Clinical diagnostic utility of ultrasound-guided fine needle aspiration biopsy in parotid masses

BACKGROUND

Fine needle aspiration (FNA) is a common diagnostic tool used in the initial evaluation of parotid masses. In the literature, variable diagnostic accuracy of FNA is reported. Therefore, when considering clinical management of these patients, the utility of FNA is unclear. The aim of this study was to determine the capability of ultrasound-guided FNA to differentiate between benign and malignant neoplasms. Further, the way in which FNA results affect clinical decision-making was assessed.

METHODS

Retrospective data were collected for all patients who underwent parotidectomy at a large Canadian tertiary care center between 2011 and 2016. Patient demographics, preoperative imaging reports, preoperative FNA results, and final pathological diagnosis were analyzed.

RESULTS

Of the 199 patients who underwent parotidectomy, 184 had preoperative ultrasound-guided FNA. There were a total of 13 non-diagnostic FNAs. In diagnosing malignancy, FNA had a sensitivity and specificity of 71.4% and 98.7%, respectively. The positive predictive value (PPV) was 83.3%. The negative predictive value was 97.5%. Of the non-diagnostic FNAs, 2 out of 13 (15.4%) were deemed malignant neoplasms on final pathology.

CONCLUSION

FNA is a useful adjunct in the work-up of parotid masses, but it should be used with caution. Due to limited sensitivity, it should not be relied upon as the sole determinant of a surgeon's management plan.

Intraoperative Ultrasound for Removal of a Fishbone Foreign Body Embedded in the Tongue

Background

Ultrasound (U/S) is a dynamic imaging modality with many applications in medicine. In Otolaryngology, U/S is used routinely in the clinic with several evolving applications intraoperatively. Case Report. A 53-year-old male presented to the emergency department with dysphagia, odynophagia, hoarseness, and sensation of foreign body after ingesting fish. A CT scan identified an approximately 2 cm horizontally-oriented foreign body consistent with a fishbone embedded in the left posterolateral tongue. Intraoperative U/S was used to localize and remove the fishbone without complications.

Results

The patient recovered well after surgery and was discharged home on postoperative day 2. No residual foreign body was found on the repeat CT scan.

Conclusion

Our case demonstrates the effectiveness of intraoperative U/S for removal of fishbone foreign bodies from the tongue and serves to inspire future applications of this modality in Otolaryngology.

Postoperative opioid use following head and neck endocrine surgery: A multi-center prospective study

Background

Opioid abuse is widespread in North America and the over-prescription of opioids are a contributing factor. The goal of this prospective study was to quantify over-prescription rates, evaluate postoperative experiences of pain, and understand the impact of peri-operative factors such as adequate pain counseling and use of non-opioid analgesia.

Methods

Consecutive recruitment of patients undergoing head and neck endocrine surgery was undertaken from January 1st 2020 to December 31st 2021 at four Canadian hospitals in Ontario and Nova Scotia. Postoperative tracking of pain levels and analgesic requirements were employed. Chart review and preoperative and postoperative surveys provided information on counseling, use of local anesthesia, and disposal plans.

Results

A total of 125 adult patients were included in the final analysis. Total thyroidectomy was the most common procedure (40.8%). Median use of opioid tablets was 2 (IQR 0-4), with 79.5% of prescribed tablets unused. Patients who reported inadequate counseling (n = 35, 28.0%) were more likely to use opioids (57.2% vs. 37.8%, p < .05) and less likely to use non-opioid analgesia in the early postoperative course (42.9% vs. 63.3%, p < .05). Patients who received local anesthesia peri-operatively (46.4%, n = 58) reported less severe pain on average [2.86 (2.13) vs. 4.86 (2.19), p < .05] and used less analgesia on postoperative day one [0 MME (IQR 0-4) vs. 4 MME (IQR 0-8), p < .05].

Conclusion

Over-prescription of opioid analgesia following head and neck endocrine surgery is common. Patient counseling, use of non-opioid analgesia, and peri-operative local anesthesia were important factors in narcotic use reduction.

Level of evidence

Level 3.

