International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

The impact of surgical resection margins on outcomes for adults with head and neck osteosarcomas: A Canadian sarcoma research and Clinical Collaboration (CanSaRCC) study

OBJECTIVE

The aim of the study is to describe the factors that influence outcome in adults with head and neck osteosarcoma (HNO) with a specific focus on the margin status.

METHODS

Patients with a diagnosis of HNO between the years 1996-2021 were reviewed from the Canadian Sarcoma Research and Clinical Collaboration (CanSaRCC) Database. Baseline characteristics, pathology, treatment, and outcomes were analyzed. Univariable (UVA) and multivariable (MVA) Cox regression models were performed. 5-year locoregional control rate and overall survival (OS) were estimated using Kaplan-Meier method and Log-Rank test.

RESULTS

Of 50 patients with a median age of 40 years (range 16-80), 27 (54%) were male. HNO commonly involved the mandible (n = 21, 42%) followed by maxilla (n = 15, 30%). Thirteen (33.3%) had low-intermediate grade and 26 (66.6%) had high grade tumors. Three patients (6%) had negative resection margins (>5 mm), 24 (48%) had close margins (1-5 mm), 15 (30%) had positive margins (<1mm) and 7 (16%) had unknown margin status. In total, 39 (78%) received chemotherapy - 22 (44%) received neoadjuvant chemotherapy while 17 (34%) received adjuvant chemotherapy. A total of 12 (24%) patients received radiotherapy, of whom 8 (16%) had adjuvant and 3 (6%) had neo-adjuvant. Median follow-up time was 6.3 years (range 0.26-24.9). Disease recurred in 21 patients (42%), of whom 15 (30%) had local recurrence only, 4 (8%) had distant metastasis, and 2 (4%) had both local and distant recurrence. 5-year locoregional control rate and OS was 62% and 79.2% respectively. Resection margins <3 mm was associated with lower 5 years OS and locoregional control rate (Log-Rank p = 0.02, p = 0.01 respectively).

CONCLUSION

Osteosarcomas of the head and neck are rare and local recurrence remains a concern. Surgical resection with negative resection margins may improve survival, and a 3 mm resection margin threshold may optimize survival. Radiotherapy and/or chemotherapy should be considered in a multidisciplinary setting based on risk-features.

Facilitation of Definitive Cancer Diagnosis With Quantitative Molecular Assays of BRAF V600E and TERT Promoter Variants in Patients With Thyroid Nodules

Importance

Molecular testing of the presence of pathogenic genomic variants in a tumor without quantifying the variant allele fraction (VAF) does not differentiate the variation extent among tumors, often resulting in an inconclusive diagnosis because of interpatient variability.

Objective

To examine the association between the quantification of VAFs of BRAF V600E and TERT promoter variants and a definitive cancer diagnosis of thyroid tumors.

Design, Setting, and Participants

This diagnostic study analyzed a cohort of 378 surgically resected thyroid tumors with a maximum dimension of 1 cm or larger between March 15, 2016, and March 16, 2020, and a separate cohort of 217 residual thyroid fine-needle aspiration (FNA) biopsy specimens obtained from January 22, 2020, to March 2, 2021, at Mount Sinai Hospital, Toronto, Ontario, Canada. Data analysis was conducted between February 1, 2021, and February 1, 2023.

Exposures

Quantitative VAF assays of BRAF V600E and TERT promoter variants (C228T and C250T) were performed by digital polymerase chain reaction molecular assays.

Main Outcomes and Measures

The VAFs of BRAF V600E and TERT promoter variants were correlated with tumor histologic diagnoses and histopathologic features to delineate the association of VAF assays with tumor malignancy. The receiver operating characteristic curve analysis, sensitivity, specificity, positive predictive value, negative predictive value, and logistic regression analysis based on follow-up histopathologic types were used to determine the diagnostic utility of the quantitative molecular assays.

Results

A total of 595 specimens, including 378 surgically resected thyroid tumors and 217 thyroid nodule FNA biopsy specimens, were collected from 580 patients (436 [75.2%] female with a mean [SD] age of 50 [16] years and 144 [24.8%] male with a mean [SD] age of 55 [14] years). Sensitive VAF assays of 378 thyroid tumors revealed the presence of the BRAF V600E variant in 162 tumors (42.9%), with 26 (16.0%) at a low VAF of 1% or less and 136 (84.0%) at a high VAF of greater than 1%, and the presence of TERT promoter variants in 49 tumors (13.0%), including 45 C228T variants (91.8%), 15 (33.3%) of which were quantified as having a low VAF (≤1%) and 30 (66.7%) as having a high VAF (>1%), and 4 C250T variants (8.2%) with VAFs between 40.0% and 47.0%. All tumors detected with BRAF V600E and/or TERT promoter variants, whether at low or high VAFs, received a definitive cancer diagnosis. Further analysis delineated a significant association between high VAFs of either variant individually or different VAF levels for both variants in coexistence and aggressive histopathologic features of tumors. Excluding low VAFs assisted in identifying patients at an intermediate-to-high risk of recurrence (odds ratio, 5.3; 95% CI, 1.9-14.6; P = .001). The VAF assays on the residual FNA biopsy specimens showed a high agreement to those on surgical tissues (κ = 0.793, P < .001) and stratified malignancy in 40 of 183 indeterminate FNA cases (21.9%), with a sensitivity of 93.8% (95% CI, 67.7%-99.7%), specificity of 90.0% (95% CI, 75.4%-96.7%), positive predictive value of 78.9% (95% CI, 53.9%-93.0%), and negative predictive value of 97.3% (95% CI, 84.2%-99.9%).

Conclusions and Relevance

This diagnostic study suggests that sensitive quantitative VAF assays of BRAF V600E and TERT promoter variants can elucidate the interpatient variability in tumors and facilitate a definitive cancer diagnosis of thyroid nodules by differentiating the variation extent of genomic variants, even at low VAFs.

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.

Association between the COVID-19 pandemic and first cancer treatment modality: a population-based cohort study

BACKGROUND

Physicians were directed to prioritize using nonsurgical cancer treatment at the beginning of the COVID-19 pandemic. We sought to quantify the impact of this policy on the modality of first cancer treatment (surgery, chemotherapy, radiotherapy or no treatment).

METHODS

In this population-based study using Ontario data from linked administrative databases, we identified adults diagnosed with cancer from January 2016 to November 2020 and their first cancer treatment received within 1 year postdiagnosis. Segmented Poisson regressions were applied to each modality to estimate the change in mean 1-year recipient volume per thousand patients (rate) at the start of the pandemic (the week of Mar. 15, 2020) and change in the weekly trend in rate during the pandemic (Mar. 15, 2020, to Nov. 7, 2020) relative to before the pandemic (Jan. 3, 2016, to Mar. 14, 2020).

RESULTS

We included 321 535 people diagnosed with cancer. During the first week of the COVID-19 pandemic, the mean rate of receiving upfront surgery over the next year declined by 9% (rate ratio 0.91, 95% confidence interval [CI] 0.88-0.95), and chemotherapy and radiotherapy rates rose by 30% (rate ratio 1.30, 95% CI 1.23-1.36) and 13% (rate ratio 1.13, 95% CI 1.07-1.19), respectively. Subsequently, the 1-year rate of upfront surgery increased at 0.4% for each week (rate ratio 1.004, 95% CI 1.002-1.006), and chemotherapy and radiotherapy rates decreased by 0.9% (rate ratio 0.991, 95% CI 0.989-0.994) and 0.4% (rate ratio 0.996, 95% CI 0.994-0.998), respectively, per week. Rates of each modality resumed to prepandemic levels at 24-31 weeks into the pandemic.

INTERPRETATION

An immediate and sustained increase in use of nonsurgical therapy as the first cancer treatment occurred during the first 8 months of the COVID-19 pandemic in Ontario. Further research is needed to understand the consequences.

Timeliness and Modality of Treatment for New Cancer Diagnoses During the COVID-19 Pandemic in Canada

IMPORTANCE

The impact of COVID-19 on the modality and timeliness of first-line cancer treatment is unclear yet critical to the planning of subsequent care.

