Audiometric outcomes following surgery for spontaneous temporal bone cerebrospinal fluid leaks - A single institution study.

PURPOSE: To assess the audiometric outcomes following surgical repair of spontaneous temporal bone cerebrospinal fluid otorrhea and compare different surgical approaches. MATERIALS AND METHODS: Retrospective review of adults (≥18 years old) who underwent repair of spontaneous CSF leak between 2011 and 2022. Audiometric outcomes were compared across the three surgical groups: transmastoid, middle cranial fossa and combined. RESULTS: Thirty-nine patients (40 ears) met the inclusion criteria (71.8 % females; mean age 59.77 +/- 12.4). Forty-two percent underwent transmastoid, 12.5 % middle cranial fossa and 45 % transmastoid-middle cranial fossa. Four patients (10 %) had recurrence, 3 in the transmastoid group and 1 in the combined approach. The mean change in air-bone gap (ABG) for all patients (postoperative-preoperative) was -7.4 (paired t-test, p-value = 0.0003). The postoperative ABG was closed in 28 (70 %) ears (postoperative ABG ≤ 15). The mean change in pure tone average (PTA) for all patients (postoperative-preoperative) was -4.1 (paired t-test, p-value = 0.13). The mean change in word recognition scores (WRS) for all patients (postoperative-preoperative) was -3 (paired t-test, p-value = 0.35). On multivariable analysis (controlling for site and reconstruction material), there was no significant difference in ABG, PTA and WRS change between surgical groups. CONCLUSIONS: Transmastoid, middle cranial fossa and combined approaches are all effective in treatment of spontaneous CSF leaks and all showed mean decrease in post-operative ABG. Transmastoid approach showed the greatest decrease in ABG and PTA (although middle cranial fossa approach shows the greatest decrease, when excluding profound hearing loss in a patient with superior canal dehiscence). Further studies comparing audiometric outcomes are needed.

Long-term cognition and speech recognition outcomes after cochlear implantation in the elderly.

OBJECTIVE: The purpose of this study is to investigate how cognition, as measured using the Self-Administered Gerocognitive Examination Test (SAGE), and age affect speech recognition scores in older adults (age > 65) at one year and two years after cochlear implantation. STUDY DESIGN: This is a prospective study. SETTING: This study was conducted at a single institution. METHODS: Unilateral cochlear implantation was performed by two surgeons on adult patients (>65 years) with postlingual bilateral sensorineural hearing loss. There were 230 patients who underwent cochlear implantation from January 2016 to June 2023. Fifty-five of these patients completed the SAGE questionnaire before implantation, one year after implantation, and 2 years after implantation. Paired t-test analysis was used to evaluate pre- and post-operative speech recognition scores (CNC, AzBio in Quiet). RESULTS: Patients who had normal preoperative cognition on SAGE showed greater improvement in postoperative speech recognition tests at 1 year and 2 years after implantation compared with patients who showed preoperative cognitive impairment. There were no significant differences in postoperative speech outcome between age group 1 (between 65 and 80 years old) and age group 2 (over 80 years old) cochlear implant recipients. There were no changes in cognitive SAGE scores after 2 years implantation. CONCLUSION: Cognitive function, as measured by SAGE, is a more reliable predictor than age in determining speech recognition improvement after cochlear implantation. Cochlear implantation did not improve postoperative cognition.

Efficacy of tranexamic acid (TXA) for post-tonsillectomy hemorrhage.