Murine model for chronic rhinosinusitis: an interventional study

BACKGROUND

Chronic rhinosinusitis (CRS) is a complex inflammatory disease of the sinonasal tract. To understand this disease entity and develop targeted treatments, a reproducible animal model is paramount.

AIMS/OBJECTIVES

To optimize a murine model of eosinophilic CRS by establishing benchmark histological markers and validate its fidelity in evaluating intranasal treatments.

MATERIAL AND METHODS

Forty-five Balb/c mice were included in the 7-week protocol. Experimental animals (n = 20) were induced a CRS disease state upon receiving intraperitoneal sensitization with ovalbumin (OVA), followed by intranasal OVA with Aspergillus oryzae protease. Analysis of complete blood count with differential, peripheral blood smear, and histological markers from the nasal cavity mucosa were performed. CRS mice were additionally treated with intranasal saline (n = 5) or mometasone (n = 10) and compared with control groups of untreated CRS (n = 5) and healthy (n = 5) mice after week 7.

RESULTS

Histological analysis of experimental animal nasal mucosa revealed significantly higher levels of eosinophilic tissue infiltration/degranulation, hyaline droplets, Charcot-Leyden crystals, and respiratory epithelial thickness compared to healthy controls. Treatment with mometasone significantly reversed the histopathological changes observed in CRS mice.

CONCLUSION AND SIGNIFICANCE

This murine model induced substantial local eosinophilic inflammation within sinonasal mucosa, that was reversible with mometasone. This model may be used to evaluate the efficacy of therapeutics designed to target CRS.

Cannabis use amongst tinnitus patients: consumption patterns and attitudes

BACKGROUND

Tinnitus has a significant impact on quality of life and causes considerable psychological distress. Cannabis is known to modulate neuron hyperexcitability, provide protection against auditory damage, and has been used for treatment for many diseases which have physiological similarities with tinnitus. The objective of this study was to survey patients presenting with tinnitus regarding their perspectives and usage patterns of cannabis.

METHODS

Patients with a primary presenting complaint of tinnitus in a tertiary neuro-otology clinic completed a 18-item questionnaire assessing perception, attitudes, and cannabis usage patterns.

RESULTS

Forty five patients completed the survey (mean age: 54.5 years, 31 females and 14 males). Overall, 96% of patients reported that they would consider cannabis as treatment for their tinnitus. Patients considered cannabis use for auditory symptoms (91%), and symptoms related to their tinnitus, such as emotional complaints (60%), sleep disturbances (64%), and functional disturbances (56%). 36% of patients had previously used cannabis and 22% of patients reported cannabis use at the time of the study. 80% of patients that were actively using cannabis reported that it helped with tinnitus-related symptoms, such as dizziness, anxiety, bodily pain, and sleep disturbances. Most patients would prefer to use edibles (62%), tablet (58%) and cream (47%) formulations of cannabis. Patients were concerned about the cost (29%), potential physical health implications (53%) and psychosocial side effects (60%) of cannabis. Over half of patients learned about cannabis from a friend or family member and only 22% of patients learned about cannabis from a physician or nurse.

CONCLUSION

Cannabis use is common amongst patients with tinnitus and current users of cannabis reported that it helped with their symptoms. Most patients would consider its use as a potential treatment to alleviate their tinnitus-related symptoms and are interested in learning more regarding its use. By understanding how cannabis is perceived by tinnitus patients, healthcare providers can provide appropriate patient education.

Discrimination, harassment, and intimidation amongst otolaryngology: head and neck surgeons in Canada

BACKGROUND

Understanding mistreatment within medicine is an important first step in creating and maintaining a safe and inclusive work environment. The objective of this study was to quantify the prevalence of perceived workplace mistreatment amongst otolaryngology-head and neck surgery (OHNS) faculty and trainees in Canada.

METHODS

This national cross-sectional survey was administered to practicing otolaryngologists and residents training in an otolaryngology program in Canada during the 2020-2021 academic year. The prevalence and sources of mistreatment (intimidation, harassment, and discrimination) were ascertained. The availability, awareness, and rate of utilization of institutional resources to address mistreatment were also studied.

