The impact of resident involvement on otolaryngology surgical outcomes.

OBJECTIVES/HYPOTHESIS: Intraoperative experience is an essential element of surgical training, but has the potential to impact patient outcomes. The purpose of this study was two-fold: 1) to evaluate the effect of resident involvement on morbidity and mortality following otolaryngology procedures and 2) to examine the influence of resident training level on the same outcomes. STUDY DESIGN: Retrospective cohort study. METHODS: This study reviewed 2,320,920 patients captured in the 2005 to 2012 National Surgical Quality Improvement Program databases to identify surgical otolaryngology cases. Outcomes of interest included surgical complications, medical complications, and mortality. Cases with and without resident involvement were propensity matched (caliper = 0.2) to account for nonrandomized assignment, and data were subject to multivariate logistic regression analyses. RESULTS: Residents participated in 38.4% of the 20,307 cases identified. Cases with resident involvement demonstrated longer operative duration (178.8 minutes vs. 80.1 minutes, P < .001), increased surgical complexity (23.5 relative value units [RVU] vs. 12.4 RVU, P < .001) and greater overall morbidity burden. Logistic regression analyses of the matched cohort revealed that resident participation did not independently increase morbidity (odds ratio [OR] = 0.969, P = .751) or mortality (OR = 0.893, P = .758). A separate logistic regression analysis of the unmatched cohort using resident postgraduate year showed that training level did not confer differential risk to patients. CONCLUSIONS: Our data indicate that resident involvement does not increase the risk of morbidity or mortality, and that trainees are being assigned to appropriate cases for their level of experience. These findings suggest that the contemporary paradigm of graduate otolaryngology surgical education does not negatively impact patient outcomes. LEVEL OF EVIDENCE: 2c Laryngoscope, 126:602-607, 2016.

Ultrasound-guided fine needle aspiration biopsy of thyroid nodules performed in the office.

INTRODUCTION: The majority of thyroid fine needle aspiration biopsies (FNAB) today are performed in the office freehand by palpation. Not infrequently, patients are sent to radiology for an ultrasound-guided FNAB (USG-FNB). Real-time ultrasound (US) allows for continuous visualization of the needle during insertion and sampling. Historically, USG-FNAB has been a procedure performed by a radiologist in a designated radiology suite. In more recent years, with the development of smaller more portable US machines, there has been a push for clinicians other than radiologists to perform the procedure. OBJECTIVE: To evaluate the accuracy and specimen adequacy of thyroid FNAB performed in the office under US guidance by one senior otolaryngologist. METHODS: Retrospective chart review of 203 patients who underwent ultrasound-guided USG-FNA of the thyroid gland between September, 2005, to February, 2007, in the office setting by one senior otolaryngologist. Specimens were reviewed onsite at the time of biopsy for cellular adequacy by a cytotechnologist. RESULTS: A total of 203 patients, 176 females and 27 males, underwent USG-FNA of the thyroid gland. The average age of the females was 52 years, and 59.4 years for the males. A total of 271 FNA biopsies were performed. Two hundred and twenty FNAB were satisfactory specimens (81.2%), 26 were unsatisfactory (9.6%), and 25 (9.2%) were limited due to blood clotting or hypocellularity. Of the FNA specimens that had enough cells to evaluate, 159 were benign, 48 were indeterminate for malignacy, and 13 were positive for malignancy. Of the nodules biopsied, 143 were greater than 1.5 cm (average 2.59 cm, unsatisfactory rate 12.6%), and 128 were less than 1.5 cm (average 1.21 cm, unsatisfactory rate 6.3%). In 44 patients, one or more nodule was biopsied at the same office visit. DISCUSSION: Thyroid US is an indispensable tool in the workup and diagnosis of thyroid disease. It may be used to help identify pathology and physical features suspicious for malignancy and guide FNAB of suspicious nodules. The availability of an office US machine allows the referring physician to perform a service that is normally done in a different department. This ultimately frees up time for both the patient and physician and reduces health care costs by eliminating extra office visits. More importantly, it allows the primary physician to be more knowledgeable and hands on with the patient's overall care. CONCLUSION: This study shows that a trained physician may perform a USG-FNA of the thyroid gland in the office with results comparable to that in the radiology literature.

Hypothyroidism following hemithyroidectomy for benign nontoxic thyroid disease.