OBJECTIVE

To explore the association of the COVID-19 pandemic with modalities of and wait times for first cancer treatment.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study using administrative data was conducted in Ontario, Canada, among adults newly diagnosed with cancer between January 3, 2016, and November 7, 2020. Participants were followed up from date of diagnosis for 1 year, until death, or until June 26, 2021, whichever occurred first, to ensure a minimum of 6-month follow-up time.

EXPOSURES

Receiving a cancer diagnosis in the pandemic vs prepandemic period, using March 15, 2020, the date when elective hospital procedures were halted.

MAIN OUTCOMES AND MEASURES

The main outcome was a time-to-event variable describing number of days from date of diagnosis to date of receiving first cancer treatment (surgery, chemotherapy, or radiation) or to being censored. For each treatment modality, a multivariable competing-risk regression model was used to assess the association between time to treatment and COVID-19 period. A secondary continuous outcome was defined for patients who were treated 6 months after diagnosis as the waiting time from date of diagnosis to date of treatment.

RESULTS

Among 313 499 patients, the mean (SD) age was 66.4 (14.1) years and 153 679 (49.0%) were male patients. Those who were diagnosed during the pandemic were less likely to receive surgery first (subdistribution hazard ratio [sHR], 0.97; 95% CI, 0.95-0.99) but were more likely to receive chemotherapy (sHR, 1.26; 95% CI, 1.23-1.30) or radiotherapy (sHR, 1.16; 95% CI, 1.13-1.20) first. Among patients who received treatment within 6 months from diagnosis (228 755 [73.0%]), their mean (SD) waiting time decreased from 35.1 (37.2) days to 29.5 (33.6) days for surgery, from 43.7 (34.1) days to 38.4 (30.6) days for chemotherapy, and from 55.8 (41.8) days to 49.0 (40.1) days for radiotherapy.

CONCLUSIONS AND RELEVANCE

In this cohort study, the pandemic was significantly associated with greater use of nonsurgical therapy as initial cancer treatment. Wait times were shorter in the pandemic period for those treated within 6 months of diagnosis. Future work needs to examine how these changes may have affected patient outcomes to inform future pandemic guideline development.

Incident Cancer Detection During Multiple Waves of COVID-19: The Tsunami After the Earthquake

No population-based study exists to demonstrate the full-spectrum impact of COVID-19 on hindering incident cancer detection in a large cancer system. Building upon our previous publication in JNCCN, we conducted an updated analysis using 12 months of new data accrued in the pandemic era (extending the study period from September 26, 2020, to October 2, 2021) to demonstrate how multiple COVID-19 waves affected the weekly cancer incidence volume in Ontario, Canada, and if we have fully cleared the backlog at the end of each wave.

Cancer Patients First Treated with Chemotherapy: Are They More Likely to Receive Surgery in the Pandemic?

Due to the ramping down of cancer surgery in early pandemic, many newly diagnosed patients received other treatments first. We aimed to quantify the pandemic-related shift in rate of surgery following chemotherapy. This is a retrospective population-based cohort study involving adults diagnosed with cancer between 3 January 2016 and 7 November 2020 in Ontario, Canada who received chemotherapy as first treatment within 6-months of diagnosis. Competing-risks regression models with interaction effects were used to quantify the association between COVID-19 period (receiving a cancer diagnosis before or on/after 15 March 2020) and receipt of surgical reSection 9-months after first chemotherapy. Among 51,653 patients, 8.5% (n = 19,558) of them ultimately underwent surgery 9-months after chemotherapy initiation. Receipt of surgery was higher during the pandemic than before (sHR 1.07, 95% CI 1.02-1.13). Material deprivation was independently associated with lower receipt of surgery (least vs. most deprived quintile: sHR 1.11, 95% CI 1.04-1.17), but did not change with the pandemic. The surgical rate increase was most pronounced for breast cancer (sHR 1.13, 95% CI 1.06-1.20). These pandemic-related shifts in cancer treatment requires further evaluations to understand the long-term consequences. Persistent material deprivation-related inequity in cancer surgical access needs to be addressed.

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.

Incident Cancer Detection During the COVID-19 Pandemic

BACKGROUND

Resource restrictions were established in many jurisdictions to maintain health system capacity during the COVID-19 pandemic. Disrupted healthcare access likely impacted early cancer detection. The objective of this study was to assess the impact of the pandemic on weekly reported cancer incidence.

PATIENTS AND METHODS

This was a population-based study involving individuals diagnosed with cancer from September 25, 2016, to September 26, 2020, in Ontario, Canada. Weekly cancer incidence counts were examined using segmented negative binomial regression models. The weekly estimated backlog during the pandemic was calculated by subtracting the observed volume from the projected/expected volume in that week.

RESULTS

The cohort consisted of 358,487 adult patients with cancer. At the start of the pandemic, there was an immediate 34.3% decline in the estimated mean cancer incidence volume (relative rate, 0.66; 95% CI, 0.57-0.75), followed by a 1% increase in cancer incidence volume in each subsequent week (relative rate, 1.009; 95% CI, 1.001-1.017). Similar trends were found for both screening and nonscreening cancers. The largest immediate declines were seen for melanoma and cervical, endocrinologic, and prostate cancers. For hepatobiliary and lung cancers, there continued to be a weekly decline in incidence during the COVID-19 period. Between March 15 and September 26, 2020, 12,601 fewer individuals were diagnosed with cancer, with an estimated weekly backlog of 450.

CONCLUSIONS

We estimate that there is a large volume of undetected cancer cases related to the COVID-19 pandemic. Incidence rates have not yet returned to prepandemic levels.

National Trends in Gender Diversity Among Trainees and Practicing Physicians in Otolaryngology-Head and Neck Surgery in Canada

Importance

Monitoring the evolution of gender diversity within medicine is essential to understanding the medical workforce and anticipating its future.

Objective

To evaluate gender distribution and trends among trainees and practicing physicians in the field of otolaryngology-head and neck surgery (OHNS) across Canada.

Design, Setting, and Participants

This cross-sectional study collected demographic data on the Canadian population, medical students, resident physicians, fellows, practicing physicians, and full-time professors from the following publicly available databases: the Canadian Post-MD Education Registry, the Canadian Medical Education Statistics from the Association of Faculties of Medicine of Canada, the Canadian Medical Association Masterfile, the Canadian Resident Matching Service archives, and the Canadian Institute for Health Information from 2000 to 2019. Information about the gender distribution in leadership positions and fellowships was obtained through publicly available websites where gender was either listed or assigned by authors.

Main Outcomes and Measures

The primary outcomes were the proportion of women in OHNS and the evolution of gender diversity over time.

Results

In 2019, 65 of 155 of OHNS trainees were female (41.9%), whereas female representation among all surgical trainees combined was 1225 of 2496 (49.1%). Female OHNS trainees and practicing physicians are underrepresented despite a 13.3% increase in female trainees and a 14.3% increase in female staff physicians from 2000 to 2019. Proportionally fewer female graduates pursued a fellowship during a 10-year period compared with their male counterparts, with otology and neurotology having the lowest female representation (6 of 27 [22.2%]). A minimal increase occurred in the number of women holding academic leadership positions (eg, 4 of 13 residency training programs had a previous or current female director).

Conclusions and Relevance

Despite the overall increase in the representation of women in the field of OHNS in Canada, these findings suggest that persistent gender gaps remain with respect to academic leadership positions and fellowship training. Continuous monitoring of the surgical workforce is important to highlight and address gender disparities within OHNS.