RESULTS

The survey was administered to 519 individuals and had an overall response rate of 39.1% (189/519). The respondents included faculty (n = 107; 56.6%) and trainees (n = 82; 43.4%). Mistreatment (intimidation, harassment, or discrimination) was reported in 47.6% of respondents. Of note, harassment was reported at a higher rate in female respondents (57.0%) and White/Caucasian faculty and trainees experienced less discrimination than their non-White colleagues (22.7% vs. 54.5%). The two most common sources of mistreatment were OHNS faculty and patients. Only 14.9% of those experiencing mistreatment sought assistance from institutional resources to address mistreatment. The low utilization rate was primarily attributed to concerns about retribution.

INTERPRETATION

Mistreatment is prevalent amongst Canadian OHNS trainees and faculty. A concerning majority of respondents reporting mistreatment did not access resources due to fear of confidentiality and retribution. Understanding the source and prevalence of mistreatment is the first step to enabling goal-directed initiatives to address this issue and maintain a safe and inclusive working environment.

Development of a management protocol for internal carotid artery injury during endoscopic surgery: a modified Delphi method and single-center multidisciplinary working group

BACKGROUND

Intra-operative internal carotid artery (ICA) injury during transnasal endoscopic surgery is a potentially catastrophic event. Such an injury is life-threatening in the immediate setting, with a reported peri-operative mortality rate of 10%. Nasal packing, muscle patches, direct vessel closure, and endovascular techniques have been described as useful strategies for managing ICA bleeds. The objective of this study was to develop a formalized management protocol for intra-operative ICA injury through engagement with a multi-disciplinary panel.

METHODS

A modified Delphi method including literature review, iterative rounds of stakeholder feedback, and expert panel discussions was used to develop a management protocol for ICA injury during transnasal endoscopic surgery. The 10-person multi-disciplinary panel included otolaryngologists, neurosurgeons, interventional neuroradiologists, anesthesiologists, and operating room nursing staff.

RESULTS

After three rounds of stakeholder engagement with the expert panel, consensus was reached on important elements to include within the protocol. The protocol was divided in three categories: Alert, Control, and Transfer. 'Alert' focusses on early communication with anesthesia and nursing staff. 'Control' focusses on techniques to expose the injury and obtain hemostasis or adequate tamponade. Lastly, 'Transfer' describes the process of contacting neuro-interventional radiology and safely transferring the patient. A one-page handout of the protocol was developed for placement in operating theatres.

CONCLUSION

Due to the life-threatening nature of ICA injury, it is imperative that endoscopic sinus and skull base surgeons are prepared to manage this complication. Using a modified Delphi method with a multidisciplinary expert panel, a protocol for management of intra-operative ICA injury was developed.

Overprescription of opioid analgesia is common following ambulatory Otolaryngology—Head and Neck surgery procedures: A multicenter study

Background

The rise in the use of prescription opioids for postoperative analgesia within surgery has mirrored an increased trend of opioid‐related morbidity within Canada and the United States. This study prospectively studied daily pain levels and medication requirements postoperatively in patients undergoing elective Otolaryngology—Head and Neck surgery procedures.

Methods

Patients were asked to prospectively document their pain level and medication use daily for 7 days postoperatively. A final survey was used to quantify unused medication left at home and clarify each patient's disposal plan. We included patients undergoing elective outpatient or short stay surgeries from three tertiary care centers in Toronto, Ontario from September 2016 to September 2017. Previous opioids users or patients suffering from chronic pain were excluded.

Results

A final cohort of 56 eligible adult patients were included in the study. The most common procedures were thyroidectomy (n = 19), endoscopic sinus surgery (n = 10), tympanoplasty/ossiculoplasty (n = 7), and cochlear implant (n = 5). Most patients received a prescription for acetaminophen/codeine (n = 29, 51.8%) or acetaminophen/oxycodone (n = 22, 39.3%) and used on average 29% of their initial prescription. Patients most commonly opted to keep their unused narcotics at home (n = 23, 41%). A total of 710 tablets of narcotics were overprescribed in our study population, 351 of which were kept in patients' home for future use.

