and a hoarse voice from the anaesthetic tube and the surgery so do not worry if this is the case.
6. Low calcium levels – Behind the thyroid gland sit 4 parathyroid glands. These control the levels of calcium in your blood and can become injured during thyroid surgery. This results in a low blood calcium level which can cause symptoms such as pins and needles in your fingers/toes and around your mouth. We will be monitoring your blood calcium levels but if you develop any of these symptoms after surgery you should tell a doctor as soon as possible as you may need to take calcium tablets for a short period following thyroid surgery.
7. Need for further surgery – In a small number of cases a further operation is needed to completely treat your hyperparathyroidism.

Anaesthetic:

Possible complications after this operation include:

1. Sore throat
2. Feeling sick or actually vomiting
3. Dizziness from low blood pressure
4. Damage to teeth (this is very rare)

You will have an opportunity to talk to the anaesthetist on the day of surgery.

You need to remain in hospital, usually just overnight. You may experience some pain, but this can usually be well controlled with simple tablet painkillers such as paracetamol and codeine phosphate. You may need to take these for a few days after the operation. Whilst you are in hospital, we will repeat blood tests for your hormone levels and blood calcium levels. Most patients can go home by lunch time the next day. 

Blood tests

You should have your calcium levels checked with a blood test by your GP within a week of your discharge.

Wound care

Your skin will have been closed with dissolvable stitches and covered with a small dressing. This can be easily removed after 3 or 4 days. It is normal for there to be some swelling in the area, which becomes slightly firm. If you are concerned about your wound you should see your GP.

Once the wound is healed over and you are able to comfortably touch your neck you can start to gently massage it E45 Cream or Bio oil.

Pain killers

Most people find that they need to take simple tablet painkillers such as paracetamol and codeine phosphate for a few days after surgery.

Driving

We advise you to avoid driving for a couple of weeks until you can comfortably turn your neck from side to side without any pain.

Talking and Singing

We recommend that you take a couple of weeks of work following this operation. This allows you to rest your voice, with no singing or shouting. 

We like to see you in outpatients 2-4 weeks after your operation to check that all has gone well with your recovery. Usually, we discharge you back to the care of the person who referred you to us (GP, endocrinologist or kidney specialist) at this stage. 

The thyroid is a small gland, shaped like a butterfly, which sits in front of your windpipe in your neck. 

The thyroid gland secretes a substance called thyroxine. This is a hormone which controls your metabolic rate and so controls your weight and appetite, body temperature and blood pressure and pulse.

This occurs when the thyroid gland is producing too much of its hormone, thyroxine. This can lead to symptoms such as a fast/irregular heart rate, high blood pressure, weight loss, diarrhoea and anxiety. The treatment of this is usually with drugs but some people may require surgery to remove all of the thyroid gland. 

When a thyroid gland becomes enlarged it is called a goitre. This can cause difficulty with swallowing or breathing and may look unsightly. In this situation, an operation to remove half or all of the thyroid gland may be necessary.

These can be either:

• non cancerous (benign)
• cancerous (malignant)

Growths in the thyroid gland are often first noted as a lump in the neck but can also be found on a scan performed for some other reason or noticed due to “pressure” symptoms in the neck, such as difficulty swallowing or breathing. These are normally investigated with an ultrasound scan in combination with a small needle test (called an FNA). Most of these lumps are not cancerous.

If the needle test confirms a cancer then surgery to remove the entire thyroid gland will be performed. In addition, some of the lymph nodes in the area may also need to be removed.

If the needle test is suspicious for a cancer or is inconclusive, surgery to remove the half of the thyroid gland containing the lump is performed. The sample is then looked at under the microscope. A second operation to remove the rest of the thyroid gland may need to be performed if a cancer is found. 

The operation performed will depend upon what condition you have and why surgery is being performed. When we meet you in the outpatients department we will ask you about your symptoms and medical history and will review your scans and blood tests. We will then discuss with you the best options for you. 