Regional Recurrences and Hyams Grade in Esthesioneuroblastoma

Objective  The aim of this study is to determine if Hyams grade may help predict which patients with esthesioneuroblastoma (ENB) tumors are likely to develop regional recurrences, and to determine the impact of tumor extent on regional failure in ENB patients without evidence of nodal disease at presentation. Design  The study was designed as a retrospective review for ENB patients. Settings  The study was prepared at tertiary care academic center for ENB patients. Participants  Patients with ENB were included in the study. Main Outcome Measures   Oncologic outcomes (5-year regional and locoregional control (LRC) and overall survival) in patients with Hyams low grade versus high grade. Oncologic outcomes based on radiographic disease extent. Results  A total of 43 patients were included. Total 25 patients (58%) had Hyams low-grade tumor, and 18 (42%) had high-grade tumor. Of the 34 patients without regional disease at presentation, 8 (24%) were treated with elective nodal radiation. There were no statistically significant differences in 5-year regional control in the Hyams low-grade versus high-grade groups (78 vs. 89%; p  = 0.4). The 5-year LRC rates in patients with low grade versus high grade were 73 versus 89% ( p  = 0.6). The 5-year overall survival rates in patients with low-grade versus high-grade tumors were 86 versus 63% ( p  = 0.1). Radiographic extension of disease into the olfactory groove, olfactory nerve, dura, and periorbita were statistically associated with decreased 5-year overall survival (5-year OS 49 vs. 91% [ p  = 0.04], 49 vs. 91% [ p  = 0.04], 44 vs. 92% [ p  = 0.02], and 44 vs. 80% [ p  = 0.04], respectively). Conclusion  ENBs are associated with a risk of regional failure. The current analysis suggests that Hyams low-grade and high-grade malignancies have comparable rates of early and delayed regional recurrences, although small sample size may limit our conclusions.

Development of a Molecular Assay for Detection and Quantification of the BRAF Variation in Residual Tissue From Thyroid Nodule Fine-Needle Aspiration Biopsy Specimens

Importance

Thyroid cancer, predominantly papillary thyroid carcinoma (PTC), is common, but an estimated 30% of ultrasonography-guided fine-needle aspiration (FNA) biopsies of thyroid nodules are indeterminate. BRAF variation, associated with poor clinicopathological characteristics, is a useful molecular marker for diagnostics.

Objective

To develop a sensitive molecular assay for BRAF V600E detection in remaining tissue of thyroid FNA biopsies to identify patients with cancer carrying a BRAF variation.

Design, Setting, and Participants

This diagnostic study used tumor tissue from surgical formalin-fixed, paraffin-embedded (FFPE) specimens and residual tissue from thyroid FNA biopsies for genomic DNA extraction. FFPE specimens served as the validation set, and residual tissue from FNA biopsies served as the test set. A molecular assay was developed for accurate detection of BRAF V600E variation using locked nucleic acid (LNA) probe-based droplet digital polymerase chain reaction (dPCR), and the assay was validated by BRAF V600E immunohistochemical staining (IHC). The study was conducted between February 2019 and May 2021.

Results

A total of 271 specimens, including 77 FFPE specimens (with a follow-up of 48 matched surgical specimens) and 146 residual FNA samples, were collected from 223 patients (mean [SD] age, 53.8 [15.3] years; 174 [78.0%] women; 49 [22.0%] men). The molecular assay by dPCR was first established to specifically and accurately detect and quantify wild-type BRAF and variant BRAF in DNA from human follicular thyroid carcinoma-derived FTC-133 and papillary thyroid carcinoma-derived BCPAP cells. The linearity of quantification of BRAF V600E was calculated (y = 0.7339x; R2 = 0.9996) with sensitivity at 0.02 copies/μL and reproducibility in detecting variant DNA at various dilutions(coefficient of variance in 0.3% DNA, 9.63%; coefficient of variance in 1.0% DNA, 7.41%). In validation testing, the dPCR assay and IHC staining exhibited 100% specificity in concordantly identifying BRAF V600E in PTCs (κ = 0.873; P < .001) and sensitivity of 32.0% (95% CI, 19.1% to 44.9%) in dPCR and 26.0% (95% CI, 13.1% to 38.9%) in IHC staining, with an improvement by 23.08% in dPCR compared with the IHC staining. The dPCR assay further detected BRAF V600E in 39 of 146 residual FNA specimens (26.7%). At short-term follow-up, 48 patients, including 14 of 39 patients with BRAF variation and 34 of 107 patients without BRAF variation on residual FNA specimens, underwent resection. The dPCR assay of BRAF status in the matched surgical specimens showed BRAF V600E variations in 12 patients and wild-type BRAF in 36 patients, with a high agreement to that in residual tissue of FNA specimens (κ = 0.789; P < .001). Among 14 patients with BRAF variations on residual FNA, 13 were diagnosed with PTC and 1 was diagnosed with anaplastic thyroid cancer at the thyroidectomy.

Conclusions and Relevance

This diagnostic study developed a sensitive molecular assay for detection and quantification of BRAF V600E variation in residual tissue from thyroid FNA biopsies to identify patients with cancer harboring BRAF V600E in a cost-effective manner, highlighting the clinical value of molecular assay of the remaining FNA tissue in the management of thyroid nodules.

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.

What is the optimal outcome after endoscopic sinus surgery in the treatment of chronic rhinosinusitis? A consultation of Canadian experts

OBJECTIVES

Many experts feel that in the absence of well-defined goals for success, they have an easier time identifying failure. As success ought to not be defined only by absence of failure, we aimed to define optimal outcomes for endoscopic sinus surgery (ESS) in chronic rhinosinusitis (CRS) by obtaining expert surgeon perspectives.

METHODS

A total of 12 surgeons participated in this targeted consultation. Face to face semi-structured interviews were performed with expert surgeons in the field of CRS and ESS. General impressions and personal definitions of acceptable operative success and optimal operative outcomes were compiled and summarized.

RESULTS

According to an expert survey, patients' main objectives are an improvement in their chief complain, a general improvement in quality of life (QoL), and a better overall symptomatic control. The most important aspects of endoscopy for defining a successful intervention were an adequate mucus circulation, a healthy mucosa, minimal edema, and patency of all explored cavities or ostia. In the assessment of surgical outcomes, it was determined that both objective and patient reported data must be carefully examined, with more attention given to subjective outcomes.

CONCLUSIONS

According to data gathered from a Canadian expert consultation, a definition of success must be based on both subjective data and nasal endoscopy. We propose to define an acceptable outcome as either a subjective improvement of at least the minimal clinically improvement difference of a validated patient reported outcome questionnaire, along with a satisfactory endoscopic result (1) or a complete subjective resolution with a sub-optimal endoscopy (2).

Outpatient versus inpatient superficial parotidectomy: clinical and pathological characteristics

Background

Superficial parotidectomy has a potential to be performed as an outpatient procedure. The objective of the study is to evaluate the safety and selection profile of outpatient superficial parotidectomy compared to inpatient parotidectomy.

Methods

A retrospective review of individuals who underwent superficial parotidectomy between 2006 and 2016 at a tertiary care center was conducted. Primary outcomes included surgical complications, including transient/permanent facial nerve palsy, wound infection, hematoma, seroma, and fistula formation, as well as medical complications in the postoperative period. Secondary outcome measures included unplanned emergency room visits and readmissions within 30 days of operation due to postoperative complications.

Results

There were 238 patients included (124 in outpatient and 114 in inpatient group). There was no significant difference between the groups in terms of gender, co-morbidities, tumor pathology or tumor size. There was a trend towards longer distance to the hospital from home address (111 Km in inpatient vs. 27 in outpatient, mean difference 83 km [95% CI,- 1 to 162 km], p = 0.053). The overall complication rates were comparable between the groups (24.2% in outpatient group vs. 21.1% in inpatient, p = 0.56). There was no difference in the rate of return to the emergency department (3.5% vs 5.6%, p = 0.433) or readmission within 30 days (0.9% vs 0.8%, p = 0.952).

Conclusion

Superficial parotidectomy can be performed safely as an outpatient procedure without elevated risk of complications.

Graphical abstract

CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on rhinologic and skull base surgery during the COVID-19 pandemic

Healthcare services in many countries have been partially or completely disrupted by the Coronavirus (COVID-19) pandemic since its onset in the end of 2019. Amongst the most impacted are the elective medical and surgical services in order to conserve resources to care for COVID-19 patients. As the number of infected patients decrease across Canada, elective surgeries are being restarted in a staged manner. Since Otolaryngologists - Head & Neck Surgeons manage surgical diseases of the upper aerodigestive tract where the highest viral load reside, it is imperative that these surgeries resume in a safe manner. The aim of this document is to compile the current best evidence available and provide expert consensus on the safe restart of rhinologic and skull base surgeries while discussing the pre-operative, intra-operative, and post-operative care and tips. Risk assessment, patient selection, case triage, and pre-operative COVID-19 testing will be analyzed and discussed. These guidelines will also consider the optimal use of personal protective equipment for specific cases, general and specific operative room precautions, and practical tips of intra-operative maneuvers to optimize patient and provider safety. Given that the literature surrounding COVID-19 is rapidly evolving, these recommendations will serve to start our specialty back into elective rhinologic surgeries over the next months and they may change as we learn more about this disease.