Conclusion

There is a clear tendency to overestimate postoperative pain resulting in significant overprescription of opioids among Otolaryngologists.

Surgeons tend to overestimate post‐operative opioid analgesic requirements, leading to over‐prescription.

Less than half of the 56 participants in this study used non‐opioid analgesia during their post‐operative course, indicating a lack of counselling.

Most commonly, patients elected to keep unused opioids at home for future use – a known risk factor for opioid diversion.

Pain Management Following Otological Surgery: A Prospective Study of Different Strategies

OBJECTIVES

The aim of this study was to prospectively assess pain and associated analgesic consumption after otological surgery comparing two prescription patterns.

STUDY DESIGN

A prospective nonrandomized consecutive cohort study.

METHODS

125 adult patients undergoing ambulatory otologic surgery-cochlear implantation and endaural middle ear surgery, were assigned (according to surgeon's preference) and prospectively studied in two arms: 1) acetaminophen 500 mg + ibuprofen 400 mg; 2) acetaminophen 500 mg + codeine 30 mg. Pain levels, medication dose, disposal patterns of opioids, and suspected side effects were evaluated.

RESULTS

All patients reported mild to moderate pain. There was a statistically significant reduction of pain from day to day, which was on average 0.26 lower than the day before. Sufficient pain control could be achieved with both drug regimens with no significant difference in pain levels. Only 50% of patients who were prescribed opioids used them. Additionally, the median tablet intake was 3 tablets while 10 to 20 tablets were prescribed. The majority of patients (97%) did not dispose of these drugs safely.

CONCLUSION

Adequate analgesia was achieved in both arms of this study. Pain control following otologic surgery with a combination of acetaminophen and nonsteroidal anti-inflammatory drugs is recommended unless contraindications or chronic opioid use are present. If opioids such as codeine (30 mg) are prescribed, the amount should be reduced as low as possible, such as five tablets, based on our studied population.

LEVEL OF EVIDENCE

Level 3-a prospective nonrandomized consecutive cohort study Laryngoscope, 2021.

Association of the Implementation of a Standardized Thyroid Ultrasonography Reporting Program With Documentation of Nodule Characteristics

Importance

Although most thyroid nodules are benign, the potential for malignant neoplasms is associated with unnecessary workup in the form of imaging, fine-needle aspiration, and diagnostic surgery. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) is commonly used to assess the malignant neoplasm risk potential of thyroid nodules imaged by ultrasonography. However, standardized reporting of ACR TI-RADS descriptors is inconsistent.

Objective

To increase the documentation rate of ACR TI-RADS thyroid nodule characteristics to 80% in 18 months.

Design, Setting, and Participants

This prospective interrupted time series quality improvement study was conducted from December 1, 2018, to March 31, 2020, at a tertiary outpatient head and neck clinic among 229 patients who had at least 1 documented thyroid nodule identified on bedside clinic ultrasonography. Data analysis was performed throughout the entire study period because this was a quality improvement study with iterative small cycle changes; final analysis of the data was performed in April 2020.

Main Outcomes and Measures

The primary outcome was the documentation rates of 6 ACR TI-RADS ultrasonographic descriptors. Secondary outcomes included nodule fine-needle aspiration biopsy rate and physician-reported clinic flow efficiency.

Results

A total of 229 patients had at least 1 documented thyroid nodule and were included in the analysis. Size was the most frequently documented nodule characteristic (72 of 74 [97.3%]) at baseline, followed by echogenic foci (31 of 74 [41.9%]), composition (23 of 74 [31.1%]), echogenicity (17 of 74 [23.0%]), margin (6 of 74 [8.1%]), and shape (1 of 74 [1.4%]). After 3 Plan, Do, Study, Act (PDSA) cycles, the final intervention consisted of a standardized ultrasonography reporting form and educational initiatives for surgical trainees. After the third PDSA cycle (n = 36), reporting of nodule size, echogenic foci, and composition increased to 100%. Similarly, reporting of echogenicity (34 of 36 [94.4%]), shape (28 of 36 [77.8%]), and margin (25 of 36 [69.4%]) all increased. This represented a cumulative 90.3% documentation rate (195 of 216), a 56.5% increase from baseline (95% CI, 50.0%-61.9%). The standardized reporting form was used in 83.3% of eligible thyroid ultrasonography cases (30 of 36) after PDSA cycle 3, demonstrating good fidelity of implementation. There were no unintended consequences associated with clinic workflow, as a balancing measure, reported by staff surgeons.

