Thyroid cancer necrosis not evident on imaging: A cautionary case series on poorly differentiated thyroid carcinoma diagnosed only on final pathology.

OBJECTIVE: Poorly-differentiated thyroid cancer (PDTC) is a highly aggressive malignancy which is recently defined and understudied in the radiologic literature. Necrosis is a key histopathologic criterion for the diagnosis of PDTC. We illustrate the current difficulty in accurate identification of histopathologic necrosis on preoperative imaging. METHODS: A series of seven patients with the final diagnosis of PDTC from our institution were identified. Multimodality preoperative imaging was analyzed by two head and neck radiologists. Final pathology reports were queried confirming histopathologic evidence of necrosis. RESULTS: Patients presented with a wide range of preoperative imaging features. A consistent imaging appearance confirming necrosis was not identified. All patients were subsequently upstaged to PDTC following final pathological analysis. CONCLUSION: A lack of definitive evidence of necrosis on preoperative imaging does not exclude the possibility of PDTC. We demonstrate the need for further research to establish a clear methodology for the preoperative diagnosis of PDTC.

Performance of Liquid Biopsy for Diagnosis and Surveillance of Human Papillomavirus-Associated Oropharyngeal Cancer.

Importance: There is growing interest in the use of circulating plasma tumor human papillomavirus (HPV) DNA for diagnosis and surveillance of patients with HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Recent advances in the assays, combining the identification of circulating HPV tumor DNA and tumor DNA fragment analysis (tumor tissue-modified viral [TTMV]-HPV DNA), have been shown to be highly accurate. However, use of these newer techniques has been limited to small cohort studies and clinical trials. Objective: To establish the clinical efficacy of plasma TTMV-HPV DNA testing in the diagnosis and surveillance of HPV-associated OPSCC in a contemporary clinical setting. Design, Setting, and Participants: This retrospective observational cohort study included patients with OPSCC who underwent TTMV-HPV DNA testing between April 2020 and September 2022 during the course of routine clinical care. For the diagnosis cohort, patients with at least 1 TTMV-HPV DNA measurement prior to initiation of primary therapy were included. Patients were included in the surveillance cohort if they had at least 1 TTMV-HPV DNA test performed after completion of definitive or salvage therapy. Main Outcomes and Measures: Per-test performance metrics, including sensitivity, specificity, positive predictive value, and negative predictive value, for TTMV-HPV DNA testing. Results: Of 399 patients included in the analysis, 163 were in the diagnostic cohort (median [IQR] age, 63 [56-68.5] years; 142 [87.1%] male), and 290 were in the surveillance cohort (median [IQR] age, 63 [57-70] years; 237 [81.7%] male). Of the 163 patients in the diagnostic cohort, 152 (93.3%) had HPV-associated OPSCC while 11 (6.7%) had HPV-negative OPSCC. The TTMV-HPV DNA sensitivity in pretreatment diagnosis was 91.5% (95% CI, 85.8%-95.4% [139 of 152 tests]), and the specificity was 100% (95% CI, 71.5%-100% [11 of 11 tests]). In the surveillance cohort, 591 tests conducted in 290 patients were evaluated. A total of 23 patients had molecularly confirmed pathologic recurrences. The TTMV-HPV DNA test demonstrated sensitivity of 88.4% (95% CI, 74.9%-96.1% [38 of 43 tests]) and specificity of 100% (95% CI, 99.3%-100% [548 of 548 tests]) in detecting the recurrences. Positive predictive value was 100% (95% CI, 90.7%-100% [38 of 38 tests]), and negative predictive value was 99.1% (95% CI, 97.9%-99.7% [548 of 553 tests]). The median (range) lead time from positive TTMV-HPV DNA test to pathologic confirmation was 47 (0-507) days. Conclusions and Relevance: This cohort study demonstrated that when evaluated in a clinical setting, the TTMV-HPV DNA assay demonstrated 100% specificity in both diagnosis and surveillance. However, the sensitivity was 91.5% for the diagnosis cohort and 88.4% for the surveillance cohort, signifying that nearly 1 in 10 negative tests among patients with HPV-associated OPSCC was a false negative. Additional research is required to validate the assay's performance and, if validated, then further research into the implementation of this assay into standard clinical practice guidelines will be required.