Quality indicators for the diagnosis and management of pediatric tonsillitis

INTRODUCTION

Pediatric tonsillitis is encountered frequently across specialties, and while high quality guidelines exist, there is persistent evidence of care which is not evidence based, including antibiotic overprescribing and surgical practice variability. Quality indicators (QIs) can be utilized for initiatives to improve the quality of care and subsequent patient outcomes. We sought to develop pediatric tonsillitis QIs that are applicable across specialties and that cover aspects of both diagnosis and the spectrum of management options.

METHODS

A guideline-based approach to QI development was employed. Candidate indicators (CIs) were extracted from international guidelines deemed high quality by two reviewers and evaluated by an eleven-member expert panel consisting of otolaryngology - head & neck surgeons, a pediatrician and a family physician. The final QIs were selected utilizing a modified RAND/UCLA appropriateness methodology.

RESULTS

Twenty-six CIs were identified after initial literature review. After the first round of evaluations, the panel agreed on thirteen candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss areas of disagreement, discuss any recently published research, and to brainstorm additional CIs not identified from the guideline extraction. Following the second round of evaluations, the expert panel agreed upon sixteen QIs as appropriate measures of high-quality care.

CONCLUSIONS

This study proposes sixteen QIs developed through a multidisciplinary lens to guide practitioners in the diagnosis and management of pediatric tonsillitis. These QIs can be used to improve transparency, accountability, and provide objective data to assist future quality improvement initiatives.

CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on return to Otolaryngology - Head & Neck Surgery Clinic Practice during the COVID-19 pandemic in Canada

The novel Coronavirus (COVID-19) has created a worldwide deadly pandemic that has become a major public health challenge. All semi-urgent and elective medical care has come to a halt to conserve capacity to care for patients during this pandemic. As the numbers of COVID-19 cases decrease across Canada, our healthcare system also began to reopen various facilities and medical offices. The aim for this document is to compile the current evidence and provide expert consensus on the safe return to clinic practice in Otolaryngology - Head & Neck Surgery. These recommendations will also summarize general precaution principles and practical tips for office across Canada to optimize patient and provider safety. Risk assessment and patient selection are crucial to minimizing exposure to COVID-19. Controversial topics such as COVID-19 mode of transmission, duration of exposure, personal protective equipment, and aerosol-generating procedures will be analyzed and discussed. Practical solutions of pre-visit office preparation, front office and examination room set-up, and check out procedures are explored. Specific considerations for audiology, pediatric population, and high risk AGMPs are also addressed. Given that the literature surrounding COVID-19 is rapidly evolving, these guidelines will serve to start our specialty back into practice over the next weeks to months and they may change as we learn more about this disease.

Development and validation of a Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN) in a scarce resource setting: Response to the COVID-19 pandemic

Background

In the wake of the coronavirus disease 2019 (COVID‐19) pandemic, access to surgical care for patients with head and neck cancer (HNC) is limited and unpredictable. Determining which patients should be prioritized is inherently subjective and difficult to assess. The authors have proposed an algorithm to fairly and consistently triage patients and mitigate the risk of adverse outcomes.

Methods

Two separate expert panels, a consensus panel (11 participants) and a validation panel (15 participants), were constructed among international HNC surgeons. Using a modified Delphi process and RAND Corporation/University of California at Los Angeles methodology with 4 consensus rounds and 2 meetings, groupings of high‐priority, intermediate‐priority, and low‐priority indications for surgery were established and subdivided. A point‐based scoring algorithm was developed, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN). Agreement was measured during consensus and for algorithm scoring using the Krippendorff alpha. Rankings from the algorithm were compared with expert rankings of 12 case vignettes using the Spearman rank correlation coefficient.

Results

A total of 62 indications for surgical priority were rated. Weights for each indication ranged from −4 to +4 (scale range; −17 to 20). The response rate for the validation exercise was 100%. The SPARTAN‐HN demonstrated excellent agreement and correlation with expert rankings (Krippendorff alpha, .91 [95% CI, 0.88‐0.93]; and rho, 0.81 [95% CI, 0.45‐0.95]).

Conclusions

The SPARTAN‐HN surgical prioritization algorithm consistently stratifies patients requiring HNC surgical care in the COVID‐19 era. Formal evaluation and implementation are required.

Lay Summary

Many countries have enacted strict rules regarding the use of hospital resources during the coronavirus disease 2019 (COVID‐19) pandemic. Facing delays in surgery, patients may experience worse functional outcomes, stage migration, and eventual inoperability.

Treatment prioritization tools have shown benefit in helping to triage patients equitably with minimal provider cognitive burden.

The current study sought to develop what to the authors' knowledge is the first cancer–specific surgical prioritization tool for use in the COVID‐19 era, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN). This algorithm consistently stratifies patients requiring head and neck cancer surgery in the COVID‐19 era and provides evidence for the initial uptake of the SPARTAN‐HN.

To the authors' knowledge, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN) is the first cancer surgery–specific prioritization tool for use during the coronavirus disease 2019 (COVID‐19) pandemic. The SPARTAN‐HN algorithm is reliable and valid for the stratification of patients with head and neck cancer who require urgent cancer care in resource‐restricted practice environments.

Management of squamous cell carcinomas of the skull-base

PURPOSE

The purpose of this review is to assess the recent evidence regarding the management of squamous cell carcinoma of the skull-base and to discuss the implications of these findings on clinical practice.

METHOD

Free text Medline and MeSH term search of publications relating to Squamous Cell Carcinoma & Skull-base and Skull base, Neoplasm respectively. Multidisciplinary clinical guidelines were also reviewed.

RESULTS

The primary search yielded a total of 271 papers which following initial review was reduced to 28. Secondary search yielded 56 papers. There were no randomised controlled trials relating to squamous cell carcinoma of the skull-base and as such this review is based on cohort studies, case series and expert opinion.

CONCLUSION

Squamous cell carcinoma (SCC) is the most common cancer occurring in the Head and Neck. Squamous cell carcinoma is also the most common cancer arising within the nose and sinuses of which skull-base squamous cell carcinoma is a rare subgroup. Evidence relating to the management and survival of skull-base SCC is based on expert opinion and. retrospective analyses Clinical examination and biopsy, imaging and a broad multidisciplinary team are key to the management of skull-base SCC. The information gathered should be used to guide informed discussion by suitably trained experts with patients regarding surgical approach, post-operative recovery and adjuvant or neoadjuvant treatments. The standard of care is currently to perform skull base resection with or without additional craniotomy, pedicled or free flap reconstruction in multiple layers and post-operative radiation (usually photons or protons). Open approaches have traditionally been the mainstay, however in certain cases endoscopic approaches can yield equivalent results and offer many advantages. Despite advances in care survival remains poor with a nearly one in five risk of nodal recurrence within two years.

Considerations for head and neck oncology practices during the coronavirus disease 2019 (COVID-19) pandemic: Wuhan and Toronto experience

The practices of head and neck surgical oncologists must evolve to meet the unprecedented needs placed on our health care system by the Coronavirus disease 2019 (COVID-19) pandemic. Guidelines are emerging to help guide the provision of head and neck cancer care, though in practice, it can be challenging to operationalize such recommendations. Head and neck surgeons at Wuhan University faced significant challenges in providing care for their patients. Similar challenges were faced by the University of Toronto during the severe acute respiratory syndrome (SARS) pandemic in 2003. Herein, we outline our combined experience and key practical considerations for maintaining an oncology service in the midst of a pandemic.

Academic benchmarks for leaders in Otolaryngology - Head & Neck Surgery: a Canadian perspective

BACKGROUND

The present study summarizes the demographics, subspecialty training, and academic productivity of contemporary leaders in Canadian Otolaryngology - Head & Neck Surgery (OHNS) training programs across Canada.

METHODS

Demographic data regarding chairpersons (CPs) and program directors (PDs) were obtained from publicly-available faculty listings and online sources, and included employment institution, residency training, fellowship training status, gender, and years of post-graduate experience. Research productivity was measured using the h-index and number of publications, obtained from Scopus. Characteristics of CPs and PDs were compared using statistical analysis.