Conclusions and Relevance

This study suggests that implementation of an ACR TI-RADS-based reporting form in conjunction with educational initiatives improved documentation of ultrasonographic thyroid nodule characteristics, potentially allowing for improved bedside risk stratification and communication among clinicians.

Hypothalamic-pituitary-adrenal axis suppression and intranasal corticosteroid use: A systematic review and meta-analysis

BACKGROUND

Intranasal corticosteroids (INCS) are used in the management of sinonasal conditions. Use of exogenous steroids can be associated with hypothalamic-pituitary-adrenal axis dysfunction and adrenal insufficiency (AI). We aimed to estimate the rate of AI after INCS use in a meta-analysis, stratified by steroid type and treatment duration.

METHODS

Ovid Medline, Embase Classic, PubMed, Web of Science, and CINAHL databases were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies investigating INCS use and AI. AI was defined as morning serum cortisol <550 nmol/L and <80 nmol/L with and without adrenocorticotropic hormone stimulation. INCS were classified as first (beclomethasone dipropionate, triamcinolone acetonide, beclomethasone, budesonide, dexamethasone) and second (ciclesonide, mometasone furoate, and fluticasone propionate) generation. Duration of treatment was classified as short (<1 month), medium (1-12 months), and long-term (>12 months) time periods.

RESULTS

This search identified 3668 articles. A total of 39 studies (1678 patients) were included in the final analysis. The pooled percentage of AI for routinely utilized first- and second-generation INCS was 0.70% (95% confidence interval [CI], 0.29-1.12%). Stratified by type, AI was observed in 0.78% (95% CI, 0.25-1.30%) of first-generation and 0.58% (95% CI, -0.1% to 1.26%) of second-generation steroids. AI was seen in 0.48% (95% CI, -0.01% to 0.96%) of short-term, 1.13% (95% CI, 0.2-2.1%) of medium-term, and 1.67% (95% CI, 0.37-2.9%) of long-term use of INCS.

CONCLUSION

Overall, the use of INCS carries a low risk for AI. Although modest, this risk may differ depending on the length of duration and type of INCS used. Informing patients of these risks is of importance for the treatment of chronic sinonasal conditions.

Radiological Anatomy of the Olfactory Fossa: Is Skull Base Anatomy Really Ever “Safe”?

Objective Computed tomography (CT) is a powerful tool for delineating the anatomy of the anterior skull base. The goal of this study is to further characterize the relevant anatomical features of this area, along with other parameters important for endoscopic sinus surgery.

Design Retrospective case review.

Setting Tertiary care hospital.

Participants Thirty patients who had CT scans of the paranasal sinuses.

Main Outcome Measures The following features were assessed using image analysis software: olfactory fossa depth, the length and angle of the lateral lamella, fovea ethmoidalis length and shape, ethmoid roof height and slope, and the position and course of the anterior ethmoid artery. Statistical analysis was performed assessing for differences in the above parameters.

Results The mean olfactory fossa depth of the anterior and posterior skull base was 3.4  ± 1.1 and 2.4  ± 0.9 mm, respectively (p < 0.05). The mean lateral lamella length was 3.6  ± 0.9 mm, which did not demonstrate significant variability. The angle of the lateral lamella varied significantly by skull base position, measuring 63.1 ± 17.8 degrees anteriorly, and 39.1 ± 17.9 degrees posteriorly (p < 0.05). In scans classified as a Keros type I, 25.3% had lateral lamellae longer than 4 mm. Furthermore, 43.7% had lateral lamellae with angles less than 45 degrees. Moving anteriorly, the posterior skull base sloped downward in 46.7% of patients.