The possible operations include:

1. Total thyroidectomy – the entire thyroid is removed. You will need to take tablets to replace the thyroxine that your body can no longer make, for the rest of your life.
2. Thyroid lobectomy– only one side of the thyroid gland is removed. In most cases the remaining gland continues to make enough thyroxine for your body. You should have a blood test 6 weeks after your surgery to make sure that do not need to take thyroxine replacement
3. Isthmusectomy – occasionally just the middle part of the thyroid gland (the body part of the “butterfly”) needs to be removed

Before you undergo surgery you will need to have the following:

1. Meeting with a surgeon to discuss your case and make a decision about surgery
2. Pre-operative assessment to check that you are fit to undergo an operation. This will include taking a full medical history from you, listening to your heart and lungs and measuring your blood pressure.
3. A check of your vocal cords. One of the potential complications of surgery on your thyroid glands is injury to the nerves to your voice box/vocal cords. Therefore, everyone has to undergo a small telescope test up the nose to look down at the vocal cords and check that they are working properly. This takes just a few minutes, and is pain free. 

To undergo this operation you must first be put to sleep completely, ie. a general anaesthetic. We then make a small incision at the lower part of the front of your neck and perform the operation through this. The type of operation that we perform will have been discussed with you prior to surgery.  At the end of the operation we will stitch up your skin with dissolvable stitches so there will be nothing to be removed. We will inject local anaesthetic before you wake up to make you as comfortable as possible. 

Possible complications

These can be divided those associated with the actual operation and those with receiving a general anaesthetic.

Surgical:

All cuts in the body can be associated with infection and bleeding

1. Infection – this is a fairly quick healing and clean part of the body so infections are not common. However, if your wound becomes red, sore or mucky after you return home then you should contact your GP who can decide if it is infected or not.
2. Bleeding – the worst bleeding most patients get is a bit of bruising which resolves with time. Bleeding that requires another operation can happen but is rare. If it does happen, it is usually apparent before you are discharged
3. Scar
4. Stiff neck – this is fairly common, but usually temporary.
5. Nerve injury -there is a nerve that supplies your voice box that runs very near the thyroid glands. This can be injured during the operation, giving you a hoarse voice. This is a temporary problem in 1 in 100 operations and permanent very rarely (1 in 1000 case). Most patients wake up with a sore throat and a hoarse voice from the anaesthetic tube and the surgery so do not worry if this is the case.
6. Low calcium levels – Behind the thyroid gland sit 4 parathyroid glands. These control the levels of calcium in your blood and can become injured during thyroid surgery. This results in a low blood calcium level which can cause symptoms such as pins and needles in your fingers/toes and around your mouth. We will be monitoring your blood calcium levels but if you develop any of these symptoms after surgery you should tell a doctor as soon as possible as you may need to take calcium tablets for a short period following thyroid surgery.
7. Need for further surgery – In some cases if a cancer is found in the one half of gland removed further surgery to remove the other side will usually be needed.

Anaesthetic:

Possible complications after this operation include:

1. Sore throat
2. Feeling sick or actually vomiting
3. Dizziness from low blood pressure
4. Damage to teeth (this is very rare)

You will have an opportunity to talk to the anaesthetist on the day of surgery. 

You need to remain in hospital, usually just overnight. You may experience some pain, but this can usually be well controlled with simple tablet painkillers such as paracetamol and codeine phosphate. You may need to take these for a few days after the operation. Whilst you are in hospital, we will monitor your blood calcium levels. Most patients can go home by lunch time the next day. 

Blood tests

You should have your thyroid levels checked with a blood test by your GP about six weeks after your discharge.

Wound care

Your skin will have been closed with dissolvable stitches and covered with a small dressing. This can be easily removed after 3 or 4 days. It is normal for there to be some swelling in the area, which becomes slightly firm. If you are concerned about your wound you should see your GP.

Once the wound is healed over and you are able to comfortably touch your neck you can start to gently massage it E45 Cream or Bio oil.

Pain killers

Most people find that they need to take simple tablet painkillers such as paracetamol and codeine phosphate for a few days after surgery.

Driving

We advise you to avoid driving for a couple of weeks until you can comfortably turn your neck from side to side without any pain.

Talking and Singing

We recommend that you take a couple of weeks off work following this operation. This allows you to rest your voice, with no singing or shouting. 

We like to see you in outpatients 2-4 weeks after your operation to check that all has gone well with your recovery. By this stage your thyroid gland will have been looked at under the microscope and we will be able to provide you with more detail about whether you need any further surgery or treatment.