RESULTS

Cross-sectional data was obtained from a total of 27 CPs and PDs from 13 accredited OHNS training programs across Canada active on July 1, 2019. All academic leaders completed at least 1 year of fellowship training. Head and neck oncology represented 77% of CPs and 59% of academic leaders overall, while pediatric otolaryngology represented 43% of PDs. Females represented 11% of academic leaders. There was a significant association between location of residency training and employment, with 56% (15/27) of physicians working where they had trained (p = 0.001, Fisher's exact test; φ = 2.63, p = 0.001). On average, individuals with a graduate (Master's) degree had a significantly higher H-index (17.7 vs 7.4, p = 0.001) and greater number of publications (106 vs. 52, p = 0.02). Compared to PDs, CPs had a significantly higher average h-index score (14.5 vs. 8.14, p = 0.04) and accrued more years of post-graduate experience (29.7 vs. 21.3 years, p = 0.008). There were no differences in the proportions of CPs and PDs with graduate degrees. There appeared to be a decline in research productivity beginning 3 years after academic appointment.

CONCLUSIONS

This cross-sectional overview of academic leaders in Canadian OHNS programs demonstrates the following key findings: 1) all leaders completed fellowship training; 2) head and neck surgical oncology was the most common fellowship training subspecialty; 3) leaders were likely to be employed at the institution where they trained; 4) a Master's degree may be associated with increased research productivity; 5) there is a potential risk of decreased productivity after appointment to a leadership position; and 6) women are underrepresented in academic leadership roles.

Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic

INTRODUCTION

The performance of tracheotomy is a common procedural request by critical care departments to the surgical services of general surgery, thoracic surgery and otolaryngology - head & neck surgery. A Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force was convened with multi-specialty involvement from otolaryngology-head & neck surgery, general surgery, critical care and anesthesiology to develop a set of recommendations for the performance of tracheotomies during the COVID-19 pandemic.

MAIN BODY

The tracheotomy procedure is highly aerosol generating and directly exposes the entire surgical team to the viral aerosol plume and secretions, thereby increasing the risk of transmission to healthcare providers. As such, we believe extended endotracheal intubation should be the standard of care for the entire duration of ventilation in the vast majority of patients. Pre-operative COVID-19 testing is highly recommended for any non-emergent procedure.

CONCLUSION

The set of recommendations in this document highlight the importance of avoiding tracheotomy procedures in patients who are COVID-19 positive if at all possible. Recommendations for appropriate PPE and environment are made for COVID-19 positive, negative and unknown patients requiring consideration of tracheotomy. The safety of healthcare professionals who care for ill patients and who keep critical infrastructure operating is paramount.

Outpatient versus Inpatient Parotidectomy: A Systematic Review and Meta-analysis

OBJECTIVE

Parotidectomies are commonly performed procedures by head and neck surgeons. Although parotidectomies are historically inpatient procedures, recent observational evidence has highlighted the potential for parotidectomies to be performed on an outpatient basis. This systematic review and meta-analysis sought to compare complications and unplanned health care utilization between patients undergoing outpatient versus inpatient parotidectomy.

DATA SOURCES

A systematic review was performed using MEDLINE, EMBASE, and the Cochrane Library.

REVIEW METHODS

Studies comparing the outcomes of outpatient parotidectomy with those of inpatient parotidectomy were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. Postoperative complications (hematoma, facial nerve dysfunction, seroma, fistulisation, Frey syndrome, and wound infection) and rates of 30-day readmission, reintervention, and emergency department presentation were compared.

RESULTS

We screened 1018 nonduplicate articles to include 5 studies, all of which were retrospective cohort studies. There were fewer complications found in the outpatient group (relative risk = 0.61, 95% confidence interval: 0.40-0.93). Outpatient procedures were more commonly performed on patients who lived close to the hospital, had fewer comorbidities, and had less extensive planned surgery.

CONCLUSION

Outpatient parotidectomy appears safe in select patients with outcomes comparable with inpatient surgery. However, evidence overall is of low quality, and further work is needed to delineate a satisfactory set of criteria for appropriate patient identification.

Quality Indicators for the Diagnosis and Management of Acute Bacterial Rhinosinusitis

Background

Acute bacterial rhinosinusitis (ABRS) is a highly prevalent disease that is treated by a variety of specialties, including but not limited to, family physicians, emergency physicians, otolaryngology—head and neck surgeons, infectious disease specialists, and allergy and immunologists. Unfortunately, despite high-quality guidelines, variable and substandard care continues to be demonstrated in the treatment of ABRS.

Objective

This study aimed to develop ABRS-specific quality indicators (QIs) to evaluate the diagnosis and management that reduces symptoms, improves quality of life, and prevents complications.

Methods

A guideline-based approach, proposed by Kötter et al., was used to develop QIs for ABRS. Candidate indicators (CIs) were extracted from 4 guiding documents and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND/University of California at Los Angeles appropriateness methodology.

Results

Twenty-nine CIs were identified after literature review and evaluated by our panel. Of these, 5 CIs reached consensus as being appropriate QIs, with 1 requiring additional discussion. After a second round of evaluations, the panel selected 7 QIs as appropriate measures of high-quality care.

Conclusion

This study proposes 7 QIs for the diagnosis and management of patients with ABRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay for performance initiatives.

Association of Vessel-Sealant Devices vs Conventional Hemostasis With Postoperative Neck Hematoma After Thyroid Operations

Importance

Vessel-sealant devices (VSDs) have been popularized for use in thyroid operations; however, the association of their use with postoperative neck hematoma, a rare but potentially fatal complication, has not been well studied.

Objective

To examine the association of VSDs vs conventional hemostasis (CH) in thyroid operations with the development of neck hematoma.

Design, Setting, and Participants

This retrospective cohort study evaluated 10 903 patients in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016, to December 31, 2017. One-to-one nearest-neighbor propensity score matching was conducted to adjust for differences in baseline covariates, including demographics, comorbidities, indications for thyroid procedure (goiter, Graves disease, malignant and benign thyroid nodule), and several other thyroid-specific characteristics, between the VSD and CH groups.

Main Outcomes and Measures

The primary outcome was postoperative hematoma requiring intervention with open evacuation, return to the operating room, tracheostomy, additional observation, or extended length of stay. Secondary outcomes include recurrent laryngeal nerve injury, operative duration, and hospital length of stay.

Results

One-to-one propensity score matching yielded 6522 patients (mean [SD] age, 52 [15] years; 8544 [78.4%] female) with 3261 in each exposure group such that distribution of observed baseline covariates was not different between groups of the same propensity score. Within the matched cohort, CH was associated with higher odds of neck hematoma compared with VSD (odds ratio, 2.33; 95% CI, 1.55-3.49; P < .001), with 34 (1.0%) hematomas in the VSD group and 78 (2.4%) in the CH group. On the basis of this analysis, the number needed to treat with a VSD to prevent 1 postoperative hematoma was 74. Secondary outcomes included longer length of hospital stay (incidence rate ratio, 1.29; 95% CI, 1.23-1.36; P < .001]) in the CH group compared with the VSD group but no difference in the odds of recurrent laryngeal nerve injury (odds ratio, 0.90; 95% CI, 0.73-1.11; P = .32) or operative duration (incidence rate ratio, 0.99; 95% CI, 0.96-1.01; P = .24).

Conclusions and Relevance

Use of VSDs during thyroid operations was associated with reduced odds of neck hematoma compared with CH techniques without increasing odds of nerve injury. The results suggest that postoperative neck hematoma rates after thyroid surgery may differ based on the hemostasis technique and that these differences should be considered when developing strategies for quality improvement of postoperative outcomes.