PURPOSE: To determine if tranexamic acid (TXA) reduces the need for operative re-cauterization in the setting of a post-tonsillectomy hemorrhage (PTH). METHODS: A retrospective chart review was performed on 1428 adult and pediatric patients who underwent tonsillectomy over a two-year period at a tertiary care hospital with continuous otolaryngologic coverage. Collected data of PTH patients included age, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, length of stay (LOS), the requirement of a blood transfusion, day of PTH, TXA usage and route, complications from TXA administration, and TXA failure requiring operative intervention. RESULTS: The incidence of pediatric PTH during the study period was 5.7 %. Twenty-seven out of fifty-five PTH patients received topical, nebulized, or intravenous TXA. No adverse effects were noted with TXA administration. TXA usage provided resolution of the PTH in 77.8 % of patients. No significant differences were found in age, gender, BMI, LOS, ASA classification, rate of blood transfusion, or TXA treatment modality between the patients that received TXA and those that did not. CONCLUSIONS: Treatment of PTH with TXA appears to reduce the need for operative control of PTH. In the setting of reducing operative risk, improving health care utilization, or in a setting without immediate otolaryngologic provider coverage, the role of TXA is promising. Further larger clinical or multi-institution studies are needed to determine the efficacy of TXA, its route of administration, and its optimal dosage. LEVEL OF EVIDENCE: Level 4, Retrospective cohort study.

Vestibular dysfunction in cochlear implant candidates: Prevalence and outcomes.

PURPOSE: Cochlear implantation (CI) has been shown to reduce vestibular function postoperatively in the implanted ear. The objective of this study was to identify the prevalence of preoperative vestibular weakness in CI candidates and identify any risk factors for postoperative dizziness. STUDY DESIGN: Retrospective cohort study. MATERIALS AND METHODS: Patients who underwent CI and had preoperative videonystagmography (VNG) at the Silverstein Institute from January 1, 2017 to May 31, 2020 were evaluated. The primary endpoint was dizziness lasting more than one month postoperatively. RESULTS: One hundred and forty nine patients were evaluated. Preoperative VNG revealed that 46 (30.9%) had reduced vestibular response (RVR) on one side and 32 (21.5%) had bilateral vestibular hypofunction (BVH). Postoperative dizziness occurred in 14 (9.4%) patients. Patients with postoperative dizziness were more likely to have abnormal preoperative VNG (RVR or BVH), compared to patients without postoperative dizziness (78.6% versus 49.6%, p = 0.0497). In cases of RVR, implantation of the weaker or stronger vestibular ear did not affect the postoperative dizziness (16.1% versus 6.7%, p = 0.38). Postoperative VNG in patients with dizziness showed decreased caloric responses in the implanted ear (28.4 to 6.4 degrees/s, p = 0.02). CONCLUSION: Preoperative caloric weakness is prevalent in CI candidates and abnormal preoperative vestibular testing may be a predictor of postoperative dizziness. CI has the potential to cause vestibular injury and preoperative testing may aid in both counseling and decision-making.

Case series of vestibular schwannoma patients with no asymmetry in hearing.

OBJECTIVE: (1) Describe the presenting symptoms and tumor characteristics of patients who are diagnosed with a vestibular schwannoma (VS) with normal hearing or symmetric hearing loss, and (2) report the prospective growth and treatment of each tumor. METHODS: This is a retrospective cohort study of acoustic neuroma patients who were found to have a VS and normal or symmetric hearing loss at a single tertiary care academic center from 1999 to 2012. Medical records were reviewed collecting the following information: patient demographics, symptoms, MRI characteristics, and treatment modality. RESULTS: 15/195 (7.7%) patients met criteria for the study. Dizziness was the most common presenting symptom occurring in 9 subjects (60%), followed by headache in 6 (40%), vision changes in 5 (33%), tinnitus in 5 (33%), and unilateral hearing loss in 1 (7%). The average tumor size was 1.07 cm (range 0.3-2.2 cm). Eight (53%) patients presented with intracanalicular tumors. Growth was observed in 6 subjects (40%) with average growth rate in those who exhibited mean growth of 1.8 mm per year. Treatment consisted of surgical removal in 4 cases (27%), gamma knife therapy in 1 (7%), and observation or loss to follow-up in 10 (66%). CONCLUSIONS: The incidence of VS with normal hearing was 7.7% Patients with VSs who do not exhibit unilateral hearing loss present most commonly with dizziness. Most of our patients had small, intracanalicular tumors with the largest tumor measuring 2.2 cm in greatest dimension. Of those who were managed conservatively with repeat imaging and observation, most showed tumor growth.