Conclusion Thorough preoperative assessment of CT scans is crucial to understanding the inherent variability of skull base anatomy. Even “safe” anatomy can still contain features such as long and acutely angled lateral lamella, which may predispose patients to iatrogenic injury.

Development of the Alberta facial clinical evaluation scale: A patient-centred outcomes instrument for facial nerve paralysis

OBJECTIVES

Facial nerve paralysis has functional, psychological and social consequences for patients. Traditionally, outcome measurements for facial nerve injuries have been clinician derived. Recent literature has shown that patient perspective is valuable and necessary in outcomes research. This study aimed to identify patient domains of concern and subsequently, develop a point-of-care questionnaire for clinical use.

DESIGN

This mixed-methods prospective study was completed in three phases. In Phase I, 15 facial nerve injury patients were interviewed individually. Interviews were digitally recorded, transcribed and coded with NVivo software. Analysis led to a conceptual framework detailing the most important quality of life outcomes. During Phase II, a focus group was held with five new patients in order to prioritise the outcome themes to a top six list. A second focus group was held with Otolaryngology-Head and Neck staff surgeons to create a 25-item questionnaire based on these six themes. In Phase III, the questionnaire was administered to 10 new patients to test for comprehension.

SETTING

University of Alberta Hospital, Edmonton, Alberta, Canada.

PARTICIPANTS

A total of 30 patients with facial nerve injury were included in the various phases in the study. In addition, 5 staff Otolaryngology-Head and Neck surgeons participated as focus group contributors.

MAIN OUTCOME MEASURES

Domains of concern and quality of life outcomes as reported by facial nerve injury patients.

RESULTS

Patients identified a total of 16 themes encompassing both functional and psychological deficits related to their facial nerve injury. From these findings, a 25-item Likert-type scale, the A-FaCE scale, was developed for clinical use.

CONCLUSIONS

Patients with facial nerve paralysis experience functional and psychological deficits. This study led to the creation of the first patient-reported instrument for this population that addresses functional impairment, social function, psychological well-being and self-perception of appearance.

A High-Definition Video Teaching Module for Thyroidectomy Surgery

OBJECTIVE

With the changing landscape of postgraduate surgical education to competency-based curricula, there emerges a need for alternative forms of training. Video teaching modules have been shown to be effective tools in surgical education, complementing traditional postgraduate curricula. There is a lack of validated modules described in the literature, specifically for teaching thyroidectomy. The primary objective of this study was to develop and validate a high definition video-based teaching module instructing thyroidectomy surgery to Otolaryngology-Head and Neck Surgery trainees.

DESIGN

This prospective study included intermediate to senior Otolaryngology-Head and Neck Surgery residents. Each participant first performed a thyroid lobectomy, serving as the initial assessment. After a washout period of at least 3 weeks, each participant was given the teaching module. The 15-minute module was developed using a 3-camera system and detailed a step-by-step approach to the surgery. After exposure to the module, each trainee performed the same procedure. Recordings of both procedures were deidentified and reviewed by a blinded, independent evaluator. Scoring was done using the Observational Clinical Human Reliability Assessment (OCHRA) system.

SETTING

University of Alberta Hospital and Royal Alexandra Hospital, Edmonton, Alberta, Canada.

PARTICIPANTS

A total of 6 intermediate to senior Otolaryngology-Head and Neck Surgery residents entered and completed the study.

RESULTS

The mean error rate was 8.8 errors per procedure before module exposure and 4.5 errors per procedure after exposure, representing a 49% decrease in error occurrence (p < 0.05). The mean staff takeover event rate was 10.5 takeovers per procedure prior to module exposure and 5.0 takeovers per procedure after exposure, representing a 52% decrease in error occurrence (p < 0.05).

CONCLUSION

High-definition video teaching modules are a useful complement to traditional surgical training. In a climate where new innovations for teaching thyroid surgery are needed, properly constructed and validated video teaching modules can serve as important tools in supplementing traditional surgical training.