Impact of Dural Resection on Sinonasal Malignancies with Skull Base Encroachment or Erosion

Objectives  (1) To determine the occult rate of dural invasion in patients with tumors extending to and/or eroding the bony anterior skull base but without evidence of dural invasion on preoperative imaging. (2) To determine the impact of dural resection and of skull base erosion on survival outcomes in this group of patients (without evidence of dural invasion upon preoperative imaging). Study Design  Retrospective study. Setting  Tertiary care academic center. Participants  Patients with sinonasal malignancies with anterior skull base encroachment/erosion without dural invasion on preoperative imaging treated surgically. Main Outcome Measures  (1) Histopathologic disease in the dura in patients who had dural resection and (2) Oncologic outcomes (5-year local recurrence, dural recurrence, disease-specific survival, and overall survival) in patients with and without dural resection, and patients with and without skull base erosion. Results  Thirty-seven patients were included. The occult rate of dural invasion was 54%. Patients with dural resection had improved margin control versus those without dural resection (90% vs 56%, p  = 0.02). Dural resection improved 5-year overall survival only in patients with esthesioneuroblastoma compared with bony skull base resection alone (100% vs 75%, p  = 0.03). Patients with skull base erosion had reduced local control versus those without erosion (63% vs 93%, p  = 0.047). Conclusion  This study suggests a substantial rate of occult dural invasion despite no overt imaging findings. Dural resection may be associated with improved margin control, but no oncologic benefit except for esthesioneuroblastomas, although treatment heterogeneity and small sample size may limit conclusions.

Consultation diagnoses and procedures billed among recent graduates practicing general otolaryngology - head & neck surgery in Ontario, Canada

Background

An analysis of the scope of practice of recent Otolaryngology – Head and Neck Surgery (OHNS) graduates working as general otolaryngologists has not been previously performed. As Canadian OHNS residency programs implement competency-based training strategies, this data may be used to align residency curricula with the clinical and surgical practice of recent graduates.

Methods

Ontario billing data were used to identify the most common diagnostic and procedure codes used by general otolaryngologists issued a billing number between 2006 and 2012. The codes were categorized by OHNS subspecialty. Practitioners with a narrow range of procedure codes or a high rate of complex procedure codes, were deemed subspecialists and therefore excluded.

Results

There were 108 recent graduates in a general practice identified. The most common diagnostic codes assigned to consultation billings were categorized as ‘otology’ (42%), ‘general otolaryngology’ (35%), ‘rhinology’ (17%) and ‘head and neck’ (4%). The most common procedure codes were categorized as ‘general otolaryngology’ (45%), ‘otology’ (23%), ‘head and neck’ (13%) and ‘rhinology’ (9%). The top 5 procedures were nasolaryngoscopy, ear microdebridement, myringotomy with insertion of ventilation tube, tonsillectomy, and turbinate reduction. Although otology encompassed a large proportion of procedures billed, tympanoplasty and mastoidectomy were surprisingly uncommon.

Conclusion

This is the first study to analyze the nature of the clinical and surgical cases managed by recent OHNS graduates. The findings demonstrated a prominent representation of ‘otology’, ‘general’ and ‘rhinology’ based consultation diagnoses and procedures. The data derived from the study needs to be considered as residency curricula are modified to satisfy competency-based requirements.

Quality indicators for the diagnosis and management of chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) has been identified as a high-priority disease category for quality improvement. To this end, this study aimed to develop CRS-specific quality indicators (QIs) to evaluate diagnosis and management that relieves patient discomfort, improves quality of life, and prevents complications.

METHODS

A guideline-based approach, proposed in 2012 by Kötter et al. was used to develop QIs for CRS. Candidate indicators (CIs) were extracted from 3 practice guidelines and 1 international consensus statement on the diagnosis and management of CRS. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology.

RESULTS

Thirty-nine CIs were identified after literature review and evaluated by our panel. Of these, 9 CIs reached consensus as being appropriate QIs, with 4 requiring additional discussion. After a second round of evaluations, the panel selected 9 QIs as appropriate measures of high-quality care.

CONCLUSION

This study proposes 9 QIs for the diagnosis and management of patients with CRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay-for-performance initiatives.

The personal financial burden of chronic rhinosinusitis: A Canadian perspective

BACKGROUND

Previous studies describe the financial burden of chronic rhinosinusitis (CRS) from the perspective of third-party payers, but, to our knowledge, none analyze the costs borne by patients (i.e., out-of-pocket expenses [OOPE]). Furthermore, this burden has not been previously investigated in the context of a publicly funded health care system.

OBJECTIVE

The purpose of this study was to characterize the financial impact of CRS on patients, specifically by evaluating its associated OOPEs and the perceived financial burden. The secondary aim was to determine the factors predictive of OOPEs and perceived burden.

METHODS

Patients with CRS at a tertiary care sinus center completed a self-administered questionnaire that assessed their socioeconomic characteristics, disease-specific quality of life (22-item Sino-Nasal Outcome Test [SNOT-22]), workdays missed due to CRS, perceived financial burden, and direct medical and nonmedical OOPEs over a 12-month period. Total OOPEs were calculated from the sum of direct medical and nonmedical OOPEs. Regression analyses determined factors predictive of OOPEs and the perceived burden.

RESULTS

A total of 84 patients completed the questionnaires. After accounting for health insurance coverage and the median direct medical, direct nonmedical, and total OOPEs per patient over a 12-month period were Canadian dollars (CAD) $336.00 (2011) [U.S. $339.85], CAD $129.87 [U.S. $131.86], and CAD $607.10 [U.S. $614.06], respectively. CRS resulted in an average of 20.6 workdays missed over a 12-month period. Factors predictive of a higher financial burden included younger age, a greater number of previous sinus surgeries, <80% health insurance coverage, residing out of town, and higher SNOT-22 scores.

CONCLUSION

Total OOPEs incurred from the treatment of CRS may amount to CAD $607.10 [U.S. $614.06] per patient per year, within the context of a single-payer health care system. Managing clinicians should be aware of patient groups with a greater perceived financial burden and consider counseling them on strategies to offset expenses, including obtaining travel grants, using telemedicine for follow-up assessments, providing drug samples, and streamlining diagnostic testing with medical visits.

Programmed death-ligand 1 expression by digital image analysis advances thyroid cancer diagnosis among encapsulated follicular lesions

Recognition of noninvasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTP) that distinguishes them from invasive malignant encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) can prevent overtreatment of NIFTP patients. We and others have previously reported that programmed death-ligand 1 (PD-L1) is a useful biomarker in thyroid tumors; however, all reports to date have relied on manual scoring that is time consuming as well as subject to individual bias. Consequently, we developed a digital image analysis (DIA) protocol for cytoplasmic and membranous stain quantitation (ThyApp) and evaluated three tumor sampling methods [Systemic Uniform Random Sampling, hotspot nucleus, and hotspot nucleus/3,3'-Diaminobenzidine (DAB)]. A patient cohort of 153 cases consisting of 48 NIFTP, 44 EFVPTC, 26 benign nodules and 35 encapsulated follicular lesions/neoplasms with lymphocytic thyroiditis (LT) was studied. ThyApp quantitation of PD-L1 expression revealed a significant difference between invasive EFVPTC and NIFTP; but none between NIFTP and benign nodules. ThyApp integrated with hotspot nucleus tumor sampling method demonstrated to be most clinically relevant, consumed least processing time, and eliminated interobserver variance. In conclusion, the fully automatic DIA algorithm developed using a histomorphological approach objectively quantitated PD-L1 expression in encapsulated thyroid neoplasms and outperformed manual scoring in reproducibility and higher efficiency.

Quality-of-life outcomes in Graves disease patients after total thyroidectomy

Historically, research into surgical treatment of Graves disease has assessed subtotal rather than total thyroidectomy. Most clinicians now recommend total thyroidectomy, but little information is available regarding quality-of-life (QOL) outcomes for this procedure. Our aim was to assess QOL after total thyroidectomy. This is a retrospective, pilot study of patients with Graves disease who underwent total thyroidectomy from 1991 to 2007 at a high-volume tertiary referral center in Toronto, Canada. Questionnaires addressing disease-specific symptoms and global QOL concerns were sent to 54 patients. Analyses included parametric and nonparametric tests to assess the differences between perception of symptoms and global QOL before and after surgery. Forty patients responded (response rate: 74%) at a median of 4.8 years postoperatively. On a 10-point scale, overall wellness improved from 4.1 preoperatively to 8.7 postoperatively (p < 0.001). Patients recalled missing less work or school after surgery (7.8 vs. 1.1 days/year; p = 0.001). Overall satisfaction with the procedure was high. On average, symptoms improved within 32 days of surgery, and all symptoms showed substantial improvement. This is the first North American study to assess QOL outcomes of patients with Graves disease after total thyroidectomy. Patients experienced marked and rapid improvement in QOL postoperatively. These findings suggest that total thyroidectomy is a safe and effective treatment.