Outcomes of Endolymphatic Sac Surgery for Meniere's Disease with and without Comorbid Migraine.

PURPOSE: To explore outcomes of endolymphatic sac surgery for patients with Meniere's disease with and without the comorbid condition of migraine. MATERIALS AND METHODS: A retrospective chart review of adult patients undergoing endolymphatic sac surgery at a single tertiary care center from 1987 to 2019 was performed. All adult patients who failed medical therapy and underwent primary endolymphatic sac surgery were included. The main outcome measures were vertigo control and functional level scale (FLS) score. Patient characteristics, comorbidities, and audiometric outcomes were tracked as well. RESULTS: Patients with Meniere's disease and migraine had a stronger association with psychiatric comorbidities (64.29% vs. 25.80%, p=0.01), shorter duration of vertigo episodes (143 vs. 393 min, p=0.02), and younger age (36.6 vs. 50.8 yr, p=0.005) at the time of endolymphatic sac surgery. Postoperative pure tone averages and word recognition scores were nearly identical to preoperative baselines. Class A vertigo control (47.92%) was most common, followed by class B vertigo control (31.25%). The FLS score improved from 4.2 to 2.8 (p < 0.001). Both patients with and without migraine had classes A-B vertigo control (66.67% vs. 80.95%) without any statistically significant difference (p=0.59). Of the patients who required secondary treatment (10.42%), none had migraine. CONCLUSIONS: Endolymphatic sac surgery is an effective surgical intervention for Meniere's disease with and without migraine. Patients with comorbid migraine tend to be younger and present with psychiatric comorbidities.

Standardization and Reduction of Narcotics After Pediatric Tonsillectomy.

OBJECTIVES: (1) To measure caregiver satisfaction with a nonstandardized postoperative pain regimen after pediatric tonsillectomy. (2) To implement a quality improvement project (QIP) to reduce the number and volume of narcotics prescribed and to describe the effect on caregiver satisfaction. METHODS: A prospective cohort study at a tertiary children's hospital examined postoperative narcotics prescribed to children following adenotonsillectomy. A QIP was implemented 3 months into the observation, with the goal to standardize nonnarcotic analgesics and reduce the volume of narcotics prescribed. Caregivers were called 2 to 3 weeks postoperatively to assess pain control and caregiver satisfaction. RESULTS: Over an 8-month period, 118 patients were recruited (66 before the QIP, 52 after induction). Prior to the QIP, 47% of patients were prescribed postoperative narcotics, as opposed to 27% after the QIP (P < .05). There was a significant reduction in the volume of narcotics prescribed before (mean ± SD, 300 ± 150 mL) versus after (180 ± 111 mL) the initiative (P < .05). The per-kilogram dose did not change over the study time frame. On a 5-point Likert scale, there was no difference in the caregivers' satisfaction regarding pain control before (4.37 ± 0.85) versus after (4.35 ± 1.0) the project started. DISCUSSION: A system shift was identified with the establishment of a posttonsillectomy pain control protocol associated with a reduction in prescribed narcotics without a significant change in caregiver satisfaction. IMPLICATIONS FOR PRACTICE: Implementing a standardized plan for the use of nonnarcotic medications was associated with reduced frequency and volume of narcotics prescribed. Future work will further standardize our postoperative pain regimen.

Post-operative infection rates in linear vs. punch technique for bone anchored hearing systems.