Hypothyroidism following hemithyroidectomy for benign nontoxic thyroid disease is an underappreciated phenomenon. Up until recently, it was common practice for physicians to place post-hemithyroidectomy patients on thyroid suppression therapy during the immediate postoperative period. That practice began to fall out of favor as a result of two developments: (1) the publication of data that put into question the efficacy of levothyroxine therapy for preventing recurrent disease or thyroid growth and (2) a heightened awareness of the morbidity associated with levothyroxine. We conducted a retrospective chart-review study of 58 patients with benign nontoxic thyroid disease who had undergone hemithyroidectomy from 1994 through 2003 at one institution. Of these 58 patients, 14 (24.1%) had become hypothyroid after surgery, including 7 who had been so diagnosed 1 month postoperatively and 6 at 2 months. The remaining 44 patients were euthyroid. The mean preoperative serum thyroid-stimulating hormone (TSH) levels in the hypothyroid and the euthyroid groups were 2.39 and 1.07 microlU/ml, respectively-a statistically significant difference (p < 0.0001). A tissue diagnosis consistent with chronic inflammation (lymphocytic thyroiditis or Hashimoto's thyroiditis) was found in 50.0% of the hypothyroid patients, compared with only 6.8% of the euthyroid patients-again, a significant difference (p < 0.001). No significant difference was seen between the two grqups with respect to age, sex, or the weight of the resected gland. We conclude that hypothyroidism after hemithyroidectomy is not an uncommon occurrence. Apparent risk factors include a high mean preoperative serum TSH level and tissue pathology consistent with chronic inflammation. It may be wise to follow patients with these identifiable risk factors more closely during the postoperative period; monitoring should include scheduled serial serum TSH draws.

Role of intrathyroidal calcifications detected on ultrasound as a marker of malignancy.

OBJECTIVES: Clinically palpable thyroid nodules are present in between 4% and 7% of the population, with only a small percentage of those harboring malignancy. Thus, it is important to find a cost-effective way to determine which nodules are more likely to be malignant. The purpose of this study was to evaluate the use of intrathyroidal calcifications detected on ultrasound as a risk factor for malignancy. STUDY DESIGN: Retrospective chart review. METHODS: One hundred fifty-nine patients with thyroid disease were included in this study. Patients were selected from a thyroid ultrasound (TUS) database. Charts were then reviewed, and only those patients who had a preoperative TUS and underwent surgery for tissue diagnosis were included. RESULTS: Of the 159 patients, 66 (41.5%) were diagnosed with cancer. Of those with malignancy, 52 (78.8%) had calcifications noted on TUS. Ninety-three of the patients were diagnosed with benign pathology. Of those 93 patients, 36 (38.7%) had TUS findings consistent with calcifications, whereas 57 (61.3%) did not. Statistical analysis using a chi-square test showed a strong association between cancer status and calcification, with P <.001. In our study, calcifications on TUS had a sensitivity of 78.8% and a specificity of 61.3%, with an odds ratio of 5.88. CONCLUSION: The presence of calcifications detected on TUS should alert the physician for the possibility of malignancy, and further work-up should be pursued. This information may be used to improve the sensitivity of other diagnostic tests such as fine needle aspiration biopsies. Given the relatively low sensitivity and specificity of the test, its use alone as a marker of malignancy is limited, but it may be used in combination with other known risk factors and tests to decide on the most appropriate treatment plan.

Auditory and facial nerve function following surgery for cerebellopontine angle meningiomas.

OBJECTIVE: To investigate the postoperative auditory and facial nerve function results after cerebellopontine angle meningioma removal. DESIGN: Retrospective chart review. SETTING: Tertiary care referral center. PATIENTS: Twenty-one patients undergoing surgical removal of cerebellopontine angle meningiomas by the senior author (R.J.W.). INTERVENTIONS: Translabyrinthine or retrosigmoid approach for tumor extirpation. MAIN OUTCOME MEASURES: Postoperative auditory (pure-tone average and speech discrimination score) and facial (House-Brackmann scale) function within 1 year of follow-up. RESULTS: Twenty-three operations were performed on 21 patients. Hearing preservation through the retrosigmoid approach was attempted in 11 patients (48%). Normal hearing (class A) was preserved in 9 of 10 patients. Normal postoperative facial nerve function (House-Brackmann grade I) was conserved in 11 (65%) of 17 patients. CONCLUSIONS: This review demonstrates that successful hearing preservation is possible with meningiomas. Therefore, the retrosigmoid approach should be used whenever serviceable hearing is present preoperatively. Normal facial nerve function can also be preserved in the majority of patients.