A challenge-response endoscopic sinus surgery specific checklist as an add-on to standard surgical checklist: an evaluation of potential safety and quality improvement issues

BACKGROUND

The goal of this study was to develop and evaluate the impact of an aviation-style challenge and response sinus surgery-specific checklist on potential safety and equipment issues during sinus surgery at a tertiary academic health center. The secondary goal was to assess the potential impact of use of the checklist on surgical times during, before, and after surgery. This initiative is designed to be utilized in conjunction with the "standard" World Health Organization (WHO) surgical checklist. Although endoscopic sinus surgery is generally considered a safe procedure, avoidable complications and potential safety concerns continue to occur. The WHO surgical checklist does not directly address certain surgery-specific issues, which may be of particular relevance for endoscopic sinus surgery.

METHODS

This prospective observational pilot study monitored compliance with and compared the occurrence of safety and equipment issues before and after implementation of the checklist. Forty-seven consecutive endoscopic surgeries were audited; the first 8 without the checklist and the following 39 with the checklist. The checklist was compiled by evaluating the patient journey, utilizing the available literature, expert consensus, and finally reevaluation with audit type cases. The final checklist was developed with all relevant stakeholders involved in a Delphi method.

RESULTS

Implementing this specific surgical checklist in 39 cases at our institution, allowed us to identify and rectify 35 separate instances of potentially unsafe, improper or inefficient preoperative setup. These incidents included issues with labeling of topical vasoconstrictor or injectable anesthetics (3, 7.7%) and availability, function and/or position of video monitors (2, 5.1%), endoscope (6, 15.4%), microdebrider (6, 15.4%), bipolar cautery (6, 15.4%), and suctions (12, 30.8%).

CONCLUSION

The design and integration of this checklist for endoscopic sinus surgery, has helped improve efficiency and patient safety in the operating room setting.

Outpatient versus inpatient thyroidectomy: A systematic review and meta-analysis

BACKGROUND

Outpatient thyroidectomy has gained popularity due to improved resource utilization.

METHODS

We conducted a systematic review and meta-analysis using MEDLINE, EMBASE, CINAHL, Web of Science, and the Cochrane library. We included all studies examining the outcomes of outpatient thyroidectomy as compared with those of inpatient thyroidectomy. Risk of bias was assessed using the Newcastle-Ottawa scale. Postoperative complications (hematoma, hypocalcemia, and recurrent laryngeal nerve injury) and readmission/reintervention rates were compared.

RESULTS

After screening 1665 records, 10 nonrandomized observational studies were included. There were fewer complication rates in the outpatient group than the inpatient group (relative risk [RR] 0.56; 95% confidence interval [CI] 0.37-0.83). There was no difference in readmission/reintervention rates (RR 0.60; 95% CI 0.33-1.09).

CONCLUSION

The results suggest outpatient thyroidectomy may be as safe as inpatient thyroidectomy in appropriately selected patients. The results are limited by high risk of bias. Well-designed prospective studies are necessary to further assess the safety of outpatient thyroidectomy.

Open versus endoscopic septoplasty techniques: A systematic review and meta-analysis

BACKGROUND

Septal deviation is a condition of high prevalence, which ranges from 22% in newborns to 90% in adults. Surgical intervention is frequently considered in the management of patients with symptoms. Although many surgeons prefer either the endoscopic or the open approach to septoplasty, there is an ongoing debate regarding comparative outcomes between the two approaches.

OBJECTIVE

The purpose of this study was to systematically review the literature and provide pooled summary estimates to evaluate the efficacy and safety of open versus endoscopic septoplasty techniques.

METHODS

This study was registered with PROSPERO (CRD42014010730). MEDLINE, EMBASE, Google Scholar, CINAHL, Web of Science, and The Cochrane Central Registry for Randomized Trials were searched for relevant studies by using the following keywords in varying combinations: "nasal septum," "nasal obstruction," "nasal cartilages," "nose," "nose diseases," "surgery," "nasal/septal deviation," and "septoplasty." All the studies that compared open versus endoscopic septoplasty techniques for the management of symptomatic septal deviation were considered. Two reviewers independently extracted data by using a preestablished extraction form and performed quality assessment by using the Jadad and Newcastle Ottawa Scales. Weighted pooled estimates were calculated and reported, along with relative risks and 95% confidence intervals.

RESULTS

Fourteen studies met our inclusion criteria. When comparing open versus endoscopic septoplasty techniques, there was significant improvement in postoperative symptoms (i.e., nasal obstruction, headaches) (p < 0.05) in the endoscopic septoplasty group. There also were significantly fewer complications associated with the endoscopic septoplasty technique (p < 0.05). Based on the quality assessment, included studies were deemed at a moderate-to-high risk of bias.

CONCLUSION

Our analysis indicated that endoscopic septoplasty may have some advantages over open septoplasty. However, our findings should be taken with caution given the poor quality of included studies.

Subcellular differential expression of Ep-ICD in oral dysplasia and cancer is associated with disease progression and prognosis

Background

Identification of patients with oral dysplasia at high risk of cancer development and oral squamous cell carcinoma (OSCC) at increased risk of disease recurrence will enable rigorous personalized treatment. Regulated intramembranous proteolysis of Epithelial cell adhesion molecule (EpCAM) resulting in release of its intracellular domain Ep-ICD into cytoplasm and nucleus triggers oncogenic signaling. We analyzed the expression of Ep-ICD in oral dysplasia and cancer and determined its clinical significance in disease progression and prognosis.

Methods

In a retrospective study, immunohistochemical analysis of nuclear and cytoplasmic Ep-ICD and EpEx (extracellular domain of EpCAM), was carried out in 115 OSCC, 97 oral dysplasia and 105 normal oral tissues, correlated with clinicopathological parameters and disease outcome over 60 months for oral dysplasia and OSCC patients. Disease-free survival (DFS) was determined by Kaplan-Meier method and multivariate Cox regression analysis.

Results

In comparison with normal oral tissues, significant increase in nuclear Ep-ICD and membrane EpEx was observed in dysplasia, and OSCC (p = 0.013 and < 0.001 respectively). Oral dysplasia patients with increased overall Ep-ICD developed cancer in short time period (mean = 47 months; p = 0.044). OSCC patients with increased nuclear Ep-ICD and membrane EpEx had significantly reduced mean DFS of 33.7 months (p = 0.018).

Conclusions

Our study provided clinical evidence for Ep-ICD as a predictor of cancer development in patients with oral dysplasia and recurrence in OSCC patients, suggesting its potential utility in enhanced management of those patients detected to have increased risk of progression to cancer and recurrence in OSCC patients.

Three-dimensional virtual navigation versus conventional image guidance: A randomized controlled trial

OBJECTIVES/HYPOTHESIS

Providing image guidance in a 3-dimensional (3D) format, visually more in keeping with the operative field, could potentially reduce workload and lead to faster and more accurate navigation. We wished to assess a 3D virtual-view surgical navigation prototype in comparison to a traditional 2D system.

METHODS

Thirty-seven otolaryngology surgeons and trainees completed a randomized crossover navigation exercise on a cadaver model. Each subject identified three sinonasal landmarks with 3D virtual (3DV) image guidance and three landmarks with conventional cross-sectional computed tomography (CT) image guidance. Subjects were randomized with regard to which side and display type was tested initially. Accuracy, task completion time, and task workload were recorded.

RESULTS

Display type did not influence accuracy (P > 0.2) or efficiency (P > 0.3) for any of the six landmarks investigated. Pooled landmark data revealed a trend of improved accuracy in the 3DV group by 0.44 millimeters (95% confidence interval [0.00-0.88]). High-volume surgeons were significantly faster (P < 0.01) and had reduced workload scores in all domains (P < 0.01), but they were no more accurate (P > 0.28).