PURPOSE: This study investigates the post-operative infection rates between two surgical approaches: linear incision and the punch technique for bone anchored hearing systems. Secondarily, it investigates the impact of smoking, comorbid disease, and operative conditions on post-operative skin reactions and infections. METHODS: A retrospective study was conducted at a single tertiary care institution. A single surgeon completed either of the two techniques on adult patients with mixed, conductive hearing loss, or single sided-deafness. Patients included had at least 6 months follow-up, and were evaluated for preexisting illnesses, perioperative complications, length of surgery, and post-operative complications including infection after surgery. Post-operative soft tissue around the abutment was assessed with Holgers Classification scale. RESULTS: Fifty-one patients were included in this study, 28 female and 23 males with an average age of 68.8. Thirty-three patients underwent linear incision surgery and 18 had the punch technique. Overall 9 patients (17.6%) had post-operative infections requiring topical or oral antibiotic treatment. Six (18.2%) were in the linear group and 3 (16.7%) in the punch group. There was no statistically significantly difference (p = 1). A multivariate analysis compared age, sex, obesity, DM, operative time, skin thickness, and abutment size to post-operative skin infection rates requiring treatment. Only DM was statistically correlative with infection (p = 0.02). CONCLUSION: No significant differences in post-operative infections were identified comparing linear incision and the punch techniques. Patients with diabetes had a higher incidence of post-operative skin infections rates.

Decision Quality Among Parents Who Are Offered Ventilation Tube Insertion for Their Children.

OBJECTIVE: To develop a Decision Quality (DQ) tool to measure parents' DQ concerning ventilation tube (VT) insertion in their children. METHOD: Parental survey during 2017 to 2018 in a tertiary care pediatric otolaryngology clinic comparing a validated Decisional Conflict (DC) scale with a DQ instrument including Shared Decision-Making (SDM) scale, parental treatment goals, and knowledge about VT. RESULTS: Of 100 parent participants, 83% were mothers and 14% were fathers. 94% elected VT insertion, 6% elected monitoring or deferred the decision. 44% of the patients were <18 months, 42% were 19 months to 3 years, and the rest were older. The mean DC score was 8.26 out of 100 (95% CI 4.82-11.69), indicating low DC. Mean DQ score was 82.45 out of 100 (95% CI 80.18-84.72), including mean SDM of 87.71 (95% CI 83.53-91.88,), mean knowledge score of 87.5% (95% CI 84.56-91.59) and mean values score of 7.16 (95% CI 6.90-7.41). Comparisons between those who elected VT and those who did not showed that electors had lower DC scores (7.15 vs 24.74, P < .001), higher DQ scores (83.00 vs 72.61, P = .028) with higher SDM scores (88.70 vs 70.22, P = .044) and higher values score (7.20 vs 6.36, P = .034). Cronbach alpha for the DQ scale was 0.76. Spearman's rho for DQ score versus DC score was -0.458, P < .001. CONCLUSIONS: DQ, as measured with this tool, was higher when parents chose to place tubes. Our DQ instrument has potential use for study of why parents may decline VT when their child meets criteria for them.

Predicting Speech Outcomes After Cochlear Implantation in Older Adults Using the Self-administered Gerocognitive Examination Test.

PURPOSE: The purpose of this study is to determine if a cognitive test, Self-administered Gerocognitive Examination (SAGE), correlates with speech recognition outcomes 1 year after cochlear implantation in adults over 65 years of age. METHODS: Retrospective study was conducted at a single institution. Surgery was performed by two surgeons on adult patients (>65 yrs) with postlingual bilateral sensorineural hearing loss meeting clinical and audiological candidacy for unilateral cochlear implantation. Patients who performed SAGE preimplantation, and speech testing (CNC, AzBio in quiet, AzBio in noise) before and 1 year after implantation were included. RESULTS: Forty patients with a mean age of 78 were included. The overall mean preoperative SAGE score was 17.4 (95% CI 16.2-18.7). Greater than 17 is considered normal. Data demonstrated a statistically significant linear correlation between preoperative SAGE scores with change in speech testing 1 year postoperatively: CNC-Adjusted R-squared: 0.1955, p value: 0.002508; AzBio in quiet-Adjusted R-squared: 0.1564, p value: 0.006686; AzBio in noise-Adjusted R-squared: 0.1543, p value: 0.007053. Multivariate linear regression analysis revealed that age and SAGE scores both statistically correlated with speech testing 1 year after implantation (p = 0.01 for both). Patients who passed the SAGE (≥17) had statistically significant higher CNC, AzBio in quiet, and AzBio in noise scores 1 year postoperatively compared with patients with low SAGE scores (<17) despite statistically similar age means in each group. CONCLUSION: SAGE can predict speech recognition testing 1 year after cochlear implantation in older adults over 65 years of age.