Does "Just in Time" teaching of ergonomic principles improve posture of trainees during otologic microscopic surgery?

PURPOSE: Musculoskeletal disorders are prevalent among otolaryngologists and otologists with symptoms starting during residency. Prior data suggested that high-risk joint angles were often adopted at procedure onset, suggesting a detrimental "natural" operating position. Despite its importance, dedicated ergonomic teaching is not systematically introduced into residency training. The objective of this study was to compare initial ergonomic positioning during microscopic temporal bone surgery between those who receive "Just in Time" ergonomic teaching prior to starting dissection with those who did not. MATERIALS AND METHODS: This was a pilot, prospective trial in which otolaryngology residents at an urban, multicenter tertiary care academic institution (n = 14) wore ergonomic sensors (inertial measurement units) during microscopic temporal bone lab drilling. Prior to recording, participants were randomized to receive an instructional presentation on ergonomic principles (n = 8, intervention group) or not (n = 6, control group). The inertial measurement units analyzed neck and back angles for the initial 5 min of drilling. RESULTS: Of 14 trainees, 78.6 % had prior experience with otologic microscopic cases and 14.3 % reported prior surgical ergonomic training or instruction. The groups were matched in trainee height (P = 0.54), handedness (P = 0.83), stage of otolaryngology training (P = 0.64), prior otologic microscopic surgery experience (P = 0.35), prior temporal bone drilling experience (P = 0.35), and prior teaching in ergonomic principles (P = 0.47). Junior trainees (PGY 1-3) who did not receive "Just in Time" teaching adopted a posture with significantly higher risk back flexion compared to junior trainees who received the training (25.3° vs. 5.7°, P = 0.04). There was no difference in back positioning among senior trainees (12.6° vs. -5.7°, P = 0.13). While there was a trend towards those in the intervention group adopting safer procedural posture, there was no significant difference in the overall cohort between the intervention and control groups in both neck positioning (-11.0° vs. -19.1°, P = 0.17) and back positioning (8.6° vs. 19.1°, P = 0.18). CONCLUSIONS: Musculoskeletal related pain is prevalent among otolaryngologists and otologists with data suggesting that symptoms begin during residency. Targeted "Just in Time" teaching of ergonomic principles is feasible and may be effective for development of healthy postural habits, especially among junior trainees.

Efficiency of microvascular free flap reconstructive surgery: An observational study.

OBJECTIVE: We aimed to assess operative workflow and efficiency in microvascular free flaps via a direct observational study based on Lean principles of quality improvement (QI). METHODS: Observers monitored the workflow of twenty-three free flaps. Pre-operative preparation and surgical duration was recorded with supplemental data provided from our institution's surgical tracking database. Traffic patterns of operating room (OR) staff were documented as "entries" and "exits" from the OR and classified by role and the reason that the entry or exit was required. Patient data was obtained via chart review. RESULTS: The mean surgical time was 9.0 h. Approximately 20% of OR time was dedicated to the pre-incision process, averaging 1.6 h per case. One third of entries and exits occurred during this period. In total, 180.2 surgical hours were observed during which 6215 "entries" and "exits" occurred. The mean number of entries and exits per case was 270; the most common reasons were supplies and communication. No association was observed between elapsed surgical time or total number of entries and exits with post-operative infection rates. CONCLUSION: Comprehensive observational workflow studies of free flaps are challenging to execute due to lengthy procedure times. At our high-volume institution, a significant portion of OR time is devoted to the pre-incision period, largely due to inadequate supply availability and pre-operative communication. These findings will serve as a foundation for QI interventions at our institution, while our observational model provides a broadly applicable framework for assessing surgical efficiency.