CONCLUSION

Real-time 3D image guidance did not influence accuracy, efficiency, or task workload when compared to conventional triplanar image guidance. The subtle pooled accuracy advantage for the 3DV view is unlikely to be of clinical significance. Experience level was strongly correlated to task completion time and workload but did not influence accuracy.

LEVEL OF EVIDENCE

N/A. Laryngoscope, 126:1510-1515, 2016.

Epistaxis in hereditary hemorrhagic telangiectasia: an evidence based review of surgical management

Patients with Hereditary Hemorrhagic Telangiectasia (HHT) frequently present with epistaxis. Up to 98 % of these patients will have epistaxis at some point in their life. There are multiple ways to deal with this problem, including conservative, medical and surgical options. We present a case and an update on the treatment options for HHT, with a focus on the newer and experimental techniques.

Comparing the traditional and Multiple Mini Interviews in the selection of post-graduate medical trainees

BACKGROUND

The traditional, panel style interview and the multiple mini interview (MMI) are two options to use in the selection of medical trainees with each interview format having inherent advantages and disadvantages. Our aim was to compare the traditional and MMI on the same cohort of postgraduate applicants to the Department of Otolaryngology - Head & Neck Surgery at the University of Toronto.

METHOD

Twenty-seven applicants from the 2010 Canadian Residency Matching Service selected for interview at the University of Toronto, Department of Otolaryngology - Head & Neck Surgery were included in the study. Each applicant participated in both a traditional interview and MMI.

RESULTS

Traditional interviews marked out of a total maximum score of 570. On the traditional interview, scores ranged from 397-543.5 (69.6 - 95.3%), the mean was 460.2. The MMI maximum score was out of 180. MMI scores ranged from 93 - 146 (51.7 - 81.1%) with a mean of 114.8. Traditional interview total scores were plotted against MMI total scores. Scores correlated reasonably well, Pearson Correlation = 0.315 and is statistically significant at p = 0.001. Inter-interview reliability for the two interview methods was 0.038, with poor overall agreement 0.07%.

CONCLUSIONS

MMI and traditional interview scores are correlated but do not reliably lead to the same rank order. We have demonstrated that these two interview formats measure different characteristics. One format may also be less reliable leading to greater variation in final rank. Further validation research is certainly required.

Immunohistochemical Subcellular Localization of Protein Biomarkers Distinguishes Benign from Malignant Thyroid Nodules: Potential for Fine-Needle Aspiration Biopsy Clinical Application

BACKGROUND

It is of critical clinical importance to select accurately for surgery thyroid nodules at risk for malignancy and avoid surgery on those that are benign. Using alterations in subcellular localization for seven putative biomarker proteins (identified by proteomics), this study aimed to define a specific combination of proteins in surgical tissues that could distinguish benign from malignant nodules to assist in future surgical selection by fine-needle aspiration biopsy (FNAB).

METHODS

Immunohistochemical subcellular localization (IHC) analyses of seven proteins were retrospectively performed on surgical tissues (115 benign nodules and 114 papillary-based thyroid carcinomas [TC]), and a risk model biomarker panel was developed and validated. The biomarker panel efficacy was verified in 50 FNAB formalin-fixed and paraffin-embedded cell blocks, and 26 cytosmears were prepared from fresh surgically resected thyroid nodules.

RESULTS

Selection modeling using these proteins resulted in nuclear phosphoglycerate kinase 1 (PGK1) loss and nuclear Galectin-3 overexpression as the best combination for distinguishing TC from benign nodules (area under the curve [AUC] 0.96 and 0.95 in test and validation sets, respectively). A computed malignancy score also accurately identified TC in benign and indeterminate nodules (test and validation sets: AUC 0.94, 0.90; specificity 98%, 99%). Its efficacy was confirmed in surgical FNAB cell blocks and cytosmears.

CONCLUSION

Using surgical tissues, it was observed that a combination of PGK1 and Galectin-3 had high efficiency for distinguishing benign from malignant thyroid nodules and could improve surgical selection for TC among indeterminate nodules. Further validation in prospective preoperative FNAB will be required to confirm such a clinical application.

Squeeze bottle versus saline spray after endoscopic sinus surgery for chronic rhinosinusitis: a pilot multicentre trial

BACKGROUND

There is a need for controlled trials to guide the perioperative management of patients undergoing endoscopic sinus surgery (ESS). The authors performed a pilot multicenter trial to compare two types of saline delivery devices in this population.

METHODS

Patients were randomized to high volume saline irrigation with a squeeze bottle and low volume saline spray after ESS in patients with chronic rhinosinusitis (CRS). Surgeons were blinded to treatment, and one-month postoperative scores for sinonasal outcomes [Sinonasal Outcome Test-22 (SNOT-22)] scale, nasal and sinus symptom score (NSS), and perioperative sinus endoscopy (POSE) scale were compared with preoperative scores.

RESULTS

Nine centers provided data for 86 patients. All three outcomes measures improved significantly for both groups. Saline spray: SNOT-22 48.8 versus. 23.7, treatment effect 25.1 (95% confidence interval [CI], 17.9-32.2), POSE 21.1 versus. 8.4, treatment effect 12.7 (95% CI, 9.2-16.1), and NSS 8.2 versus 5.0, treatment effect 3.1 (95% CI, 1.4-4.9) pre- and postoperatively, respectively (all p < 0.0001). Squeeze bottle: SNOT-22 49.5 versus 23.6, treatment effect 25.9 (95% CI, 20.3-31.6), POSE 18.6 versus 9.2, treatment effect 9.3, (95% CI 6.7-12.0), and NSS 9.0 versus 5.7, treatment effect 3.3 (95% CI, 2.3-4.3) pre- and postoperatively, respectively (all p < 0.0001). Analysis of variance did not identify a difference between the two treatment groups. Subgroup analysis based on preoperative disease severity did not change the nonassociation of saline bottle with outcome measures. Post hoc sample size calculation determined that 176 patients is required to detect an 8.9-point difference in SNOT-22 scores.

CONCLUSION

In this pilot multicenter trial examining patients with chronic rhinosinusitis undergoing ESS, both squeeze bottle and saline spray showed significant improvement in SNOT-22, POSE, and NSS scores at one-month postoperatively. Because the study was nonpowered, we cannot rule out a potential difference between the two treatment groups.

Post-operative stimulated thyroglobulin and neck ultrasound as personalized criteria for risk stratification and radioactive iodine selection in low- and intermediate-risk papillary thyroid cancer

The purpose of this study was to demonstrate the utility of a personalized risk stratification and radioactive iodine (RAI) selection protocol (PRSP) using post-operative stimulated thyroglobulin (Stim-Tg) and neck ultrasound in low- and intermediate-risk papillary thyroid carcinoma (PTC) patients. Patients with PTC tumors ≥1 cm were prospectively followed after total thyroidectomy and selective therapeutic central compartment neck dissection. Low/intermediate risk was defined as PTC confined to the thyroid or central (level VI) lymph nodes. Stim-Tg and neck ultrasound were performed approximately 3 months after surgery and used to guide RAI selection. Patients with Stim-Tg < 1 µg/L did not receive RAI, while those with Stim-Tg >5 µg/L routinely did. Those with Stim-Tg 1-5 µg/L received RAI on the basis of several clinical risk factors. Patients were followed for >6 years with serial neck ultrasound and basal/stimulated thyroglobulin. Among the 129 patients, 84 (65 %) had undetectable Stim-Tg after initial surgery, 40 (31 %) had Stim-Tg of 1-5 µg/L, and 5 (4 %) had Stim-Tg >5 µg/L. RAI was administered to 8 (20 %) patients with Stim-Tg 1-5 µg/L and 5 (100 %) with Stim-Tg >5 µg/L. Using this approach, RAI therapy was avoided in 17/20 (85 %) patients with tumors >4 cm, in 72/81 (89 %) patients older than 45 years, and in 6/9 (67 %) patients with central lymph node involvement. To date, 116 (90 %) patients in this cohort have not received RAI therapy with no evidence of residual/recurrent disease, whereas among the 13 patients who received RAI, 1 (8 %) had pathologic residual/recurrence disease. Using the proposed PRSP, RAI can be avoided in the majority of low/intermediate-risk PTC patients. Moreover, traditional risk factors considered to favor RAI treatment were not always concordant with the PRSP and may lead to overtreatment.