Minimally invasive surgery for the treatment of hyperacusis: New technique and long term results.

OBJECTIVE: A minimally invasive surgery developed by the senior author has previously been reported to significantly improve sound tolerance after surgery. This report compares the new versus original surgical technique used and long-term results of all patients who have undergone minimally invasive surgery for hyperacusis. STUDY DESIGN: A prospective, IRB approved clinical research trial at a single institution with surgery performed by the author (HS). SETTING: All patients were evaluated and treated at a tertiary level otologic referral center. SUBJECTS AND METHODS: 47 subjects were enrolled from 2014 through 2019, 40 met inclusion criteria including adequate follow-up in the analysis. All subjects underwent oval and round window reinforcement. 20 subjects underwent surgery before 2017 with the original technique of round window reinforcement. 20 subjects underwent new technique with additional oval window and stapes reinforcement. RESULTS: 80% of subjects who underwent the new surgical technique had improvement in hyperacusis symptoms after surgery compared to 60% of subjects who underwent the original technique. Long term follow-up showed sustained results with both techniques with a mean follow-up of 2 years after surgery. CONCLUSIONS: The most recent, newer technique employed appears to have an 80% success rate in improving sound tolerance with small changes to hearing. The improvement in hyperacusis symptoms after surgery is significant and now found to be sustainable with a mean follow-up of 2 years after initial surgery. Psychological measures of anxiety and depression also were found to be significantly improved after surgery in the newer technique group.

Experience with key indicator cases among otolaryngology residents.

OBJECTIVE: To describe the resident experience with respect to key indicator cases for each year of training. STUDY DESIGN: Multi-institution, cross-sectional assessment. METHODS: Using an electronic survey, current otolaryngology residents were solicited to complete a survey regarding their experiences with the key indicator cases to that point. The survey was sent to this cohort in the winter of 2017-2018. RESULTS: Three hundred and three residents responded, with 293 completing the survey. Twenty-three percent were PGY1, 19% PGY2, 21% PGY3, 18% PGY4, and 19% PGY5 or higher. The majority of residents progress from resident assistant as a PGY2, to resident surgeon as a PGY3 and self-assessed competent surgeon as a PGY4 for the majority of the key indicator cases. Less than 50% of the surveyed PGY5 residents had reached independent practice in all the key indicator cases, with stapedectomy (16%), rhinoplasty (18%), and paramedian forehead flap (14.5%) being the cases least frequently performed independently. Ninety-five percent of the respondent residents felt their program provided adequate training, but 20% of the respondents were either unsure or believed that they would be unable to perform all the key indicator cases by the completion of their training. CONCLUSIONS: The majority of otolaryngology residents feel confident in their training, but experience with certain cases lags behind and may not currently be taught as resident level cases. These findings raise the question of whether the current key indicator cases are the best option for assessing breadth and depth of residency training. LEVEL OF EVIDENCE: NA.

Stapes hypermobility as a possible cause of hyperacusis.

OBJECTIVE: Hyperacusis is a reduction of normal tolerances for everyday sounds. Although several publications have been produced demonstrating that minimally invasive surgical procedures may improve patient symptoms, the precise etiology of hyperacusis often remains elusive. This study describes 21 patients, 7 of whom stapes hypermobility is believed to be a mechanical genesis of their hyperacusis symptoms. STUDY DESIGN: A prospective, repeated-measure single-arm design was used for this study. SETTING: All patients were evaluated and treated at a tertiary level otologic referral center. SUBJECTS AND METHODS: 21 patients (Cohort A) with severe hyperacusis underwent oval and round window reinforcement. Seven patients (Cohort B) intraoperatively appeared to have subjective hypermobility of the stapes. Additional reinforcement of the stapes superstructure was performed in these patients. RESULTS: In Cohort A, loudness discomfort level (LDL) values improved on average from 72.7 dB to 81.9 dB. Hyperacusis questionnaire (HQ) scores improved from 30.1 to 14.7. Numeric Rating Scale scores (0-10) decreased from 8.5 to 4.0. In Cohort B, values similarly improved from an average of 72.4 dB to 88.2 dB. HQ scores improved from 35.8 to 18.9. Numeric Rating Scale scores fell from 10.0 to 3.7. Postoperatively there were no complaints of hearing loss. Sixteen out of 21(76%) reported improved quality of life and diminished symptoms of hyperacusis. CONCLUSION: It is possible that patients suffering from hyperacusis may have a mechanical cause for their symptoms. Further research is necessary to clarify stapes mobility in patients with these symptoms. Excess temporalis tissue reinforcement of the stapes along with round window reinforcement shows promise as a minimally invasive surgical option for patients suffering from hyperacusis.

Outcomes of Primary Radiosurgery Treatment of Glomus Jugulare Tumors: Systematic Review With Meta-analysis.

OBJECTIVE: 1) Determine tumor control, symptomatic control, and complication rates of primary radiosurgery (PRS) for treatment of glomus jugulare tumors (GJTs) via systematic review and meta-analysis. 2) Identify risk factors for these outcomes. DATA SOURCES: 1) Search of English articles in PubMed, Web of Science, Cochrane, and EBSCOhost databases from January 1950 to August 2017. STUDY SELECTION: Inclusion criteria: 1) treated GJT patients who had no previous treatment with radiosurgery, 2) follow-up with magnetic resonance imaging for at least 12 months, 3) reported pre and posttreatment symptoms, tumor control, or complications for individual PRS patients or for PRS patients as a cohort. DATA EXTRACTION: The following were extracted: number of patients, level of evidence, mean age, mean pretreatment tumor volume, tumor control rate, criteria for change in tumor size, symptom control rate, and complications. At the individual patient level the following were extracted: age, number of treatment fractions, total radiation dose to tumor margin, pretreatment tumor volume, Fisch or Glasscock-Jackson stage, pre- and posttreatment symptoms, tumor control, symptom control/improvement, length of follow-up, and complications. DATA SYNTHESIS: Fifteen studies encompassing 91 patients met criteria. Tumor control was achieved in 92% of patients, symptom control in 93%, and complications occurred in 8%. There was one major complication. Smaller tumor volume predicted improvement in symptoms with PRS. CONCLUSIONS: In the short term, PRS is safe and effective at controlling growth and clinical symptoms for patients with GJTs, though there exists significant selection bias, inconsistent reporting, and clinical heterogeneity among existing studies.

Isolated Inferior Rectus Muscle Entrapment following Endoscopic Sinus Surgery.

Orbital complications are known risks of endoscopic sinus surgery (ESS). The lamina papyracea and medial rectus muscle are the most commonly injured structures during ESS. Inferior rectus injury is more rare, with only one reported case of isolated inferior rectus injury in the literature. Guidelines for managing ESS-induced inferior rectus injury do not exist, and delayed intervention and management of adjacent sinuses may affect long-term outcomes such as persistent diplopia and disfigurement. In this report, we present a case of a 67-year-old man with diplopia due to isolated left inferior rectus muscle entrapment and injury from violation of the orbital floor during previous ESS. We postulate that an incomplete maxillary antrostomy contributed to scar band formation and entrapment of the inferior rectus muscle after the orbital floor was violated, and advocate early intervention with a wide, complete maxillary antrostomy if the orbital floor is injured during ESS.

How Was Your Otology Training? A Survey of Recent Otolaryngology Residents.

OBJECTIVE: To survey graduating residents or recent graduates of otolaryngology residency programs to evaluate their Otology/Neurotology (ON) experience in residency and discern if they had received adequate training in time to decide whether to pursue a fellowship in Otology or Neurotology. STUDY DESIGN: Internet-based survey. METHODS: A survey was distributed to all US otolaryngology residency programs to distribute to 5th year residents and recent graduates in last 4 years. The survey assessed satisfaction in ON experience, presence of ON fellows, adequacy of experience to decide on ON fellowship, post-graduate year (PGY) year at which residents observed, performed, and proficiently performed five procedures (tympanoplasty, mastoidectomy, ossiculoplasty, stapedectomy, and cochlear implant), and plan for performing these surgeries in practice. RESULTS: 89/106 (84%) of respondents felt they had adequate training in Otology in time to decide whether or not to pursue a fellowship and were found to observe and perform surgeries significantly earlier in training by PGY including: mastoidectomy (observed PGY 1.9 versus PGY 2.3, performed PGY 2.9 versus PGY 3.5), ossiculoplasty (observed 2.1 versus 3.0, performed 3.6 versus 4.3), stapedectomy (observed 2.3 versus 3.0, performed 3.9 versus 4.5), and cochlear implant (observed 2.1 versus 2.8, performed 3.4 versus 4.1) all p < 0.05. There were 19/106 (17.9%) respondents who came from programs with fellowships and 78.9% thought fellows were beneficial to their ON experience. CONCLUSIONS: Early exposure to ON surgeries may aid in residents' decision to pursue a fellowship in ON. The presence of fellows appears to facilitate residents' ON experience.

Cost-effectiveness of Gene Expression Classifier Testing of Indeterminate Thyroid Nodules Utilizing a Real Cohort Comparator.

Objective To predict the cost-effectiveness of implementing routine gene expression classifier testing for thyroid nodules with indeterminate fine-needle aspiration cytology, by utilizing a real cohort of patients as a comparator. Study Design Cost-effectiveness analysis of a retrospective cohort compared with a simulated cohort. Setting Tertiary academic medical center. Subjects and Methods We reviewed the records of all patients who underwent ultrasound-guided fine-needle aspiration from 2010 to 2014 at a tertiary academic medical center. All patients with Bethesda class III or IV cytopathology had the details of their management catalogued over the subsequent 2 years of care. These patients were assigned to the standard-of-care arm of the study. We compared the third-party payer costs of care and the proportion of patients who underwent surgery with a simulated cohort who underwent gene expression classifier testing after an initial indeterminate fine-needle aspiration (molecular test arm). Results The cost of managing 1 nodule over 2 years was $2399 higher (range, $397-$4399) for the molecular test group than the standard of care group. The molecular test group had a 13.1% decrease (base parameters; range, 0.73%-45.09%) in the number of patients undergoing surgery. Conclusion When applied to a real cohort of patients, routine gene expression classifier is predicted to reduce the number of patients undergoing surgery but will increase cost of care. Cost-effectiveness is heavily dependent on prevalence of malignancy and gene expression classifier specificity.

Nodular Lymphocyte-Predominant Hodgkin Lymphoma in Progressive Transformation of Germinal Centers.

Nodular lymphocyte-predominant Hodgkin lymphoma is an uncommon variant of Hodgkin lymphoma. Progressive transformation of germinal centers has been associated with and can develop prior to, concurrent with, or after the diagnosis of nodular lymphocyte-predominant Hodgkin lymphoma. We present a patient with a history of progressive transformation of germinal centers of the right parotid who presented 4 years later with ipsilateral parotid mass and cervical adenopathy. Knowledge of her previous diagnosis raised our concern for lymphoma, influenced our surgical management, and spared the patient additional surgery with risk of facial nerve injury inherent in revision parotidectomy.